Fluid and electrolyte imbalance Samah Suleiman 18/4/2006

Distribution of body fluid *TBW *ICF *ECF ( intravascular, interstitial &trancelluler) Fluid % in child body ( 75%-80%) *keep balance of water & electro ( Bwt, age ,activity level ,&body temp)

Pediatric Fluid Therapy Principles Maintenance H2O needs: Weight in Kg H2O fluid needs 1-10 100cc /kg /day 11-20 1000+50cc/kg/day > 20 1500 + 20cc/kg/day Add 12 % for every 0C

Na+ & K+ Daily Needs Na+ = 2-3 meq / kg / day K+ = 1-2 meq / kg / day Notice: Daily fluid maintenance in pediatrics: 0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc

Nursing requirements of FLUID Increased requirement : Fever Vomiting Renal failure Burn Shock Tachypnea Gastroenteritis Diabetes (Insipidus, mellitus - DKA) Cystic fibrosis

Decreased requirement CHF Postoperatively oliguric ( RF ) Increase ICP

Diagnostic Evaluation 1. Physical assessment (V/S) 2. Type of dehydration Nursing Therapeutic management of fluid loss Oral rehydration therapy Parenteral fluid therapy Meet ongoing daily loss Replace previous deficit Replace ongoing abnormal losses

Disturbance of F&E balance 1. Na 2. K 3. Ca ( Na is the primary osmatic farce ) Serum Osmolality Defined as the number of particles per liter. May be approximated by: 2(Na) + Glucose (mg/dl)/18 + BUN(mg/dl)/2.8 Normal range: 275-295 mOsm/L 300-500 cc/M2/day Less in patients on the ventillator

Composition of Body fluids 1. D5W (5 g sugar/100 ml) 252 mOsm/L 2. D10W (10 g sugar/100 ml) 505 mOsm/L 3. NS (0.9% NaCl) 154 mEq Na/L 308 mOsm/L 4. 1/2 NS (0.45% NaCl) 77 mEq Na/L 154 mOsm/L 5. D5 1/4 NS 34 mEq Na/L 329 mOsm/L 6. 3% NaCl 513 mEq Na/L 1027 mOsm/L 7. 10% NaCl 1.7 mEq/cc 8. 20% NaCl 3.4 mEq/cc 9. 8.4% NaHCO3 (1 meq/cc Na & HCO3) 2000 mOsm/L

IV fluids Lactated Ringer’s 0-10 gram glucose/100cc Na 130 meq/L NaHCO3 28 meq/L as lactate K 4 meq/L 273 mOsm/L  Amino acid 8.5 % 8.5 gm protein/100 cc 880 mOsm/L

Albumin 25% (salt poor) 25 gm protein/100 cc Na 100-160 meq/L 300 mOsm/L Intralipid 2.25 gm lipid/100cc 284 mOsm/L

Pediatric Fluid Therapy Principles Assess water deficit by: 1. weight: weight loss (Kg) = water loss (L) OR 2. Estimation of water deficit by physical exam: Mild moderate severe Infants < 5 % 5 - 10 % >10 % Older children < 3 % 3 - 6 % > 6 %

Type of Dehydration 1. Isotonic (affect ECF ,Na = 135meq /l) 2. Hypotonic ( loss in ECF 2 correct ICF, Na = less than 135meq/l ) 3. Hypertonic ( sever loss in ICF ,Na = more than 150meq/l

Physical Signs of Dehydration

Correction of Dehydration Moderate to severe dehydration: IV push 10-20 cc / Kg Normal saline (5 % albumin) May repeat. Half deficit over 8 hours, and half over 16 hours. If hypernatremic dehydration, replace deficit over 48 hours (evenly distributed).

Estimate Fluid Deficit (% :- Mild, Moderate, Severe). Find Type of Dehydration (Isonatremic, Hyponatremic, Hypernatremic). Give daily Maintenance. Give Deficit as follows: Half volume over 8 hours, half volume over 16 hours (Exception: in Hypernatremic Dehydration, replace deficit over 48 hours).

