F&E and Respiratory Flashcards
What is the difference between dehydration and volume depletion?
Dehydration: Hypernatremia with water loss (losing water as sodium rises)
Volume depletion: Isotonic loss - water and sodium are lost equally
What is TBW mad up of?
Intracellular and extracellular fluids
What are intracellular fluids
Fluids in the cell
Remain constants at 35% throughout lifespan
No easily affected by fluid shifts
What are extracellular fluids? Are they affect by fluid shifts?
Intravascular plasma, cerebrospinal fluid, digestive secretions, pleural and pericardial fluids, synovial fluids, interstitial spaces, lymph fluids, collagen
Change throughout lfiespan
Susceptible to fluid shifts
When does the distribution of TBW become normal?
around 5 years old
What is the difference between the distribution of fluids in children under 5 and those over 5?
Under 5: More volume in the extracellular so unstable and can shift rapidly with changes in either metabolic or environmental facts causing F&E imbalances
Over 5: More volume in intracellular so their fluid is more stable
What is TBW maintained at? How do I&Os affect this? What is the percent of oral intake?
TBW is maintained at 0.2% of body weight over a 24 hour period
Intake should equal output
About 70% of intake is orally
What is the insensible water loss of an infant?
20-30%
What are pediatric risk factors for fluid and electrolyte imbalances?
Increase ECF –> rapid fluid shifts
Increased ISW loss –> rapid fluid shifts
Immature kidneys
Immature immune system
Cant express thirst (infant/toddlers, developmentally delayed)
What are examples of ISW loss that increase the risk for F&E imbalances?
Increase BSA vs. Wt
Increased metabolic demands
Inpatient interventions (suctioning, hyperventilation d/t inaccurate vent settings, radiant warmers, phototherapy)
How do immature kidneys put a child at increased risk of F&E imbalances?
Kidneys do not respond to ADH or aldosterone so they are unable to adjust to fluid shifts
Cant concentrate urine/acidify urine
How do immature immune system put a child at increased risk of F&E imbalances?
Fevers
React to any type of sickness with a high fever –> metabolic demands, transepidermal fluid loss, insensible fluid loss
What is shock?
condition that peripheral tissues and end organs (kidney, brain, skin, GI tract) do not receive adequate oxygen and nutrients
A child with fluid loss could lead to..
hypovolemic shock
What is the clinical assessment of mild (less than 5%) of body weight fluid loss?
Normal VS
Active and well appearing
Mildly decrease UO
Moist MM, AF flat, has tears, eyes not sunken
Cap refill and turgor are normal
No thirst
What is the clinical assessment of moderate (5-10%) of body weight fluid loss? (9)
VS slight increased
Irritable but consolable
Abnormal skin turgor
Cool extremities
Decrease UO/concentrated UA
Sunken eyes, decrease tears, dry MM
Depressed anterior fontanel
Cap refill 2-4 seconds
Thirsty
What is the clinical assessment of severe (over 10%) of body weight fluid loss? (11)
HR tachy to Brady
Thready pulse
Hypotension (late)
RR deep and rapid
Obtunded/coma
Cold, mottled extremities
Cap refill over 4 seconds
Oliguria/anuria
AF markedly depressed
MM parched, no tears
Skin tenting
What is the minimum UO for under 3? 3-10? over 10?
Under 3: 2-3mL/kg/hr
3-10 years: 1-2 mL/kg/hr
Over 10: 0.5-1 ml/kg/hr
Why do we expect more UO in infants/under 2
Can’t concentrate urine so still urinating despite volume depletion therefore UO is not on PEWS and is a late indicator
Why are tears not an accurate indicator of hydration in infants?
Tears do not form until 6 months old
What is AKI define by?
less than 1 mL/kg/hr
IV fluid resuscitation is indicated in..
Moderate to severe dehydration
How is IVF resuscitation given?
Given via two phases
What is phase one of IVF
Restores intravascular volume to prevent hypovolemic shock
Rapid and agressive
Initial bolus 20mL/kg of isotonic fluid (0.9% NS or LR) over 5-20 minutes
How often should you assess after a bolus for phase one IVF resuscitation? Can you repeat?
Assess s/s of hydration and improvement after each bolus hourly
Can be repeated based on % of BW loss
What is phase two of IVF
Ongoing deficit replacement
Routine and less urgent
4-2-1 fluid calculation rules of ongoing losses
When is oral rehydration solutions indicated?
Mild to moderate dehydration
What is ORS? How can it be given?
Balanced F&E drinks for infants
Orally, Gtube or NG tube
What is phase one in ORS? Phase 2?
