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2. Case Studies Improve your critical thinking skills Fluids & Electrolytes – Dehydration Critical Thinking Exercises

3. Fluids & Electrolytes – Dehydration Critical Thinking Exercises Agenda – Event

4. Fluids & Electrolytes – Dehydration Critical Thinking Exercises Use the information in the Fluids and Electrolytes Algorithms section of the Fluids and Electrolytes learner guide as you work through the various case studies that will be discussed today.

5. Case Studies Improve your critical thinking skills Case Study #1 Colin

6. Case Study #1 – Collin Read the information under Case Study #1 for Collin in your learner guide. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

7. Case Study #1 – Collin Question for discussion: What is the percentage of Collin’s weight loss and what is his degree of dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Collin has a seven percent weight loss 21.4 kg – 20 kg = 1.4 kg (1.4 kg ÷ 21.4) X 100= 6.5% or 7% Degree of dehydration = Moderate Answer

8. Case Study #1 – Collin Question for discussion: What is Collin’s fluid deficit replacement? Fluids & Electrolytes – Dehydration Critical Thinking Exercises (21.4kg x 7) x 10ml = 1498ml (low replacement) (21.4kg X 7) X 20ml = 2996 ml (high replacement) Answer

9. Case Study #1 – Collin Questions for discussion: 1.Would you expect that Collin would receive a bolus of fluid during initial therapy (Phase I)? 2.What symptoms might indicate the need for a bolus? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Although Collin’s fluid deficit indicates moderate dehydration, his symptoms indicate that he has been able to compensate the fluid loss at this point, although his HR is elevated. Answer

10. Fluids & Electrolytes – Dehydration Critical Thinking Exercises Case Study #1 – Collin Questions for discussion: What amount would you expect him to be given in an initial bolus? The physician opts to begin him on a high – fluid replacement rate (20 ml/kg) while monitoring his vital signs closely for the first eight hours of admission. If the physician had decided to initiate bolus therapy, a bolus of 20 ml/kg over one to two hours might be given. Answer

11. Case Study #1 – Collin Question for discussion: How much of Collin’s fluid deficit should be replaced during the first 24 hours? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Two-thirds (1997 ml) Remember that if Collin received a bolus, this amount would be subtracted from the two-thirds (1997 ml) to calculate the remaining fluid replacement rate so that a total of two-thirds of the deficit fluid of 2996 ml is returned to him in the first 24 hours of therapy. Answer

12. Page 12 Case Study #1 – Collin Question for discussion: How much of this fluid deficit would generally be administered during the first eight hours of therapy? Fluids & Electrolytes – Dehydration Critical Thinking Exercises 999 ml (one-half of 1997 ml) If no bolus were given,125 ml/hr would be required during the first eight hours. If he received a bolus of 20 ml/kg (428ml) in the first two hours, 95 ml/hr would be required during the next six hours to replace his fluid deficit. Answer

13. Case Study #1 – Collin Question for discussion: What is Collin’s maintenance fluid needs for a 24-hour period? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Maintenance fluid = 1500 ml + (20 ml X 1.4 kg) = 1528 ml/24 hours or 64 ml/hour Answer

14. Case Study #1 – Collin Question for discussion: What is the total amount of replacement fluid Collin requires per hour during the first eight hours of treatment? Fluids & Electrolytes – Dehydration Critical Thinking Exercises 189 ml/hr, if no bolus given: Collin should receive 125 ml/hour deficit replacement + 64 ml/hour maintenance fluid. 159 ml/hr, if 428 ml bolus was given over the first two hours: Collin should receive 95ml/hour deficit replacement + 64 ml/hour maintenance fluid over the last six hours. Answer

15. Case Study #1 – Collin Question for discussion: What will happen to the rate of Collin’s replacement fluid during the next 16 hours? Fluids & Electrolytes – Dehydration Critical Thinking Exercises It will drop to 126 ml/hour: 62 ml/hour deficit replacement + 64 ml/hr maintenance fluid Answer

16. Case Study #1 – Collin Question for discussion: What are Collin’s sodium and potassium maintenance needs? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Sodium 2 - 4 mEq/kg/24 hours: 2 - 4 mEq x 21.4 kg = 42.8 mEq - 85.6 mEq/24 hrs Potassium 2 - 3 mEq/kg/24 hours: 2 - 3 mEq x 21.4 kg = 42.8mEq - 64.2 mEq/24 hrs Answer

