Module 3A: Alterations in Fluids & Electrolytes PDF

ALTERATIONS IN FLUIDS AND ELECTROLYTES TREATMENT MODALITIES TOPIC OUTLINE Classification of degree of dehydration (adapted from WHO) I. Dehydration...

ALTERATIONS IN FLUIDS AND ELECTROLYTES TREATMENT MODALITIES TOPIC OUTLINE Classification of degree of dehydration (adapted from WHO) I. Dehydration SEVERE SOME NO II. Acute Glomerulonephritis DEHYDRATION DEHYDRATION DEHYDRATION III. Urinary Tract Infection IV. Burn At least 2 of the At least 2 of the No signs of following signs: following signs: "severe" or "some" INTRODUCTION dehydration MENTAL Lethargic or Restless or Normal ▪ Fluids STATUS unconscious irritable Vital to all forms of life RADIAL Weak or absent Palpable Easily palpable Help maintain body temperature and cell shape PULSE Help transport nutrients, gases, and wastes EYES Sunken Sunken Normal To maintain fluid balance: Input = Output SKIN Goes back very Goes back Goes back ▪ Electrolytes PINCH slowly (> 2 slowly (< 2 quickly (< 1 Crucial for nearly all cellular reactions and functions seconds) seconds) second) ▪ Urinary System THIRST Drinks poorly or Thirst, drinks No thirst, drinks not able to drink quickly normally Maintains the proper balance of fluid and electrolytes in the blood. When disease occurs such as abnormal kidney function, an excessive amount of fluid may occur. SEVERE DEHYDRATION DEHYDRATION 1. Treat Shock if present a. If able to drink administer oral rehydration solution ▪ Pediatric dehydration – is common complication of illness. (ORS)while with IV access Volume depletion in children is caused by fluid losses from b. Insert peripheral IV line using large IV catheter g24 vomiting or diarrhea. c. Administer Lactated Ringer and monitor infusion rate. Monitor if presence of peri orbital edema, this means DEVELOPMENT AND BIOLOGICAL over hydration, regulate flow rate accurately 1. Smaller the child the greater proportion of body water to 2. Observe child within 2 hours, continue giving ORS if able to weight and proportion of extracellular fluid to intracellular drink fluid 3. Monitor ongoing losses closely. Strict monitoring regularly 2. Infants larger proportional surface area of GI tract than 4. If remains lethargic check blood glucose and treat if adults hypoglycemic or low sugar level 3. Infants greater body surface area and higher metabolic rate 5. One stabilized reassess degree of dehydration and continue than adults IV rehydration if still needed. If IV rehydration not anymore required ORS maybe given. GENERAL APPEARANCE SOME DEHYDRATION 1. Skin a. Check for dry skin and their mucous membrane 1. Administer ORS for 4 hours specially for every loose stool or b. Poor skin turgor, tenting, dough- like feel vomiting c. Temperature increase 2. Encourage additional age-appropriate fluid intake including d. Sunken eyeballs, no tears breastfeeding e. Pale, ashen, cyanotic nail beds or mucous membranes 3. Monitor ongoing losses closely. Assess clinical condition and f. Delayed capillary refill >3 seconds degree of dehydration at regular intervals to ensure 2. Cardiovascular continuation of appropriate treatment. a. Pulse rate change – rapid, weak, or thready, bounding NO DEHYDRATION or arrythmias, rate and quality increase b. Blood Pressure – take note on the increase or decrease 1. Prevent dehydration –Encourage age-appropriate fluid BP intake, including breastfeeding in young children. 3. Respiratory rate 2. If with Diarrhea – administer zinc sulfate to children under 5 a. Change in rate or quality years of age b. Dehydration of hypovolemia – shows tachypnea, apnea, or deep shallow respirations Diet: may give banana, rice apple and toast (BRAT) c. Fluid overload – shows moist breath sounds and may have presence of cough NUR 1210 – MODULE 3A: ALTERATIONS IN FLUIDS AND ELECTROLYTES ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 TEACHING/PARENT INSTRUCTION URINARY TRACT INFECTION Things to watch out for go to hospital for consult and treatment: ▪ Is a clinical condition that may involve the: Urethra 1. If diarrhea or vomiting increases. Renal pelvis 2. No improvement seen in child’s hydration status Bladder 3. Child appear wore pr weak Calyces 4. Child will not take fluids Ureters 5. No urine output Renal parenchyma ACUTE GLOMERULONEPHRITIS RISK FACTORS ▪ Inflammation of the glomerulus of the kidney. 