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Fluids and Electrolytes in Infants and Children
- 1. Fluid and Electrolytes Infants and children
- 2. Alteration in Fluid and Electrolyte Status Lungs Ball & Bender Urine & faeces Skin Normal routes of fluid excretion in infants and children.
- 3. 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.
- 4. Developmental and Biological Smaller the child, greater proportion of body water to weight and proportion of extracellular fluid to intracellular fluid. Infants larger proportional surface area of GI tract than adults. Infants greater body surface area and higher metabolic rate than adults.
- 5. Water Balance Regulated by Anti-diuretic Hormone ADH. Acts on kidney tubules to reabsorb water. The young infant is highly susceptible to dehydration.
- 6. Increased Water Needs Fever / sepsis Vomiting and Diarrhoea High-output in renal failure Diabetes insipidus Burns Shock Tachypnea
- 7. Decreased Water Needs Congestive Heart Failure Mechanical Ventilation Renal failure Head trauma / meningitis
- 8. 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
- 9. Loss of Skin Elasticity Loss of skin elasticity Due to dehydration. Whaley & Wong Text
- 10. Cardiovascular Pulse rate change: Note rate and quality Rapid, weak, or thready - inappropriate Bounding or arrhythmias Blood Pressure (poor indicator) Note increase or decrease
- 11. Respiratory Change in rate or quality Dehydration of hypovolemia Tachypnea Apnea Deep shallow respirations Fluid overload Moist breath sounds Cough
- 12. Diagnostic Tests Make sure free flowing specimen is obtained, a hemolysed or clotted blood specimen may give false values.
- 13. Hemoglobin and Hematocrit Measures hemoglobin, main component of erythrocytes, vehicle for transporting oxygen. Hb and hct will be increased in extracellular fluid volume loss. Hb and hct will be decreased in extracellular fluid volume excess.
- 14. Electrolytes Electrolytes account for approximately 95% solute molecules in body water. Sodium Na+ predominant extracellular cation. Potassium K+ is the predominant intracellular cation.
- 15. 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
- 16. 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: < 2.5 mEq /L or > 7.0 mEq / L
- 17. Hyperkalemia 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.
- 18. CM: Hyperkalemia Nausea Irregular heart rate Pulse slow / irregular
- 19. Causes of Hyperkalemia Acute renal failure Chronic renal failure Glomerulonephritis
- 20. Diagnostic tests: Serum potassium ECG Bradycardia Heart block Ventricular fibrillation
- 21. 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
- 22. CM: Hypokalemia Neuromuscular manifestations are: neck flop, diminished bowel sounds, truncal weakness, limb weakness, lethargy, and abdominal distention.
- 23. 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
- 24. Foods high in potassium Apricots, bananas, oranges, pomegranates, prunes Baked potato with skin, spinach, tomato, lima beans, squash Milk and yogurt Pork, veal and fish
- 25. Monitor Potassium Levels A child with a nasogastric tube in place that is set to suction, needs to have potassium levels monitored.
- 26. Sodium Sodium is the most abundant cation and chief base of the blood. The primary function is to chemically maintain osmotic pressure and acid-base balance and to transmit nerve impulses. Normal values: 135 to 148 mEq / L
- 28. IV Therapy Ball & Bender
- 29. Intraosseous Therapy Intraosseous needle in place for emergency vascular access.
- 31. Total Parental Nutrition A tunneled catheter should have Whaley & Wong An occlusive dressing in place.
- 32. TPN Therapy TPN provides complete nutrition for children who cannot consume sufficient nutrients through gastrointestinal tract to meet and sustain metabolic requirements. TPN solutions provide protein, carbohydrates, electrolytes, vitamins, minerals, trace elements and fats.
- 33. Complications of TPN Sepsis: infection Liver dysfunction Respiratory distress from too –rapid infusion of fluids
- 34. TPN: care reminder The TPN infusion rate should remain fairly constant to avoid glucose overload. The infusion rate should never be abruptly increased or decreased.
- 35. Dehydration
- 36. 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.
- 37. Skin Turgor
- 38. 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, jelly, fruit juices Commercially prepared solutions are the best.
- 39. 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
- 40. Teaching / Parent Instruction Call H/S If diarrhea or vomiting increases No improvement seen in child’s hydration status. Child appears worse. Child will not take fluids. NO URINE OUTPUT
- 41. Moderate to Severe Dehydration IV Therapy needed
- 42. Fluid replacement Isotonic fluids initially: Normal Saline 0.9% Potassium is added only after child has voided.
- 43. Nursing Interventions Assess child’s 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 odema.
- 44. Care Reminder A child with severe dehydration will need more than maintenance to replace lost fluids. 1 ½ 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
- 45. Over hydration Occurs when child receives more IV fluids that needed for maintenance. In pre-existing conditions such as meningitis, head trauma, kidney shutdown, nephrotic syndrome, congestive heart failure, or pulmonary congestion.
- 46. Signs and Symptoms Tachypnea Dyspnea Cough Moist breath sounds Weight gain from edema Jugular vein distention
- 47. Congestive Heart Failure Ball & Bender
- 48. Safety Precautions Use buretrol to control fluid volume. Check IV solution infusion against physician orders. Always use infusion pump so that the rate can be programmed and monitored. Even mechanical pumps can fail, so check the intravenous bag and rate frequently. Record IV rate hourly
- 49. Acid – Base Imbalances Acidosis: Alkalosis. Respiratory acidosis Respiratory alkalosis is too much carbonic is too little carbonic acid in body. acid. Metabolic Acidosis is Metabolic alkalosis is too much metabolic too little metabolic acid. acid.
- 50. Respiratory Acidosis Caused by the accumulation of carbon dioxide in the blood. Acute respiratory acidosis can lead to tachycardia and cardiac arrhythmias.
- 51. 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 odema, epiglottitis, croup, pulmonary odema, cystic fibrosis, and Bronchopulmonary dysplasia. Sedation overdose, head injury, or sleep apnoea.
- 52. Medical Management Correction of underlying cause. Bronchodilators: asthma Antibiotics: infection Mechanical ventilation Decreasing sedative use.
- 53. Ventilation Assist Ball & Bender
- 54. Respiratory Alkalosis Occurs when the blood contains too little carbon dioxide. Excess carbon dioxide loss is caused by hyperventilation.
- 55. Causes of hyperventilation Hypoxemia Anxiety Pain Fever Salicylate poisoning: ASA Meningitis Over-ventilation
- 56. Management Stress management if caused by hyperventilation. Pain control. Adjust ventilation rate. Treat underlying disease process.
- 57. Metabolic Acidosis Caused by an imbalance in production and excretion of acid or by excess loss of bicarbonate.
- 58. 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.
- 59. Ingestion of large doses of Aspirin
- 60. Management Treat and identify underlying cause. IV sodium bicarbonate in severe cases. Assess rate and depth of respirations and level of consciousness.
- 61. Metabolic Alkalosis A gain in bicarbonate or a loss of metabolic acid can cause metabolic alkalosis.
- 62. Causes: Gain in bicarbonate: Ingestion of baking soda or antacids. Loss of acid: Vomiting, nasogastric suctioning, diuretics massive blood transfusion
- 63. Clinical Manifestations Hypertonicity or tetany Management: Correct the underlying condition