fluid, electrolyte, acid base balance (1) Flashcards
what fraction of total body water is extracellular and what fraction is intracellular?
1/3 is extracellular
2/3 is intracellular
What are the two types of extracellular fluid
intravascular and interstitial
What type of extracellular fluid is in blood vessels
intravascular
what makes pediatrics more vulnerable to dehydration?
- High daily food requirement with little fluid volume reserve
- small stomach size
- more dependent on intake, lose greater proportion of fluid
children of which age have greater body surface area, more skin surface
infants and children under two years old.
Why does having a greater body surface area increase dehydration
there is greater insensible water loss through the skin, can’t be measured
Describe respiratory and metabolic rates in childhood
- high during early childhood
- Greater water loss from the lungs
- Greater water demands to fuel the body’s metabolic processes
What parts of the kidney are immature under two years old
glomeruli, tubules, and nephrons
why do pediatric kidneys lead to increased dehydration
- unable to conserve or excrete water and solute effectively
- More water is excreted
- Difficulty regulating electrolytes
what is the term for dehydration?
Extracellular fluid volume deficit
What is extracellular fluid volume defecit, dehydration, usually caused by
The loss of sodium containing fluid from the body
what kind of fluid lack is dehydration
not enough extra cellular fluid, intravascular and interstitial
What are sodium levels like during extracellular fluid volume deficit
can be normal, low, or high depending on the cause
what are the physical causes of extracellular fluid volume deficit
prolong vomiting and diarrhea!, nasogastric suction, hemorrhage and burns
what is the leading cause of death among children less than three years old
Dehydration
what days during dehydration have the highest loss of extracellular fluid
First 3 days
What are symptoms of mild dehydration?
- Hard to detect
- Infants may be irritable
- older children are thirsty
- moist mucous membranes
- No vital sign changes
What is the main indicator of mild dehydration
Up to 5% weight loss
What are signs of moderate dehydration
- drive mucus membranes
- flirt, thirsty, restless
- anterior fontanel sunken
- Cap refill >3 sec
- Poor turgor
- Eyes sunken
- urine output less than one milliliter / kilogram / hour, dark color
what percent of weight loss is during moderate dehydration
6 to 9%
what are vital sign changes during dehydration
- blood pressure is normal or low with postural hypotension
- tachycardic, usual respirations or tachypneic
What state is a child with severe dehydration in?
Hypovolemic shock
what changes that are not vital signs appear in kids with severe dehydration?
- Lethargic to comatose
- parched mucus membranes
- Very decreased or absent to urine output
- Increased thirst
- Sunken fontanel
- Extremity school, discolored, and delay capillary refill
what vital sign changes occur during severe dehydration
- low to undetectable blood pressure
- rapid, weak or non palpable pulse
- Respirations change rate and regularity
Case study:
chloe is a 2 month old admitted at 8 PM today with a two day history of diarrhea and vomiting. She weighs 4 kilograms. As a temperature of 38.9 degrees Celsius. Her heart rate is 188. The resp rate is 62. urine output since 0800 is 20 milliliters.
her anterior fontanel Is sunken and she has decreased tears when she cries. She is lethargic.
What symptoms of dehydration does she have?
What level of dehydration does she have?
Symptoms:
* high heart rate
* high respiratory rates
* urine output 20 milliliters in two hours
* anterior fontanel sunken
* decreased tears, mucus membranes dry
* lethargic
Type: Moderate? Severe?
what is the bicarbonate level like with dehydration?
low
Case study:
chloe is a 2 month old admitted at 8 PM today with a two day history of diarrhea and vomiting. She weighs 4 kilograms. As a temperature of 38.9 degrees Celsius. Her heart rate is 188. The resp rate is 62. urine output since 0800 is 20 milliliters.
her anterior fontanel Is sunken and she has decreased tears when she cries. She is lethargic.
Would she require oral or IV rehydration?