1. Common in kids 5 years old; During the first few months of ▪ May occur as a separate entity but usually occurs in children life, incidence in boys exceeds that in girls. By the end of the as an immune complex disease after infection with first year and thereafter, first-time and recurrent UTIs are nephritogenic streptococci. most common in girls. ▪ Inflammation of tiny filters in the kidneys (glomeruli). 2. Alteration of the peri urethral flora by antibiotic therapy. ▪ Glomeruli remove excess fluid, electrolytes, and waste from 3. Genetic factors. the bloodstream and pass out through urine. 4. Local inflammation. ▪ May come sudden or gradually chronic. a. Cystitis – An infection of the urethra and bladder. ASSESSMENT b. Pyelonephritis – Infection of the ureters up to the kidneys. ▪ Acute glomerulonephritis is most common in children ages 5. Anatomical abnormality of the urinary tract (malformed 5-10 years old. kidney or a blockage somewhere along the tract of normal ▪ Boys appear to develop the disease more often than girls. urine flow). ▪ A child with history of streptococci infection like respiratory 6. Vesicoureteral reflux (VUR) - an abnormal backward flow tract infection, otitis media, tonsillitis, streptococcus throat (reflux) of urine from the bladder up the ureters and toward infection should have a urinalysis test 2 weeks after the the kidneys. infection to evaluate glomerulonephritis. 7. Poor toilet and hygiene habits. 8. Use of bubble baths or soaps that irritate the urethra. Symptoms: 9. Family history of UTIs. ▪ Pink or cola colored urine from RBC (hematuria). 10. Infrequent urination. ▪ Foamy urine due to excess protein (Proteinuria). 11. Incomplete emptying of the bladder (permit incubation of ▪ High blood pressure. bacteria in the bladder). ▪ Fluid retention (Edema) with swelling in the face, hands, feet 12. Constipation (rectum chronically dilated by feces). and abdomen. 13. Catheterization. 14. Previous UTIs. TREATMENT MANAGEMENT 15. Children who receive antibiotics. a. These agents may alter gastrointestinal (GI) and 1. Antibiotics will be prescribed for 1-2 weeks. peri urethral flora, disturbing the urinary tract’s 2. Diuretics may be given. natural defense against colonization by pathogenic 3. If with heart failure: keep the child in a semi-fowler's bacteria. position, give digitalis and oxygen. 16. Tight clothing or diapers. 4. If with hypertension: an anti-hypertensive medication be 17. Sexual intercourse. given. 18. Altered urine and bladder chemistry 5. Diet: restricting salt to avoid edema and low protein intake to reduce protein in the urine. ETIOLOGY 6. Weigh the child every day. Best time is early morning upon waking up. 1. Bacterial infections 7. Monitor intake and output. a. E coli 8. Bed rest may be advised b. Streptococcus group B, especially among neonates c. Enterococcus species NURSING DIAGNOSIS d. Proteus species e. Pseudomonas aeruginosa 1. Excessive Fluid volume - due to decrease regulatory f. Klebsiella species mechanism (renal failure). g. Staphylococcus saprophyticus, especially among 2. Activity Intolerance - may be related to anemia and on bed female adolescents & sexually active females rest. 2. Fungi (Candida species) 3. Risk for Injury - due to renal function. Target to put the blood pressure in normal. PATHOPHYSIOLOGY 4. Risk for Infection - Chronic disease, Target to have no sore throat and throat cultures will be negative. a. In a urinary tract infection (UTI), bacteria usually enter the urinary tract through the urethra. b. Typically, UTIs develop when uropathogens that have colonized the periurethral area ascend to the bladder via the urethra. NUR 1208 – MODULE 3A: ALTERATIONS IN FLUIDS AND ELECTROLYTES Page | 2 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 c. From the bladder, pathogens can spread up the urinary tract THERAPEUTIC MANAGEMENT to the kidneys (pyelonephritis) and possibly to the bloodstream (bacteremia). 