Alteration in Fluid and Electrolyte Status Lecture Notes

8/3/2019 Alteration in Fluid and Electrolyte Status Lecture Notes

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Alteration in Fluid and Electrolyte Status Lecture notes

Fluid and Electrolytes

Alteration in Fluid and Electrolyte Status Lecture notes

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 andDiarrhea

High-output in renal failure

Diabetes insipidus

Burns

Shock

Tachypnea

Decreased Water Needs

CongestiveHeart Failure

Mechanical Ventilation

Renal failure

Head trauma /meningitis
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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

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 falsevalues.

Hemoglobin and Hematocrit

Measures hemoglobin, themain component of erythrocytes, which is the vehicle for transporting

oxygen.

Hgb and hct will be increased in extracellular fluid volume loss.


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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

Panic Values:

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

Irregular heart rate

Pulse slow / irregular

Causes of Hyperkalemia

Acute renal failure

Chronic renal failure

Glomerulonephritis

Diagnostic tests:

Serum potassium

ECG

Bradycardia

Heart block


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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 fishMonitor Potassium Levels

Sodium

Sodium is the most abundant cation and chief base of the blood.

The primary function is to chemicallymaintain osmotic pressure and acid-base balance and to

transmit nerve impulses.

Normal values: 135 to 148 mEq / L

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.

Pathophysiology

When sodium levels drop in the fluids outside the cells, water will sweep into the cells in an attempt


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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, mucousmembrane 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

Inad

equate 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


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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 ModalitiesIntraosseous Therapy

Central Venous Catheter

Total Parental Nutrition

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 ofweight

Level of consciousness

Alert to irritable


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Restless to lethargic

Lethargic to coma

Skin Turgor

In moderate 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 themost 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


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Call PMD

If diarrhea or vomiting increases

No improvement seen in childs hydration status.

Child appears worse.

Child will not take fluids.

NO URINE OUTPUT

Moderate to Severe Dehydration

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 childs 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 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 formaintenance.

In pre-existing conditions such as meningitis, head trauma, kidney shutdown, nephrotic syndrome,


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congestive heart failure, or pulmonary congestion.

Signs and Symptoms

Tachypnea

Dyspnea

Cough

Moist breath 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 andmonitored.

Even mechanical pumps can fail, so check the intravenous bag and rate frequently.

Record IV rate q hour

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.

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


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Mechanical ventilation

Decreasing sedative use.

Respiratory Alkalosis

Occurswhen 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:


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Gain in bicarbonate:

Ingestion of baking soda or antacids.

Loss of acid:

Vomiting, nasogastric suctioning, diuretics massive blood transfusion

Clinical Manifestations

Hypertonicity or tetany

Management: Correct the underlying condition

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Alteration in Fluid and Electrolyte Status Lecture Notes