Exam 1: Fluid Balance And Imbalance Flashcards
Maintaining Water Balance: Increased requirements in
- Fever
- V/D
- Diabetes Insipidus
- DKA
- Burns, Shock, Tachypnea
- Warmer/Phototherapy
Maintaining Water Balance: Decreased requirements in
- Congestive HF
- SIADH
- Mechanical ventilation
- Increased ICP
- Post-Op
Fluid Balance/Imbalance: Differences in Children
- Infants and young children have greater need for water.
- Water and electrolyte disturbances occurs more frequently, more rapidly and adjust less promptly.
- Metabolism is higher -> higher rate of peristalsis.
- Kidney function is immature.
Dehydration
Whenever the total output of fluids exceeds the total intake.
What should the nurse monitor for dehydration?
- Monitor I&O closely: 1 g wet diaper = 1 mL urine
- Calculate fluid requirements! 100, 50, 20 rule.
What are types of dehydration?
- Isotonic
- Hypotonic
- Hypertonic
Isotonic Dehydration**
- Most common
- Reduces circulating blood volume
- Shock is the greatest threat to life.
What are clinical manifestations of dehydration?
- No tears >3 months old**
- Tachycardia
- Dry mucous membranes
- Sunken eyes
- Sunken fontanel → anterior fontanel closes at 18 mo
- Loss of skin elasticity
- Prolonged capillary refill
- Decrease to no urine output (elevated urine SG >1.020)
- SHOCK
Dehydration Symptoms: Shock
- Caused by severe depletion
- Preceded by tachycardia and signs of poor perfusion.
- BP alterations are a very late sign of shock
Mild Dehydration: Signs and Symptoms
- <5% weight loss
- Normal VS
- Well alert
- Moist mucus membranes
- Capillary refill <2 seconds
- UO slightly decreased
Management of Mild Dehydration
- Monitor amount of fluid lost
- Replace fluid orally: oral rehydration therapy aka pedialyte
- Continue age appropriate diet
Moderate Dehydration: Signs and Symptoms
- 5-10% weight loss
- Weak pulse, fast RR
- Fatigued, thirsty and eager to drink
- Dry mucus membranes/sunken fontanel
- Decreased skin turgor, prolonged capillary refill
- Decreased, concentrated urine
Management of Moderate Dehydration
- Oral rehydration solution; 50-100 ml/kg
- If can’t take oral, do IV bolus (20 ml/kg); evaluate after each bolus
- Can only bolus 3x’s max; After 3rd bolus give some sort of blood product.
- Resume age appropriate diet as soon as dehydration corrected.
Severe Dehydration: Signs and Symptoms
- > 10% weight loss
- Tachycardia (bradycardia more severe)
- Decreased BP; increased RR
- Lethargic
- Drinks poorly, unable to drink
- Absent tears
- Minimal UO
- Depressed fontanel
Management of Severe Dehydration
- IV therapy
- Bolus 20 ml/kg or NS or LR
- Evaluate after each bolus
- If able, also take oral rehydration
How can you calculate percentage of weight loss?
- Old weight minus new weight
- Divide answer by old weight
- Multiply by 100
Dehydration Management: What should not be given?
- Sports drinks make diarrhea worse, especially in children
- Do not give large amounts of water alone
- Do not give potassium if UO is not appropriate for age.
Dehydration Treatment
- PO Replacement (if alert and awake): replacement of fluid loss over 4-6 hours with oral rehydration solution (i.e pedialyte)
- IV Rehydration (if unable to drink or drink adequate amounts): Administer isotonic solution (i.e 0.9% NS or LR)
Dehydration: Administration of IV Bolus
- 20 ml/kg per bolus**
- Can only give 3 bolus because if you give a whole bunch of fluid, you are diluting the blood o oxygen rate will be low and pulse ox will go down.
- Will give blood after 3 bolus
Urine Output by Age: Infant and Toddlers
> 2-3 ml/kg/hr
Urine Output by Age: Preschool and Young school-age
> 1-2 ml/kg/hr
Urine Output by Age: School-age and Adolescent
0.5-1ml/kg/hr
Dehydration Management: What is particularly important to assess?
- I&O, UO, V.S.
- Daily weight
- Stools, Vomiting
- Sweating, behaviors
- Serum electrolytes
- Skin, mucus membranes, tears
- Anterior fontanel
Water Intoxication
- Occurs less frequently than dehydration
- May occur after ingestion of large amounts of fluid.
- Decrease in serum sodium leads to CNS symptoms
- Could cause death
Symptoms of Water Intoxication
- Increased urinary output
- Irritable
- Headache
- Vomiting/diarrhea
- Seizures
Causes of Water Intoxication Include
- Outdoor activities
- Alteration in formula preparation in infants
- Excessive water ingestion
- Tap water enemas
Types of IV Access Include
- Peripheral IV
- Central Lines
Central Line IV’s include
- PICC line
- Short-term Central Venous Catheter
- Broviac
- Portacath
Peripheral IV Guidelines
- Using a light to visualize the vein can be helpful
- Secure the IV site
- Keep fingers/toes accessible to check capillary refill
- Do not attach ID Band to the same extremities as IV (could act as a tourniquette)
How often should you check IV site?
Minimum q2h
How can you secure the peripheral IV site?
A “pillow” will help secure the site and keep it flat/straight, but only if needed.
What are the preferred peripheral IV sites?
…
Central Line
- Utilized for long term access
- Surgically placed
- An order is needed to discontinue
What is the most common complication of central line IV’s?
Blood stream infections
Management for Central Line IV’s
Dressing must be changed weekly.
PICC Line
- Done in arms and legs (NICU)
- NOT sutured in so be careful with dressing changes!
Short-term Central Venous Catheter
- Neck or groin area
- 1-3 lumens
- Big catheter
Central IV: Broviac
- Comes out of the center of the chest
- Long term
- Surgical placed above heart on center of chest.
- Used for patients on TPN all the time.
What is important to remember about a Broviac IV line?
- Needs dressing on it so patient isn’t breathing on it.
- Needs to always be covered/sealed; needs to remain sterile!
- Sterile procedure to change the dressing
Central IV: Portcath
- Surgically placed under skin
- 1-2 lumens
- For chemotherapy and sickle cell therapy.