Phase 1: 50-100 mL/kg bolus
Phase 2: ORS after each stool 60-240mL based on weight. Should do small sips 5mL (teaspoon) every 2-5 minutes so that the stomach is able to handle it and not cause vomitting
Should you continue breast milk/formula with ORS? Should you dilute?
Yes you should
Alternate between formula/breast milk and ORS
DO NOT dilute milk with ORS because it is usually done incorrectly and can cause hypoNa or HyperNa seizures
What is appropriate oral rehydration for a 12 month old? Why?
Pedilyte
Infalyte
Both electrolyte balanced
What oral rehydration is inappropriate? Why?
Gatorade and apple juice is high in carbs/sugar which can cause an osmotic effect –> diarrhea
Water and juice have no electrolytes so not replacing sodium
Milk - lactose which can trigger diarrhea
What are gastroenteritis considerations?
- Implement transmission based precautions
- Assess and monitor F&E with strict I&Os, labs PEWS, daily weights
- Maintain fluid balance - don’t want to fall behind so stay on top of fluid losses and adjust accordingly
- IV assessment every hour for complications
- Avoid food and drinks high in sugar, avoid greasy foods, ORS
- Probiotic: lactobacillus
- Avoid pesto/immodium/ASA/NSAID
Why do you use a probiotic in patient with gastroenteritis?
To restore normal GI flora
Why do you avoid pepto/immodium in patients with gastroenteritis
These medications slow down the transit of stools and the most common cause of diarrhea in children is infections so want to get it out of the body not slow it down
What do popcorn and balloons have in common?
They are the leading cause of choking in children
What is a childs airway like?
SMALL
Size of a straw
Can easily be obstructed
What is the alveolar development in a child? When is it fully developed?
Lack surfactant
Poor alveolar compliance (especially before 34 weeks old)
Ari trapping
3-8 years fully developed
What are children’s respiratory muscles like?
Weak
Fatigue easily
Poor reserves
Accessory muscle use
Why does small airway, undeveloped alveoli and weak respiratory muscles matter?
Increases the risk of obstruction and aspiration especially with foreign objects, edema, and mucus
Wheeze b/c you are able to hear more since less fat, CT and muscle
Increased use of accessory muscles
Fatigue easily –> Resp failure
Air trapping d/t poor alveolar compliance (barrel chested)
What are upper respiratory disease? What is the problem they cause?
Croup
Epiglottis
Tonsilitis
Choking
Airway obstruction
What are lower respiratory diseases? What is the problem that they cause?
Pertussis
Bronchiolitis (RSV) - pneumonia
Chronic lung diseases like cystic fibrosis and asthma
How do you prevent respiratory diseases?
Vaccines
Avoid second hand smoke
What is the defining point between upper and lower respiratory disease?
Trachea
What is included in the basic respiratory assessment?
Rate
Effort (retractions, depth of resp, position)
Air movement (coughing??)
Breath sounds - upper vs. lower
Need for oxygen
What does positioning look like for a child that is experiencing respiratory distress?
Tripod position
Leaning on hands, mouth open, almost looks like sniffing
What are signs of early respiratory distress?
Increase RR
Wheezing
Coarse respirations
What are signs of moderate (9)
Retractions
Grunting
Wheezing
Irritability/anxiety
Tachycardia
Tachypnea
HTN
Orthopnea
Nasal flaring
What are signs of severe respiratory distress? (9)
Bradycardia
Hypotension
Decrease RR
Quiet chest
Cyanosis
Stupor
Coma
See raw chest
Tripod positioning
Why is a quiet chest not a good sign?
Misleading b/c think they are getting better but it is really quiet because there is no movement of air
What retractions are mild?
Isolated substernal and subcostal retractions
What retractions are moderate?
Substernal and subcostal retractions
Suprasternal and supraclavicular retractions
What retractions are severe?
Substernal and subcostal retractions
Suprasternal and supraclavicular retractions
Use of accessory muscles in neck
Sternal retractions
What is epiglottitis caused by? Is it serious?
Bacterial - haemophilus influenza
LIFE THREATENING
On assessment of epiglottitis what would you expect?
4 D’s
Dyspnea
Dysphagia
Drooling
Distress
Tripod
Inspiratory strider
Sore throat
High fever
What should you not assess with epiglottitis?
DO NOT assess oropharynx
What is the treatment for epiglottitis?
Urgent intubation
IV antibiotics
IVF
HIB vaccination
What is croup caused by? What does it affect? Treatment?
Viral
Larynx/trachea
Usually self limiting
What would you expect to see on assessment of a patient with croup?
Barky cough
Worse at night
What is the treatment for croup?
Symptomatic treatment
Cool humidified air
Racemic epinephrine
Dexamethasone
IVF
What is bronchiolitis caused by? Who is at high risk? Is hospitalization required?
