Fluid and Electrolyte 10 r

8/6/2019 Fluid and Electrolyte 10 r

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Fluid and ElectrolytesFluid and ElectrolytesJan BaznerJan Bazner--ChandlerChandler

CPNP, CNS, MSN, RNCPNP, CNS, MSN, RN


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Alteration in Fluid andAlteration in Fluid and

Electrolyte StatusElectrolyte Status

Normal routes of fluid excretion in infants and children.

Lungs

SkinUrine & feces

Ball &Bender


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Regulatory MechanismsRegulatory Mechanisms

KidneysKidneys

Gastrointestinal tractGastrointestinal tract

Thermoregulatory mechanismThermoregulatory mechanism Thirst mechanismThirst mechanism


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KidneysKidneys

Regulate fluid by their ability toRegulate fluid by their ability to

concentrate and dilute urine.concentrate and dilute urine.

When serum sodium levels are high, ADHWhen serum sodium levels are high, ADHis secreted and increases permeability ofis secreted and increases permeability of

kidneys distal tubules and ducts.kidneys distal tubules and ducts.

AngiotensinAngiotensin--reninrenin system along withsystem along with

aldosteronealdosterone assists in regulating fluids andassists in regulating fluids and

electrolytes homeostasis.electrolytes homeostasis.


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Gastrointestinal TractGastrointestinal Tract

In GI tractIn GI tract water and sodium arewater and sodium are

reabsorbed and potassium is secreted.reabsorbed and potassium is secreted.

Fluid is replaced through oral intake.Fluid is replaced through oral intake.Due to large surface area of GI tractDue to large surface area of GI tract

changed in fluid and electrolyte balancechanged in fluid and electrolyte balance

can occur rapidly.can occur rapidly.


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Thermoregulatory MechanismThermoregulatory Mechanism

Insensible lossInsensible loss passive water losspassive water loss

through skin and lungsthrough skin and lungs

No electrolytes are lostNo electrolytes are lost


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Thirst MechanismThirst Mechanism

Thirst center is located in theThirst center is located in the

hypothalamushypothalamus

Thirst is stimulated by decrease inThirst is stimulated by decrease inintravascular volumeintravascular volume


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Developmental and BiologicalDevelopmental and Biological

VariancesVariances Infants younger than 6 weeks do notInfants younger than 6 weeks do not

produce tears.produce tears.

In an infant aIn an infant a sunken fontanelsunken fontanel maymayindicate dehydration.indicate dehydration.

Infants are dependant on others to meetInfants are dependant on others to meet

their fluid needs.their fluid needs.

Infants have limited ability to dilute andInfants have limited ability to dilute and

concentrate urine.concentrate urine.


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Developmental and BiologicalDevelopmental and Biological

The smaller the child, the greater theThe smaller the child, the greater the

proportion of body water to weight andproportion of body water to weight and

proportion of extracellular fluid toproportion of extracellular fluid to

intracellular fluid.intracellular fluid.

Infants have a larger proportional surfaceInfants have a larger proportional surface

are of the GI tract than adults.are of the GI tract than adults.

Infants have a higher metabolic rate thanInfants have a higher metabolic rate than

adults. (increased HR and RR)adults. (increased HR and RR)


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Developmental and BiologicDevelopmental and Biologic

Because of immature kidney function,Because of immature kidney function,

children lack ability to adjust to majorchildren lack ability to adjust to major

changes in sodium and other electrolytes.changes in sodium and other electrolytes.

Normal urine output is 1 mL / kg / hr.Normal urine output is 1 mL / kg / hr.

More prone than adults to conditions thatMore prone than adults to conditions that

affect fluid and electrolyte status (diarrhea,affect fluid and electrolyte status (diarrhea,

vomiting, high fever).vomiting, high fever).


