Presentation on theme: "Fluid and Electrolytes"— Presentation transcript:
1 Fluid and Electrolytes Jan Bazner-ChandlerCPNP, CNS, MSN, RN
2 Alteration in Fluid and Electrolyte Status LungsBall &BenderUrine & fecesSkinNormal routes of fluid excretion in infants and children.
3 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.
4 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.
5 Developmental and Biologic Because of immature kidney function, children lack ability to adjust to major changes in sodium and other electrolytes.Normal urine output is 1 mL / kg / hr.More prone than adults to conditions that affect fluid and electrolyte status (diarrhea, vomiting, high fever.
6 Water Balance Regulated by Anti-diuretic Hormone ADH. Acts on kidney tubules to reabsorb water.The young infant is highly susceptible to dehydration.
7 Increased Water Needs Fever Vomiting and Diarrhea High-output in renal failureDiabetes insipidusBurnsShockTachypnea
9 AssessmentFocused Health HistoryFocused Physical Assessment
10 Focused Health History Recent fluid intake including type of fluid ingestedHow many voids in past 12 to 24 hours.Recent weight loss
11 Focused Physical Assessment How does the child look?Skin:TemperatureDry skin and mucous membranesPoor turgor, tenting, dough-like feelSunken eyeballs; no tearsPale, ashen, cyanotic nail beds or mucous membranes.Delayed capillary refill > 2-3 seconds
13 Cardiovascular Pulse rate change: Blood Pressure Note rate and quality: rapid, weak, or threadyBounding or arrhythmiasTachycardia #1 sign that something is wrongIncreased HR may be first subtle sign of hypovolemiaBlood PressureNote increase or decrease (remember it takes a 25% decrease in fluid or blood volume for change to occur)
14 Respiratory Change in rate or quality Dehydration or hypovolemia TachypneaApneaDeep shallow respirationsFluid overloadMoist breath soundsCough
15 Diagnostic TestsMake sure free flowing specimen is obtained, a hemolyzed or clotted specimen may give false values.
16 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.
17 ElectrolytesElectrolytes 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.
18 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
19 Potassium Adults: 3.5 to 5.3 mEq /L Child: 3.5 to 5.5 mEq / L Infant: 3.6 to 5.8 mEq / LPanic Values< 2.5 mEq /L or > 7.0 mEq / L
20 Hyperkalemia Defined as potassium level above 5.0 mEq / L Significant dysrhythmias and cardiac arrestAdequate intake of fluids to insure excretion of potassium through the kidneys.
21 Causes of Hyperkalemia Acute renal failureChronic renal failureGlomerulonephritis
25 Causes of Hypokalemia Vomiting / diarrhea Malnutrition / starvation Stress due to trauma from injury or surgery.Gastric suction / intestinal fistulaPotassium wasting diureticsIngestion of large amounts of ASA
26 Foods high in potassium Apricots, bananas, oranges, pomegranates, prunesBaked potato with skin, spinach, tomato, lima beans, squashMilk and yogurtPork, veal and fish
27 Monitor Potassium Levels A child with a nasogastric tube in place that is set to suction,needs to have potassium levels monitored.
28 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
29 HyponatremiaReflects 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.
30 PathophysiologyWhen 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
31 Early Manifestations Anorexia, nausea, lethargy and apathy More advanced symptoms: disorientation, agitation, seizures, depressed reflexes, focal neurological deficitsSevere: coma and seizures: sodium concentration less than 120 mEq/L
32 HypernatremiaSerum 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.
33 Clinical PearlMost infant with severe dehydration have a history of lethargy, listlessness, and decreased responsiveness; those with hypernatremia dehydration tend to be irritable and fussy.
34 Hypernatremia Inadequate fluid intake – 75% Gastrointestinal losses – 44%Occurs primarily in infants with diarrhea dehydrationDiabetes insipidus was major reason for excessive urinary outputLoss from high fever, environmental temperatures and hyperventilation
35 Primary Sodium ExcessImproperly mixed formula or re-hydration solutionIngestion of sea waterHypertonic saline IVHigh breast milk sodium
36 Primary Water Deficit Diabetes Insipidus Diabetes Mellitus Gastroenteritis (water loss greater than solute loss)Inadequate breast feedingWithholding of water: handicappedIncreased insensible loss – premature infant
37 Additional Lab Values Arterial blood gas to determine acid-base status Urine specific gravity: measures kidney’s ability to dilute and concentrate urine.normal values to 1.020Low specific gravity may indicate fluid excess of kidney disease.High specific gravity may indicate fluid deficit.
38 Treatment ModalitiesPeripheral IV with IVhouse.
39 Intraosseous TherapyIntraosseous needle in place for emergency vascular access.
41 Total Parental Nutrition A tunneled catheter should haveAn occlusive dressing in place.Whaley & Wong
42 Complications of TPN Sepsis: infection Liver dysfunction Respiratory distress from too –rapid infusion of fluids
43 TPN TherapyTPN 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.
44 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.
