Fluid and ElectrolytesFluid and ElectrolytesInfants and childrenInfants and children

Alteration in Fluid and Alteration in Fluid and Electrolyte StatusElectrolyte Status

Normal routes of fluid excretion in infants and children.

Lungs

SkinUrine & faeces

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Developmental and Biological Developmental and Biological VariancesVariances

Infants younger than 6 weeks do not Infants younger than 6 weeks do not produce tears.produce tears.In an infant a sunken fontanel may In an infant a sunken fontanel may indicate dehydration.indicate dehydration.Infants are dependant on others to meet Infants are dependant on others to meet their fluid needs.their fluid needs.Infants have limited ability to dilute and Infants have limited ability to dilute and concentrate urine.concentrate urine.

Developmental and BiologicalDevelopmental and Biological

Smaller the child, greater proportion of Smaller the child, greater proportion of body water to weight and proportion of body water to weight and proportion of extracellular fluid to intracellular fluid.extracellular fluid to intracellular fluid.Infants larger proportional surface area of Infants larger proportional surface area of GI tract than adults. GI tract than adults. Infants greater body surface area and Infants greater body surface area and higher metabolic rate than adults.higher metabolic rate than adults.

Water BalanceWater Balance

Regulated by AntiRegulated by Anti--diuretic Hormone ADH.diuretic Hormone ADH.Acts on kidney tubules to reabsorb water.Acts on kidney tubules to reabsorb water.The young infant is highly susceptible to The young infant is highly susceptible to dehydration.dehydration.

Increased Water NeedsIncreased Water Needs

Fever / sepsisFever / sepsisVomiting and Vomiting and DiarrhoeaDiarrhoeaHighHigh--output in renal failureoutput in renal failureDiabetes insipidusDiabetes insipidusBurnsBurnsShockShockTachypneaTachypnea

Decreased Water NeedsDecreased Water Needs

Congestive Heart FailureCongestive Heart FailureMechanical VentilationMechanical VentilationRenal failureRenal failureHead trauma / meningitisHead trauma / meningitis

General AppearanceGeneral Appearance

How does the child look?How does the child look?Skin:Skin:•• TemperatureTemperature•• Dry skin and mucous membranesDry skin and mucous membranes•• Poor turgor, tenting, doughPoor turgor, tenting, dough--like feellike feel•• Sunken eyeballs; no tearsSunken eyeballs; no tears•• Pale, ashen, cyanotic nail beds or mucous Pale, ashen, cyanotic nail beds or mucous

membranes. membranes. •• Delayed capillary refill > 3 secondsDelayed capillary refill > 3 seconds

Loss of Skin ElasticityLoss of Skin Elasticity

Loss of skin elasticityDue to dehydration.

Whaley & Wong Text

CardiovascularCardiovascular

Pulse rate change:Pulse rate change:Note rate and qualityNote rate and qualityRapid, weak, or Rapid, weak, or threadythready -- inappropriateinappropriateBounding or arrhythmiasBounding or arrhythmias

Blood Pressure (poor indicator)Blood Pressure (poor indicator)Note increase or decreaseNote increase or decrease

RespiratoryRespiratory

Change in rate or qualityChange in rate or qualityDehydration of hypovolemiaDehydration of hypovolemia

TachypneaTachypneaApneaApneaDeep shallow respirationsDeep shallow respirations

Fluid overloadFluid overloadMoist breath soundsMoist breath soundsCoughCough

Diagnostic TestsDiagnostic Tests

Make sure free flowing specimen is Make sure free flowing specimen is obtained, a obtained, a hemolysedhemolysed or clotted blood or clotted blood specimen may give false values.specimen may give false values.

Hemoglobin and HematocritHemoglobin and Hematocrit

Measures hemoglobin, main component of Measures hemoglobin, main component of erythrocytes, vehicle for transporting erythrocytes, vehicle for transporting oxygen.oxygen.

HbHb and and hcthct will be will be increasedincreased in extracellular in extracellular fluid volume loss.fluid volume loss.

HbHb and and hcthct will be will be decreaseddecreased in extracellular in extracellular fluid volume excess.fluid volume excess.

ElectrolytesElectrolytes

Electrolytes account for approximately Electrolytes account for approximately 95% solute molecules in body water.95% solute molecules in body water.Sodium Na+ predominant extracellular Sodium Na+ predominant extracellular cation.cation.Potassium K+ is the predominant Potassium K+ is the predominant intracellular cation.intracellular cation.

