Understanding Fluid Volume Excess and Management

Hey everyone, it's Nurse Sarah with RegisteredNurseRN.com and in this video I'm going to be talking about fluid volume excess. So let's get started. Fluid volume excess is sometimes referred to as fluid volume overload, overhydration, hypervolemia, or water intoxication. So it has a lot of names and what's happening is that there's just too much fluid in our body and our body needs just the right amount of fluid in it in order to be able to function. If it has too much or too little, it's going to start to fail and you're going to start to see these certain signs and symptoms. So with fluid volume overload, where is all this fluid hanging out? Well, whenever the system becomes overloaded, this fluid likes to go into the different fluid compartments we have in our body. So let's quickly review those fluid compartments. So the first fluid compartment we have is called the intracellular compartment. And this is the fluid found inside of the cell. And there's actually a lot of fluid inside the cell. It accounts for two thirds of our body water. Then we have the extracellular compartment. And this is the fluid outside of the cell and accounts for about one third of our body water. And we can take that extracellular compartment and divide it into other sections. For instance, part of the extracellular compartment is the interstitial compartment. And this is the fluid that is found around those cells. So outside of the cells in between them, then we have the intravascular compartment, and this is our blood plasma. As nurses, we access this compartment a lot. Whenever we're starting IVs, we are getting access to this compartment. And many times the reason we're even accessing this intravascular compartment. is because we need to give them fluids. And then there's another part of the extracellular compartment known as the transcellular. And this is the smallest part of all the extracellular compartments. And it's the fluid that is found around certain joints and certain organs in our body like the heart and the lungs and all of these compartments are really interconnected they work together because they can shift fluid around as needed to help correct certain problems and they do this through various processes with one process being osmosis and osmosis is highly influenced by the osmolarity hence the solute concentration of a fluid and what happens in osmosis is that water is going to move from a fluid that has a low osmolarity hence a low concentration of solutes, to a fluid that has a higher concentration of solutes, hence a higher osmolarity. So depending on where those solutes are hanging out will depend on where that fluid is going to move. And these are all important concepts that you want to be familiar with to help you understand the different types or causes of fluid volume overload. So there are three types of fluid volume overload. We have hypertonic, hypotonic, and isotonic. So first, let's talk about hypertonic fluid volume overload. With this type of overload, there's going to be the movement of water from the intracellular compartment to the extracellular compartment. And this happens due to an increase of osmolarity, hence the solute concentration in the extracellular compartment. which cause fluid, hence our water, to move from that intracellular compartment to the extracellular compartment. So we're going to have an increased amount of water here in this extracellular compartment. Now when you're trying to think of the causes of this type of overload, think of causes where we're introducing something in the body that has a high concentration of solutes, hence a high osmolarity. And this would happen if the patient ingested too much sodium. Because remember, water loves sodium. And whenever we have a lot of sodium on board in the body, water just flows to it. And whenever it flows to it, we're going to increase our fluid volume. In addition, excessive administration of hypertonic IV solutions can do this as well. Because what's happening is that we're administering these high osmolarity fluids, hence they have a high solute concentration to that intravascular space. which is part of the extracellular compartment. And it's going to cause water to be pulled from the intracellular space, the inside of the cell. It's going to shrink it down, but that fluid's going to go somewhere and it's going to go into the extracellular space. And we're going to overload that compartment. Then another type of overload is called hypotonic fluid volume overload. And this is also sometimes referred to as water intoxication. Therefore, we're increasing body water, but not osmolarity. We're actually going to dilute the solutes. And with this, we're going to have the movement of water from the extracellular space to the intercellular space. So you're going to have an intercellular compartment that's going to become overloaded along with the extracellular compartment. So both compartments. And when you're trying to think of the causes of this, think of causes where free water is just being introduced into the body. One way is through excessive intake of free water orally. And a condition that can cause this is known as priming. polydipsia and this is where the patient has a very strong compulsion to just drink water over and over. So as they introduce all this water into their system they become water intoxicated and it will water down the extracellular compartment hence changing its osmolarity which is going to according to osmosis pull water into the intracellular compartment. which will overload it as well. SIADH can also cause this as well. And this stands for syndrome of inappropriate antidiuretic hormone. And this is where there's too much antidiuretic hormone being released. And antidiuretic hormone is also referred to as ADH. And whenever