1. Complete oral antibiotics specific causative organism. d. Poor containment of infection, including bacteremia, is more 2. Increase Fluid Intake to flush the infection out of the urinary often seen in infants younger than 2 months. system. e. Urine in the proximal urethra and urinary bladder is normally 3. Cranberry juice to acidify the urine. sterile. Entry of bacteria into the urinary bladder can result 4. Suggest child to sit and void in the bathtub of warm water. from turbulent flow during normal voiding, voiding 5. Acetaminophen (Tylenol) to reduce pain enough to allow dysfunction, or catheterization. voiding. f. Sexual intercourse or genital manipulation may foster the 6. Encourage child to drink extra fluids as soon as symptoms are entry of bacteria into the urinary bladder. noticed and for the next 24 hours. g. More rarely, the urinary tract may be colonized during 7. Encourage child to urinate often and to empty his or her systemic bacteremia (sepsis); this usually happens in infancy. bladder each time. h. Pathogens can also infect the urinary tract through direct 8. Teach preventive measures. spread via the fecal-perineal-urethral route. PREVENTION CLASSIFICATION OF UTI 1. Frequent diaper changes. 1. Bacteriuria - Bacteria in the urine. 2. Teach children not to "hold it" when they have to go. a. Asymptomatic bacteriuria – Significant bacteriuria 3. Avoid bubble baths and strong soaps that might cause with no evidence of clinical infection. irritation. b. Symptomatic bacteriuria – Accompanied by 4. Wear cotton underwear instead of nylon because it's less physical signs of UTI. likely to encourage bacterial growth. c. Recurrent UTI – Repeated episode of bacteriuria or 5. Drink plenty of fluids. symptomatic UTI. 6. Avoid caffeine, which can irritate the bladder. d. Persistent – Persistent of bacteriuria despite BURN antibiotic treatment. 2. 2. Febrile UTI - Accompanied by fever and other physical signs ▪ A type of injury to skin or flesh of UTI. a. Cystitis – Inflammation of the bladder COMMON CAUSES b. Urethritis – Inflammation of the urethra. 1. Thermal c. Pyelonephritis – Inflammation of upper urinary a. Scalding (exposure to hot drinks, high temperature tract and kidneys tap water in showers, hot cooking oil, or steam). d. Urosepsis – Febrile UTI coexisting with systemic b. Contact with hot objects (tipped-over coffee cups, signs of bacterial illness; blood culture reveals hot foods, cooking fluids). the presence of the urinary pathogen. c. Fireworks. CLINICAL MANIFESTATION 2. Electricity a. High voltage (greater than or equal to 1000 volts). ▪ Pain, burning, or a stinging sensation when peeing b. Low voltage (less than 1000 volts). ▪ Increased urge to urinate or frequent urination 3. Chemicals ▪ Fever (though this is not always present) a. Ingestion. ▪ Frequent night waking to go to the bathroom (Enuresis) b. Spilling onto the skin. ▪ Wetting problems, even though the child is toilet-taught ▪ Low back pain or abdominal pain in the bladder (generally COMMON AGENTS below the navel) ▪ Acids are those with pH less than 7 (common household ▪ Foul-smelling urine that may look cloudy or contain blood compounds like acetic acid, hydrochloric acid, or sulfuric acid ▪ Jaundice like toilet cleaners). ▪ Hematuria (may not be present) ▪ Bases or alkali compounds with pH greater than 7 (Ammonia, ▪ Poor feeding Sodium hypochlorite or bleach). DIAGNOSTIC AND LABORATORY PROCEDURE ▪ Friction (Contact with flames or hot objects (from the stove, fireplace, curling iron, etc.). 