17. Case Study #1 – Collin Serum electrolytes must be checked frequently to assure that sodium levels are not changing dramatically and sudden shifts in fluid between compartments are prevented. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

18. Case Studies Improve your critical thinking skills Case Study #2 Suzette

19. Case Study #2 – Suzette Read the information under Case Study #2 for Suzette in your learner guide. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

20. Case Study #2 – Suzette Question for discussion: Which assessment parameters indicate that Suzette was dehydrated on admission? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Lethargy Skin is gray, slightly mottled and cool to touch. Capillary refill is 5 to 6 seconds and her heart rate is 220. Her skin tents when pinched. Answer

21. Case Study #2 – Suzette Question for discussion: Suzette is suffering from hypotonic dehydration. Why? Fluids & Electrolytes – Dehydration Critical Thinking Exercises At home, Suzette was losing fluids and electrolytes from frequent vomiting and was receiving supplemental water between feedings. Answer

22. Case Study #2 – Suzette Question for discussion: Suzette’s admission weight is 6.8 pounds (3.1kg). What is Suzette’s percent of weight loss and degree of dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Answer

23. Case Study #2 – Suzette Question for discussion: Suzette’s physician admitted her to the hospital. Intravenous fluids of 5% Dextrose/0.2% NS with 20mEq KCL/Liter were started, to run at 25 ml/hr. Is Suzette receiving adequate fluid therapy to meet her deficit and maintenance needs? Fluids & Electrolytes – Dehydration Critical Thinking Exercises

24. Fluids & Electrolytes – Dehydration Critical Thinking Exercises Suzette Fluid deficit 13 x 10 ml/kg = 13 X 36 = 468 ml Suzette should receive two-thirds of this amount within the first 24 hours, or 312 ml Of the 312 ml, half (156 ml) should be given within the first 8 hours (20 ml/hr) Over the next 16 hours she should receive10 ml/hr Fluid maintenance 100 ml/kg = 360 ml/24 hours (or 15 ml/hr) Total, Suzette should receive 312 ml + 360 ml = 672 ml/24hr For the first 8 hours, Suzette should receive 35 ml/hr (20 ml/hr deficit replacement+15 ml/hr maintenance). For the next 16 hours, she should receive 25 ml/hr (10 ml/hr deficit replacement+ 15 ml/hr maintenance). Calculations

25. It would appear that Suzette’s physician is only providing fluids for the period following initial fluid resuscitation (Phase II), which will not meet her fluid deficit needs. Fluids & Electrolytes – Dehydration Critical Thinking Exercises Suzette Answer

26. Case Study #2 – Suzette Question for discussion: What are Suzette’s maintenance electrolyte requirements? Fluids & Electrolytes – Dehydration Critical Thinking Exercises

27. Electrolyte Maintenance Formula (per 24 hours) Potassium = 2 mEq/kg/24hrs Sodium = 3 mEq/kg/24hrs Fluids & Electrolytes – Dehydration Critical Thinking Exercises Suzette Calculations Answer For Suzette Potassium 3.6kg x 2mEq = 7mEq/24hrs Sodium 3.6kg x 3mEq = 11mEq/24hrs

28. Case Study #2 – Suzette Fluids & Electrolytes – Dehydration. Critical Thinking Exercises Treatment of hypotonic dehydration is aimed at restoring the sodium concentration while avoiding the production of fluid volume excess. Avoid hypotonic solutions and remember that sodium should be corrected slowly to avoid neurological damage.