we have too much ADH on board, what happens is that we are retaining way too much water in our body. And we're going to have this same concept happen. We're going to have fluid volume overload. We're going to dilute everything really, especially sodium in the extracellular compartment. And then lastly, we have isotonic fluid volume overload. And this is sometimes referred to as hypervolemia. This is a very common type of overload that we see in patients. And with this, there is no movement of water between those compartments like how we had with the other two because osmolarity is equal. Remember, iso means equal. So we're not going to have the shifting of this fluid. But we're going to have the overload of the extracellular compartment because we can have problems with major organs in our body that normally help us regulate our fluid volume. For instance, if we have heart failure or kidney failure, it can lead to this type of overload. or if we administer too much isotonic IV solutions to the patient, we can overload the cellular compartment. In addition, over usage of corticosteroids can lead to this because corticosteroids cause our body to retain sodium and water. Now let's talk about the signs and symptoms of fluid volume overload. So to help you truly understand what you're going to be seeing in your patient, you need to think about what is going on with my patient. Well, we've already established that the patient is overloaded with fluid in their body fluid compartments, and they are just oversaturated with fluid from head to toe. So signs and symptoms are going to be based on how they're affecting that certain body system. So first, let's start with our head, the neuro part. So from a neuro standpoint, you want to monitor for brain swelling, because what happens is that those cells that make up your brain can start to expand and swell. And this can lead to mental status changes. And that is actually one of the earliest signs and symptoms that your patient is experiencing. brain swelling. So be monitoring for confusion. In addition, what can happen is that your patient can experience a headache or pressure in the head from that fluid overload. Now let's move down to the cardiovascular system. So this system has a lot of fluid in it and it can become overwhelmed quite easily. And how I like to think of this system being affected is the same concept with a water hose. So your water hose is like your vessels in your body. And if we have a lot of water connected to that water hose, there's going to be a lot of pressure in it and almost the same is true for your body if you have a lot of fluid in that system you're going to have a very strong bounding pulse whenever you go to fill the patient's pulses because we have a lot of fluid in there they are going to have a high blood pressure so hypertension in addition their jugular veins are going to be distended so they could have JVD which is known as jugular venous distension and they can experience sinus tachycardia Then we can move out from this system to the respiratory system and our lungs can be majorly affected, especially depending on how severe the fluid volume overload is because then fluid can start to leak into our lungs and cause pulmonary edema. So you may see that the patient has shortness of breath with any simple activity. They're having difficulty breathing. You could also hear crackles in their lungs whenever you listen to them and here's an example of what crackles may sound like. In addition, the respiratory rate can be increased and they can have this dry hacking cough. Now, this cough can actually become productive. And if it becomes productive, this is a really bad sign. Whenever they start to cough, it will be this like foamy, frothy, blood-tinged sputum. That tells you that you need to get your patient treatment immediately because they're experiencing like flash pulmonary edema. And then we start to see signs and symptoms peripherally where we're going to see swelling and edema in the upper and lower extremities. And this edema can actually pit whenever you touch it, which we're going to go over here in a moment in nursing interventions. The skin will also feel cool to the touch because it can be so swollen that will diminish blood return, causing it to feel cool. And the outer skin will feel cool. Abdomen can be swollen which we term ascites because fluid can back up into our liver veins which can cause congestion. In addition, the patient can have nausea where there's just so much pressure in the belly and the patient is going to have weight gain. And one thing you want to remember about weight gain that's helpful, especially whenever you're monitoring the patient, seeing how much fluid they're losing, is that one kilogram, which is 2.2 pounds, is equal to about one liter of fluid. So whenever we're diuresing them, we definitely want to monitor their weight. But whenever they're having fluid volume overload, weight gain is one of those signs and symptoms they can experience. Now let's talk about labs and diagnostics. What are you going to see as a nurse whenever your patient has fluid volume overload? So remember, your patient has a lot of fluid in their body. So if we have a lot of fluid and other fluids of the body, what is it going to do to the concentration of electrolytes? or other important things in that blood, it's going to dilute it. So it's going to decrease it. When we go and get our reports back, we're going to see that certain labs are going to be decreased. And the reason they're decreased is because we have way too much fluid watering down that blood and that urine. So remember, everything is going to be diluted, which starts with a D and everything is going to be decreased. So when we look at the patient's hemoglobin and hematocrit, it will be decreased. When we check the patient's