Fluid & Electrolytes Flashcards
How does calculation of F&E in peds differ from adults?Why?
Calculations are weight based.
The younger an infant, the more their body composition is made up of fluid.
Plus, the needs of an 16 yr old are not the same as 1 month old newborn.
What do we mean by maintenance fluid?
The required amount of fluid needed for someone to maintain there functioning.
- generally what they are at all the time
- when things like fever, diarrhea, or metabolic processes increase this.
- this can alter much faster in infants.
What are the proportions of fluid in the infants intracellular and extracellular compartment?
Why can this be an issue?
Half of the fluid is in intracellular. Half in extracellular.
Adults typically have more fluid in the intracellular compartment where the fluid is protected. Infants have half of their fluid in that extracellular space which means they automatically expose more fluid to changes bc of the location the fluid is in. So when a change like fever, vomiting, or diarrhea takes place - that fluid will be lost and thus expose the infant to all sorts of fluid issues.
What is the issue with metabolic changes in infants?
If the metabolic rate is increased then this requires more glucose, oxygen, and water to be used up. And since the liver is immature and fat cells aren’t as much, their cells can die.
T/F
Fluid replacement containing electrolytes is not necessary for children
False. Electrolytes should be included.
How are children more at risk for cerebral edema and neuro effects?
Due to water being able to flow freely across the blood brain barrier & their fluid compartments being different from ours.
Size of GI tract in infants compared to adults? How does this have an effect?
GI tract in infants is larger than in the adult. This can increase their fluid loss.
When infants are cold, will they shiver?
How should you regulate their temp?
NO! They have non-shivering thermogenesis. And so they’ll increase metabolism (which leads to cells dying since they don’t have the glucose & fat reserve).
Keep them warm but don’t let them overheat.
How does an infant’s body surface affect their loss of fluids?
Increase in insensible loss from sweating.
Can infant kidneys preserve fluids?
No. Adult kidneys can concentrate urine to do that but infants can’t.
How much do fluid needs go up for infants when having a fever?
7 cc/kg/24 hrs for each degree above 99F
Why check input and output when dealing with anything that can effect infant hydration?
Input and output can help you keep track of when exactly there is a imbalance taking place. If the output isn’t matching the input, then something is likely wrong.
- it can also be used to determine if the imbalance is getting better
Why check fontanel for hydration status?
The fontanel will concave and sink in if dehydrated
What will skin turgor be like if an infant is dehydrated?
The skin on the abdomen does not retract back when pulled or pinched up. If they are hydrated, the skin will go back down.
Why is weight a good method for checking hydration and fluid balance?
By checking the weight over a short period of intervals, an infant may gain weight from fluid accumulation. They may lose weight too if the excess of fluid improves.
Amount of weight that is acceptable for infant in 24 hrs to fluctuate?
Young child?
Older adolescent?
Up to …
50 grams in infants
200 grams in child
500 grams in adolescent
all within 24 hrs.
How long should a cap refill be in infants?
Still less than 2 seconds. If longer, you have a perfusion issue and can be related to fluid balance.
How are tears a good assessment of hydration status?
Mucous membranes?
Well if an infant’s not able to cry, that means there’s no available fluid for it.
Mucous membranes may be dry as well.
What may pulse and bp look like if an infant is dehydrated?
Their blood pressure actually may appear fine but if accompanied by tachycardia (+160) , then you know that that is an effort to compensate and keep the blood pressure normal.
- If you see the HR is up, you need to find a solution before the compensation stops working and the blood pressure drops.
Whenever there are signs of dehydration through any of the hydration assessments (turgor, bp, hr, membranes, etc) .. what should we be asking ourselves next?
1) Are we not giving them enough fluid to meet their maintenance?
OR
2) Are they actually losing too much fluid somehow? (fever, diarrhea, vomiting, etc)
And.. 3) How soon will they stop compensating? Bc things will go to shit a lot quicker in an infant & it can be life threatening when that happens.
What is Fluid Volume Deficit?
FVD - This is really the end product of dehydration through things like
- vomiting
- diarrhea
- polyuria (too much urine)
- Hemorrhage
- or other Iatrogenic causes
[But don’t worry about the difference between this and dehydration. They’re one in the same for now. Focus on the causes.]
