Exam 2: Fluids and Electrolytes Flashcards
Sources of Fluid (3)
- Insensible losses
- Urinary
- Fecal
Insensible Losses
2/3rd through skin and 1/3rd through respiratory tract
Things that increase insensible loss include:
1. Increased RR
- High Fever; children can get ~105 fever, which doesn’t usually happen with adults
- Heat and humidity; In the summer, they have a higher risk of losing fluids than adults
Major Fluid Compartments (2)
- Intracellular (fluid inside cell)
- Extracellular (fluid outside cell)
A. Intravascular fluid
B. Interstitial fluid
Fluid Loss in Neonates and Young Children (6)
- Greater amount of BSA causes ↑ in insensible losses
* *This is because they have a greater proportion of their skin surface that occupies their weight
* *This increases their insensible losses
* *Child more likely to loose ECF first with fluid loss - Increased metabolic rate - ↑ fluid demand to fuel metabolic process (Due to increased demand for growth)
- Greater amount of metabolic wastes to be excreted by kidneys (Due to increase in metabolic demand)
- Glomeruli tubules & nephrons of kidney are immature & unable to conserve H2O/fluids and electrolytes effectively
- Much easier to have fluid and electrolyte loss
- Children maintain larger amounts of ECF until about 2 yrs. of age, so they are more susceptible to rapid fluid depletion
* *They have a larger proportion of their body that has fluid and it is extracellular fluid
H20 Compartment Components
75% in infants,
55-60% in adults
Under 2 years old you see that there is a larger TBW and greater proportion of ECF
Solute Compartment Components (in ECF and ICF)
ECF (Na+)
- *Main composition of ECF is Na
- *Other components in ECF: Cl-, Ca, Bicarbonate
ICF (K+)
- *Main composition of ICF is K
- *Other components: Ca, Mg, Phosphorus
Under 2 years old you see that there is a larger TBW and greater proportion of ECF
Daily Maintenance Fluid Requirements
These calculations tell us how much fluid children need to maintain their ECF:
- Weight. in kg.
- 100ml/kg for first 10 kg.
- 50ml/kg for second 10 kg.
- 20 ml/kg for remainder of wt in kg.
- Divide total amt. by 24 hrs. & obtain rate in ml/hr
- You can use this for IV fluid, oral intake, etc.
- Very imp. to ensure daily maintenance, especially in the hospital/if they are NPO
Urine Output in infants and toddlers
*Urine output can also help you see if child is dehydrated
Infants and toddlers: > 2-3ml/kg/hr
Urine Output in preschool and young school age
> 1-2ml/kg/hr
Urine Output in school age and adolescents
0.5-1ml/kg/hr
Dehydration
Classified according to serum Na+ concentration & osmolarity
*Need to know degree of child’s dehydration to dictate how and what to treat them with
Isotonic Dehydration (with causes)
Primary/most common form of dehydration in children
*When fluid and electrolyte losses are in equal proportion
Most common causes of isotonic dehydration:
- Diarrhea
- Vomiting
Fluid loss is mostly from the ECF
Greatest threat with Isotonic Dehydration
Shock/Hypovolemic shock
*would indicate there is decreased blood volume in circulation
Treatment for Mild/Moderate Isotonic Dehydration
Oral rehydration therapy (Pedialyte or Isolyte)
- This is for a child who is dehydrated and needs to be rehydrated
- Want to replace fluids and electrolytes balance while keeping their balance at an equilibrium
- Don’t give something with too much glucose, juice, salt, etc.
