FLuids and Electrolyte Disorders In Pediatric Nursing

							Fluid and Electrolytes
     Pediatric Nursing
         Alteration in Fluid and
           Electrolyte Status
                              Lungs




                                                    Ball &
                                                    Bender




              Urine & feces     Skin

Normal routes of fluid excretion in infants and children.
  Developmental and Biological
          Variances
 Infants  younger than 6 weeks do not
  produce tears.
 In an infant a sunken fontanel may
  indicate dehydration.
 Infants are dependant on others to meet
  their fluid needs.
 Infants have limited ability to dilute and
  concentrate urine.
 Developmental and Biological
 The  small the child, the greater the
  proportion of body water to weight and
  proportion of extracellular fluid to
  intracellular fluid.
 Infants have a larger proportional surface
  are of the GI tract than adults.
 Infants have a greater body surface area
  and higher metabolic rate than adults.
              Water Balance
 Regulated  by Anti-diuretic Hormone ADH.
 Acts on kidney tubules to reabsorb water.
 The young infant is highly susceptible to
  dehydration.
      Increased Water Needs
 Fever
 Vomiting and Diarrhea
 High-output in renal failure
 Diabetes insipidus
 Burns
 Shock
 Tachypnea
     Decreased Water Needs
 Congestive  Heart Failure
 Mechanical Ventilation
 Renal failure
 Head trauma / meningitis
           General Appearance
 How     does the child look?
    Skin:
      • Temperature
      • Dry skin and mucous membranes
      • Poor turgor, tenting, dough-like feel
      • Sunken eyeballs; no tears
      • Pale, ashen, cyanotic nail beds or mucous
        membranes.
      • Delayed capillary refill > 3 seconds
Loss of Skin Elasticity

            Loss of skin elasticity
            Due to dehydration.

            Whaley & Wong Text
                  Cardiovascular
   Pulse rate change:
       Note rate and quality: rapid, weak, or thready
       Bounding or arrhythmias
       Tachycardia #1 sign that something is wrong
       Increased HR may be first subtle sign of hypovolemia
   Blood Pressure
       Note increase or decrease (remember it takes a 25%
        decrease in fluid or blood volume for change to occur)
                 Respiratory
 Change in rate or quality
 Dehydration or hypovolemia
     Tachypnea
     Apnea
     Deep shallow respirations
 Fluid   overload
     Moist breath sounds
     Cough
         Diagnostic Tests
 Make sure free flowing specimen is
 obtained, a hemolyzed or clotted
 specimen may give false values.
  Hemoglobin and Hematocrit
 Measures  hemoglobin, the main
 component of erythrocytes, which is the
 vehicle for transporting oxygen.
     Hgb and hct will be increased in extracellular
      fluid volume loss.

     Hgb and hct will be decreased in extracellular
      fluid volume excess.
                 Electrolytes
 Electrolytes  account for approximately
  95% of the solute molecules in body
  water.
 Sodium Na+ is the predominant
  extracellular cation.
 Potassium K+ is the predominant
  intracellular cation.
               Potassium
 High  or low values can lead to cardiac
  arrest.
 With adequate kidney function excess
  potassium is excreted in the kidneys.
 If kidneys are not functioning, the
  potassium will accumulate in the
  intravascular fluid
               Potassium
 Adults:  3.5 to 5.3 mEq /L
 Child: 3.5 to 5.5 mEq / L
 Infant: 3.6 to 5.8 mEq / L


 PanicValues:
< 2.5 mEq /L or > 7.0 mEq / L
              Hyperkalemia
 Defined   as potassium level above 5.0 mEq
  /L
 Significant dysrhythmias and cardiac
  arrest may result when potassium levels
  arise above 6.0 mEq/L
 Adequate intake of fluids to insure
  excretion of potassium through the
  kidneys.
          CM: Hyperkalemia
 Nausea
 Irregularheart rate
 Pulse slow / irregular
     Causes of Hyperkalemia
 Acuterenal failure
 Chronic renal failure
 Glomerulonephritis
             Diagnostic tests:
 Serum     potassium
 ECG
     Bradycardia
     Heart block
     Ventricular fibrillation
              Hypokalemia
 Potassium   level below 3.5 mEq / L
 Before administering make sure child is
  producing urine.
 A child on potassium wasting diuretics is
  at risk – Lasix
         CM: Hypokalemia
Neuromuscular manifestations are: neck
 flop, diminished bowel sounds, truncal
 weakness, limb weakness, lethargy, and
 abdominal distention.
      Causes of Hypokalemia
 Vomiting  / diarrhea
 Malnutrition / starvation
 Stress due to trauma from injury or
  surgery.
 Gastric suction / intestinal fistula
 Potassium wasting diuretics
 Ingestion of large amounts of ASA
     Foods high in potassium
 Apricots,bananas, oranges,
  pomegranates, prunes
 Baked potato with skin, spinach, tomato,
  lima beans, squash
 Milk and yogurt
 Pork, veal and fish
        Monitor Potassium Levels