Disturbance of acid based balance Plasma PH Plasma PCO2 Plasma HCO3 Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

Nursing Intervention 1. Assessment 2. History 3. Clinical observation 4. Intake & output measurement 5. Replace orally or IVF ( 1g wet diaper wt =1 ml urine )

Types of I.V solutions Solutions are three types - Isotonic it's total osmolality (TO) = TO of blood - Hypotonic: It's TO  TO of blood - Hypertonic: it's TO  TO of blood. * Electrolyte solutions considered isotonic If total electrolyte content (TEC)  310mEq/L. and hypotonic if TEC  250 meq/L and hypertonic if TEC  375 Meq/L

When administrating I.V fluid nurse should Monitors the response of the fluids.   Considering the fluid volume.     Content of fluid. Patient clinical status.

1. Isotonic fluids: -Have a total osmolality close to that of extra cellular fluids (ECF) and don't cause RBCs to shrink or swell. - 3 L of isotonic solutions are needed to replace 1 L of blood, so pt should be carefully monitored for signs of fluid overload. Examples of Isotonic fluids: D5W: has a serum osmolality of 252 mosm/L. D5W s mainly used supply water and to correct an increased serum osmolality

Normal Saline Solution NS (0.9% Sodium chloride with TO of 308 NS osmolality is contributed by electrolytes -   So the solution remains within ECF. - NS is used to treat ECF deficit. - Ringer's solutions: Contains Ca, K and NaCl

2. Hypotonic Fluids - The purpose of hypotonic fluids is to replace cellular fluids, because it is hypotonic as compared with plasma. - It also used to provide free water for excretion of body wastes. - It may used to treat hypernatramia (hypotonic Na solutions). Examples of hypotonic solutions: 0.45% Nacl Half-strength saline.

Complications of excessive use of hypotonic solutions include:   Intravascular fluid depletion.   Decreased blood pressure.   Cellular edema. Cell damage

3.Hypertonic Solutions Hypertonic solutions exert an osmotic pressure greater than that of ECF Examples * High concentrations of dextrose such as 50% dextrose in water are used to help meet caloric requirements. These hypertonic solutions must be administered into control veins so that they can be diluted by rapid blood flow.

Saline solutions are also available in osmolar pressures greater than that of ECF and cause cells to shrink. If administered rapidly or in large quantities, they may cause an extra cellular volume excess and cause circulatory overload and dehydration.

*Management and Nsg Care for certain fluid and electrolyte balance disturbances 1-Water depletion - Provide replacement of fluid. -Determine and correct cause of water depletion. - Measure intake and output. - Monitor V/S

2- Water Excess: - Limit fluid intake. - Administer diuretics. - Monitor V/S - Determine and treat cause. - Analyze laboratory electrolyte measurement frequently

3- Hyponatremia   - Determine and treat cause - Administer I.V fluids with appropriate saline concentration 4- Hypernatramia: -   Determine and treat cause. Administer fluids as prescribed. -   Measure intake and output. -   Monitor lab. Data.

- Administer supplemental K. 5- Hypokalemia: -   Determine and treat cause. - Monitor V/S and ECG. - Administer supplemental K. - Assess for adequate renal output before administration. IV: administered slowly. Oral: after high K fluids and foods.

6- Hyperkalemia - Determine and treat cause. - Monitor V/S and ECG - Administer I.V fluids if prescribed. - Monitor serum potassium levels.  7- Hypocalcaemia: - Determine and treat cause. - Administer calcium supp. as prescribed and administered slowly. Monitor serum calcium levels. Monitor serum protein level

8- Hypocalcaemia: - Determine and treat cause. - Monitor serum Ca levels. -   Monitor ECG.