1. Urinalysis ▪ Radiation (Overexposure to the sun). a. (+) for proteinuria – presence of bacteria Exposure to ultraviolet light (from the sun, tanning b. (+) RBC or hematuria – mucosal irritation booths or arc welding). c. pH elevated – presence of RBCs or WBCs and Ionizing radiation (from radiation therapy, X-rays or bacteria make urine more alkaline radioactive fallout. 2. Urine culture collected by: a. Midstream clean - catch technique PATHOPHYSIOLOGY b. Suprapubic aspiration a. The skin is the body's first defense against infection by c. Catheterization microorganisms. 3. Ultrasound of the kidneys and bladder b. A burn is also a break in the skin, and the risk of infection 4. Voiding Cystourethrogram (VCUG) exists both at the site of the injury and potentially a. X-rays taken during urination throughout the body. NUR 1208 – MODULE 3A: ALTERATIONS IN FLUIDS AND ELECTROLYTES Page | 3 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 c. Burns that extend deeper may cause permanent injury and CLASSIFICATION OF BURNS BY DEPTH, MECHANISM OF INURY, scarring and not allow the skin in that area to return to EXTENT, AND ASSOCIATED INJURIES normal function ▪ The size of a burn is measured as a percentage of total body THREE SKIN LAYERS surface area (TBSA) affected by partial thickness or full thickness burns 1. Epidermis – The outer layer of the skin; Only the epidermis has the ability to regenerate itself. 1. Wallace Rule of Nines - Easy to remember but only accurate 2. Dermis – Made up of collagen and elastic fibers and where in people over 16 y/o. nerves, blood vessels, sweat glands, and hair follicles reside. 3. Hypodermis or subcutaneous tissue a. Where larger blood vessels and nerves are located. b. Most important in temperature regulation. c. At temperatures greater than 44 °C (111 °F), proteins begin losing their three-dimensional shape and start breaking down. This results in cell and tissue damage. d. They include disruption of the skin's sensation. e. Disruption of cell membranes. f. In large burns (over 30% of the total body surface 2. Person’s Palmar Size - Size of a person’s handprint (including area), there is a significant inflammatory response. the palm and fingers is approximately 1% of their TBSA). g. Poor blood flow to organs such as the kidneys and gastrointestinal tract may result in renal failure and stomach ulcers. h. Increased levels of catecholamines and cortisol can cause a hypermetabolic state that can last for years. THREE TYPES OF BURNS ACCORDING TO DEPTH TYPES CLINICAL MANIFESTATION Superficial or First-Degree ▪ Redness, pain, and minor Burn swelling, skin may ▪ be very tender to touch. 3. Lund and Browder Chart – Takes into account the different ▪ The mildest form. ▪ Skin is dry without proportions of body parts in adults and children. ▪ Burns that cause local blisters. inflammation of the ▪ Healing time: 3 to 6 days; superficial skin. the superficial skin ▪ layer over the burn may peel off in ▪ 1 or 2 days Partial-thickness or Second- ▪ Blisters, severe pain, and Degree Burn redness. ▪ The blisters sometimes ▪ More serious and break open and the area involves the skin layers is wet-looking with a beneath the top layer bright pink to cherry red color. ▪ Healing time: Can take up to 3 weeks or more THERAPEUTIC MANAGEMENT Full-thickness or Third- ▪ The surface appears dry Degree Burn and can look waxy white, 1. Remove the victim from the burning area, remembering not leathery, brown, to put the rescuer in danger. ▪ The most serious type of or charred. 2. Remove the child from the heat source. burn. ▪ There may be little or no 3. Remove clothing from the burned area immediately. ▪ Involve all the layers of pain or the area may feel 4. Do not break any blisters. the skin and underlying numb at first because of 5. Gently clean the wound with lukewarm water. tissue, in effect killing ▪ nerve damage. 