A child with a nasogastric tube in place that is set to suction,
needs to have potassium levels monitored.
                Sodium
 Sodium  is the most abundant cation and
  chief base of the blood.
 The primary function is to chemically
  maintain osmotic pressure and acid-base
  balance and to transmit nerve impulses.
 Normal values: 135 to 148 mEq / L
             Hyponatremia
 Reflects an abnormal rate of sodium to
  water and is defined as a serum sodium
  concentration less than 135 mEq/L.
 Results from retention of water secondary
  to impairment in free water excretion.
           Pathophysiology
 When    sodium levels drop in the fluids
  outside the cells, water will sweep into the
  cells in an attempt to balance the
  concentration of salt outside the cells.
 Cells will swell as the result of the excess
  water.
 Brain cells cannot accommodate –
  symptoms of hyponatremia result from
  brain swelling
                Diagnosis
 10 to 15% of patients
 Vomiting, diarrhea, or excessive sweating
 Vital Signs: BP (orthostatic), skin turgor,
  mucous membrane appearance, jugular
  vein distention, edema
 Lab values
 History of oral intake of low-electrolyte or
  electrolyte free fluids
        Early Manifestations
 Anorexia,  nausea, lethargy and apathy
 More advanced symptoms: disorientation,
  agitation, seizures, depressed reflexes,
  focal neurological deficits
 Severe: coma and seizures: sodium
  concentration less than 120 mEq/L
       Medical Management
 Normal  saline given as resuscitative fluid
 May need to reduce the fluid rate to 75%
  of maintenance
 Supplemental oxygen
 Water and salt restrictions
           Hypernatremia
 Serum  sodium greater than 150 mEq/L is
 caused by conditions that produce an
 excessive gain of sodium or excessive
 loss of water that is greater than the loss
 of sodium.
            Clinical Pearl
 Most  infant with severe dehydration have
 a history of lethargy, listlessness, and
 decreased responsiveness; those with
 hypernatremia dehydration tend to be
 irritable and fussy.
            Hypernatremia
 Inadequate  fluid intake – 75%
 Gastrointestinal losses – 44%
 Occurs primarily in infants with diarrhea
  dehydration
 Diabetes insipidus was major reason for
  excessive urinary output
 Loss from high fever, environmental
  temperatures and hyperventilation
     Primary Sodium Excess
 Improperly   mixed formula or re-hydration
  solution
 Ingestion of sea water
 Hypertonic saline IV
 High breast milk sodium
       Primary Water Deficit
 Diabetes  Insipidus
 Diabetes Mellitus
 Gastroenteritis (water loss greater than
  solute loss)
 Inadequate breast feeding
 Withholding of water: handicapped
 Increased insensible loss – premature
  infant
           Treatment Modalities




Peripheral IV with IV
house.
          Intraosseous Therapy




Intraosseous needle in place for emergency vascular access.
Central Venous Catheter
    Total Parental Nutrition




                A tunneled catheter should have
Whaley & Wong   An occlusive dressing in place.
             TPN Therapy
 TPN   provides complete nutrition for
  children who cannot consume sufficient
  nutrients through gastrointestinal tact to
  meet and sustain metabolic requirements.
 TPN solutions provide protein,
  carbohydrates, electrolytes, vitamins,
  minerals, trace elements and fats.
       Complications of TPN
 Sepsis: infection
 Liver dysfunction
 Respiratory distress from too –rapid
  infusion of fluids
        TPN: care reminder
caREminder:
 The TPN infusion rate should remain fairly
  constant to avoid glucose overload. The
  infusion rate should never be abruptly
  increased or decreased.
Dehydration
          General Assessment
 Loss of weight
 Level of consciousness
     Alert to irritable
     Restless to lethargic
     Lethargic to coma
              Skin Turgor
 Inmoderate dehydration the skin may
  have a doughy texture and appearance.

 In severe dehydration the more typical
  “tenting” of skin is observed.
Skin Turgor
                 Urine Output
   Normal urine output is 1-2 mL/kg/hr
   In mild dehydration urine output may be low –
    parent may report decrease in voiding
   Moderate dehydration urine output would be low
    and concentrated (oliguric) with elevated specific
    gravity.
   Severe dehydration would by (anuric) very low –
    very concentrated urine with high S.G.
               Vital Signs
 The  heart rate is the most sensitive
  indicator of dehydration / hypovolemia.
 HR will be elevated in an attempt to
  compensate for fluid loss.
 Blood pressure will only drop as child is
  severely dehydrated (>10%).
 Treatment of Mild to Moderate
 ORT   – oral re-hydration therapy
    50 ml / kg every 4 hours
    Increase to 100 ml / kg every 4 hours
    Non carbonated soda, jell-o, fruit juices or tea.
    Commercially prepared solutions are the
     best.
         Re-hydration Therapy
 Increase  po fluids if diarrhea increases.
 Give po fluids slowly if vomiting.
 Stop ORT when hydration status is normal
 Start on BRAT diet
     Bananas
     Rice
     Applesauce
     Toast
  Teaching / Parent Instruction
 Call  PMD
 If diarrhea or vomiting increases
 No improvement seen in child’s hydration
  status.
 Child appears worse.
 Child will not take fluids.
 NO URINE OUTPUT
Moderate to Severe Dehydration