PotassiumPotassium

High or low values can lead to cardiac High or low values can lead to cardiac arrest.arrest.With adequate kidney function excess With adequate kidney function excess potassium is excreted in the kidneys.potassium is excreted in the kidneys.If kidneys are not functioning, the If kidneys are not functioning, the potassium will accumulate in the potassium will accumulate in the intravascular fluidintravascular fluid

PotassiumPotassium

Adults: 3.5 to 5.3 mEq /LAdults: 3.5 to 5.3 mEq /LChild: 3.5 to 5.5 mEq / LChild: 3.5 to 5.5 mEq / LInfant: 3.6 to 5.8 mEq / LInfant: 3.6 to 5.8 mEq / L

Panic Values: Panic Values: < 2.5 mEq /L or > 7.0 mEq / L< 2.5 mEq /L or > 7.0 mEq / L

HyperkalemiaHyperkalemia

Potassium level above 5.0 mEq / LPotassium level above 5.0 mEq / LSignificant dysrhythmias and cardiac Significant dysrhythmias and cardiac arrest may result when potassium levels arrest may result when potassium levels arise above 6.0 mEq/Larise above 6.0 mEq/LAdequate intake of fluids to insure Adequate intake of fluids to insure excretion of potassium through the excretion of potassium through the kidneys.kidneys.

CM: HyperkalemiaCM: Hyperkalemia

NauseaNauseaIrregular heart rateIrregular heart ratePulse slow / irregularPulse slow / irregular

Causes of HyperkalemiaCauses of Hyperkalemia

Acute renal failureAcute renal failureChronic renal failureChronic renal failureGlomerulonephritisGlomerulonephritis

Diagnostic tests:Diagnostic tests:

Serum potassiumSerum potassiumECGECG

BradycardiaBradycardiaHeart blockHeart blockVentricular fibrillationVentricular fibrillation

HypokalemiaHypokalemia

Potassium level below 3.5 mEq / LPotassium level below 3.5 mEq / LBefore administering make sure child is Before administering make sure child is producing urine.producing urine.A child on potassium wasting diuretics is A child on potassium wasting diuretics is at risk at risk –– Lasix Lasix

CM: HypokalemiaCM: Hypokalemia

Neuromuscular manifestations are: neck Neuromuscular manifestations are: neck flop, diminished bowel sounds, flop, diminished bowel sounds, truncaltruncalweakness, limb weakness, lethargy, and weakness, limb weakness, lethargy, and abdominal distention. abdominal distention.

Causes of HypokalemiaCauses of Hypokalemia

Vomiting / diarrheaVomiting / diarrheaMalnutrition / starvationMalnutrition / starvationStress due to trauma from injury or Stress due to trauma from injury or surgery.surgery.Gastric suction / intestinal fistulaGastric suction / intestinal fistulaPotassium wasting diureticsPotassium wasting diureticsIngestion of large amounts of ASAIngestion of large amounts of ASA

Foods high in potassiumFoods high in potassium

Apricots, bananas, oranges, Apricots, bananas, oranges, pomegranates, prunespomegranates, prunesBaked potato with skin, spinach, tomato, Baked potato with skin, spinach, tomato, lima beans, squashlima beans, squashMilk and yogurtMilk and yogurtPork, veal and fishPork, veal and fish

Monitor Potassium LevelsMonitor Potassium Levels

A child with a nasogastric tube in place that is set to suction,needs to have potassium levels monitored.

SodiumSodium

Sodium is the most abundant cation and Sodium is the most abundant cation and chief base of the blood. chief base of the blood. The primary function is to chemically The primary function is to chemically maintain osmotic pressure and acidmaintain osmotic pressure and acid--base base 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

Treatment ModalitiesTreatment Modalities

Peripheral IV

IV TherapyIV Therapy

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Intraosseous TherapyIntraosseous Therapy

Intraosseous needle in place for emergency vascular access.

Central Venous CatheterCentral Venous Catheter

Total Parental NutritionTotal Parental Nutrition

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A tunneled catheter should haveAn occlusive dressing in place.

TPN TherapyTPN Therapy

TPN provides complete nutrition for TPN provides complete nutrition for children who cannot consume sufficient children who cannot consume sufficient nutrients through gastrointestinal tract to nutrients through gastrointestinal tract to meet and sustain metabolic requirements.meet and sustain metabolic requirements.TPN solutions provide protein, TPN solutions provide protein, carbohydrates, electrolytes, vitamins, carbohydrates, electrolytes, vitamins, minerals, trace elements and fats.minerals, trace elements and fats.