Serum Na level with Isotonic Dehydration
Serum Na+ (130 – 150 meq/l)
*This is a normal serum sodium because fluid and electrolyte loss is in equal proportion
Treatment for Severe Isotonic Dehydration
0.9%NS ISOTONIC IV SOLUTION
This will be for a child who is vomiting excessively and you can’t use oral rehydration
*Child will come into the hospital and get an isotonic IV solution, normally it will be 0.9%NS which is the safest for children who can’t tolerate oral rehydration
Hypotonic Dehydration (Hyponatremia) (with serum Na level)
- When electrolyte losses > H2O deficits (more water than solutes)
- ICF more concentrated than ECF
- Decreased osmolarity of blood
- Serum Na is
Causes of Hyponatremia
- Vomiting and/or Diarrhea
- Drinking a lot of water but not fluids with electrolytes in it
- *If a mother is bottle feeding, teach how to reconstitute formula adequately so that it doesn’t cause hyponatremia if there is too much water in it
- Syndrome of too much anti-diuretic hormone (SIADH)
SIADH
Syndrome of too much anti-diuertic hormone
- *Losing Na but retaining H2O
- *ADH is secreted from the pituitary, so a child may suffer from SIADH if they have a head trauma or tumor
- *Can also see it with bacterial meningitis or if patient is taking Lasix
- *If a child has these syndromes, know they are at risk for SIADH and they may need to get weighed everyday or have the sodium content in their urine checked each day
Symptoms of Hyponatremia (6)
- Headache
- Confusion
- Edema
- Hypertension
- Hyper-reflexia
- Elevated specific gravity of urine
Treatment for Minor/Moderate Hyponatremia
- Get electrolyte imbalance
- Cut back on water intake and replace with sodium
- Start correcting the imbalance with an isotonic solution
* *Always start with this because it is the safest for children
Treatment for Severe Hyponatremia
When Na level is less than 110 mEq/L
Use hypertonic solution (child will be in ICU)
*D5W, 0.5NS, or 10% Dextrose
Be very careful when infusing it and must gradually increase volume; too much too quickly can cause shrinkage of cells as extracellular fluid becomes too concentrated and then water leaves the cells to balance it
Hypertonic Dehydration (Hypernatremia) (with Na level)
- When fluid/H2O losses > electrolyte losses
- ECF more concentrated than ICF
- Serum Na >150 mEq/L
Causes of Hypernatremia (7)
- Diarrhea and vomiting
- Sweating
- Decrease in amount of ADH (Could occur if patient has diabetes insipidus)
- Extensive burns
- Inadequate fluid intake
- When a mother doesn’t reconstitute formula with enough fluid
- Diabetes
Treatment of Hypernatremia
1st: Start by giving isotonic solution to correct electrolyte imbalances
2nd: If this doesn’t work, then give hypotonic solution
* *Common hypotonic solution: .45NS
- *If you give too much of a hypotonic solution to someone with hypernatremia, the fluid goes into the intracellular space and the cells could swell and burst
- Signs and symptoms of this: neurological changes in the patient
Symptoms of Hypernatremia (8)
- Tenting of skin
- Sunken eyes or sunken fontanels
- Dry mucous membranes
- Flushed color to skin
- Tachycardia
- May have low grade fever
- Very thirsty
- Decrease in urine output
Caution when administering IV fluids
Always remember to be careful when giving hyper or hypotonic solution to balance loss of electrolytes or fluids; only use them when absolutely necessary and follow scheduling of infusion to prevent shrinkage or swelling of cells; kids should be in ICU with this
- Too much hypertonic solution when treating hyponatremia: causes cell shrinking (cardiovascular or neurological changes)
- Too much hypotonic solution when treating hypernatremia: causes cell swelling/bursting (neurological changes)
Hypokalemia
When Serum K is less than 3.5 mmol/L
Causes of Hypokalemia (3)
- Increased K excretion
- Decreased K intake
- Loss of K
Increased K excretion causes (2)
- Diuretics such as Lasix can cause this
2. Osmotic Diuresis with uncontrolled Type I diabetes
Decreased K intake causes (3)
- Anorexia Nervosa
- Let’s say a child was getting maintenance 0.9NS IV infusion b/c he is going to the OR and NPO… if they have been bumped and are not going to get surgery for another couple of hours, then they are at risk for developing hypokalemia (since they aren’t taking in anything)
- They are getting rid of potassium in their urine but they are not taking in any
Loss of K causes (3)
- Could be due to indwelling NG tube (Not NG tube for feeding)
* *These patients will usually have a maintenance IV to ensure they are replacing what they are losing from the NG tube - Vomiting
- Metabolic alkalosis
* *Metabolic alkalosis puts you at risk for hypokalemia because you have a lower amount of hydrogen ions; in order for the body to correct this, it tries to exchange potassium for hydrogen
* *Any potassium in extracellular fluid will go into intracellular space and hydrogen intracellularly goes extracellularly
* *When you measure the blood work, measure it extracellularly!!
