8Diagnostic Evaluation 1. Physical assessment (V/S)2. Type of dehydrationNursing Therapeutic management of fluid lossOral rehydration therapyParenteral fluid therapyMeet ongoing daily lossReplace previous deficitReplace ongoing abnormal losses
9Disturbance of F&E balance 1. Na K Ca( Na is the primary osmatic farce )Serum OsmolalityDefined as the number of particles per liter.May be approximated by:2(Na) + Glucose (mg/dl)/18 + BUN(mg/dl)/2.8Normal range: mOsm/Lcc/M2/dayLess in patients on the ventillator
13Pediatric Fluid Therapy Principles Assess water deficit by:1. weight:weight loss (Kg) = water loss (L)OR2. Estimation of water deficit by physical exam:Mild moderate severeInfants < 5 % % >10 %Older children < 3 % % > 6 %
14Type of Dehydration 1. Isotonic (affect ECF ,Na = 135meq /l) 2. Hypotonic( loss in ECF 2 correct ICF, Na = less than 135meq/l )3. Hypertonic( sever loss in ICF ,Na = more than 150meq/l
16Correction of Dehydration Moderate to severe dehydration:IV push10-20 cc / Kg Normal saline(5 % albumin)May repeat.Half deficit over 8 hours, and half over 16 hours.If hypernatremic dehydration, replace deficit over 48 hours (evenly distributed).
17Estimate Fluid Deficit (% :- Mild, Moderate, Severe).Find Type of Dehydration(Isonatremic, Hyponatremic, Hypernatremic).Give daily Maintenance.Give Deficit as follows:Half volume over 8 hours, half volume over 16 hours(Exception: in Hypernatremic Dehydration, replace deficit over 48 hours).
18Disturbance of acid based balance Plasma PHPlasma PCO2Plasma HCO3Respiratory AcidosisRespiratory AlkalosisMetabolic AcidosisMetabolic Alkalosis
19Nursing Intervention 1. Assessment 2. History 3. Clinical observation 4. Intake & output measurement5. Replace orally or IVF( 1g wet diaper wt =1 ml urine )
20Types of I.V solutions Solutions are three types - Isotonic it's total osmolality (TO) = TO of blood- Hypotonic: It's TO TO of blood- Hypertonic: it's TO TO of blood.* Electrolyte solutions considered isotonicIf total electrolyte content (TEC) 310mEq/L. and hypotonic if TEC 250 meq/L and hypertonic if TEC 375 Meq/L
21When administrating I.V fluid nurse should Monitors the response of the fluids. Considering the fluid volume. Content of fluid.Patient clinical status.
221. Isotonic fluids:-Have a total osmolality close to that of extra cellular fluids (ECF) and don't cause RBCs to shrink or swell.- 3 L of isotonic solutions are needed to replace 1 L of blood, so pt should be carefully monitored for signs of fluid overload.Examples of Isotonic fluids:D5W: has a serum osmolality of 252 mosm/L.D5W s mainly used supply water and to correct an increased serum osmolality
23Normal Saline Solution NS (0.9% Sodium chloride with TO of 308NS osmolality is contributed by electrolytes- So the solution remains within ECF.- NS is used to treat ECF deficit.- Ringer's solutions: Contains Ca, K and NaCl
242. Hypotonic Fluids- The purpose of hypotonic fluids is to replace cellular fluids, because it is hypotonic as compared with plasma.- It also used to provide free water for excretion of body wastes.- It may used to treat hypernatramia (hypotonic Na solutions).Examples of hypotonic solutions: 0.45% Nacl Half-strength saline.
25Complications of excessive use of hypotonic solutions include: Intravascular fluid depletion. Decreased blood pressure. Cellular edema.Cell damage
263.Hypertonic SolutionsHypertonic solutions exert an osmotic pressure greater than that of ECFExamples* High concentrations of dextrose such as 50% dextrose in water are used to help meet caloric requirements.These hypertonic solutions must be administered into control veins so that they can be diluted by rapid blood flow.
27Saline solutions are also available in osmolar pressures greater than that of ECF and cause cells to shrink.If administered rapidly or in large quantities, they may cause an extra cellular volume excess and cause circulatory overload and dehydration.
28*Management and Nsg Care for certain fluid and electrolyte balance disturbances 1-Water depletion- Provide replacement of fluid.-Determine and correct cause of water depletion.- Measure intake and output.- Monitor V/S
292- Water Excess:- Limit fluid intake.- Administer diuretics.- Monitor V/S- Determine and treat cause.- Analyze laboratory electrolyte measurement frequently
303- Hyponatremia - Determine and treat cause- Administer I.V fluids with appropriate saline concentration4- Hypernatramia:- Determine and treat cause.Administer fluids as prescribed.- Measure intake and output.- Monitor lab. Data.