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Increased Water NeedsIncreased Water Needs

FeverFever

Vomiting and DiarrheaVomiting and Diarrhea

DiabetesDiabetes insipidusinsipidus BurnsBurns

Shock (Shock (hypovolemichypovolemic))

TachypneaTachypnea


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Decreased Water NeedsDecreased Water Needs

Congestive Heart FailureCongestive Heart Failure

Mechanical VentilationMechanical Ventilation

Renal failureRenal failureHead trauma / meningitisHead trauma / meningitis


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Focused Health HistoryFocused Health History

Recent fluid intake including type of fluidRecent fluid intake including type of fluid

ingestedingested

How many voids in past 12 to 24 hours.How many voids in past 12 to 24 hours.RecentRecent weight lossweight loss oror gaingain


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Focused Physical AssessmentFocused Physical Assessment

How does the child look?How does the child look?

Skin:Skin:

TemperatureTemperature

Dry skin and mucous membranesDry skin and mucous membranes

PoorPoor turgorturgor, tenting, dough, tenting, dough--like feellike feel

Sunken eyeballs; no tearsSunken eyeballs; no tears

Pale, ashen, cyanotic nail beds or mucousPale, ashen, cyanotic nail beds or mucousmembranes.membranes.

Delayed capillary refill > 2Delayed capillary refill > 2--3 seconds3 seconds


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Loss of Skin ElasticityLoss of Skin Elasticity

Loss of skin elasticityDue to dehydration.


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RespiratoryRespiratory

Change in rate or qualityChange in rate or quality

Dehydration or hypovolemiaDehydration or hypovolemia

TachypneaTachypnea ApneaApnea

Deep shallow respirationsDeep shallow respirations

Fluid overloadFluid overload Moist breath soundsMoist breath sounds

CoughCough


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WeightWeight

Weigh the child and compare withWeigh the child and compare with

previous recent weights if available.previous recent weights if available.

Substantial fluid loss or gain will beSubstantial fluid loss or gain will bereflected inreflected in weight changesweight changes..

MostMost accurateaccurate indicator of fluid status.indicator of fluid status.

In the hospitalized child daily weight mayIn the hospitalized child daily weight maybe ordered.be ordered.


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Kidney FunctionKidney Function

Urine outputUrine output

Urine specific gravityUrine specific gravity

Blood Urea NitrogenBlood Urea Nitrogen BUN > 100 mg/dl =BUN > 100 mg/dl = dehyrationdehyration

AlbuminAlbumin

CreatinineCreatinine


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Hemoglobin and HematocritHemoglobin and Hematocrit

Measures hemoglobin, the mainMeasures hemoglobin, the main

component of erythrocytes, which is thecomponent of erythrocytes, which is the

vehicle for transporting oxygen.vehicle for transporting oxygen.

HgbHgb andand hcthct will bewill be increasedincreased in extracellularin extracellular

fluid volume loss.fluid volume loss.

HgbHgb andand hcthct will bewill be decreaseddecreased in extracellularin extracellularfluid volume excess.fluid volume excess.


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Urine Specific GravityUrine Specific Gravity

Normal values:Normal values:

Neonate: 1.001 to 1.020Neonate: 1.001 to 1.020

Infant / child: 1.010 to 1.020 (infant) 1.010 toInfant / child: 1.010 to 1.020 (infant) 1.010 to1.030 in older child / adult1.030 in older child / adult

Low specific gravity = fluid excess orLow specific gravity = fluid excess or

kidney diseasekidney disease

High specific gravity = fluid deficitHigh specific gravity = fluid deficit

(hypovolemia).(hypovolemia).


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ElectrolytesElectrolytes

Electrolytes account for approximatelyElectrolytes account for approximately

95% of the solute molecules in body95% of the solute molecules in body

water.water.

SodiumSodium Na+ is the predominantNa+ is the predominant

extracellularextracellular cationcation..

PotassiumPotassium K+ is the predominantK+ is the predominant

intracellularintracellular cationcation..


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SodiumSodium

Sodium is the most abundant cation andSodium is the most abundant cation and

chief base of the blood.chief base of the blood.