Types of dehydration/FVD
Isotonic = equal water and solute Hypertonic = more solute than water (shrivel appearance Hypotonic = more water present than solute (bulging appearance)
We figure this out which types of fluid replacement to use by categorizing dehydration into these categories. It is important to know which fluid will help bc by using the wrong fluid, we can make the imbalance worse.
FVD presents itself the same dehydration for the most part.
(- weight loss
- dry skin and membranes
- poor skin turgor
- tachycardia w normal bp if compensating
- low bp if not able to compensate)
What other might we see?
- Increased thirst
- Irritability, lethargy, fatigue
- High specific gravity (means the urine is more concentrated)
- High serum osmolality & High BUN
- Low serum CO2 & High anion gap
What is the normal serum Co2 range?
Why might this decrease be a sign of dehydration/FVD?
Explain in detail
23-30
meq/L
Serum Co2 and Bicarb (HCO3) are two different sides of the same coin. So if Bicarb drops, the overall Co2 will drop.
Dehydration leads to poor perfusion & therefore more lactic acid appears in the body. The bicarb will be taken from the kidneys and then used to compensate to avoid metabolic acidosis occurring. And so, if the Bicarb gets used up, Bicarb falls which means serum Co2 falls. Making Co2 a good way to mark dehydration.
What is normal range for anion gap?
Why is this indicative of FVD or dehydration if it rises?
12-18
meq/L
If anion gaps are high that means acidosis may be occurring.
- dehydration > no perfusion > lactic acid > acidosis
Isotonic dehydration signs
Skin color:
Temp:
Turgor:
Membranes:
Actual body temp:
Pulse:
Na:
Urine output:
Behavior:
Fontanels:
Isotonic : equal parts water and sodium dehydration
Skin gray (all 3 will be)
Temp cold.
Turgor poor
Membranes dry
Body Temp both up or down
Pulse High
Na normal
UO decreased (all 3 will be)
lethargic
Sinking fontanel (all 3 will be)
Hypotonic dehydration signs
Skin color:
Temp:
Turgor:
Membranes:
Actual body temp:
Pulse:
Na:
Urine output:
Behavior:
Fontanels:
Hypotonic: more fluid than solute
Skin gray (all 3 will be)
Temp cold
Turgor Very poor
Membranes slightly moist
Low body temp
Pulse rapid
Na below 135 or low
UO decreased (all 3 will be)
Lethargic
Hypovolemic shock signs
Sinking fontanel (all 3 will be)
Hypertonic dehydration signs
Skin color:
Temp:
Turgor:
Membranes:
Actual body temp:
Pulse:
Na:
Urine output:
Behavior:
Fontanels:
Hypertonic: more solute than water
Skin gray (all 3 will be)
Temp both cold or hot
Turgor fair
Membranes thirsty
Low body temp
High pulse
Na above 145 or high
UO decreased (all 3 will be)
Lethargic and hyperirritable
Neuro signs
Sinking fontanel (all 3 will be)
What percentage amounts of fluid are pertinent to isotonic dehydration and thus have varying degrees of signs and symptoms?
5% mild
10% moderate
15% severe
What type of acid/base imbalance can vomiting lead to?
What about diarrhea?
Vomiting can cause metabolic alkalosis since you are throwing up HCL.
Diarrhea can cause metabolic acidosis due to loss of bicarb.
But, vomiting & diarrhea often happen at the same time & that can be very hard to manage so watch closely.
Organisms that typically cause diarrhea? With each, how long may symptoms last?
If someone is having diarrhea, which area of skin should you be checking?
Rotavirus (5-7 days)
Salmonella (2-3 weeks)
Shigella (5-10 days)
Check around anal/perineal area for skin breakdown and hygiene to avoid infection.
Also note: commercial wipes on the skin can be irritating if there are already cracks/skin breaking. Can choose to use wash cloth and warm water.
Nursing care for the skin?
Use barriers. Avoid commercial wipes if you can. Keep skin moisturized ig?
Nursing care for hydration?
In short, just replace with fluids and electrolytes.
Also can do things like tell them to take sips of water if they’re allowed to.
Try to give them best fluid possible as well. No sugar.
T/F
All infants can wear the same types of diapers
False.
Some diapers are too rough for infant skin.
Likely post operation fluid imbalances?
Hyponatremia
Hypokalemia
due to fluid retention, NG suction, and postop vomiting
If on gastric suctioning, can patient have ice chips?