29. Case Studies Improve your critical thinking skills Case Study #3 Jerome

30. Case Study #3 – Jerome Read the information under Case Study #3 for Jerome in your learner guide. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

31. Case Study #3 – Jerome Question for discussion: Jerome is dehydrated. Which lab values would be indicative of isotonic dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Sodium 130 - 150 mEq/L, but will be on the low side of normal. Potassium 3.5 to 4.0 mEq/L; it also will be on the low side of normal. Answer

32. Case Study #3 – Jerome Question for discussion: Jerome’s present weight is 11.4 lbs (5.2kg). His weight two weeks ago was 13 lbs (5.9kg). What is the percentage of Jerome’s weight loss and what is his degree of dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Jerome has a 12 percent weight loss 5.9 kg – 5.2 kg = 0.7 kg 0.7 kg/5.9 kg = 12% Degree of dehydration = Severe Answer

33. Case Study #3 – Jerome Question for discussion: What is Jerome’s fluid deficit replacement? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Fluid deficit replacement 12% weight loss(10ml x 5.9kg) = 12 x 59 = 708ml 12% weight loss(20ml x 5.9kg) = 12 x 118 = 1416ml Answer

34. Case Study #3 – Jerome Questions for discussion: Would you expect that Jerome would receive a bolus of fluid during initial therapy (Phase I)? What symptoms might indicate the need for a bolus? What amount would you expect to be given in an initial bolus? Fluids & Electrolytes – Dehydration Critical Thinking Exercises

35. More than likely, Jerome would need a bolus. Jerome is showing symptoms of severe dehydration with early signs of developing circulatory compromise (grayish color, cool skin, heart rate 150/minute, dry mucous membranes, depressed anterior fontanel). Thus, a bolus of 20 ml/kg over one to two hours is given. Fluids & Electrolytes – Dehydration Critical Thinking Exercises Answer

36. Case Study #3 – Jerome Question for discussion: How much of Jerome’s fluid deficit should be replaced during the first 24 hours? Fluids & Electrolytes – Dehydration Critical Thinking Exercises 472 - 944 ml (two-thirds of 708 to 1416 ml) Remember that if Jerome received a bolus (118ml), fluid deficit replacement would then be adjusted so that a total of two-thirds of the deficit fluid is returned to him in the first 24 hours of therapy. Answer

37. Case Study #3 – Jerome Question for discussion: Following the bolus, what assessment parameters would indicate that Jerome has improved and fluid replacement should continue at 10ml/kg/24 hours (low replacement rate)? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Color pink Skin warm Flat fontanel Heart Rate 110 Alert Voiding Answer

38. Case Study #3 – Jerome Question for discussion: If the PNP opts to begin replacement at the low level of fluid replacement (10ml/kg/24hrs) following the 20ml/kg bolus, how much of this fluid deficit would generally be administered during the first eight hours of therapy? Fluids & Electrolytes – Dehydration Critical Thinking Exercises 236 ml (one-half of 472 ml) If he received a bolus of 20 ml/kg (20 x 5.9)118 mL) in the first two hours, 20 ml/hr would be required during the next six hours to replace his fluid deficit. Answer

39. Case Study #3 – Jerome Question for discussion: What is Jerome’s maintenance fluid needs for a 24 hour period? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Maintenance fluid = 100 ml/kg = 100 ml x 5.9 kg = 590 mL/24 hrs or = 25 ml/hr Answer

40. Case Study #3 – Jerome Question for discussion: What is the total amount of fluid Jerome requires per hour during the first eight hours of his treatment regimen? Fluids & Electrolytes – Dehydration Critical Thinking Exercises 45 ml/hr, after bolus was given (20 ml/hr deficit replacement + 25 ml/hr maintenance fluid) Answer

41. Case Study #3 – Jerome Question for discussion: What will happen to the Jerome’s IV rate for the next 16 hours. Fluids & Electrolytes – Dehydration Critical Thinking Exercises It will drop to 40 ml/hr. (15 ml/hr deficit replacement + 25 ml/hr maintenance fluid) Answer

42. Case Study #3 – Jerome Question for discussion: What are Jerome’s sodium and potassium maintenance needs? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Maintenance needs: Sodium = 3 mEq x 5.9 kg = 18 mEq/24 hours Potassium = 2 mEq x 5.9 kg = 12 mEq/24 hours Answer

43. Case Study #3 – Jerome Fluids & Electrolytes – Dehydration Critical Thinking Exercises With moderate to severe dehydration, a bolus (and perhaps a second) is indicated, and fluid rates should be calculated after the bolus is administered. With isotonic dehydration and the beginning signs of circulatory compromise, the goal for Jerome’s therapy is to correct hypovolemic shock. Recall that potassium should not be replaced until urine output returns, and should be given over 3-4 days. As potassium is administered, sodium returns to the extracellular fluid compartment; therefore if total sodium loss is replaced in the first day an excess of sodium could result. Therefore, close monitoring of electrolytes is vital.