The primary function is to chemicallyThe primary function is to chemicallymaintain osmotic pressure and acidmaintain osmotic pressure and acid--basebase

balance and to transmit nerve impulses.balance and to transmit nerve impulses.

Normal values: 135 to 148 mEq / LNormal values: 135 to 148 mEq / L


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HyponatremiaHyponatremia

Serum sodium levels less than 130Serum sodium levels less than 130 mEqmEq/L./L.


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Clinical ManifestationsClinical Manifestations

Anorexia, nausea, lethargy and apathyAnorexia, nausea, lethargy and apathy

More advanced symptoms: disorientation,More advanced symptoms: disorientation,

agitation, irritability,agitation, irritability, depressed reflexesdepressed reflexes,,seizuresseizures

Severe: coma and seizures: sodiumSevere: coma and seizures: sodium

concentration less than 120concentration less than 120 mEqmEq/L/L


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ManagementManagement

IV sodium and fluid replacementIV sodium and fluid replacement

Restricting water intakeRestricting water intake

Oral reOral re--hydration commercial fluidshydration commercial fluids Stop diuretic therapyStop diuretic therapy

Make sure family is preparing formulaMake sure family is preparing formula

correctlycorrectly do not overdo not over--dilutedilute


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HypernatremiaHypernatremia

Serum sodium levels exceeding 150Serum sodium levels exceeding 150

mEqmEq/L/L


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Primary Sodium ExcessPrimary Sodium Excess

Improperly mixed formula or reImproperly mixed formula or re--hydrationhydration

solutionsolution

Ingestion of sea waterIngestion of sea waterHypertonic saline IVHypertonic saline IV

High breast milk sodiumHigh breast milk sodium


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Bring sodium levels down to normal andBring sodium levels down to normal and

restore hydration gradually over 48 hours.restore hydration gradually over 48 hours.

Check for proper formula preparationCheck for proper formula preparation totolittle water mixed with formulalittle water mixed with formula

Lactation consultantLactation consultant

Do not give boiled skim milk

Do not give boiled skim milk


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PotassiumPotassium

High or low values can lead to cardiacHigh or low values can lead to cardiac

arrest.arrest.

With adequate kidney function excessWith adequate kidney function excesspotassium is excreted in the kidneys.potassium is excreted in the kidneys.

If kidneys are not functioning, theIf kidneys are not functioning, the

potassium will accumulate in thepotassium will accumulate in the

intravascular fluidintravascular fluid


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PotassiumPotassium

Adults: 3.5 to 5.3Adults: 3.5 to 5.3 mEqmEq /L/L

Child: 3.5 to 5.5Child: 3.5 to 5.5 mEqmEq / L/ L

Infant: 3.6 to 5.8Infant: 3.6 to 5.8 mEqmEq / L/ L

Panic ValuesPanic Values

< 2.5< 2.5 mEqmEq /L or > 7.0/L or > 7.0 mEqmEq / L/ L


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HyperkalemiaHyperkalemia

Defined as potassium level above 5.0Defined as potassium level above 5.0 mEqmEq/ L/ L

Causes: dehydration or renal diseaseCauses: dehydration or renal disease


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Diagnostic tests:Diagnostic tests:

Serum potassiumSerum potassium

ECGECG

BradycardiaBradycardia Heart blockHeart block

Ventricular fibrillationVentricular fibrillation


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Interdisciplinary InterventionsInterdisciplinary Interventions

CalciumCalcium gluconategluconate 10% IV to stabilize cell10% IV to stabilize cell

membranemembrane

Peritoneal dialysis until kidney function isPeritoneal dialysis until kidney function isrestoredrestored


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HypokalemiaHypokalemia

Potassium level below 3.5 mEq / LPotassium level below 3.5 mEq / L

Before administering make sure child isBefore administering make sure child is

producing urine.producing urine. A child on potassium wasting diuretics isA child on potassium wasting diuretics is

at riskat risk LasixLasix


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Clinical Manifestations:Clinical Manifestations:

HypokalemiaHypokalemia

Neuromuscular manifestations are: neckNeuromuscular manifestations are: neck

flop, diminished bowel sounds,flop, diminished bowel sounds, truncaltruncal

weakness, limb weakness, lethargy, andweakness, limb weakness, lethargy, and

abdominal distention.abdominal distention.