sodium level, it will be decreased. It can be less than 135 milliequivalents per liter. In addition, there'll be you in along with a decreased serum osmolality. And this is the concentration of substances in the blood. So because we have so much fluid in there, it's going to be diluted. And when we check the urine, there's going to be a decreased urine specific gravity and osmolality test. And these look and measure the solute concentration in the urine. The urine specific gravity actually looks at the number and size of them and the osmolality looks at the number of them, the electrolytes. So again, it's fluid and it's going to be low. Now if the patient has a really severe case of fluid volume overload, we can look at a chest x-ray and we could see pulmonary edema where there's fluid in those lungs. Now let's talk about nursing interventions. So treatment goals revolve around removing this extra fluid from the patient, but we don't want to remove too much fluid from the patient because if we do, we're going to flip them into fluid volume deficit and we don't want them to go there. Plus, we don't want to remove too many electrolytes because we're going to be giving them diuretics and other things which could throw off our electrolyte balance. So as a nurse, we're going to play a vital role in helping administer treatments that removes this fluid. But we also got to monitor those body systems. How are they responding to us removing all this fluid? and make sure that their electrolytes are staying balanced. So what we're going to do is we're going to drain the water. So remember the word drain to help you remember all those nursing interventions for this patient. D is for diuretics. So diuretics are medications we can administer to the patient. And what happens is it causes them to urinate a lot. And what they're going to do is they're going to urinate this extra fluid out. And there's a wide variety of diuretics that can be used. You can use loop diuretics, osmotics, or thiazides. It really depends on the type of overload the patient is experiencing, their renal function, and the severity. R is for restrict fluids and sodium. So we don't want to be giving this patient all these fluids because it's literally going to counteract what we're trying to do for the patient. So they're going to be on some type of fluid restriction. It can be anywhere between one to two liters of fluid. per day that they're restricted to. If your patient does have this, a lot of patients struggle with this, you just want to remind them why we're doing it and then help them develop a plan of how they can space out their fluid throughout the day if they can cognitively do this with you. In addition, you want to restrict the sodium foods that they're consuming. So chances are they're going to be on a low sodium diet and again patients don't like this a lot of times because the food tastes bland but you want to explain to them why we're on this type of diet. because sodium loves water. Sodium and water go together and if we're just throwing in a bunch of sodium we're going to be pulling a lot of water and we're not really solving our problem of fluid volume overload. A is for assess daily weight and assessing a patient's weight is actually a great way to monitor their fluid status. So again remember as you're weighing this patient you need to be doing at the same time every day with the same scale so we can get the most accurate results. And we want to see how those weights are trending. We don't want our patient gaining more than two to three pounds in a 24 hour period, because that tells us what we're doing is not working. They're actually gaining fluid. And again, you just want to remember that concept. One kilogram, which is equal to 2.2 pounds equals one liter of fluid. fluid. So if your patient's losing one kilogram, hey, you've removed around one liter of fluid. And you also want to routinely be checking their edema. Is it decreasing? So many of these patients are going to have pitting edema and you want to grade it. And it's helpful to use the lower leg and press over the fibula or tibia region. And here is a little guide to help you grade it. One plus is like two millimeters of pitting. Two plus would be four millimeters of pitting. 3 plus is 6 millimeters of pitting and then 4 plus which is pretty significant is about 8 millimeters of pitting. And if your patient is very edematous in these extremities you want to know that that skin is very fragile and that can easily break down. So you want to reposition these extremities and keep them dry and clean. I is for intake and output strict measurements. So you want to know everything that patient is taking in not only orally but through their IV flushes, anything you give that patient, and exactly what they're putting out. This is a very important measurement because one reason is you're giving them diuretics and you want to make sure that they're putting out enough urine because if they're not, we may be over diuresing them and they're starting to get kidney problems. And then we want to make sure that the patient's just not taking in too much fluid. So it's really counteracting what we're doing. And then lastly is in for sodium level monitored along with other electrolytes because we can again throw these patients into electrolyte imbalances. Our sodium could be naturally diluted because of the fluid volume overload and we want to make sure it doesn't get too severe or they're going into hyponatremia. Plus we're going to be giving them diuretics, for instance like loop diuretics, and these like to waste potassium. So we want to make sure that they're not experiencing hypokalemia. Okay, so that wraps up this video over fluid volume excess. And if you'd like to watch more videos in this series, you can access the link in the YouTube description below.