31- Administer supplemental K. 5- Hypokalemia:- Determine and treat cause.- Monitor V/S and ECG.- Administer supplemental K.- Assess for adequate renal output before administration.IV: administered slowly.Oral: after high K fluids and foods.
326- Hyperkalemia- Determine and treat cause.- Monitor V/S and ECG - Administer I.V fluids if prescribed.- Monitor serum potassium levels. 7- Hypocalcaemia:- Determine and treat cause.- Administer calcium supp. as prescribed and administered slowly.Monitor serum calcium levels.Monitor serum protein level
338- Hypocalcaemia:- Determine and treat cause.- Monitor serum Ca levels.- Monitor ECG.
34SODIUMNa+ are very important for regulating blood and interstitial fluid pressures as well as nerve and muscle cell conduction of electrical currents. Aldosterone causes retention of Na+.
35a. HYPONATREMIA:-Vomiting, diarrhea, sweating, and burns cause Na+ loss. Dehydration, tachycardia and shock (see above) can result. Intake of plain water worsens the condition. Pedialyte is a better fluid to drink. Explain this.b. HYPERNATREMIASevere water deprivation, salt retention or excessive sodium intake causes this. Increased Na+ draws water outside of cells, resulting in tissue dehydration. Thirst, fatigue and coma result.
36CHLORIDECl- anion is necessary for the making of HCl, hyper polarization of neurons, regulating proper acid levels, and balancing osmotic pressures between compartments.
37a. HYPOCHLOREMIA Excessive vomiting causes chloride loss, resulting in blood and tissue alkalosis, and a depressed respiration rate. b. HYPERCLOREMIA Dehydration or chloride gain can result in renal failure or acidosis (increases in Cl- are accompanied by increases in H+).
38POTASSIUMK+ is important in the intracellular fluid. Aldosterone causes excretion of K+.a. HYPOKALEMIACaused by diarrhea, exhaustion phase of stress, excessive aldosterone secretions in adrenal cortical hyperplasia and some diuretics. K+ loss from cells contributes to tissue dehydration and acidosis. Flattened T waves, bradycardia, muscle spasms, a lengthened P-R, and mental confusion can also result.
39b. HYPERKALEMIACaused by eating large amounts of "light salt" (KCl), kidney failure, and decreased aldosterone secretions in Addison's Disease; resulting in elevated T waves and fibrillation of the heart. The movement of K+ into cells accompanies tissue alkalosis.
40CALCIUMCalcium Ca++ cations are needed for bone, muscle contraction, and synaptic transmission.
41a. HYPOCALCEMIAExcessive calcitonin, inadequate PTH, decreased Vita. D, or reduced Ca++ intake results in muscle cramps, and convulsions.b. HYPERCALCEMIAIncreased PTH, Vita. D or calcium intake can cause kidney stones, bone spurs, and lethargy.
42RESPIRATORY ACIDOSISIncreased pCO2 and pH below 7.35 due to hypoventilation, emphysema etc. Compensation occurs in the kidney through increased H+ excretion and HCO3- reabsorption. Bicarbonate/carbonic acid ratio is 10-15:1.
43RESPIRATORY ALKALOSIS Hyperventilation due to O2 deficiency, CVA, or anxiety are causes of respiratory alkalosis. Renal compensation occurs by decreasing H+ excretion and HCO3- reabsorption.H+ is reabsorbed. Bicarbonate/carbonic acid ratio is 30-40:1.
44METABOLIC ACIDOSISDue to loss of HCO3- by diarrhea, ketoacidosis, keto acids from a high protein diet, high stomach acidity, anaerobic fermentation, and renal disease. Compensation occurs by an increase in respiration rate. Bicarbonate/carbonic acid ratio is 10-15:1.
45METABOLIC ALKALOSISIncreased intake of antacids, low protein/high vegetable diet, and vomiting/loss of HCl are common causes. Compensation is by hypoventilation. Bicarbonate/carbonic acid ratio is 35:1.
46Child vs. Adult in medication administration 1. Water %2. Body service area3. Type of food4. Stomach acidity(infant much less than adult )5. Enzyme chains not maturity6. Rate of break down of drug ( growth &development rate )TPN replacement for chronic case
477. % of protein binding & fat distributions 8. Drug half life9. Excretion10. Gastric empty time11. Eating habits12. Exercise pattern13.sexual development
48Rout of medication administration 1. Orally Rectally Nasal4. IM IV transdermally7. Topical Inhalation* Calculation of medication1. Bwt Hight G&D4. Swallowing Past experience* 6 medication right
49Steps to give medication 1. Identification the child2. Oral medication ( infant…preschool …school age)3. Teach the child how to swallowing ( liqide need ½ hr ,Tablet (1/2-1hr)* Safe storage of medication* Determination of the correct dosage