Complications of TPNComplications of TPN

Sepsis: infectionSepsis: infectionLiver dysfunctionLiver dysfunctionRespiratory distress from too Respiratory distress from too ––rapid rapid infusion of fluidsinfusion of fluids

TPN: care reminderTPN: care reminder

The TPN infusion rate should remain fairly The TPN infusion rate should remain fairly constant to avoid glucose overload. The constant to avoid glucose overload. The infusion rate should never be abruptly infusion rate should never be abruptly increased or decreased.increased or decreased.

DehydrationDehydration

Skin TurgorSkin Turgor

In moderate dehydration the skin may In moderate dehydration the skin may have a doughy texture and appearance.have a doughy texture and appearance.

In severe dehydration the more typical In severe dehydration the more typical ““tentingtenting”” of skin is observed.of skin is observed.

Skin TurgorSkin Turgor

Treatment of Mild to ModerateTreatment of Mild to Moderate

ORT ORT –– oral reoral re--hydration therapyhydration therapy50 ml / kg every 4 hours50 ml / kg every 4 hoursIncrease to 100 ml / kg every 4 hoursIncrease to 100 ml / kg every 4 hoursNon carbonated soda, jelly, fruit juices Non carbonated soda, jelly, fruit juices Commercially prepared solutions are the Commercially prepared solutions are the best.best.

ReRe--hydration Therapyhydration Therapy

Increase Increase popo fluids if diarrhea increases.fluids if diarrhea increases.Give Give popo fluids slowly if vomiting.fluids slowly if vomiting.Stop ORT when hydration status is normalStop ORT when hydration status is normalStart on BRAT dietStart on BRAT diet

BananasBananasRiceRiceApplesauceApplesauceToastToast

Teaching / Parent InstructionTeaching / Parent Instruction

Call H/SCall H/SIf diarrhea or vomiting increasesIf diarrhea or vomiting increasesNo improvement seen in childNo improvement seen in child’’s hydration s hydration status.status.Child appears worse.Child appears worse.Child will not take fluids.Child will not take fluids.NO URINE OUTPUTNO URINE OUTPUT

Moderate to Severe DehydrationModerate to Severe Dehydration

IV Therapy needed

Fluid replacementFluid replacement

Isotonic fluids initially:Isotonic fluids initially:

Normal Saline 0.9%Normal Saline 0.9%

PotassiumPotassium is added only after child has voided.is added only after child has voided.

Nursing InterventionsNursing Interventions

Assess childAssess child’’s hydration statuss hydration statusAccurate intake and outputAccurate intake and outputDaily weights Daily weights

most accurate way to monitor fluid levelsmost accurate way to monitor fluid levels

Hourly monitoring of IV rate and site of infusion.Hourly monitoring of IV rate and site of infusion.Increase fluids if increase in vomiting or diarrhea.Increase fluids if increase in vomiting or diarrhea.Decrease fluids when taking Decrease fluids when taking popo fluids or signs of fluids or signs of odemaodema..

Care ReminderCare Reminder

A child with severe dehydration will need A child with severe dehydration will need more than maintenance to replace lost more than maintenance to replace lost fluids. 1 fluids. 1 ½½ to 2 times maintenance.to 2 times maintenance.Adding potassium to IV solution.Adding potassium to IV solution.

Never add in cases of oliguria / Never add in cases of oliguria / anuriaanuria•• Urine output less than 0.5 mg/kg/hourUrine output less than 0.5 mg/kg/hour

Never give IV pushNever give IV pushDouble check dosageDouble check dosage

Over hydrationOver hydration

Occurs when child receives more IV fluids Occurs when child receives more IV fluids that needed for maintenance.that needed for maintenance.In preIn pre--existing conditions such as existing conditions such as meningitis, head trauma, kidney shutdown, meningitis, head trauma, kidney shutdown, nephrotic syndrome, congestive heart nephrotic syndrome, congestive heart failure, or pulmonary congestion.failure, or pulmonary congestion.

Signs and SymptomsSigns and Symptoms

TachypneaTachypneaDyspneaDyspneaCoughCoughMoist breath soundsMoist breath soundsWeight gain from edemaWeight gain from edemaJugular vein distentionJugular vein distention

Congestive Heart FailureCongestive Heart Failure

Ball & Bender

Safety Precautions Safety Precautions Use Use buretrolburetrol to control fluid volume.to control fluid volume.Check IV solution infusion against physician Check IV solution infusion against physician orders.orders.Always use infusion pump so that the rate can Always use infusion pump so that the rate can be programmed and monitored.be programmed and monitored.Even mechanical pumps can fail, so check the Even mechanical pumps can fail, so check the intravenous bag and rate frequently.intravenous bag and rate frequently.Record IV rate hourlyRecord IV rate hourly

Acid Acid –– Base ImbalancesBase Imbalances

Acidosis:Acidosis:Respiratory acidosis Respiratory acidosis is too much carbonic is too much carbonic acid in body.acid in body.Metabolic Acidosis is Metabolic Acidosis is too much metabolic too much metabolic acid.acid.