Viral infection < 2 years
80% respiratory syncytial virus (RSV)
Preemies high risk for hospitalization
Under 2 months routinely hospitalized
How is bronchiolitis transmitted? Is it a seasonal disease?
Droplet b/c very contagious
Winter and spring
Is pertussis preventable? How?
YES
Tdap vaccine
What does upper airway disease cause? What is the goal for treatment?
Ineffectively airway clearance
Goal is to clear the airway
What does a lower airway disease cause? What is the goal for treatment?
Impaired gas exchange
Goal is to optimize gas exchange
What is a common complication of both upper and lower respiratory disease? Why?
Fluid volume deficit
Especially if it is infectious and causes a fever which leads to ISWL
What are common respiratory interventions for both upper and lower respiratory diseases?
- Reassess every 1-4 hours
- Conserve energy by clustering care and small/frequent feeds
- Oxygen
- Suctioning
- IVF
- Strict I&Os
- Infection control w/ precautions
- Medications (antibiotics/antivirals, inhalers/nebulizers, steroids)
- Evaluate for improvement
What is asthma? What causes it? What do you hear?
Inflammation of the airways
Caused by environmental triggers, URIs
Silent chest (not moving air)
What is the treatment for asthma? How do you prevent it?
Treated with SABA
Prevent with an asthma action plan, avoiding triggers, and vaccines (annual flu)
What is cystic fibrosis?
Genetic autosomal recessive disorder
Causes excessive loss of NaCl due to a defect in Cl receptors
Slaty skin
Thick/dehydrated secretions
Who does cystic fibrosis commonly affect?
Caucasian males
How do you diagnose CF?
Sweat test
What happens to the lungs with CF?
- Airway obstruction (mucus)
- Chronic infection
- Chronic inflammation
- Impaired gas exchange
- Fibrosis
What are major clinical s/s of CF?
Salty tasting skin
Chronic respiratory problems
Lung infections
Poor growth/weight loss
Meconium ileus
Chronic obstructions in GI d/t mucus
Issue w/ gaining weight
Delayed puberty
What respiratory care should patients with CF have?
Oxygen
Mobilize secretions (vibration or percussion)
Prevent infections with meticulous hand hygiene and vaccines
Treat infections early with nebs, mucolytics, hydration, O2, antibiotics based on cultures
Know baseline cough
What should the diet and exercise for a patient with CF look like?
High fat, High protein
Supplemental enzymes w/ meals
High salt and adequate hydration
Exercise balanced with rest
What organ systems could you see complications in with a patient with CF?
Cardiac
Endocrine
GI complications
How should a patient with CF get airway clearance?
Increase pressure
Huff cough
TID - QID
Postural drainage
Does O2 requires an order?
Yes, considered a medicine
What are the types of oxygen devices? What are the allowed LPM?
NC
- 2L for infants
- 4L small children
Mask: over 6L to clear CO@ (10-15L), needed for higher flow
Oxygen hood for infants that need high flow
CPAP
What are two non-invasive ways to assess O2?
Pulse ox
End tidal CO2 - attached to nasal prongs
What is an invasive way to assess O2? What can this also assess?
Atrial blood gas
Acid-base balance
What is the goal for pulse ox? What conditions can it not be used in?
90-95% based on their baseline
95% for completely healthy
Cant be used with cardiac child that normally has decreased distal perfusion and CF (clammy skin)
How long does it take for bronchiolitis to resolve?
can take 2 weeks
What is the treatment for bronchiolitis?
Treat the s/s
When can an infant be vaccinated against pertussis?
at 2 months
What is an OK SpO2 for children?
88-100
Why are you extra worried about ISWL in children that have respiratory diseases?
B/C there breath so fast which increases their ISWL
Should you suction before or acter the patient eats?
before
What are medications like antibiotics/antivirals, inhalers/nebulizers and steroids be used for?
Chronic conditions
What are the s/s of hypernatermia?
Na above 150
THIRST
Flushed
Oliguria
CNS alterations
What are the s/s of hyperkalemia?
K+ above 5.5-6
Cardiac arrhythmia/arrest
Often asymp
What are the s/s of hyponatremia?
Na less than 130
Cool
Clammy
Irritable
Weak
N/V
Hypotension
What are the s/s of hypokalemia?
K+ less than 3
Muscle weakness
Cramps
N/V
Hypotension
How do you are for an IV site in an child/infants?
Touch to IV section to see if it is soft, warm, dry and pain free
Look to see if the IV insertion site is dry and without redness
Compare the IV insertion site with the opposite extremity to look for swelling
What will you determine if ORS is working?
Focused perfusion and hydration assessment after every bolus
UOP increases/returns to normal
PEW score normalizes
Daily weight returns to baseline
Strict I&O