What about NPO?
Need to limit them at least
If on NPO you can have ice chips sometimes. ask doctor
If caring for a post op patient why is it important to know their intake and output from the OR?
Bc the blood loss, decompression of stomach causing fluid loss, and insensible losses in other ways .
What type of surgery is it common to have third spacing with?
In abdominal surgery due to abdominal walls and peritoneal. Can have ascites essentially. Now remember - just bc they have third spacing and ascites going on doesn’t mean they aren’t in a deficit. Just means they’re in a deficit but its bc the fluid is stuck in peritoneal.
If a patient is doing a bowel prep preop, what should you consider in relation to dehydration?
Patient may have been dehydrated already before they even did the bowl prep & the prep then made them even more dehydrated.
How can hyperthermia cause fluid deficit after surgery?
Metabolic process
Can blood loss effect fluid after surgery?
Yep if they lose to much blood that can shift the fluid amounts in their body
Why might there be some fluid retention going on in the first 48 hours after surgery?
Due to increase in ADH & aldosterone from the heart not perfusing the kidneys well enough. - i think.
Just causes fluid excess
What is Hemolytic Uremic Syndrome?
What organs are affected?
Due to e.coli , the arterioles of organs are edematous and occluded with platelets and fibrin
Affects kidneys, liver, pancreas, heart muscles
In Hemolytic Uremic syndrome, what is the triad we are looking for?
Acute kidney injury - renal failure can happen
Hemolytic anemia - due to rbc being damaged
Thrombosyopenia - low levels of platelets too ; so bleeding can happen
First symptoms of Hemolytic Uremic Syndrome?
Other strange presentations?
Change in ability to perfuse symptoms?
Kidney symptoms?
Neuro?
Can have GI symptoms such as diarrhea and vomiting at first.
Also Uti or even respiratory infection Or varicella (chicken pox)
Change in perfusion causes irritability and pallor. Increased bruising or purpura
Rectal bleeding
Hypertension due to kidneys and declining urine output . Can have complete renal failure too.
Check LOC and seizures
How to diagnose Hemolytic Uremic Syndrome?
Diagnose the triad
- Acute kidney injury, anemia, thrombocytopenia
Why do we focus on fluid balance and electrolytes in Hemolytic Uremic Syndrome?
What can HUS develop into?
what meds?
Procedures/interventions?
Due to excretion issues from kidneys. Also need electrolytes bc they won’t want to eat either.
Metabolic acidosis
Give antihypertensive due to hypertension going on
Dialysis intervention or plasmapheresis
Which dialysis will they use on a kid with Hemolytic Uremic Syndrome?
Peritoneal dialysis most likely. Hemo is hard for kids.
- Use solute solutions into peritoneal cavity and the fluid is pulled off and add/remove electrolytes
Or
Continous
- difficult but can be done in older kids. Done continuously and adjusting it
What is Plasmapheresis for Hemolytic Uremic Syndrome?
When doing dialysis and plasmerheresis , what intervention is super important?
Effort to remove byproduct of rbcs and platelets from the body
- can also pull of toxins from infectious illness too
Super important to keep track of input and output & do weights.
How do they make sure the child has enough oxygen carrying capacity if they have Hemolytic Uremic Syndrome?
How are they fed?
Due to anemia —-
Will do rbc transfusion to make sure they can perfuse alright.
Transpyloric tube - NG tube w weighted tube to stomach and through sphincter into intestine to the jejunum . A continuous feeding over 2 hrs or so and then resting. Small amounts are key.
How likely is a child to recover from Hemolytic Uremic syndrome?
What is recovery like?
Depends how early it is taken care of.
- 95% if prompt
- 10-50% may end up w chronic renal impairment or nervous system issue
So take this illness seriously.
Can take some time to recover.
Hypopituitarism?
Which hormones?
Which one is most affected?
Deficiency of hormones from pituitary
Gonadtropin, Growth Hormone (GH), TSH , and corticotropin.
GH is most affected. Can be moderate to severe
When hypopituitarism causes decreased GH, how long does it take to detect?
Which aspect of growth is most affected?
What other delays?
Can take about a year. They just notice the growth curve. They have some just not enough.
Mostly affects height due to bone age being delayed. Check growth plates to see if they are where they’re meant to be. .
Delays in sex and reproduction.
