The Child with Fluid & Electrolyte Alterations

Question 1

ECF Total birth weight at birth

Answer 1

45-50%

Question 2

ECF Total birth weight at 2 years

Answer 2

30%

Question 3

ECF Total birth weight at maturity

Answer 3

20%

Question 4

Cerebral changes in hypertonic dehydration

Answer 4

Disturbances of consciousness
poor ability to focus attention
lethargy
increased muscle tone with hyperreflexia
hyperirritability to stimuli (tactile, auditory, bright light)
Decorticate posturting
unable to talk
Unresponsive to pain

Question 5

Treatment of hypernatremia

Answer 5

treat by IV hypotonic fluids -> dilutes body fluids back to normal
If dehydrated, may give isotonic first to replenish volume then hypotonic to correct osmolality. Careful monitoring

Question 6

S&S of hypernatremia

Answer 6

will be thirst, decreased urine output
decreased LOC -> confusion, lethargy, coma from shrinking of brain cells; seizures if rapid or severe; can be fatal
Increased osmolality

Question 7

Special consideration with hypertonic solutions

Answer 7

Interstitial IV burns

Question 8

Manifestations of Dehydration

Answer 8

Thready, rapid pulse
Dry skin & mucous membranes
Sunken fontanel
Coolness & mottling of extremities
Decreased skin turgor
Delayed capillary refill
Increased small vein filling time
Dizziness, syncope
Oliguria
Weight loss
Postural BP drop (older children)

Question 9

Clinical manifestations are a result of

Answer 9

Decreased fluid
Body’s response to decreased fluid

Question 10

Earliest detectable sign of dehydration

Answer 10

Tachycardia

Question 11

how is magnitude of fluid loss described?

Answer 11

described as a % (5,10,15) & ascertained by comparison of pre-illness weight & current weight.
However, water is only 60-70% of infant weight, & adipose tissue, which contains very little water is highly variable.
More accurate to reflect acute loss in mL/kg of body weight

Question 12

Clinical signs:

Answer 12

provide clues to extent of dehydration. Earliest detectable sign is usually tachycardia, followed by dry skin & mucous membranes, sunken fontanels, signs of circulatory failure (coolness & mottling of extremities), loss of skin elasticity, & delayed capillary filling time.

Question 13

Dehydration caused by loss of Na+ containing fluid form body

Answer 13

• vomiting
• diarrhea
• NG suction
• hemorrhage
• burns
• LBW infants under radiant warmers, adrenal insufficiency
• overuse of diuretics
• third space accumulation

Question 14

Etiology ECF deficit: decreased fluid volume

Answer 14

Manifestation: weight loss, sunken fontanel

Question 15

Etiology ECF deficit: inadequate circulating blood volume to offset

Answer 15

Manifestation: postural BP drop, dizziness

Question 16

Etiology ECF deficit: decreased intravascular volume

Answer 16

delayed cap refill, flat neck veins when supine (older children)

Question 17

Etiology ECF deficit: Inadequate circulation to brain

Answer 17

dizziness, syncope

Question 18

Etiology ECF deficit: Inadequate circulation to kidneys

Answer 18

oliguria

Question 19

Etiology ECF deficit: Cardiac reflex response to decreased intravascular volume

Answer 19

Thready, rapid pulse

Question 20

Decreased interstitial fluid volume

Answer 20

decreased skin turgor

Question 21

Early Compensation

Answer 21

Interstitial fluid moves to vascular compartment; vasoconstriction maintains pumping pressure.
When BP is involved it is usually a late sign and more significant

Question 22

Compensatory mechanisms

Answer 22

attempt to maintain fluid volume by adjusting to these losses. Interstitial fluid moves into vascular compartment to maintain blood volume in response to hemoconcentration & hypovolemia, & vasoconstriction of peripheral arterioles helps maintain pumping pressure.

Question 23

Late Compensation

Answer 23

BP falls - tissue hypoxia & metabolic acidosis (accumulation of lactic acid, pyruvate)
Renal compensation impaired due to reduced blood flow; urine output decreased
- ADH to conserve fluid
- Renin-angiotensin -> vasoconstriction
- Aldosterone -> Na retention & water conservation.