                       IV Therapy
                       needed
             Fluid replacement

 Isotonic   fluids initially:

     Normal Saline 0.9%
     Followed by: Dextrose 5% in.45 NS

  Potassium is added only after child has voided.
             Nursing Interventions
   Assess child’s hydration status
   Accurate intake and output
   Daily weights
       most accurate way to monitor fluid levels
   Hourly monitoring of IV rate and site of infusion.
       Increase fluids if increase in vomiting or diarrhea.
       Decrease fluids when taking po fluids or signs of
        edema.
               Care Reminder
A   severely dehydrated child will need
  more than maintenance to replace lost
  fluids. 1 ½ to 2 times maintenance.
 Adding potassium to IV solution.
     Never add in cases of oliguria / anuria
       • Urine output less than 0.5 mg/kg/hour
     Never give IV push
     Double check dosage
            Over hydration
 Occurs   when child receives more IV fluids
  that needed for maintenance.
 In pre-existing conditions such as
  meningitis, head trauma, kidney shutdown,
  nephrotic syndrome, congestive heart
  failure, or pulmonary congestion.
          Signs and Symptoms
 Tachypnea
 Dyspnea
 Cough
 Moistbreath sounds
 Weight gain from edema
 Jugular vein distention
             Safety Precautions
   Use small bags of fluid or buretrol to control fluid
    volume.
   Check IV solution infusion against physician
    orders.
   Always use infusion pump so that the rate can
    be programmed and monitored.
   Even mechanical pumps can fail, so check the
    intravenous bag and rate frequently.
   Record IV rate q hour
      Acid – Base Imbalances
Acidosis:                 Alkalosis.
 Respiratory acidosis     Respiratory alkalosis
  is too much carbonic      is too little carbonic
  acid in body.             acid.
 Metabolic Acidosis is    Metabolic alkalosis is
  too much metabolic        too little metabolic
  acid.                     acid.
        Respiratory Acidosis
 Caused   by the accumulation of carbon
  dioxide in the blood.
 Acute respiratory acidosis can lead to
  tachycardia and cardiac arrhythmias.
Causes of Respiratory Acidosis
 Any  factor that interferes with the ability of
  the lungs to excrete carbon dioxide can
  cause respiratory acidosis.
 Aspiration, spasm of airway, laryngeal
  edema, epiglottitis, croup, pulmonary
  edema, cystic fibrosis, and
  Bronchopulmonary dysplasia.
 Sedation overdose, head injury, or sleep
  apnea.
       Medical Management
 Correction  of underlying cause.
 Bronchodilators: asthma
 Antibiotics: infection
 Mechanical ventilation
 Decreasing sedative use.
        Respiratory Alkalosis
 Occurs when the blood contains too little
  carbon dioxide.
 Excess carbon dioxide loss is caused by
  hyperventilation.
    Causes of hyperventilation

   Hypoxemia
   Anxiety
   Pain
   Fever
   Salicylate poisoning: ASA
   Meningitis
   Over-ventilation
             Management
 Stress management if caused by
  hyperventilation.
 Pain control.
 Adjust ventilation rate.
 Treat underlying disease process.
        Metabolic Acidosis
 Caused by an imbalance in production and
 excretion of acid or by excess loss of
 bicarbonate.
                  Causes:
 Gain  in acid: ingestion of acids, oliguria,
  starvation (anorexia), DKA or diabetic
  ketoacidosis, tissue hypoxia.
 Loss of bicarbonate:
  diarrhea, intestinal or pancreatic fistula, or
  renal anomaly.
Ingestion of large doses of Aspirin
             Management
 Treat  and identify underlying cause.
 IV sodium bicarbonate in severe cases.
 Assess rate and depth of respirations and
  level of consciousness.
       Metabolic Alkalosis
A gain in bicarbonate or a loss of
 metabolic acid can cause metabolic
 alkalosis.
                 Causes:
 Gain  in bicarbonate:
Ingestion of baking soda or antacids.
Loss of acid:
Vomiting, nasogastric suctioning, diuretics
  massive blood transfusion
      Clinical Manifestations
             or tetany
 Hypertonicity
 Management: Correct the underlying
  condition