44. Case Studies Improve your critical thinking skills Case Study #4 Lori

45. Case Study #4 – Lori Read the information under Case Study #4 for Lori in your learner guide. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

46. Case Study #4 – Lori Question for discussion: Which assessment parameters indicated that Lori was dehydrated on admission? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Dry skin with abdominal tenting, dry mucous membranes, eyes dull and gray, lethargic, decreased urinary output and weight loss. Answer

47. Case Study #4 – Lori Question for discussion: Lori is suffering from hypotonic dehydration. Why? Fluids & Electrolytes – Dehydration Critical Thinking Exercises At home, during a rather extended period of electrolyte losses through diarrhea, no electrolyte replacements were given. Instead, only water was provided, through weak tea and sugar water given orally. Answer

48. Case Study #4 – Lori Question for discussion: What is Lori’s percent of weight loss and degree of dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Lori has a six percent weight loss = 14.5 kg – 13.6 kg = 0.9 kg 0.9 kg/14.5 =.06 or 6% Degree of dehydration = Moderate Answer

49. Case Study #4 – Lori Question for discussion: Is Lori receiving adequate fluid therapy to meet her deficit and maintenance needs? (Intravenous fluid of 5% Dextrose/0.2% NS with 20 mEq KCl/L was started, to run at 50 mL/hr.) Fluids & Electrolytes – Dehydration Critical Thinking Exercises

50. Fluid deficit Replacement 6 percent weight loss(10ml X 14.5kg) = 870ml 6 percent weight loss(20ml X 14.5kg) = 1740ml Fluid maintenance 1000 ml + 50 ml/kg >10kg 1000ml + 4.5 kg x 50 ml/kg = 1000 ml + 225 ml = 1225 ml/24 hours or 51 ml/hour Fluids & Electrolytes – Dehydration Critical Thinking Exercises CalculationsAnswer It would appear that Lori’s physician is only providing maintenance fluids, which will not replace her fluid deficit.

51. Case Study #4 – Lori Question for discussion: What would be an appropriate way to meet Lori’s fluid needs? Fluids & Electrolytes – Dehydration Critical Thinking Exercises

52. Maintenance fluids = 51 ml/hr Deficit fluids = 54 ml/hr (half of 870 ml or 435 ml over 8 hours) Total fluids (for first 8 hours) = 105 ml/hr AnswerCalculations During the next 16 hours, the deficit fluid should be reduced to 27 ml/hr (half of 870 ml or 435 ml over 16 hours), so total fluid rate: = 51 ml/hr + 27 ml/hr = 78 ml/hr

53. Case Study #4 – Lori Treatment of hypotonic dehydration is aimed at restoring the sodium concentration while avoiding the production of fluid volume excess. Avoid hypotonic solutions and remember that sodium should be corrected slowly to avoid neurological damage. Replacement of potassium should not begin until urine output is established and should occur over 3-4 days. The maximum recommended concentration of KCl in intravenous solution for a peripheral line is 40 mEq/L. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

54. Case Studies Improve your critical thinking skills Case Study #5 James

55. Case Study #5 – James Read the information under Case Study #5 for James in your learner guide. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

56. Case Study #5 – James Question for discussion: What assessment data indicate that James is experiencing hypertonic dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises The following signs & symptoms are indicative of hypertonic dehydration: Skin feels heavy or doughy Irritability Dark eyes Sunken fontanel Twitching of extremities Answer

57. Case Study #5 – James Question for discussion: Although James demonstrates many signs of a serious state of dehydration, his vital signs remain only slightly elevated above normal and his extremities are warm with strong pulses bilaterally. Why? Fluids & Electrolytes – Dehydration Critical Thinking Exercises In hypertonic dehydration, hypovolemic shock is less apparent since fluid loss from the extracellular compartment is less severe. The intravascular fluid volume is maintained at cellular expense. Thus, symptoms of clinical shock are often not present. When shock does occur in children with hypertonic dehydration, it is a sign of a severe dehydration status. Answer