Question 24

Shock

Answer 24

Tachycarida, poor perfusion (skin cool & mottled, decreased cap refill), oliguria & azotemia (nitrigenous waste esp. urea), low BP (late sign & may herald onset of cardiovascular collapse)

Question 25

Degrees of dehydration: Mild

Answer 25

Up to 5% weight loss
Irritable (infants); thirsty

Question 26

Degrees of dehydration: Moderate

Answer 26

6-9% weight loss
- lethargic & sleepy; restless & irritable
- decreased skin turgor; dry mucous membranes; urine dark & decreased
- pulse increased & BP normal or decreased

Question 27

Degrees of dehydration: Severe

Answer 27

> 10% weight loss
lethargy or non-responsive, decreased BP, rapid pulse, poor skin turgor, dry mucous membranes, decrease or absent urine output

Question 28

ECF Deficit (Dehydration)

Answer 28

occurs when total output of fluid exceeds total intake, regardless of underlying cause.
may result from lack of intake but more often result of abnormal losses (vomiting, diarrhea), when oral intake only partially compensates for the abnormal losses. Other significant causes of dehydration are DKA & excessive burns.
Dehydration - not enough fluid in ECF compartment (vascular & interstitial). Na+ generally lose with water, therefore may be hyponatremia
Signs vary with severity or degree of body water deficit.
Signs are result of: decreased fluid (turgor, dry mucous membranes), body’s response to fluid deficit (increased HR, decreased BP) Mild -> hard to detect

Question 29

Increased Fluid Requirements

Answer 29

Fever (add 12% per rise of 1 degree C)
Vomiting
Diarrhea
High-output kidney failure
Diabetes insipidus
Diabetic ketoacidosis
Burns
Shock
Tachypnea
Radiant warmer
Phototherapy
Post-op bowel surgery

Question 30

Normal Urine Output: Infant

Answer 30

2 ml/kg/h

Question 31

Normal Urine Output: Child (>1 yr)

Answer 31

1 ml/kg/h

Question 32

Normal Urine Output: Adolescent (10-19)

Answer 32

0.5 ml/kg/h

Question 33

Diarrhea

Answer 33

Caused by abnormal intestinal water & electrolyte transport which results
- dehydration
- electrolyte imbalance
- metabolic acidosis
Intestinal mucosa of young infant is more permeable to water than that of older child, therefore, more fluids & electrolytes are lost in infant with diarrhea

Question 34

Dehydration caused by diarrhea: patho

Answer 34

voluminous losses of fluid in frequent, watery stools
losses with vomiting
reduced fluid intake from nausea or anorexia
increased insensible water losses from fever, hyperpnea
continued (although diminished) renal losses

Question 35

Electrolyte imbalance cause by diarrhea

Answer 35

losses of Na, Cl, K & sometimes bicarb
inadequate replacement of electrolytes when hypotonic or hypertonic solutions used

Question 36

metabolic acidosis caused by diarrhea

Answer 36

increased absorption of short-chain fatty acids produced in colon from bacterial fermentation of unabsorbed dietary CHO
lactic acid from tissue hypoxia secondary to hypovolemia
loss of bicarb in stools
ketosis from fat metabolism when glycogen stores are depleted in untreated diarrhea dehydration or inadeqaute CHO intake; may result in malnutrition

Question 37

Acute Diarrhea

Answer 37

Leading cause of illness in children < 5 years
often caused by infectious agent (rotavirus, norwalk-like organisms, E. coli, Salmonella)
may be associated with URTI or UTI, antibiotic therapy, or laxative use
Usually self-limited (< 14 days)
- no specific treatment occurs usually required unless dehydration occurs
Spread through fecal-oral route, through contaminated water or close contact
Major risk factors: lack of clean water, crowding, poor hygiene, nutritional deficiency, poor sanitation

Question 38

Chronic Diarrhea

Answer 38

> 14 days
Often caused by malabsorption causes, IBD, immunodeficiency, food allergy, lactose intolerance, radiation, motility disorders, endocrine causes, parasitic infestations
Increase in stool frequency & increased water content
Malabsorption: celiac, short bowel, lactose intolerance
Motility: hirschusprung disease
Parasites: Giardia

Question 39

Factors that Predispose to Diarrhea

Answer 39

Age: the younger the child, the greater the susceptibility & the more severe the diarrhea
Impaired health: malnourished or immunocompromised child
Environment: crowding, substandard sanitation, poor facilities for preparation & storage of food, inadequate health care education

Question 40

Therapeutic Management Goals of Acute Diarrhea

Answer 40

Assessment of fluid & electrolyte imbalance
Rehydration
Maintenance fluid therapy
Reintroduction of adequate diet
First-line treatment is oral rehydration therapy (ORT)
- more effective, safer, less costly, & less painful than IV rehydration

Question 41

Therapeutic Management

Answer 41

Oral rehydration solutions (ORS)
- enhance & promote reabsorption of sodium & water
- reduce vomiting, volume loss from diarrhea & duration of illness
Continued feeding or reintroduction of normal diet (when child is dehydrated we want to promote eating normally and whatever they can tolerate)
- lessens severity & duration of illness
- Continue with BF & use ORS for replacement
- lactose-free formula if usual formula not tolerated
IV therapy for severe dehydration & shock (usually use saline solution with 5% dextrose. may add bicarb.
Antibiotics - maybe