45 DehydrationSignificant depletion of body water. Signs and symptoms include thirst, lethargy, dry mucosa, decreased urine output, and as the degree of dehydration progresses, tachycardia, hypotension, and shock.
46 Cause of DehydrationMost common cause is fluid loss in the GI tract from vomiting, diarrhea or both.Hypovolemic Shock = second most common cause of cardiac arrest in infants / childrenLoss of FluidsLoss of blood volume
47 Diarrhea Most common cause of diarrhea in infant / child is Rotovirus WHO recommends immunization against Rotovirus to decrease infant deaths world wide.
49 Isotonic Dehydration Sodium and water are lost in proportional amounts Reduction in circulating blood volume
50 Hyponatremic Dehydration Hypotonic dehydration: results from water retention or sodium loss.Two causes:Formula is diluted with water beyond manufacturer recommendationFluid loss is replaced with electrolyte-free water.
51 Hypernatremic Dehydration Marked by elevated sodium levels
53 General Assessment Loss of weight Level of consciousness Alert to irritableRestless to lethargicLethargic to coma
54 Vital SignsThe 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%).
55 Skin TurgorIn moderate dehydration the skin may have a doughy texture and appearance.In severe dehydration the more typical “tenting” of skin is observed.
57 WeightCaREminder; one kilogram of body weight equals the weight of 1 L of water, thus, the amount of fluid gain or loss can be calculated from weight gain or loss.Nursing intervention: compare daily weight with previous measurement and note trends.
58 Urine Output Normal urine output is 1-2 mL/kg/hr In mild dehydration urine output may be low – parent may report decrease in voidingModerate 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.
59 Treatment of Mild to Moderate ORT – oral re-hydration therapy50 ml / kg every 4 hoursIncrease to 100 ml / kg every 4 hoursNo carbonated soda, jell-o, fruit juices or tea.Commercially prepared solutions are the best.
60 Re-hydration Therapy Increase po fluids if diarrhea increases. Give po fluids slowly if vomiting.Stop ORT when hydration status is normalStart on BRAT dietBananasRiceApplesauceToast
61 Teaching / Parent Instruction Call PMDIf diarrhea or vomiting increasesNo improvement seen in child’s hydration status.Child appears worse.Child will not take fluids.NO URINE OUTPUT
62 Moderate to Severe Dehydration IV Therapy needed
63 Fluid ResuscitationCrystalloid Solution: used for volume resuscitation to expand the interstitial volume rather that the plasma volume.Isotonic Saline is the prototype crystalloid fluid. 0.9% NaCl or normal saline.Lactated Ringers contains potassium and calcium.
64 Fluid Replacement Standard Orders: Normal Saline or 0.9% NaCl at 20 mL / kgFollowed by Dextrose 5% in 0.45 normal salineFollowed by Dextrose 5% in 0.45 normal saline with 20 mEq KCL per 1000 mLPotassium is only added to the IV when there is documentation of voiding.
65 Nursing Interventions Assess child’s hydration statusAccurate intake and outputDaily weightsmost accurate way to monitor fluid levelsHourly 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.
66 Care ReminderA 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 / anuriaUrine output less than 0.5 mg/kg/hourNever give IV pushDouble check dosage
67 Over hydrationOccurs 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.
68 Signs and Symptoms Tachypnea Dyspnea Cough Moist breath sounds Weight gain from edemaJugular vein distention
69 Safety PrecautionsUse 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
70 Acid – Base Imbalances Acidosis: Respiratory acidosis is too much carbonic acid in body.Metabolic Acidosis is too much metabolic acid.Alkalosis.Respiratory alkalosis is too little carbonic acid.Metabolic alkalosis is too little metabolic acid.
71 Respiratory AcidosisCarbonic acid excess: CO2 is retained and pH decreasesCaused by the accumulation of carbon dioxide in the blood.Acute respiratory acidosis can lead to tachycardia and cardiac arrhythmias.
72 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.
80 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.
81 Assessment Kussmaul respirations SOB on exertion Weakness Drowsiness to stuporWhen pH is < 7.2 cardiac contractility is reduced – BP will decrease
82 Management Treat and identify underlying cause. IV sodium bicarbonate in severe cases.Provide low-protein, high-calorie dietPosition to facilitate ventilation
83 Metabolic AlkalosisA gain in bicarbonate or a loss of metabolic acid can cause metabolic alkalosis.
84 Causes: Gain in bicarbonate: Ingestion of baking soda or antacids. Loss of acid:Vomiting, nasogastric suctioning, diuretics massive blood transfusion
85 Assessment Signs similar to dehydration Tachycardia Hypoventilation Muscle hypertonicityConfusion, irritability, coma
86 Treatment Administer fluid containing sodium and potassium Avoid antacidsManagement: Correct the underlying condition