58. Case Study #5 – James Question for discussion: What has caused James’ dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises By continuing to ingest a high – solute formula with little additional water intake over a four – day period of diarrhea, James’ serum sodium has likely increased in relation to the excess water excreted via his gastrointestinal tract. Answer

59. Case Study #5 – James Question for discussion: James’ mother reports that his weight at his last check up several weeks ago was 9.5 kg. His current weight is 8.6 kg. What is his percent weight loss and degree of dehydration? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Weight loss 9.5 kg – 8.6 kg = 0.9 kg 0.9 kg ÷ 9.5kg = 9% Degree of dehydration = Moderate Answer

60. Case Study #5 – James Question for discussion: How would you expect James’ treatment to be initiated? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Because James is not severely dehydrated and is not showing signs of circulatory compromise, he does not require a large bolus of fluids to initiate treatment. He has not voided, so therapy should begin with 5 to 10 ml/kg/hr of IV fluid for the first four to five hours to establish adequate urine output. Answer

61. Case Study #5 – James Question for discussion: James’ physician orders 5 ml/kg/hr of D 5 /0.45 NS for the first four hours. How fast should his IV run during that time? Fluids & Electrolytes – Dehydration Critical Thinking Exercises 5 ml/kg/hr x 9.5kg = 47.5 or 48 ml/hr Answer

62. Case Study #5 – James Question for discussion: After 4 hours James is voiding an average of 13 ml/hr. How should his IV rate be changed during the next 48 hours? Fluids & Electrolytes – Dehydration Critical Thinking Exercises

63. In hypertonic dehydration, a steady rate of infusion should continue over a 48-hour period to replace the remaining deficits. James has continued to have a large amount of diarrhea and is currently having an average of 17ml/hour of liquid stool-these losses need to be added to his maintenance fluid requirements. Maintenance fluid 100 ml/kg/24 hrs = 100 ml x 9.5 kg x 2 (for a 48 hour period) = 950 x 2 = 1900 ml/48 hrs = 40 ml/hr Replacement fluids (9.5kg x 9) x 10 = 855ml 855ml -192ml (already received)=663ml/48hrs=13.8 or 14ml/hr Total infusion rate for next 48 hours 40 ml/hr + 14 ml/hr + 17 ml/hr (diarrhea replacement) = 71 ml/hr Fluids & Electrolytes – Dehydration Critical Thinking Exercises Answer Note: If urine output is not established, this rate may need to be reduced by as much as 25 to 50 percent of maintenance.

64. Case Study #5 – James Question for discussion: When will you expect potassium to be added to his IV solution? Fluids & Electrolytes – Dehydration Critical Thinking Exercises Potassium will be added after urine output has been established. Urine output may be delayed because high levels of antidiuretic hormone (ADH) are released in response to the hypernatremic extracellular fluid. Urine retention will occur until ADH levels are reduced. Answer

65. Case Study #5 – James Question for discussion: Will James need any replacement sodium and/or potassium? Fluids & Electrolytes – Dehydration Critical Thinking Exercises

66. Case Study #5 – James Frequent checks of serum sodium are essential. If the sodium level falls too slowly, changing the solution to D 5 /0.2% NS may increase the amount of free water. 20 - 30 mEq of potassium should be added to each liter of fluid after the first void. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

67. New slide to discuss Case Study #5 – James Question for discussion: If the sodium level drops too quickly, what are the potential side effects? 67 Answer If fluids are replaced too quickly, or if hypo- osmolar solutions are introduced into the extracellular fluid compartment, it will result in a higher solute level in the intracellular fluid than in the extracellular fluid. Thus, the osmotic pull will cause rapid movement of fluids out of the extracellular fluid compartment into the intracellular fluid compartment. Fluids moving too quickly into dehydrated brain cells may cause marked cerebral edema and seizures.

68. Case Study #5 – James The primary goal of therapy is to replace the fluid loss at a rate that will be safely tolerated by the infant or child. Sodium levels need to be reduced slowly, since sodium requires more time than water to move in and out of brain cells. Remember that serum sodium levels should not be reduced by more than 10 mEq/L/day. Fluids & Electrolytes – Dehydration Critical Thinking Exercises

69. Case Studies Improve your critical thinking skills Congratulations! You have completed the Critical Thinking Exercises on Dehydration!