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Causes ofHypokalemiaCauses ofHypokalemia

Vomiting / diarrheaVomiting / diarrhea

Malnutrition / starvationMalnutrition / starvation

Stress due to trauma from injury orStress due to trauma from injury orsurgery.surgery.

Gastric suction / intestinal fistulaGastric suction / intestinal fistula

Potassium wasting diureticsPotassium wasting diuretics Ingestion of large amounts ofASAIngestion of large amounts ofASA


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Nursing AlertNursing Alert

Before administering a potassiumBefore administering a potassium

supplement make sure the child issupplement make sure the child is

producing urine.producing urine.


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Foods high in potassiumFoods high in potassium

Apricots, bananas, oranges,Apricots, bananas, oranges,

pomegranates, prunespomegranates, prunes

Baked potato with skin, spinach, tomato,Baked potato with skin, spinach, tomato,lima beans, squashlima beans, squash

Milk and yogurtMilk and yogurt

Pork, veal and fishPork, veal and fish


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Treatment ModalitiesTreatment Modalities

Peripheral IV with IVhouse.


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Intraosseous TherapyIntraosseous Therapy

Intraosseous needle in place for emergency vascular access.


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DehydrationDehydration

Significant depletion of body water. SignsSignificant depletion of body water. Signs

and symptoms include thirst, lethargy, dryand symptoms include thirst, lethargy, dry

mucosa, decreased urine output, and asmucosa, decreased urine output, and as

the degree of dehydration progresses,the degree of dehydration progresses,

tachycardia, hypotension, and shock.tachycardia, hypotension, and shock.


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Cause ofDehydrationCause ofDehydration

Most common cause is fluid loss in the GIMost common cause is fluid loss in the GI

tract from vomiting, diarrhea or both.tract from vomiting, diarrhea or both.

H

ypovolemic ShockH

ypovolemic Shock = second most= second mostcommon cause of cardiac arrest in infantscommon cause of cardiac arrest in infants

/ children/ children

Loss of FluidsLoss of Fluids

Loss of blood volumeLoss of blood volume


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DiarrheaDiarrhea

Most common cause of diarrhea in infant /Most common cause of diarrhea in infant /

child ischild is RotovirusRotovirus

WH

O recommends immunization againstWH

O recommends immunization againstRotovirusRotovirus to decrease infant deaths worldto decrease infant deaths world

wide.wide.


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DehydrationDehydration


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Treatment of Mild to ModerateTreatment of Mild to Moderate

ORTORT oral reoral re--hydration therapyhydration therapy

50 ml / kg every 4 hours50 ml / kg every 4 hours

Increase to 100 ml / kg every 4 hoursIncrease to 100 ml / kg every 4 hours

No carbonated soda, jellNo carbonated soda, jell--o, fruit juices or tea.o, fruit juices or tea.

Commercially prepared solutions are theCommercially prepared solutions are the

best.best.


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Moderate to Severe DehydrationModerate to Severe Dehydration

IV Therapyneeded


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Fluid ResuscitationFluid Resuscitation

Crystalloid Solution: used for volumeCrystalloid Solution: used for volumeresuscitation to expand the interstitialresuscitation to expand the interstitial

volume rather that the plasma volume.volume rather that the plasma volume. Isotonic Saline is the prototype crystalloidIsotonic Saline is the prototype crystalloid

fluid. 0.9%fluid. 0.9% NaClNaCl or normal saline.or normal saline.


