Fluid & Electrolyte Balance & Imbalance

Body fluids composed of Intracellular fluid (ICF) and Extracellular fluid (ECF).
ICF- in the cells

ECF- has 3 components: Intravascular - blood vessels, vascular depleted =

hypovolemic, not a lot in veins
 Where all fluid exchange takes place
Interstitial - surrounds cell, relates to edema
Transcellular - special cavities

Total body water: 45-75% of total body weight

Newborn: 50% body fluid is in the ECF
o Fluid shifts are much greater and happen faster, concerned with
dehydration
Toddler: 30% is in the ECF
Adult: ~ 20% is in the ECF

Physical forces that influence fluid balance:

Hydrostatic pressure: Pumping action of the heart increases fluid pressure in arterial
portion of circulatory system, forcing fluid through capillary walls.

Osmotic pressure: Physical force, or “pull”, created by a solution of higher

concentration across a semipermeable membrane

Diffusion: Random movement of molecules from a region of greater concentration to

regions of lesser concentration.

Active transport: A substance is transported by way of a carrier substance against a

pressure gradient, from a region of lesser or equal concentration to a region of equal or
higher concentration.

Vesicular transport: A portion of a membrane engulfs a large molecule and releases it

on the other side of the membrane.

Maintenance water balance- volume of water needed to replace obligatory fluid loss
such as from:
 Insensible – water loss through respiratory tract and skin (sweating, breathing)
 Evaporative loss – fever and sweat, specific to temperatures
 Urine & stool formation: I=O, maybe 200 more output in adults

***Maintenance fluid requirements:

Body Weight (kg) Amount of fluid per day

1-10 100 ml/kg
11-20 1000 ml plus 50 ml/kg for each kg>10kg
>20 1500 ml plus 20 ml/kg for each kg>20kg

 Smaller child = quicker they dehydrate

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Sample Problem 1
What will be the maintenance fluid requirements be for a 9kg baby?
900ml
At what rate should his IV be administered? (ml/hr)
900ml/24hr = 37 mL/hr

Sample Problem 2
What will be the maintenance fluid requirements for a 5 year old who weighs 46 pounds?
46 lbs = 21 kg
1520 ml/24 = 64 mL/hr

Differences in the infant:

 Expanded extracellular compartments
o Contributes to greater and more rapid water loss
 Body surface area— larger quantities of fluid loss
o 2-3x more than adults
 Metabolic rate is significantly higher
 Kidneys of an infant are more immature, more inefficient in excretion
 Hypothermic vitals: temperature drop, HR decrease

DEHYDRATION
**Most common body fluid disturbance seen in infants and children
 Signs: decreased number of diapers/urine output, depressed fontanels, Hct
increase
 Total output exceeds total intake!
Normal Lab Values: (table 24-2)
 Hematocrit—35 - 45
 WBC—11,000
 Platelet – 150k-400k
 K – 3.5-4.5
 Na – 135-145
 Glucose – 80-100
 BUN – 5-20
 Creatinine - 0.3-0.7

Types:
 Isotonic: Occurs when electrolyte and water deficits are present in approximately
balanced proportion
o Normal sodium can be seen
o Losing water and electrolytes at same rate
o TREAT: Normal saline, Lactated Ringers
 Hypotonic: Occurs when electrolyte deficit > water deficit
o Sodium is less than 130
o Losing more electrolytes (specifically Na) than water
o Hyponatremic shock
 Hypertonic: Occurs when water loss is > electrolyte loss, or the electrolyte intake
exceeds the water intake
o Sodium is greater than 150
o Losing more water than electrolytes
o Hypernatremic shock
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  #1 fear with abnormal sodium in pediatrics—seizure risk*

Degree of dehydration: (isotonic, p 953)