So with fluid volume overload, where is all this fluid hanging out? Well, whenever the system becomes overloaded, this fluid likes to go into the different fluid compartments we have in our body. So let's quickly review those fluid compartments.

So the first fluid compartment we have is called the intracellular compartment. And this is the fluid found inside of the cell. And there's actually a lot of fluid inside the cell.

It accounts for two thirds of our body water. Then we have the extracellular compartment. And this is the fluid outside of the cell and accounts for about one third of our body water. And we can take that extracellular compartment and divide it into other sections. For instance, part of the extracellular compartment is the interstitial compartment.

And this is the fluid that is found around those cells. So outside of the cells in between them, then we have the intravascular compartment, and this is our blood plasma. As nurses, we access this compartment a lot.

Whenever we're starting IVs, we are getting access to this compartment. And many times the reason we're even accessing this intravascular compartment. is because we need to give them fluids. And then there's another part of the extracellular compartment known as the transcellular. And this is the smallest part of all the extracellular compartments.

And it's the fluid that is found around certain joints and certain organs in our body like the heart and the lungs and all of these compartments are really interconnected they work together because they can shift fluid around as needed to help correct certain problems and they do this through various processes with one process being osmosis and osmosis is highly influenced by the osmolarity hence the solute concentration of a fluid and what happens in osmosis is that water is going to move from a fluid that has a low osmolarity hence a low concentration of solutes, to a fluid that has a higher concentration of solutes, hence a higher osmolarity. So depending on where those solutes are hanging out will depend on where that fluid is going to move. And these are all important concepts that you want to be familiar with to help you understand the different types or causes of fluid volume overload.

So there are three types of fluid volume overload. We have hypertonic, hypotonic, and isotonic. So first, let's talk about hypertonic fluid volume overload.

With this type of overload, there's going to be the movement of water from the intracellular compartment to the extracellular compartment. And this happens due to an increase of osmolarity, hence the solute concentration in the extracellular compartment. which cause fluid, hence our water, to move from that intracellular compartment to the extracellular compartment. So we're going to have an increased amount of water here in this extracellular compartment.

Now when you're trying to think of the causes of this type of overload, think of causes where we're introducing something in the body that has a high concentration of solutes, hence a high osmolarity. And this would happen if the patient ingested too much sodium. Because remember, water loves sodium.

And whenever we have a lot of sodium on board in the body, water just flows to it. And whenever it flows to it, we're going to increase our fluid volume. In addition, excessive administration of hypertonic IV solutions can do this as well. Because what's happening is that we're administering these high osmolarity fluids, hence they have a high solute concentration to that intravascular space. which is part of the extracellular compartment.

And it's going to cause water to be pulled from the intracellular space, the inside of the cell. It's going to shrink it down, but that fluid's going to go somewhere and it's going to go into the extracellular space. And we're going to overload that compartment.

Then another type of overload is called hypotonic fluid volume overload. And this is also sometimes referred to as water intoxication. Therefore, we're increasing body water, but not osmolarity. We're actually going to dilute the solutes.

And with this, we're going to have the movement of water from the extracellular space to the intercellular space. So you're going to have an intercellular compartment that's going to become overloaded along with the extracellular compartment. So both compartments. And when you're trying to think of the causes of this, think of causes where free water is just being introduced into the body. One way is through excessive intake of free water orally.

And a condition that can cause this is known as priming. polydipsia and this is where the patient has a very strong compulsion to just drink water over and over. So as they introduce all this water into their system they become water intoxicated and it will water down the extracellular compartment hence changing its osmolarity which is going to according to osmosis pull water into the intracellular compartment. which will overload it as well. SIADH can also cause this as well.

And this stands for syndrome of inappropriate antidiuretic hormone. And this is where there's too much antidiuretic hormone being released. And antidiuretic hormone is also referred to as ADH. And whenever we have too much ADH on board, what happens is that we are retaining way too much water in our body. And we're going to have this same concept happen.

We're going to have fluid volume overload. We're going to dilute everything really, especially sodium in the extracellular compartment. And then lastly, we have isotonic fluid volume overload. And this is sometimes referred to as hypervolemia.