6. Early cooling (within 30 minutes of the burn) with cool water that area of skin. ▪ Healing time: Healing 10-25 °C (50.0-77.0 °F) or hold a clean, cold compress on the ▪ The nerves and blood time depends on the burn for approximately 3-5 minutes to reduces. vessels are damaged severity of the burn. 7. Keep your child lying down with the burned area elevated. Fourth-Degree Burn 8. Remove all jewelry and clothing from around the burn (in case there's any swelling after the injury), except for clothing Involves injury to deeper that's stuck to the skin. tissues, such as muscle or bone. 9. The burn may be dressed in a topical antibiotic ointment like Bacitracin or Neosporin. Silvadene (silver sulfadiazine) topical is the preferred agent for most burns Do not apply butter, NUR 1208 – MODULE 3A: ALTERATIONS IN FLUIDS AND ELECTROLYTES Page | 4 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 grease, powder, or any other remedies to the burn, as these 9. Care of the burn wound itself [Sulfamylon (mafenide can make the burn deeper and increase the risk of infection. acetate)] crean which produces a burning sensation when 10. Manage first-degree burns without dressings. applied. 11. Ask somebody to call for emergency medical care while ding 10. Pain management by analgesics (Ibuprofen and topical is the preferred agent for most burns Do not apply acetaminophen). butter, grease, powder, or any other remedies to the burn, as 11. Antihistamines and massage during the healing process to aid these can make the burn deeper and increase the risk of with itching. infection. 12. Calcium gluconate is an antidote for burns caused by hydrofluoric acid (fluorescent lights, fire extinguishers, etc). For Flame Burns: Surgery 1. Extinguish the flames by having your child roll on the ground. 2. Cover him or her with a blanket or jacket. 1. Skin grafts or flaps 3. Remove smoldering clothing and any jewelry around the 2. Escharotomy – Surgical release of the skin done to treat or burned area. prevent problems with distal circulation, or ventilation. 4. Call for medical assistance. 3. Fasciotomy – Fascia is cut to relieve tension or pressure to treat the resulting loss of circulation to an area of tissue or For Electrical Burns: muscle (may be required for electrical burns). 1. Make sure the child is not in contact with the electrical Alternative Medicine source before touching him. 1. Honey has been used since ancient times to aid wound For Chemical burns: healing & may be beneficial in first- & second-degree burns 1. Flush the area with lots of running water for 5 minutes or PREVENTING BURNS more. If the burned area is large, use a tub, shower, buckets of water, or a garden hose. 1. Proper construction of buildings. 2. Do not remove any of child's clothing before flushing the 2. Keep matches, lighters, chemicals, and lit candles. burn with water. Continue flushing the burn, then remove 3. Put child-safety covers on all electrical outlets. clothing from the burned area. 4. Get rid of equipment and appliances with old or frayed cords 3. If the burned area from a chemical is small, flush for another and extension cords that look damaged. 10-20 minutes. 5. If using a humidifier or vaporizer, use a cool mist model 4. Clean with soap and water. rather than a hot-steam one. 5. Apply a sterile gauze pad or bandage. 6. Use of fire-resistant clothing. 6. Call your doctor. 7. Care when using irons, flat irons, or curling irons. 7. Chemical burns to the mouth or eyes require immediate 8. Provide smoke alarms and sprinkler systems; check these medical evaluation after thorough flushing with water. monthly and change the batteries twice a year. 9. Don't smoke inside the house. Seek Medical Help Immediately When: 10. Care when using fireworks or sparklers. 1. Child has a second- or third-degree burn. 11. Limit hot water temperatures to 120°F (49°C), or use the 2. The burned area is large (2-3 inches in diameter). "low-medium setting." 3. For any burn that appears to cover more than 10% of the 12. Always test bath water with the elbow before putting the body. child in it. 4. The burn comes from a fire, an electrical wire or socket, or 13. Always turn the cold water on first and turn it off last when chemicals. running water in the bathtub or sink. 5. The burn is on the face, scalp, hands, joint surfaces, or 14. Turn kids away from the faucet or fixtures. genitals. 