**Keep in mind that a newborn has 80-85ml/kg of circulating blood volume (adults have
70-75ml/kg)

Mild Moderate Severe

Infant 3-5% Infant 6-9% Infant >10%
Child 3-4% Child 6-8% Child >10%
Pale color Grey Mottled (see all veins)
Decreased Skin elasticity Poor skin elasticity Very poor skin elasticity
(pinch it and it stays
pinched, doesn’t bounce
back)
Normal membranes Dry membranes Parched membranes
Normal pulse Increased pulse Very Increased Pulse
Urine output decreases Oliguria: Oliguria or anuria
<200mL/hr (very low) <50 mL/hour (almost
none)
Normal BP Normal or low BP Low BP (shock)
Relatively normal weight Low weight Very low weight

*Know heart rate

Compensatory mechanisms:

 Interstitial fluid moves into vascular compartment in response to the

hemoconcentration and hypovolemia, vasoconstriction of peripheral arterioles
helps maintain pumping pressure
o In response to hemoconcentration and hypovolemia
o Vasoconstriction maintains pumping pressure
o Start to have poor perfusion in extremities (will be very cool/pale)

 Kidney Factors - reducing blood flow through the kidneys, with little urine being
formed

EDEMA
 Presence of excess fluid in interstitial spaces
 Puffiness in extremities
 Defect in normal cardiovascular circulation or
 Failure of lymphatic system to remove increased amounts.
 Different types: generalized, peripheral
 #1 med: Lasix 1mg/kg
DIARRHEA

 Acute: sudden increase in frequency and change in consistency

 Chronic: duration >14 days
 Results in:
o Dehydration
o Electrolyte imbalance
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 o Metabolic acidosis
Diagnosis:
 Good history
o Travel, anyone close to them who has been sick
 Lab tests: Na, BUN, Hct
 Stool specimens

Treatment/Nursing:
 Correct F and E imbalances
 Oral rehydration
o Solution (pedialyte), breast milk (mostly water, considered a clear fluid)
 IVF (normal saline) for severe dehydration or if vomiting
 DO NOT use drugs—need to figure out why they are sick, then consider
medication

Nursing
 Assessment
o fontanelles, sunken eyes, mottled
 I&O, specific gravity, weight
 Diet
o Have parents quantify bottles—how many mL/oz is each bottle?
 Prevention!
o Good hand washing (C. Diff)

VOMITING
Diagnosis:
 Good history & physical
o Feeding intolerances, food changes
 Good descriptions

Treatment/Nursing:
 Oral rehydration or IVF (small amounts; can be done at home)
 Antiemetic medications (once e know why they’re sick)
 Good assessment & teaching
 ** Morning vomiting (and that’s it) is classic for brain tumors

Nursing Responsibilities (with F&E Disturbances):

Assessment
History
 Recent vomiting, diarrhea
 Type & volume of drinks
 # stools/wet diapers*
 History weight loss or gain
 Behavior changes

Observation
 General appearance
o Chapped lips, agitated
 Overall look and expression
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  Eyes
o Sunken in is classic for dehydration
 Appetite
o Decreased
 Activity
o Decreased
 Behavior
 LOC

Clinical Observations
 HR
 Skin
 Temperature
 Respirations
 BP
 No tears when crying
 Weight (only useful when you have a baseline)

**Best 3 signs:
 Prolonged cap refill >3 seconds
 Abnormal skin turgor
 Abnormal respiratory pattern

Treatment
 Good monitoring
 ORT – oral rehydration therapy
 Parenteral fluids
o Often treated at home
o Diluted fruit juices, water, warm milk, soda
o Don’t want too much sugar
 Good prep
 Sites
 Other info

 Most dreaded potential outcomes of Hypertonic Dehydration:

o Hypovolemic shock
o Neurologic disturbance
o Impaired kidney function
o Parenteral therapy complications

Which replacement is not added until kidney function is reestablished?