This is a very common type of overload that we see in patients. And with this, there is no movement of water between those compartments like how we had with the other two because osmolarity is equal. Remember, iso means equal. So we're not going to have the shifting of this fluid.

But we're going to have the overload of the extracellular compartment because we can have problems with major organs in our body that normally help us regulate our fluid volume. For instance, if we have heart failure or kidney failure, it can lead to this type of overload. or if we administer too much isotonic IV solutions to the patient, we can overload the cellular compartment.

In addition, over usage of corticosteroids can lead to this because corticosteroids cause our body to retain sodium and water. Now let's talk about the signs and symptoms of fluid volume overload. So to help you truly understand what you're going to be seeing in your patient, you need to think about what is going on with my patient.

Well, we've already established that the patient is overloaded with fluid in their body fluid compartments, and they are just oversaturated with fluid from head to toe. So signs and symptoms are going to be based on how they're affecting that certain body system. So first, let's start with our head, the neuro part.

So from a neuro standpoint, you want to monitor for brain swelling, because what happens is that those cells that make up your brain can start to expand and swell. And this can lead to mental status changes. And that is actually one of the earliest signs and symptoms that your patient is experiencing.

brain swelling. So be monitoring for confusion. In addition, what can happen is that your patient can experience a headache or pressure in the head from that fluid overload.

Now let's move down to the cardiovascular system. So this system has a lot of fluid in it and it can become overwhelmed quite easily. And how I like to think of this system being affected is the same concept with a water hose. So your water hose is like your vessels in your body.

And if we have a lot of water connected to that water hose, there's going to be a lot of pressure in it and almost the same is true for your body if you have a lot of fluid in that system you're going to have a very strong bounding pulse whenever you go to fill the patient's pulses because we have a lot of fluid in there they are going to have a high blood pressure so hypertension in addition their jugular veins are going to be distended so they could have JVD which is known as jugular venous distension and they can experience sinus tachycardia Then we can move out from this system to the respiratory system and our lungs can be majorly affected, especially depending on how severe the fluid volume overload is because then fluid can start to leak into our lungs and cause pulmonary edema. So you may see that the patient has shortness of breath with any simple activity. They're having difficulty breathing.

You could also hear crackles in their lungs whenever you listen to them and here's an example of what crackles may sound like. In addition, the respiratory rate can be increased and they can have this dry hacking cough. Now, this cough can actually become productive. And if it becomes productive, this is a really bad sign. Whenever they start to cough, it will be this like foamy, frothy, blood-tinged sputum.

That tells you that you need to get your patient treatment immediately because they're experiencing like flash pulmonary edema. And then we start to see signs and symptoms peripherally where we're going to see swelling and edema in the upper and lower extremities. And this edema can actually pit whenever you touch it, which we're going to go over here in a moment in nursing interventions.

The skin will also feel cool to the touch because it can be so swollen that will diminish blood return, causing it to feel cool. And the outer skin will feel cool. Abdomen can be swollen which we term ascites because fluid can back up into our liver veins which can cause congestion.

In addition, the patient can have nausea where there's just so much pressure in the belly and the patient is going to have weight gain. And one thing you want to remember about weight gain that's helpful, especially whenever you're monitoring the patient, seeing how much fluid they're losing, is that one kilogram, which is 2.2 pounds, is equal to about one liter of fluid. So whenever we're diuresing them, we definitely want to monitor their weight.

But whenever they're having fluid volume overload, weight gain is one of those signs and symptoms they can experience. Now let's talk about labs and diagnostics. What are you going to see as a nurse whenever your patient has fluid volume overload?

So remember, your patient has a lot of fluid in their body. So if we have a lot of fluid and other fluids of the body, what is it going to do to the concentration of electrolytes? or other important things in that blood, it's going to dilute it. So it's going to decrease it. When we go and get our reports back, we're going to see that certain labs are going to be decreased.

And the reason they're decreased is because we have way too much fluid watering down that blood and that urine. So remember, everything is going to be diluted, which starts with a D and everything is going to be decreased. So when we look at the patient's hemoglobin and hematocrit, it will be decreased. When we check the patient's sodium level, it will be decreased.

It can be less than 135 milliequivalents per liter. In addition, there'll be you in along with a decreased serum osmolality. And this is the concentration of substances in the blood. So because we have so much fluid in there, it's going to be diluted. And when we check the urine, there's going to be a decreased urine specific gravity and osmolality test.