Symptoms of Hypokalemia (7)
- Skeletal muscle weakness
- Leg cramps
- Decreased deep tendon reflexes
- Irregular, weak pulse
- Constipation
- Orthostatic hypotension
- At risk for Digoxin toxicity if they have low K+ levels
- -Dig toxicity signs: bradycardia, arrhythmias, vomiting
Treatment of Hypokalemia (3)
- Replacing Potassium
* *Encourage foods high in potassium
* *May use supplemental potassium (tastes very bad; kid may try and spit it out) - May need IV fluids
* *Can use IV replacement of Potassium AS LONG AS PATIENT HAS GOOD URINE OUTPUT - If patient has severely low K+ and is in the ICU for significant K+ replacement, you absolutely must make sure to monitor their heart/put them on a cardiac monitor because they are at risk for vtach
Hyperkalemia
When Serum K is over 5.8 mmol/l
Symptoms of Hyperkalemia (5)
- Abdominal cramping
- Diarrhea
- Nausea
- Irregular pulse and bradycardia
* *If patient is on telemetry, you may notice ELEVATED T WAVE with hyperkalemia - Muscle weakness, especially of the lower extremities
Causes of Hyperkalemia (5)
- Anything that causes massive cell death
- Excessive or too rapid K IV infusion
- Metabolic acidosis
- -This is why patients who go into DKA are at risk for hyperkalemia - Diabetes
- Decreased K+ excretion
* Mainly will be due to renal disease, dialysis, etc.
Common Childhood Causes of Massive Cell Death (4)
Hyperkalemia occurs with massive cell death because the potassium leaves the cell as cells die
- Crushing injury
- Sickle Cell Anemia
* *Normal RBC lifespan= 120 days
* *RBC lifespan with SCA= 10-20 days
* *Massive turnover of RBC puts them at risk - Chemotherapy
- Leukemia
* *Due to rapid turnover of WBC
Hyperkalemia Treatment (3)
Focus is to manage underlying condition
- Medications
- Peritoneal dialysis (if in end stage renal disease)
- Diet
* *Would need to eat a lot of potassium if it’s causing hyperkalemia
Medications to treat Hyperkalemia (4)
- K wasting diuretics
* *Lasix
* *Aldactone is K sparring - Kayexalate
* *Binds with potassium and is excreted in the stool - IV bicarbonate
- IV insulin
* *Driving glucose and potassium back into the cell
Diagnostic Evaluation of Dehydration: WEIGHT LOSS
Need to look at the type of dehydration and the degree of dehydration; one way to look at degree of dehydration is to look at the percent of weight loss the child has
5% = mild 10% = moderate 15% = severe
*To figure it out, calculate:
((original wt – present wt.) ÷ original wt.)