IV rehydration because of her symptoms
what kind of Bolus (and amount) should be given for rehydration
normal saline or lactated ringers (20 ml/kg over 20”)
What maintenance fluids are used for dehydration
Isotonic solutions:
D5 1/2 NS with 20 mEq of KCl/L
OR
D5 NS with 20 mEq KCl/L
NO POTASSIUM UNTIL AFTER THEY PEE
what fluid should never be used as a bolus
dextrose, will cause fluid shifts
how do you calculate maintenance fluid needs in children
weight based:
up to 10 kg: 100 ml/kg/day
11-20 kg: 1000 ml + 50ml/kg / day
Above 20 kg: 1500 ml + 20ml/kg / day
Case study:
susie is a 12 month old with a one day history of diarrhea. Heart rate is 190. Respiratory rate of 54. Her temperature is 38. Alert and playful and irritable at times. She has three wet diapers today. She has tears when she cries. Her fontanel Is soft and flat. Her mucus membranes are tacky. Capillary refill is less than three seconds. Skin turgor is brisk.
Oral or IV rehydration?
Oral
in what amount do you give pedialyte to a kid
one to three teaspoons every 10 to 15 minutes
What is the term for too much fluid in extracellular compartment
extracellular fluid volume excess (overhydration)
what are causes of extracellular fluid volume excess
conditions that cause retention of sodium or water
What conditions cause overhydration, or retention of sodium and water
- Adrenal tumors which cause extra aldosterone secretion, retaining saline
- congestive heart failure
- chronic renal failure
- Infant or child who has been given an overload of sodium containing isotonic IV fluid
1 kg = __ L of fluid
1
What are clinical manifestations of extracellular fluid volume excess
- weight gain
- Edema
- Tight clothes/shoes
- Bounding pulse
- Respiratory difficulty
How much weight gained in one day is due to fluid accumulation
0.5 kg in a day
What is the clinical therapy for extracellular fluid volume excess
Determine cause and treat
describe what edema looks like in infants and children with extracellular fluid volume excess
Infants: genrealized over body
Children: Dependent areas of body
What pulses do you assess in children with over hydration
Radial and pedal
What condition increases the osmolality of blood and had the body fluids too concentrated
Hypernatremia
Describe hypernatremia
Too much sodium compared to water
What are causes of hypernatremia
- breast fed infants who are poorly feeding with normal diuresis at two to three days old
- limited water intake
- excessive concentration of formula
- diarrhea
- vomiting
- diabetes insipidus
Clinical manifestations of hypernatremia
- Inc thirst
- Dec urine output
- Confusion
- Seizures
- Lethargy
- Coma
- Dec LOC
Treatment of hypernatremia
- Serum sodium levek
- Hypotonic fluid; more dilute than normal body fluid
- .45 NS
- D5W: Once Dextrose is absorbed it acts on the body as hypotonic, only plain water left
Nursing management of hypernatremia
- monitor lab values, monitor IV infusion, intake and output
- Education for prevention
- 4-6 wet diapers per day
- Formula prep
what is when osmolality of the blood is decreased, body fluids are too dilute
hyponatremia
describe water and sodium in hyponatremia
body fluids contain more water relative to sodium
what are causes of hyponatremia
- water intoxication (pool water)
- dilute formula
- exercise
clinical manifestations of hyponatremia?