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Fluid ReplacementFluid Replacement

Standard Orders:Standard Orders:

Normal Saline or 0.9%Normal Saline or 0.9% NaClNaCl at 20 mL / kgat 20 mL / kg

Followed by Dextrose 5% in 0.45 normalFollowed by Dextrose 5% in 0.45 normal

salinesaline

Followed by Dextrose 5% in 0.45 normalFollowed by Dextrose 5% in 0.45 normal

saline with 20saline with 20 mEqmEq KCL per 1000 mLKCL per 1000 mL

Potassium is only added to the IV when therePotassium is only added to the IV when thereis documentation of voiding.is documentation of voiding.


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Care ReminderCare Reminder

A severely dehydrated child will needA severely dehydrated child will need

more than maintenance to replace lostmore than maintenance to replace lost

fluids. 1 to 2 times maintenance.fluids. 1 to 2 times maintenance.

It is the nurses responsibility to check fluidIt is the nurses responsibility to check fluid

calculations at the beginning of the shiftcalculations at the beginning of the shift

(24 hour fluid needs / hourly IV rate)(24 hour fluid needs / hourly IV rate)


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Over hydrationOver hydration

Occurs when child receives more IV fluidsOccurs when child receives more IV fluids

that needed for maintenance.that needed for maintenance.

In preIn pre--existing conditions such asexisting conditions such as

meningitis, head trauma, kidney shutdown,meningitis, head trauma, kidney shutdown,

nephrotic syndrome, congestive heartnephrotic syndrome, congestive heart

failure, or pulmonary congestion.failure, or pulmonary congestion.


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Assessment of overAssessment of over--hydrationhydration

TachypneaTachypnea

DyspneaDyspnea

CoughCoughMoist breath soundsMoist breath sounds

Weight gainWeight gain from edemafrom edema

Jugular vein distentionJugular vein distention


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Safety PrecautionsSafety Precautions

Use small bags of fluid orUse small bags of fluid or buretrolburetrol to control fluidto control fluidvolume.volume.

Check IV solution infusion against physicianCheck IV solution infusion against physician

orders.orders. Always use infusion pump so that the rate canAlways use infusion pump so that the rate can

be programmed and monitored.be programmed and monitored.

Calculate 24 hour fluid needsCalculate 24 hour fluid needs

Record IV rate q hourRecord IV rate q hour


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AcidAcid Base ImbalancesBase Imbalances

Acidosis:Acidosis:

Respiratory acidosisRespiratory acidosis

is too much carbonicis too much carbonic

acid in body.acid in body. Metabolic Acidosis isMetabolic Acidosis is

too much metabolictoo much metabolic

acid.acid.

Alkalosis.Alkalosis.

Respiratory alkalosisRespiratory alkalosis

is too little carbonicis too little carbonic

acid.acid. Metabolic alkalosis isMetabolic alkalosis is

too little metabolictoo little metabolic

acid.acid.


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Respiratory AcidosisRespiratory Acidosis

Carbonic acid excess: CO2 is retained andCarbonic acid excess: CO2 is retained and

pH decreasespH decreases

Caused by the accumulation of carbonCaused by the accumulation of carbon

dioxide in the blood.dioxide in the blood.

Acute respiratory acidosis can lead toAcute respiratory acidosis can lead to

tachycardia and cardiac arrhythmias.tachycardia and cardiac arrhythmias.


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Causes of Respiratory AcidosisCauses of Respiratory Acidosis

Any factor that interferes with the ability ofAny factor that interferes with the ability ofthe lungs to excrete carbon dioxide canthe lungs to excrete carbon dioxide cancause respiratory acidosis.cause respiratory acidosis.

Aspiration, spasm of airway, laryngealAspiration, spasm of airway, laryngealedema, epiglottitis, croup, pulmonaryedema, epiglottitis, croup, pulmonaryedema, cystic fibrosis, andedema, cystic fibrosis, andBronchopulmonary dysplasia.Bronchopulmonary dysplasia.

