Transcript Fluid and electrolyte imbalance

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
0
Add 12 % for every C
+
+
Na & K Daily Needs
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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
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Renal failure
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Burn
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Shock
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Tachypnea
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Gastroenteritis
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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
2.25gm 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%
Older children < 3 %
5 - 10 %
3-6%
>6%
>10 %
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
Signs & sympt.
MILD
Moderate
Severe
General
Thirsty, allert,
restless
Normal rate
Normal
Normal
Pinch retracts
immediately
Normal
Present
Moist
Normal
Thirsty, irritable,
or drowsy
Rapid, weak
Deep
Sunken
Retracts slowly
Drowsy – limp,
skin cold / sweaty
Rapid, feeble
Deep & rapid
Very sunken
Poor
Sunken
Absent
Dry
Dark &
decreased
Grossly sunken
Absent
Very dry
Oliguria / anuria
Radial pulse
Respiration
Anterior font.
Skin turgor
Eyes
Tears
Mucous memb.
Urine flow
Correction of Dehydration
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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).
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Disturbance of acid based balance
Disturbance
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
Plasma PH
Plasma PCO2
Plasma HCO3
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.
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Considering the fluid volume.
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Content of fluid.
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Patient clinical status.
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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
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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.
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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
depletion.
- Measure intake and output.
- Monitor V/S
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of
water
2- Water Excess:
- Limit fluid intake.
- Administer diuretics.
- Monitor V/S
- Determine and treat cause.
- Analyze laboratory electrolyte measurement
frequently
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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.
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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
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8- Hypocalcaemia:
- Determine and treat cause.
- Monitor serum Ca levels.
- Monitor ECG.
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SODIUM
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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+.
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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
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Cl- anion is necessary for the making of HCl,
hyper polarization of neurons,
regulating proper acid levels, and balancing
osmotic pressures between compartments.
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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
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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.
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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
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Calcium Ca++ cations are needed for bone,
muscle contraction, and synaptic
transmission.
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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
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Increased pCO2 and pH below 7.35 due to
hypoventilation, emphysema etc.
Compensation occurs in the kidney through
increased H+ excretion and HCO3reabsorption. Bicarbonate/carbonic acid ratio
is 10-15:1.
RESPIRATORY ALKALOSIS
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Hyperventilation due to O2 deficiency, CVA,
or anxiety are causes of respiratory
alkalosis. Renal compensation occurs by
decreasing H+ excretion and HCO3reabsorption.
H+ is reabsorbed. Bicarbonate/carbonic acid
ratio is 30-40:1.
METABOLIC ACIDOSIS
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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
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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
4. IM
7. Topical
2. Rectally
5. IV
8. Inhalation
* Calculation
3. Nasal
6.transdermally
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