- brain edema
- dec. LOC (from swelling)
- HA
- anorexia
- muscle weakness
- seizures
- lethargy
- confusion
- coma
clinical therapy for hyponatremia
- serum sodium level
- correct cause
- hypertonic IV solution
what types of IV fluid are used for hyponatremia
hypertonic
* D5 .45 NS
* D5 .9 NS
nursing management of hyponatremia
- monitor sodium levels
- monitor I&O, IV infusions
- assessments
- NS rather than distilled water for irrigation
- no tap water enemas
which electrolyte has a huge role is muscle function?
potassium
causes of hyperkalemia
- renal insufficiency
- too much potassium in IV
- blood transfusions
- crush injuries
- sickle cell anemia crisis
clinical manifestations of hyperkalemia
- hyperactivity of GI smooth muscle causing intestinal cramping & diarrhea
- weak skeletal muscle
- lethargy
- arrythmias
clinical therapy of hyperkalemia
- potassium level, 12 lead EKG, treatment of cause
- potassium removed via dialysis, potassium wasting diuretics, kayexalate
nursing management of hyperkalemia
- monitor potassium levels
- assessment
- monitor HR and arrythmia
how can potassium be falsely elevated?
if a person drawing blood takes too long, RBCs burst releasing potassium
what kind of children are at risk for hyperkalemia
ones receiving IV therapy
what should be checked before implementing potassium in IV fluid
check urine output
what are causes of hypokalemia
- diarrhea/vomiting (also self-induced like bulemia)
- NG suction
clinical manifestations of hypokalemia
- GI smooth mucle slowed, distention, constipation/ileus
- skeletal muscle weak/unresponsive
- cardiac arrythmias
- respiratory muscles affected
- polyuria from kidney damage
clinical therapy of hypokalemia
- serum potassium level, 12 lead EKG, identify cause adn treat
- potassium replacement
management of hypokalemia
- monitor potassium
- assess muscle weakness
- all assessments
- potassium replacement: diet high in potassium/IV fluid
accululation of carbon dioxide in blood; carbon dioxide and water combined into carbonic acid
respiratory acidosis
what causes respiratory acidosis
anything that interferes with lung excretion of CO2
describe pH and PCO2 in respiratory acidosis
PCO2 increased, pH decreased
describe the compensatory mechanism in respiratory acidosis
nonbicarb buffers; additional hydrogen excreted by kidneys, formation and decreased bicarb excertion of kidneys
causes of respiratory acidosis
- decreased aeration
- resp muscle injury
- head injury
- cardiac/resp arrest
clinical manifestations of respiratory acidosis
- CNS depression
- confusion
- lethargy
- HA
- inc. intracranial pressure
- tachycardia
- arrythmias
clinical therapy of respiratory acidosis
treatement of cause
nursing management of respiratory acidosis
- assessment
- interventions speciic to correcting cause
what is when blood contains too little CO2; CO2 and water are combined into carbonic acid (PCO2)
respiratory alkalosis
describe PCO2 and pH in resp alkalosis
dec. PCO2, pH elevated
causes of resp alkalosis
hyperventilation, hypoxia, sepsis
clinical manifestations of resp alkalosis
- neuromuscular irritability and paresthesia is extremities and around mouth
clinical therapy of resp alkalosis
treatment of cause
nursing management of resp alkalosis
- assessments
- interventions specific to correcting cause
what is excess of any acid other than carbonic acid
metabolic acidosis
what is metabolic acidosis caused by (chemically, patho)?
imbalance in production and excretion of acid or by excess loss of bicarbonate
what happens to the chemoreceptors int eh brain when pH of the blood decreases below normal
they are stimulated caausing respiratory compensation
conditions/problems that cause metabolic acidosis
- DM
- ingestion of antifreeze
- ingestion if ASA
- renal failure
- diarrhea
- starvation
clinical manifestations of metabolic acidosis
- dec. pH, dec. HCO3, normal PCO2
- resp compenation causes Kussmaul respirations (inc. rate/depth)
clinical therapy of metabolic acidosis
treat cause
nursing management of metabolic acidosis
- assessment
- intervention specific to correcting cause
what occurs with loss of metabolic acid or too much bicarb
metabolic alkalosis
what neutralizes bicarb to return pH to normal
carbonic acid
pH, HCO3, and PCO2 in metabolic alkalosis
- pH elevated
- HCO3 elevated
- PCO2 normal
physical causes of metabolic alkalosis
- prolonged vomiting
- NG suction
- antacids
- diuretics
- reconstruction of powder formula
clinical manifestations of metabolic alkalosis
- hypokalemia
- neuromuscular irritability
- resp rate and depth decrease
clinical therapy and management for metabolic alkalosis
- treat cause
- assessment
- interventions to correct cause
assessment for infiltration
edema, cool, discomfort
assessment fro phlebitis
red, warm, irritated, pain, red streak
Case scenario:
Johnny is a four month old you are currently admitting to the emergency department. The mom gives you the following history: two days of diarrhea, temperature of 39, sleepy and difficult to wake up
What questions do you need to ask?