Question 42

ORS

Answer 42

ORT is first line treatment.
After rehydration, use ORS during maintenance fluid therapy by alternating ORS with water, breastmilk, lactose-free formula, or ½ strength lactose-containing formula.
In older children, continue regular diet with ORS
Replace ongoing stool losses 1:1 with ORS
If vomiting, give small amounts of ORS frequently (5-10 mL q 1-5 mins.); may give with NGT or GT
If no clinical signs of dehydration in infants, they do not need ORT

Question 43

Diarrhea Treatment “no-nos”

Answer 43

• Do not encourage po clear fluids, such as fruit juices, carbonated soft drinks & jello (high in CHO & low electrolyte, high osmolality
• Do not drink caffeinated pop or other drinks (caffeine is mild diuretic)
• Do not give chicken or beef broth (excessive sodium & inadequate CHO)
• Do not use BRAT diet (bananas, rice, applesauce, & toast or tea) - little nutritional value (low in energy & protein), high in CHO, low in electrolytes

Question 44

What should you do when you have diarrhea

Answer 44

eat to what is tolerated with oral rehydration therapy

Question 45

Nursing Care Management of Diarrhea

Answer 45

Education re: treatment & prevention
Accurate weight
Accurate intake & output
Monitor IV therapy
Specimen collection (sometimes they are not making urine it just looks like it)
Skin care

Question 46

Hypovolemic Shock

Answer 46

Complex clinical syndrome
Circulatory failure (shock)
- tissue perfusion that is inadequate to meet metabolic demands of body
- results in cellular dysfunction & eventual organ failure

Question 47

Physiological consequences of hypovolemic shock

Answer 47

1. hypotension (later sign)
2. tissue hypoxia
3. metabolic acidosis

Question 48

Pathophysiology of Hypovolemic Shock

Answer 48

If hemorrhage reduces the circulating blood volume sufficiently then the compensatory mechanisms support blood circulation by increasing the heart rate and constricting the peripheral blood vessels. This response shifts the remaining blood to larger blood vessels so that the vital organs continue to be perfused. When the blood loss exceeds 20% to 25%, the child’s body can no longer compensate; blood pressure falls and circulatory collapse is imminent.
Very fatal in little kids

Question 49

Hypovolemic shock: etiology

Answer 49

Most common type in children
Reduction in circulating blood volume beyond child’s physiological ability to compensate related to:
- blood loss (trauma, major bleeding)
- plasma losses (burns)
- ECF losses (diarrhea, dehydration)

Question 50

Hypovolemic Shock Clinical Manifestation - Early Compensated
Cardiac
Respiratory
Neurologic
Skin Renal

Answer 50

mild tachycardia, weak distal pulses, strong central pulses, normal BP
Mild tachypnea
Normal, anxious, irritable
Mottled; cap refill > 2 sec; cool, clammy extremities
Renal: decreased urine output; increased SG

Question 51

Hypovolemic Shock Clinical Manifestation - Moderate Uncompensated
Cardiac
Respiratory
Neurologic
Skin Renal

Answer 51

Mod tachycardia; thready distal pulses, weak central pulses, decreased systolic BP
mod tachypnea
confusion, agitation, combative behaviour, lethargy, decreased pain response
pallor, cap refill > 3 sec, dry extremities, sunken eyes
Oliguria, increased SG

Question 52

Hypovolemic Shock Clinical Manifestation - Severe Uncompensated shock
Cardiac
Respiratory
Neurologic
Skin Renal

Answer 52

Extreme tachycardia, decreased BP, absent distal pulses, thready central pulses
Severe tachypnea
Comatose state
pale, cold skin, cyanosis, cap refill > 5 sec
no urine output

Question 53

Principal differentiating signs at all stages of shock are

Answer 53

degree of tachycardia & perfusion to extremities
level of consciousness
blood pressure
Compensated: vital organ function maintained by intrinsic mechanisms & child’s ability to compensate is effective
Subtle signs initially
In decompensated, signs become more obvious

Question 54

Therapeutic Management of Hypovolemic Shock

Answer 54

1. Ventilation
2. Fluid administration
3. Improvement of pumping action of heart (vasopressor support)
   - first priority is to establish airway & administer oxygen
   - place one or more multi-lumen central lines or cutdown or intraosseous needle
   - preferably place central line above diaphragm to deliver drugs closer to heart & limit tissue injury from caustic meds
   - lines needed for rapid volume replacement, administration of drugs, and hemodynamic monitoring.