And these look and measure the solute concentration in the urine. The urine specific gravity actually looks at the number and size of them and the osmolality looks at the number of them, the electrolytes. So again, it's fluid and it's going to be low. Now if the patient has a really severe case of fluid volume overload, we can look at a chest x-ray and we could see pulmonary edema where there's fluid in those lungs.

Now let's talk about nursing interventions. So treatment goals revolve around removing this extra fluid from the patient, but we don't want to remove too much fluid from the patient because if we do, we're going to flip them into fluid volume deficit and we don't want them to go there. Plus, we don't want to remove too many electrolytes because we're going to be giving them diuretics and other things which could throw off our electrolyte balance.

So as a nurse, we're going to play a vital role in helping administer treatments that removes this fluid. But we also got to monitor those body systems. How are they responding to us removing all this fluid?

and make sure that their electrolytes are staying balanced. So what we're going to do is we're going to drain the water. So remember the word drain to help you remember all those nursing interventions for this patient. D is for diuretics. So diuretics are medications we can administer to the patient.

And what happens is it causes them to urinate a lot. And what they're going to do is they're going to urinate this extra fluid out. And there's a wide variety of diuretics that can be used. You can use loop diuretics, osmotics, or thiazides.

It really depends on the type of overload the patient is experiencing, their renal function, and the severity. R is for restrict fluids and sodium. So we don't want to be giving this patient all these fluids because it's literally going to counteract what we're trying to do for the patient. So they're going to be on some type of fluid restriction.

It can be anywhere between one to two liters of fluid. per day that they're restricted to. If your patient does have this, a lot of patients struggle with this, you just want to remind them why we're doing it and then help them develop a plan of how they can space out their fluid throughout the day if they can cognitively do this with you.

In addition, you want to restrict the sodium foods that they're consuming. So chances are they're going to be on a low sodium diet and again patients don't like this a lot of times because the food tastes bland but you want to explain to them why we're on this type of diet. because sodium loves water. Sodium and water go together and if we're just throwing in a bunch of sodium we're going to be pulling a lot of water and we're not really solving our problem of fluid volume overload. A is for assess daily weight and assessing a patient's weight is actually a great way to monitor their fluid status.

So again remember as you're weighing this patient you need to be doing at the same time every day with the same scale so we can get the most accurate results. And we want to see how those weights are trending. We don't want our patient gaining more than two to three pounds in a 24 hour period, because that tells us what we're doing is not working.

They're actually gaining fluid. And again, you just want to remember that concept. One kilogram, which is equal to 2.2 pounds equals one liter of fluid.

fluid. So if your patient's losing one kilogram, hey, you've removed around one liter of fluid. And you also want to routinely be checking their edema. Is it decreasing? So many of these patients are going to have pitting edema and you want to grade it.

And it's helpful to use the lower leg and press over the fibula or tibia region. And here is a little guide to help you grade it. One plus is like two millimeters of pitting. Two plus would be four millimeters of pitting. 3 plus is 6 millimeters of pitting and then 4 plus which is pretty significant is about 8 millimeters of pitting.

And if your patient is very edematous in these extremities you want to know that that skin is very fragile and that can easily break down. So you want to reposition these extremities and keep them dry and clean. I is for intake and output strict measurements. So you want to know everything that patient is taking in not only orally but through their IV flushes, anything you give that patient, and exactly what they're putting out. This is a very important measurement because one reason is you're giving them diuretics and you want to make sure that they're putting out enough urine because if they're not, we may be over diuresing them and they're starting to get kidney problems.

And then we want to make sure that the patient's just not taking in too much fluid. So it's really counteracting what we're doing. And then lastly is in for sodium level monitored along with other electrolytes because we can again throw these patients into electrolyte imbalances. Our sodium could be naturally diluted because of the fluid volume overload and we want to make sure it doesn't get too severe or they're going into hyponatremia.

Plus we're going to be giving them diuretics, for instance like loop diuretics, and these like to waste potassium. So we want to make sure that they're not experiencing hypokalemia. Okay, so that wraps up this video over fluid volume excess. And if you'd like to watch more videos in this series, you can access the link in the YouTube description below.

Transcript for:Understanding Fluid Volume Excess and Management

Transcript for:
Understanding Fluid Volume Excess and Management