15. Turn pot handles toward the back of the stove every time 6. The burn looks infected (with swelling, pus, increasing you cook. redness, or red streaking of the skin near wound). 16. Block access to the stove as much as possible. 17. Never let a child use a walker in the kitchen. MEDICAL MANAGEMENT 18. Avoid using tablecloths or large placemats. Youngsters can pull on them & overturn a hot drink or plate of food. 1. Isotonic crystalloid solution is given. 19. Keep hot drinks and foods out of reach of children. 2. Maintenance fluid because of the subsequent inflammatory 20. Never drink hot beverages or soup with a child sitting on your response that causes significant capillary fluid leakage and lap or carry hot liquids or dishes around kids. If you have to edema. walk with hot liquid in the kitchen make sure you know 3. Blood transfusions when hemoglobin level falls below 60-80 where kids are so you don't trip over them. g/L (6-8 g/dL) due to associated risk of complications. 21. Never hold a baby or small child while cooking. 4. Early feeding. 22. Never warm baby bottles in the microwave oven. The liquid 5. Tetanus booster shot should be given if an individual has not may heat unevenly, resulting in pockets of breast milk or been immunized within the last five years. formula that can scald a baby's mouth. 6. Hyperbaric oxygenation may be useful in addition to 23. Use playground equipment with caution. Use the equipment traditional treatments. only in the morning, when it's had a chance to cool down 7. Early intubation. during the night. 8. Resuscitation begins with assessment and stabilization of the 24. Remove child's safety seat or stroller from the hot sun when person's airway, breathing and circulation. not in use. NUR 1208 – MODULE 3A: ALTERATIONS IN FLUIDS AND ELECTROLYTES Page | 5 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 25. Before leaving the car on a hot day, hide the seat belts' metal latch plates in the seats to prevent the sun from hitting them directly. 26. Don't forget to apply sunscreen 20-30 minutes before going out and reapply every 2 hours or more often if in water. Use a product with the SPF of 15 or higher. Do not use sunscreen on infants under 6 months of age. COMMON COMPLICATIONS OF BURNS 1. Infection. 2. Pneumonia occurs particularly commonly in those with inhalation injuries. 3. Cellulitis. 4. Urinary tract infections. 5. Respiratory Failure. 6. Anemia secondary to full thickness burns of greater than 10% TBSA. 7. Compartment syndrome due to electrical burns. 8. Rhabdomyolysis due to muscle breakdown. 9. Keloids particularly in those who are young and dark skinned. 10. Breathing problems if the burn involves the face, nose, mouth or neck causing. inflammation and swelling resulting to obstruction of the airway. 11. If circumferential burns occur to arms, legs, fingers, or toes, the same constriction.may not allow blood flow and put the survival of the extremity at risk. 12. Burns to areas of the body with flexion creases, like the palm of the hand, the back of the knee, the face, and the groin may need specialized care. As the burn matures, the skin may scar and shorten, preventing full range of motion of the body area. 13. Fluid and electrolyte problems If more than 15%-20% of the body is involved. 14. Shock if inadequate fluid is not provided intravenously. 15. Risk of death if burns involve greater than 50% 16. Disturbance in body image. 17. Post-traumatic stress disorder. PROGNOSIS ▪ The prognosis is worse in those with larger burns, those who are older, and those. who are females The Baux score used to determine prognosis of major burns. ▪ The score is determined by adding the size of the burn (% TBSA) to the age of the person, to predict percent mortality after trauma. NUR 1208 – MODULE 3A: ALTERATIONS IN FLUIDS AND ELECTROLYTES Page | 6 ALMEÑANA, JOHN RENDEW | BSNR 2026