Fluids and Electrolytes PDF

Fluids and Electrolytes Sources of Fluid Loss  Insensiblelosses – 2/3 through skin & 1/3 through respiratory tract  Urinary  Fecal Major Fluid Compartments  Intracellular ( fluid inside cell )  Extracellular ( fluid outside cell ) * intravascular fluid * interstiti...

Fluids and Electrolytes Sources of Fluid Loss  Insensiblelosses – 2/3 through skin & 1/3 through respiratory tract  Urinary  Fecal Major Fluid Compartments  Intracellular ( fluid inside cell )  Extracellular ( fluid outside cell ) * intravascular fluid * interstitial fluid  Children under 2 get dehydrated quicker because Infants & children ↓ 2 years loose a greater proportion of fluid each day Greater amount of BSA causes ↑ in insensible losses Body Surface Children maintain larger amount of ECF until about 2 years of age Increased metabolic rate - ↑ fluid demand to fuel metabolic process Growth Causes higher metabolic rate Greater amount of metabolic wastes to be excreted by kidneys Glomeruli tubules & nephrons of kidney are immature & unable to conserve H2O effectively Causing greater fluid loss This what greater body Children have a higher risk of fluid surface area means and electrolyte imbalance Fluid Compartment Components - - - - - - - Fluid Requirements  Daily Maintenance ensure kids get daily maintenance 1. wt. in kg. 2.100ml/kg for first 10 kg. 75ml per hr for a child that weighs 35kg 3. 50ml/kg for second 10 kg. 4. 20 ml/kg for remainder of wt in kg. 5. divide total amt. by 24 hrs. & obtain rate in ml/hr JUST TO MAINTAIN EXTRACELLULAR FLUID  Urine Output Infants and toddlers: > 2-3ml/kg/hr Preschool and young school age: >1-2ml/kg/hr Older school age and adolescents: 0.5-1ml/kg/hr Dehydration  Classified according to serum Na+ concentration & osmolarity  Isotonic (electrolytes and fluid loss is equal is isotonic loss) * primary form of dehydration * H2O losses = electrolyte deficits * causes – vomiting and diarrhea * fluid loss mostly from ECF · * shock greatest threat Hypovolemic Shock - * replace with isotonic solution safest solution to use; hydrates ECF without distupting ICF and volumes * serum Na+ (130 – 150 meq/l) example of Isotonic solution example is 5% in dextrose in water is isotonic Hypotonic Dehydration (Hyponatremia)  Electrolyte losses > H2O deficits SIADH - caused by increased ICP; head trauma; bacterial  ICF more concentrated than ECF meningitis; anything that puts pressure on posterior pituatary  Causes – taking in solutions too low in solutes, excessive ADH, excessive sweating, burns, diuretics, vomiting, diarrhea, renal - disease and heart failure. Furosemide (Lasix)  Symptoms – confusion, headache, weakness, decreased deep tendon reflexes, agitation or lethargy, anorexia, nausea, vomiting, and possibly seizures Loss of electrolytes!!!!!  Serum Na+ < 130meq/l  Treatment – treat underlying cause, restrict fluids, administer Na+ and give appropriate IV solution if necessary. We always start with isotonic solution even if its hypotonic because its the safest. If it can't be corrected then we move onto a hypertonic solution. 10% glucose is hypertonic start low and slow, rapid changes from administering hypertonic solutions quickly can cause a shift from ICF to ECF. In older children first signs of this shift are changes in LOC, seizures etc. Hypertonic Dehydration (Hypernatremia)  H2O losses > electrolyte losses  ECF more concentrated than ICF diabetes insipidus  Causes – inadequate fluid intake, decrease in ADH, diarrhea, vomiting, excessive sweating, high solute intake without adequate H2O, renal disease, osmotic diuresis (Type 1 Diabetes).  Symptoms – agitation, low grade fever, thirst, tachycardia, hypotension, oliguria, jaundice in newborn, change in level of consciousness.  Treatment – treat underlying cause, restrict Na+, administer appropriate IV fluid.  Serum Na+ > 150 meq/l 0.45 NS is a hypotonic solution can be used. too fast of an infusion can cause a rapid shift from a ECF to ICF causing cell swelling. (sx: dizziness, changes in LOC etc) Hypokalemia  Serum K+ ↓ 3.5 mmol/l for severe hypokalemia = concentrated potassium solution and has to be monitored constantly (in an ICU)  Causes  increased K+ excretion: diuretics, osmotic diuresis, renal disease, - diarrhea, elevated aldosterone and cortisol aldosterone and cortisol combines with potassium and gets excreted  decreased K+ intake: NPO, anorexia, prolong IV therapy w/o K+  loss of K+: vomiting, NG tube losses, metabolic alkalosis NG Tube for gastric emptying due to surgery 3  Symptoms: skeletal muscle weakness, leg cramps, decrease DTRs, EKG changes, constipation, digoxin toxicity, irregular weak pulse, orthostatic hypotension for a person on digoxin; ekg changes in the U wave digoxin toxicity: bradycardia; dysrhytmia; vomitting  Nursing: manage underlying cause, monitor cardiac status, adequate K+ intake, patient voiding before adding K+ to IV because you can develop hyperkalemia maintain ekg monitoring exchanges EC potassium to correct alkalosis = hypokalemia Hyperkalemia  Serum K+ ↑ 5.8 mmol/l  Symptoms: abdominal cramping, diarrhea, nausea, elevated T - wave on EKG, irregular pulse, bradycardia, muscle weakness, increase in DTRs  Causes Sickle cell anemia can cause this rapid turnover can cause hyperkalemia * massive cell death Leukemia cell death releases potassium in ICF into ECF; from a crushing injury rapid turnover of WBC's * excessive or too rapid K+ IV infusion * metabolic acidosis Diabetes Ketoacidosis * diabetes * ↓K+ excretion renal disease continued  Treatment – manage underlying condition * medications – K+ wasting diuretics, LASIX Kayexalate, IV bicarbonate, IV insulin * peritoneal dialysis end stage renal failure * diet  Nursing monitor cardiac status; adequate diet if they have wounds Diagnostic Evaluation of Dehydration  Weight loss * 5% mild * 10% moderate * 15% severe * calculate (original wt – present wt. ÷ original wt.) Continued  Changing level of consciousness  Response to stimuli  Decreased skin elasticity & turgor  Prolonged capillary refill  Increased heart rate  Sunken eyes & fontanels  Dry mucus membranes  Absent tears  Decreased urine output Signs of Dehydration Degrees of Dehydration continued 2of the following factors→5% dehydrated > capillary refill > 2 seconds > decrease tears > dry mucus membranes > ill appearance Nursing I &O look @ output; ask about output (color of urine; how much; frequency) same for stools (color; consistency; mucus-blood etc)  Vital signs  Skin  Mucus membranes  Body weight  Fontanel  Sensory loc Diarrhea  Caused by abnormal intestinal H2O & electrolyte transport  Acute ~ leading cause ↓ 5 yrs. ~ sudden ↑in frequency & change in consistency of stool ~ causes ~ usually self limited (↓14 days) ~ acute infectious diarrhea ( gastroenteritis) antibiotics; laxatives (teenager with anorexia) Continued  Chronic ~ ↑ 14 days first few months of life- diarrhea lasting more than 14 days that was not managed well ~ causes  Intractable diarrhea of infancy absorption issues: celiac disease; cystic fibrosis inflammatory diseases: crohns and UC. food allergies; lactose intolerance ~ occurs in first few months of life ~ longer than 14 days ~ most common cause is acute infectious diarrhea that was not managed adequately continued  Chronic non-specific diarrhea ~ cause of chronic diarrhea in children 6-54 months ~ loose stools with undigested food particles ↑ 14 days ~ grow normally & not malnourished ~ no blood in stool or infection ~ causes too much concentrated juices can cause chronic diarrhea and diet sodas food sensitivities; Etiology  Fecal - oral route  Contaminated food or water  Organisms ♦ viral – Rotavirus ♦ bacterial- Salmonella, Shigella, Campylobacter giardi is a common too ♦parasite – Cryptosporidium  Antibiotics Diagnosis  History ask for duration, severity, symptoms and potential cause  Lab data – stool specimens  Urine specific gravity ask for intake and output to determine dehydration  CBC, serum electrolytes, creatinine, BUN for infection look at kidney function and in dehydrated these two are elevated Management 1. Assessment of fluid & electrolyte imbalance oral rehydration therapy 2. Rehydration: start with ORT for mild to moderate dehydration For mild dehydration, 50 mL per kg of ORT solution should be administered over four hours using a spoon, syringe, or medicine cup this can be accomplished by giving 1 mL per kg of the solution to the child every five minutes. we use pedialyte to correct. For moderate dehydration, 100 mL per kg of ORT solution should be given over four hours in the physician's office or emergency department.14 If - treatment is successful and ongoing losses are not excessive, the child may be sent home. 3.Maintenance of fluid therapy children who are formula fed = stop formula and give pedialyte breastfed milk can continue breast feeding 4.Reintroduction of adequate diet solids = stop solids and just pedialyte for solids you can start with lean meats (chicken, fish) cooked once symptoms improve you can slowly introduce diet again vegetables; rice; yogurt; avoid fatty foods and high in sugar. Nursing  Assessment  Implementation & education regarding oral rehydration  Accurate weight  Monitor I&O – urine output must be sufficient to add K+ to IV solution  Skin care especially if you are wearing diapers and have diarrhea; prevent skin breakdown; give barrier cream (butt paste) nystatin powder and aquaphor and can only be used 3 times a day. if its in the creases = fungal and if its not its just dermatitis  Prevention