A: Potassium—with renal insufficiency, it can get very high very fast
 ACID-BASE BALANCE
 *Review on your own
 Tables 27-1, 2&3 (p130)
 Boxes 27-3, 4&5
 Blood Gas
o pH 7.35- 7.45
o pCO2 35-45
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 o pO2 80-100
(arterial)
o HCO3 22-26
Respiratory acidosis is common when not breathing effectively (ex: after surgery)
because respiratory is affected before circulation

SHOCK

 4 different kinds:
 Hypovolemic - see after a reduction in circulating blood volume
o Blood loss, plasma loss, ECF loss
o Treat: fluid replacement (Normal saline, blood)
o Most common in pediatrics
 Cardiogenic - d/t impaired cardiac muscle function that results in decreased
cardiac output
 Distributive or vasogenic - d/t a vascular abnormality.
o 3 types:
o Neurogenic: massive vasodilation d/t loss of sympathetic nervous system tone
 Post brain tumor surgery
o Anaphylactic: d/t hypersensitivity reaction causing massive vasodilation & cap.
leak
o Septic: d/t overwhelming infection causing decreased cardiac output & changes
in peripheral circulation.
 Obstructive: Mechanical obstruction of blood flow to or from heart
o Poor perfusion
o Cardiac tamponade, congenital heart disease, pulmonary embolism

Pathophysiology of Hypovolemic Shock:

REDUCED BLOOD FLOW

Venous return to heart

Low Central Venous Pressure
Low Cardiac Output
Low BP
 In response to Hypovolemic Shock:
 Centers in medulla signaled:
o Increases force & rate or contractions
o Constriction of arterioles & veins
 Release of Catecholamines:
o VC, reduce blood flow to skin, kidneys, muscles so blood to brain and heart
 ADH and aldosterone also released
 Metabolic alterations:
o Lactic acidosis
o Problems with glucose uptake
When plasma fluid is lost, hemoconcentration of blood

Other complications for Hypovolemic Shock:

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  Cerebral edema and IVH – interventricular hemorrhages
 ARDS (Adult Respiratory Distress Syndrome)
 Kidney dysfunction
o Kidneys don’t get perfused because other vital organs (brain, heart) are
more important and need bloodflow
Clinical signs:
 Hypotension
 Tissue hypoxia
 Metabolic acidosis

3 Stages of shock
 Compensated
o Decreased perfusion in hand and feet
o Tachycardia
o Normal or increased BP/CO
o Irritable
o Pallor
o Decreased urine output
 Decompensated
o Tachycardia, tachypnea
o Oliguria
o Cool, pale extremities
o Skin turgor and poor capillary refill
o Hypotension – LATE sign
o As it progresses – heart and brain affected
 Irreversible

Diagnosis of Shock:
 History & Physical
 VS and labs

Treatment:
3 major areas
 Oxygenation & ventilation: usually intubated early on.
 Cardiovascular support: must restore blood volume quickly
o Isotonic solution or Albumin given
 Inotropic support: increase cardiac contractility
o Dopamine or epinephrine
 Additionally:
o Bicarbonate
o CaCl/Gluconate because it helps muscle/prevents arrest

Initial Nursing Support:

 Administer O2
 Lay flat
 Monitor VS carefully
 I&O
o Output should be about 1mL/kg/hr
 IV lines
o Patent, working
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Continuing care:
 Monitor circulation and perfusion
 Neurological status
 Labs
 Dialysis (if kidneys were damaged)

Support the family!!

Child is being admitted with the diagnosis of dehydration. What is the nurse’s first
responsibility?
A. Orient family to the unit
B. Get vital signs
C. Weigh the patient
D. Start an IV

Is B, get vitals

BURNS

 Scald – most common cause <3 years old

o Hot water burns approximately 50% all burns (under age 2)
 10% abuse cases are burn injuries
 Prevention is key!
 Nursing priority is infection prevention

Extent of injury:
Called total body surface area (TBSA)

Depth of injury:

Superficial: 1st degree

 Low intensity, brief scald
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  See red, dry surface area
 Blanches with pressure and is painful
 Example: scald, sun burn

Partial-thickness: 2nd degree

 Involves the epidermis and part of dermis
 See blistered skin, may be moist, pink or mottled or very red, blanches with pressure
 Very painful

Full-thickness: 3rd degree

 Very serious. Involve epidermis, dermis and SQ tissue
 Nerve endings, sweat glands and hair follicles are destroyed
 Skin may look red, tan, waxy white or brown and leathery
 The actual area will not hurt but is usually associated with superficial and partial-thickness
areas, so will have some pain
 Fourth degree burn: basically down to the bone