SODIUM Na+ are very important for regulating blood and interstitial fluid pressures as well as nerve and muscle cell conduction of electrical currents. Aldosterone causes retention of Na+.

a. HYPONATREMIA:- Vomiting, diarrhea, sweating, and burns cause Na+ loss. Dehydration, tachycardia and shock (see above) can result. Intake of plain water worsens the condition. Pedialyte is a better fluid to drink. Explain this. b. HYPERNATREMIA Severe water deprivation, salt retention or excessive sodium intake causes this. Increased Na+ draws water outside of cells, resulting in tissue dehydration. Thirst, fatigue and coma result.

CHLORIDE Cl- anion is necessary for the making of HCl, hyper polarization of neurons, regulating proper acid levels, and balancing osmotic pressures between compartments.

a. HYPOCHLOREMIA  Excessive vomiting causes chloride loss, resulting in blood and tissue alkalosis, and a depressed respiration rate.  b. HYPERCLOREMIA  Dehydration or chloride gain can result in renal failure or acidosis (increases in Cl- are accompanied by increases in H+).

POTASSIUM K+ is important in the intracellular fluid. Aldosterone causes excretion of K+. a. HYPOKALEMIA Caused by diarrhea, exhaustion phase of stress, excessive aldosterone secretions in adrenal cortical hyperplasia and some diuretics. K+ loss from cells contributes to tissue dehydration and acidosis. Flattened T waves, bradycardia, muscle spasms, a lengthened P-R, and mental confusion can also result.

b. HYPERKALEMIA Caused by eating large amounts of "light salt" (KCl), kidney failure, and decreased aldosterone secretions in Addison's Disease; resulting in elevated T waves and fibrillation of the heart. The movement of K+ into cells accompanies tissue alkalosis.  

CALCIUM Calcium Ca++ cations are needed for bone, muscle contraction, and synaptic transmission.

a. HYPOCALCEMIA Excessive calcitonin, inadequate PTH, decreased Vita. D, or reduced Ca++ intake results in muscle cramps, and convulsions. b. HYPERCALCEMIA Increased PTH, Vita. D or calcium intake can cause kidney stones, bone spurs, and lethargy.

RESPIRATORY ACIDOSIS Increased pCO2 and pH below 7.35 due to hypoventilation, emphysema etc. Compensation occurs in the kidney through increased H+ excretion and HCO3- reabsorption. Bicarbonate/carbonic acid ratio is 10-15:1.

RESPIRATORY ALKALOSIS Hyperventilation due to O2 deficiency, CVA, or anxiety are causes of respiratory alkalosis. Renal compensation occurs by decreasing H+ excretion and HCO3- reabsorption. H+ is reabsorbed. Bicarbonate/carbonic acid ratio is 30-40:1.  

METABOLIC ACIDOSIS Due to loss of HCO3- by diarrhea, ketoacidosis, keto acids from a high protein diet, high stomach acidity, anaerobic fermentation, and renal disease. Compensation occurs by an increase in respiration rate. Bicarbonate/carbonic acid ratio is 10-15:1.

METABOLIC ALKALOSIS Increased intake of antacids, low protein/high vegetable diet, and vomiting/loss of HCl are common causes. Compensation is by hypoventilation. Bicarbonate/carbonic acid ratio is 35:1.

Child vs. Adult in medication administration 1. Water % 2. Body service area 3. Type of food 4. Stomach acidity (infant much less than adult ) 5. Enzyme chains not maturity 6. Rate of break down of drug ( growth &development rate ) TPN replacement for chronic case

7. % of protein binding & fat distributions 8. Drug half life 9. Excretion 10. Gastric empty time 11. Eating habits 12. Exercise pattern 13.sexual development

Rout of medication administration 1. Orally 2. Rectally 3. Nasal 4. IM 5. IV 6.transdermally 7. Topical 8. Inhalation * Calculation of medication 1. Bwt 2. Hight 3.G&D 4. Swallowing 5. Past experience * 6 medication right

Steps to give medication 1. Identification the child 2. Oral medication ( infant…preschool …school age) 3. Teach the child how to swallowing ( liqide need ½ hr ,Tablet (1/2-1hr) * Safe storage of medication * Determination of the correct dosage