Alkalosis.Alkalosis.Respiratory alkalosis Respiratory alkalosis is too little carbonic is too little carbonic acid.acid.Metabolic alkalosis is Metabolic alkalosis is too little metabolic too little metabolic acid.acid.

Respiratory AcidosisRespiratory Acidosis

Caused by the accumulation of carbon Caused by the accumulation of carbon dioxide in the blood.dioxide in the blood.Acute respiratory acidosis can lead to Acute respiratory acidosis can lead to tachycardia and cardiac arrhythmias.tachycardia and cardiac arrhythmias.

Causes of Respiratory AcidosisCauses of Respiratory Acidosis

Any factor that interferes with the ability of Any factor that interferes with the ability of the lungs to excrete carbon dioxide can the lungs to excrete carbon dioxide can cause respiratory acidosis.cause respiratory acidosis.Aspiration, spasm of airway, laryngeal Aspiration, spasm of airway, laryngeal odemaodema, epiglottitis, croup, pulmonary , epiglottitis, croup, pulmonary odemaodema, cystic fibrosis, and , cystic fibrosis, and Bronchopulmonary dysplasia.Bronchopulmonary dysplasia.Sedation overdose, head injury, or sleep Sedation overdose, head injury, or sleep apnoeaapnoea..

Medical ManagementMedical Management

Correction of underlying cause.Correction of underlying cause.Bronchodilators: asthmaBronchodilators: asthmaAntibiotics: infectionAntibiotics: infectionMechanical ventilationMechanical ventilationDecreasing sedative use.Decreasing sedative use.

Ventilation AssistVentilation Assist

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Respiratory AlkalosisRespiratory Alkalosis

Occurs when the blood contains too little Occurs when the blood contains too little carbon dioxide.carbon dioxide.Excess carbon dioxide loss is caused by Excess carbon dioxide loss is caused by hyperventilation.hyperventilation.

Causes of hyperventilationCauses of hyperventilation

HypoxemiaHypoxemiaAnxietyAnxietyPainPainFeverFeverSalicylateSalicylate poisoning: ASApoisoning: ASAMeningitisMeningitisOverOver--ventilationventilation

ManagementManagement

Stress management if caused by Stress management if caused by hyperventilation.hyperventilation.Pain control.Pain control.Adjust ventilation rate.Adjust ventilation rate.Treat underlying disease process.Treat underlying disease process.

Metabolic AcidosisMetabolic Acidosis

Caused by an imbalance in production and Caused by an imbalance in production and excretion of acid or by excess loss of excretion of acid or by excess loss of bicarbonate.bicarbonate.

Causes:Causes:

Gain in acidGain in acid: ingestion of acids, oliguria, : ingestion of acids, oliguria, starvation (anorexia), DKA or diabetic starvation (anorexia), DKA or diabetic ketoacidosis, tissue hypoxia.ketoacidosis, tissue hypoxia.Loss of bicarbonateLoss of bicarbonate::diarrhea, intestinal or pancreatic fistula, or diarrhea, intestinal or pancreatic fistula, or renal anomaly.renal anomaly.

Ingestion of large doses of AspirinIngestion of large doses of Aspirin

ManagementManagement

Treat and identify underlying cause.Treat and identify underlying cause.IV sodium bicarbonate in severe cases.IV sodium bicarbonate in severe cases.Assess rate and depth of respirations and Assess rate and depth of respirations and level of consciousness.level of consciousness.

Metabolic AlkalosisMetabolic Alkalosis

A gain in bicarbonate or a loss of A gain in bicarbonate or a loss of metabolic acid can cause metabolic metabolic acid can cause metabolic alkalosis.alkalosis.

Causes:Causes:

Gain in bicarbonate:Gain in bicarbonate:Ingestion of baking soda or antacids.Ingestion of baking soda or antacids.Loss of acid:Loss of acid:Vomiting, nasogastric suctioning, diuretics Vomiting, nasogastric suctioning, diuretics

massive blood transfusionmassive blood transfusion

Clinical ManifestationsClinical Manifestations

Hypertonicity or tetanyHypertonicity or tetanyManagement: Correct the underlying Management: Correct the underlying conditioncondition