Severity of Injury:

 Major
o Specialized burn center
o >20% TBSA
 Moderate
o Treated place with expertise
o 10-20% TBSA
 Minor
o Outpatient
o <10% TBSA

 Depends on Extent and Depth:

o Cause of the burn
o Areas involved
o Age of child
o Overall health status

Pathophysiology:
 Area of wound:
 Edema: injury to vessels causes capillary permeability. VD causes increase in
hydrostatic pressure in capillaries
 Fluid loss: Have no skin to hold in moisture, 5-10x greater
 Circulatory alterations: reduced blood flow to wound area d/t fluid shifts, decreased
c.o. and edema
 Risk for thrombus development
 Tissue repair:
 Superficial & superficial partial thickness heal spontaneously
 Deeper partial thickness heal more slowly.
 Full thickness – dead tissue turns into eschar within 48-72 hrs
o Graft from another part of the body

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Systemic consequences:
 Cardiovascular: Burn shock. Decreased CO due to a circulating myocardial
depressant factor that affects heart contractility
o Circulating blood volume greatly reduced
o Capillary permeability increases and fluid leaks all over

 Renal: Renal vasoconstriction occurs due to loss of intravascular fluid

o Decreased renal plasma flow
o Decrease GFR (worse for infants)
o Increased BUN and creatinine

 GI system: Changes in blood flow, see less blood going to GI tract

o Acid production stopped 48-72 hours
o Start feeds right away – need high protein for wound to heal

 Metabolic: Metabolic rate greatly increased

o Glycogen -
o Temperature – keep room warm because skin is no longer intact

 Growth & Development: May see delays, especially if extensive treatments

required

 Neuroendocrine: related to stress on body

o Adrenal activity increased
o Catecholamines released
o Other mediators

 Anemia & metabolic acidosis:

o Increased Hct
o Fluid loss and heat damaged calls
o Disruption in buffering mechanisms

Review Complications
Treatment:
Emergency
– Stop the burning process
– Assess child’s condition
o CPR
– Cover the burn.
– Transport child to hospital
– Family support

Minor Burns
- Good cleansing of area with soap and tepid water. Debridement of tissue done.
- Teaching very important here if parents or child will do the dressing. VERY important to
keep these wounds clean.
- Make sure tetanus is UTD
- OTC pain meds
- Place under cool, running water to stop burning process and promote vasoconstriction
- Do not use ice, can cause major damage
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 - Remove all clothing/jewelry from burned area
- Apply topical antibiotic such as Neosporin

Major Burns:

– Airway management always first.

o Give 100% O2
o Blood gas
o LOC
o Bronchodilators
o Fluid replacement to compensate for water and Na loss
 Type
 Output
o Watch for shock

– Good nutrition essential.

o Hypometabolic then hyper
o High protein, high calories
o Supplemental feeds

– Medications
o Morphine is drug of choice - dose is .1mg/kg/dose IV.
o Antibiotics to avoid infection
o Sedation and analgesia
 Fentanyl/Versid IV for dressing changes

 Wound
o Primary excision – clean out black tissue and eschar
o Hygiene
o Dressings
 **Primary concern is infection, always look for signs when changing dressing
o Topical agents
 Silver sulfadiazine, silver nitrate, bacitracin
o Skin coverings – temporary, synthetic, permanent
 Permanent: allo-graft: another part of someone else’s body

NURSING
Pain management
 Make sure it is enough (meds and non-pharmalogical)
 Pre medicate
Infection
 Good assessment
 Wound care

Fluid management
 Good assessment
 Capillary refill, neuro status, urine output

Nutrition
 Oral is best
 Nutritionist is involved
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Prevention of complications
 Infection prevention
 ROM
 Pressure devices

Psychosocial support of child and family

 Multidisciplinary team approach
 Strive for independent child care
 Use ABCX model (family stressors equation)
 Team approach

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