- What does the diarrhea look like
- when was the last time he had a bottle
- how many wet diapers has he had today
- When he cries does he have tears
- When did he begin to get sleepy
Case scenario:
Johnny is a four month old you are currently admitting to the emergency department. The mom gives you the following history: two days of diarrhea, temperature of 39, sleepy and difficult to wake up
What would the assessment include?
vital signs, head to toe assessment
Case scenario:
Johnny is a four month old you are currently admitting to the emergency department. The mom gives you the following history: two days of diarrhea, temperature of 39, sleepy and difficult to wake up
assessment data:
Heart rate 200, respirations 50, blood pressure 84/54, 39.5 temp, Difficult to arouse, PERRLA, sunken fontanel, dry, pink, decreased tears, tachycardia, no edema, resp good, hyperactive BS, soft round and, brown watery stool. Diaper rash, 0 pain.
What information would you give to the HCP?
What orders would you expect?
- Labs, electrolytes
- IV fluid bolus, maintenance
- I&O
- Assess and vitals evey 4 hours
- Stool culture
- Regular diet
- Contact precautions
- Daily weight
Case scenario:
Johnny is a four month old you are currently admitting to the emergency department. The mom gives you the following history: two days of diarrhea, temperature of 39, sleepy and difficult to wake up
lab results:
High sodium, high potassium, high chloride, low carbon dioxide, good urine nitrogen, good glucose
What is the significance?
- Hypovolemia
- Low co2 is metabolic acidosis
Case scenario:
Johnny is a four month old you are currently admitting to the emergency department. The mom gives you the following history: two days of diarrhea, temperature of 39, sleepy and difficult to wake up
mom stayes he lost .45 kg, almost a pound
What is your plan of care?
- initiate IV fluid bolus, then maintenance
- reassessment when fluid is complete
- assess output hourly
- take additional labs and reweigh in the morning
- stool culture, virus?
- contact precautions
- safety
Infants and children under two years old lose a greater proportion of fluid each day and are more dependent on which of the following?
1. IV fkuid intake
2. Oral liquid intake
3. Oral food intake
4. Urine output
Oral liquid jntake
choose all the symptoms that apply for a one year old with moderate dehydration?
1. Lethargy, poor turgor
2. Cap refill <2-3 sec
3. Urine output <1 ml/kg/hr
4. eyes slightly sunken and decreased tears
1, 3, and 4
an infant ways 10.2 kg, Hourly urine output for this infant needs to be what?
1. 10 ml/hr
2. 11 ml/hr
3. 10.2 ml/hr
4. 10.5 ml/hr
10.2
IV fluid bolus rehydration would be which type of IV fluid?
1. NS
2. D5LR
3. .45 NS
4. D5NS
NS
A child with extracellular fluid volume access will need which of the following nursing interventions. choose all that apply
1. Daily weights on the same scale
2. Edema assessments
3. education on skin care with family
4. Diuretics
1,2,3
Hyperkalemia may occur in infants and children due to which of the following?
1. diet
2. Blood draw technique
3. Overhydration
4. Urine output
Blood draw technique
respiratory acidosis could occur in which diagnosis?
1. Asthma
2. Gastroenteritis
3. Dehydration
4. Vomiting
A