Sedation overdose, head injury, or sleepSedation overdose, head injury, or sleepapnea.apnea.


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AssessmentAssessment

Respiratory distressRespiratory distress

CNS depression: disorientation, comaCNS depression: disorientation, coma

Hypoxia: restlessness, irritability,

Hypoxia: restlessness, irritability,tachycardia, arrhythmiastachycardia, arrhythmias

Muscle weaknessMuscle weakness


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Medical ManagementMedical Management

Correction of underlying causeCorrection of underlying cause

Bronchodilators: asthmaBronchodilators: asthma

Antibiotics: infection

Antibiotics: infection

Mechanical ventilationMechanical ventilation

Decreasing sedative useDecreasing sedative use


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Respiratory AlkalosisRespiratory Alkalosis

Carbonic acid deficit; not enough CO2 isCarbonic acid deficit; not enough CO2 is

retained, and pH increases.retained, and pH increases.

Excess carbon dioxide loss is caused byExcess carbon dioxide loss is caused by

hyperventilation.hyperventilation.


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Causes of hyperventilationCauses of hyperventilation

HypoxemiaHypoxemia

AnxietyAnxiety

PainPain FeverFever

Salicylate poisoning: ASASalicylate poisoning: ASA

MeningitisMeningitis

OverOver--ventilationventilation


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DizzinessDizziness

Numbness orNumbness or paresthesiasparesthesias of fingers andof fingers and

toestoes

TetanyTetany

ConvulsionsConvulsions

UnconsciousnessUnconsciousness


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Stress management if caused byStress management if caused by

hyperventilation.hyperventilation.

Pain control.Pain control.

Adjust ventilation rate.Adjust ventilation rate.

Treat underlying disease process.Treat underlying disease process.

Have child slow respirations, breathe into

Have child slow respirations, breathe intopaper bagpaper bag


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Metabolic AcidosisMetabolic Acidosis

Bicarbonate deficitBicarbonate deficit


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Causes:Causes:

Gain in acidGain in acid: ingestion of acids,: ingestion of acids, oliguriaoliguria,,starvation (anorexia), DKA or diabeticstarvation (anorexia), DKA or diabeticketoacidosisketoacidosis, tissue hypoxia., tissue hypoxia.

Loss ofbicarbonateLoss ofbicarbonate::diarrhea, intestinal or pancreatic fistula, ordiarrhea, intestinal or pancreatic fistula, orrenal anomaly.renal anomaly.


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KussmaulKussmaul respirationsrespirations slow and deepslow and deep

SOB on exertionSOB on exertion

WeaknessWeaknessDrowsiness to stuporDrowsiness to stupor

When pH is < 7.2 cardiac contractility isWhen pH is < 7.2 cardiac contractility is

reducedreduced BP will decreaseBP will decrease


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Treat and identify underlying cause.Treat and identify underlying cause.

IV sodium bicarbonate in severe cases.IV sodium bicarbonate in severe cases.

Provide lowProvide low--protein, highprotein, high--calorie dietcalorie diet Position to facilitate ventilationPosition to facilitate ventilation


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Causes:Causes:

Gain in bicarbonate:Gain in bicarbonate:

Ingestion of baking soda or antacids.Ingestion of baking soda or antacids.

Loss

ofacid:

Loss

ofacid:

Vomiting, nasogastric suctioning, diureticsVomiting, nasogastric suctioning, diuretics

massive blood transfusionmassive blood transfusion


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Signs similar to dehydrationSigns similar to dehydration

TachycardiaTachycardia

Hypoventilation

Hypoventilation

MuscleMuscle hypertonicityhypertonicity

Confusion, irritability, comaConfusion, irritability, coma


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TreatmentTreatment

Administer fluid containing sodium andAdminister fluid containing sodium and

potassiumpotassium

Avoid antacidsAvoid antacids

Management: Correct the underlyingManagement: Correct the underlying

conditioncondition

Fluid and Electrolyte 10 r

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