General Symptoms of Dehydration (9)
- Changing level of consciousness
- Response to stimuli
* *Can measure this by flicking the bottom of the foot, the patient should move their foot away when you do this - Decreased skin elasticity & turgor
* *Tenting is an indication of dehydration - Prolonged capillary refill (>3 seconds)
- Increased heart rate
* *Important because dehydration can cause decreased CO, so a compensation for this in children is for HR to increase - Sunken eyes & fontanels
- Dry mucus membranes
- Absent tears
- Decreased urine output
5% Dehydrated Symptoms
Include two of the following factors:
- Capillary refill > 2 seconds
- Absent tears
- Dry mucus membranes
- Ill appearance
Management of Dehydration (9)
- I and O
* *Assess urine output color, amount, frequency and document it
* *Asses and document stool output color, consistency, amount, frequency - Vital signs
* *May see an increase in temperature, HR, RR
* *BP will decrease - Skin/Good Skin care: cream or butt paste
* *Check for tenting, warmth, color
* *Frequent loose green stools will cause skin breakdowns there –> must protect this by putting a barrier on and maintaining good skin care
* *Green stool is very acidic and once skin breakdown starts, it is very difficult to reverse - Mucus membranes
- Maintain Body weight
- Fontanel
- Sensory
- Constantly checking to see any changes in LOC
Acute Diarrhea
- Most common cause in
Acute Diarrhea Causes (3)
- Antibiotics (encourage probiotic use)
- Acute infectious diarrhea (gastroenteritis= diarrhea due to an infection)
* Stomach virus
* Baterial organism such as salmonella
* Parasite such as cryptosporidium - Taking laxatives
* May happen with anorexia and trying to lose weight
Chronic Diarrhea Duration
Lasts over 14 days
Chronic Diarrhea Causes (5)
Causes are usually due to a chronic disease that causes chronic diarrhea
- Inflammatory bowel disease such as Crohn’s disease or ulcerative colitis
- Different malabsorption syndromes
A. Celiac disease
B. Cystic fibrosis - Food allergies
A. Lactose Intolerance - Immunodeficiency
- Not managing acute diarrhea properly
Intractable diarrhea of infancy
Chronic diarrhea in children that occurs in first few months of life
- Longer than 14 days
- Most common cause is acute infectious diarrhea that was not managed properly and has gone on for over 14 days
Chronic non-specific diarrhea (5)
- Most common cause of chronic diarrhea in children
- usually in children between 6-54 months
- Loose stools with undigested food particles ↑ 14 days
- Grow normally & not malnourished
- No blood in stool or infection
Causes of chronic non-specific diarrhea
Number one cause is 100% apple juice!
**Apple juice needs to be diluted
In teenagers it could be caused by drinking a lot of diet soda, such as TAB
Etiology of Diarrhea (4 and organism types)
- Fecal - oral route
- Contaminated food or water
- Organisms
- -Viral (Rotavirus)
- - Bacterial (Salmonella, Shigella, Campylobacter)
- -Parasite (Cryptosporidium) - Antibiotics (Prevention: probiotics)
Diagnosing Diarrhea and Dehydration
- History (need to ask pertinent questions such as travel, GI problems, diet, close proximity to illness, etc.)
- Lab data – do stool specimens to check for a specific organism
- Urine specific gravity
* *Tells you what type of dehydration it is
* *Generally the more concentrated = the greater the dehydration - CBC, serum electrolytes, creatinine, BUN
* *Creatinine and BUN elevate with dehydration
Rehydration therapy management for patient with v/d
Oral rehydration therapy
- Give about 5-10cc (1-2 tsp) every 10 minutes
- Give small, frequent amounts
Breastfeeding mothers management of dehydrated baby
Continue breastfeeding and alternate with pedialyte
- Need to know how many wet diapers the baby is having per day and how much urine output there is
- -Change diaper every 2 hours and check for good urine
- -If there is a dry diaper 6 hours, 8 hours, etc. then the baby needs to come into the hospital because oral rehydration won’t work
Bottle feeding mothers management of dehydrated baby
Discontinue breastfeeding and only give pedialyte
- Progressively increase dilution concentration of formula as baby gets better over time
- Keep an eye on urine output and stools
- Need to know how many wet diapers the baby is having per day and how much urine output there is
- -Change diaper every 2 hours and check for good urine
- -If there is a dry diaper 6 hours, 8 hours, etc. then the baby needs to come into the hospital because oral rehydration won’t work
Rehydration management of dehydrated toddler
Discontinue food and only give pedialyte
*Once toddler is getting better, can begin to slowly reintroduce adequate diet and see how they tolerate it
Introducing foods to previously dehydrated child
- Start with low fat meat (chicken, fish) and nothing with sugar
- Rice
- Cooked vegetables
- Give small amounts to see how they tolerate it
*No more BRAT diet!
Nursing Care of Dehydration (6)
- Implementation & education regarding oral rehydration
- Accurate weight
- Monitor IandO
* **Urine output must be sufficient to add K+ to IV solution - Skin care
- Prevention
- Full Assessment
