Fluids & Electrolytes

imbalance
By
Hidayatullah khan
KMU
 Composition of Body Compartments

Total Body Water (TBW)= 50-75% of Total Body Mass

TBW = Intracellular Fluid (ICF) + Extracellular Fluid (ECF)

ICF = 2/3 of TBW

ECF = 1/3 of TBW -- 25% of body weight

ECF = Plasma (intravascular) + Interstitial fluid

Fluid % in child body ( 75%-80%)

Regulation of Body Fluids and
Electrolytes
 Anti-Diuretic Hormone (ADH)
 Thirst

 Aldosterone

 Atrial Natriuretic Factor

Daily Maintenance Requirements

0
Add 12 % for every C
4cc, 2cc, 1cc rule
4 cc for the first 10 kg
 2 cc for the next 10 kg

 1 cc for each kg after

 Example:
 27kg child
 4 cc for the first 10 kg = 40cc
 2 cc for the next 10 kg = 20cc
 1 cc for each kg after = 7 cc
67 cc/hr
Estimation of Dehydration
Mild Moderate Severe
Weight Loss 3-5% 6-9% >10%

Blood pressure Normal Orthostatic Shock

Pulse Normal Increase Tachycardic

Behavior Normal Irritable Lethargic

Membranes Moist Dry Parched

Tears Present Decrease Absent

Cap. Refill 2 seconds 2-4 seconds >4 seconds

Urine SG >1.020 >1.030 Oliguria

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
Dehydration
Classification
 Isotonic

 Serum Sodium 130-150 mEq

 Hypotonic

 Serum Sodium < 130 mEq

Hypertonic
 Serum Sodium >150 mEq
 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
Management of Dehydration
General Principles:

 Supply Maintenance Requirements

 Correct volume and electrolyte deficit

 Replace ongoing abnormal losses

Management of Dehydration
Oral Rehydration:
 Effective for mild and some moderate dehydrations
 Child may be able to tolerate PO intake
 Small aliquots as tolerated
 Mild:
50 cc/kg over 4 hours
 Moderate: 100 cc/kg over 4 hours
2 types of oral solution
 Maintenance
 Rehydration
 Composition of Body fluids
1. D5W (5 g sugar/100 ml)
2. D10W (10 g sugar/100 ml)
3. NS (0.9% NaCl) 9 gm NaCl/L
4. 1/2 NS (0.45% NaCl) 4.5gm/L
5. D5 .18 NS 1.80gm/L
6. 3% NaCl 30gm/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
 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%
Physical Signs of Dehydration
Signs & sympt. MILD Moderate Severe
General Thirsty, allert, Thirsty, irritable, Drowsy – limp,
restless or drowsy skin cold / sweaty
Radial pulse Normal rate Rapid, weak Rapid, feeble
Respiration Normal Deep Deep & rapid
Anterior font. Normal Sunken Very sunken
Skin turgor Pinch retracts Retracts slowly Poor
immediately
Eyes Normal Sunken Grossly sunken
Tears Present Absent Absent
Mucous memb. Moist Dry Very dry
Urine flow Normal Dark & Oliguria / anuria
decreased
Correction of Dehydration
Mild dehydration: increase oral intake
Moderate to severe dehydration:
IV push
10-20 cc / Kg Normal saline
May repeat.
Half deficit over 8 hours, and half over 16 hours.
If hypernatremic dehydration, replace deficit over 48
hours .
 Disturbance of acid based balance
Disturbance 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 )
When administrating I.V fluid nurse
should
 Monitors the response of the
fluids.
  Considering the fluid volume.
    Content of fluid.
 Patient clinical status.
Hyponatremia
Predisposing Factors
 Diabetes mellitus (hyperglycemia)
 Cystic fibrosis

 Gastroenteritis

 Excessive water intake (formula dilution)

 Diuretics (thiazides and furosemide)

 Renal disease
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.
Hyponatremia
Hyponatremic Dehydration
 Hypovolemic Hyponatremic Dehydration
 High urine output and Na excretion
 Increase in atrial natriuretic factor

 Hypervolemic Hyponatremic Dehydration

 Edematous disorder (nephrotic syndrome, CHF, cirrhosis)
 Hyponatremia

Acute Hyponatremia (<24 hours)

 Early Onset (Serum Sodium <125 meq/L)
 Nausea
 Vomiting
 Headache

 Later or Severe (Serum Sodium <120 meq/L)

 Seizure
 Coma
 Respiratory arrest
Hyponatremia
 Chronic Hyponatremia (>48 hours)
 Lethargy

 Confusion

 Muscle cramps
 Neurologic Impairment
Hyponatremia
Management
Na Deficit:
 Na Deficit = (Na Desired - Na observed) x 0.6 x body weight(kg)
Replace half in first 8 hours and the rest in the following
16 hours
Rise in serum Na should not exceed 2 mEq/L/h to
prevent Central Pontine Myelinolysis
In cases of severe hyponatremia (<120 mEq) with CNS
symptoms:
 3% NaCl 3-5 ml/kg IV push for hyponatremia induced seizures
6 ml/kg of NaCl will raise serum Na by 5 mEq/L
Hypernatremia
 Hypernatremia leads to hypertonicity
 Increase secretion of ADH
 Increase thirst

 Patients at risk
 Inability
to secrete or respond to ADH
 No access to water
 Hypernatremia
 Etiology
 Pure water depletion
 Diabetes insipidus (Central or Nephrogenic)
 Sodium excess
 Salt poisoning (PO or IV)
 Water depletion exceeding Na depletion
 Diarrhea, vomiting, decrease fluid intake
 Pharmacologic agents
 Lithium, Cyclophosphamide, Cisplatin
Hypernatremia
Signs and symptoms
 Disturbances of consciousness
 Lethargy or Confusion
 Neuromuscular Irritability
 Muscle twitching, hyperreflexia
 Convulsions
 Hyperthermia
 Skin may feel thick
 Hypernatremia
 Management
Normal Saline or Ringer lactate to restore volume
Hypotonic solution (D5 1/5 NS) to correct calculated
deficit over 48 hours
 Water Deficit
 Normal body H20 - Current body H20
 Current body water
 0.6 x body weight (kg) x Normal Na/Observed Na
 Normal Body water
 0.6 x body weight (kg)

Decrease Na concentration at a rate of 0.5 mEq/hr or ~

10 mEq/day: Faster correction can result in Cerebral
Edema
 Potassium

Most abundant intracellular cation

Normal serum values 3.5-5.5 mEq

Abnormalities of serum K are potentially life-

threatening due to effect in cardiac function

 Hypokalemia
 Diagnosis
 Symptoms
 Arrhythmias
 Neuromuscular excitability (hyporreflexia, paralysis)
 Gastrointestinal (decreased peristalsis or ileus)

 Serum K < 3mEq/L

 ECG:
 FlatT waves
 Short P-R interval and QRS
 U waves
 Hypokalemia
Nutritional GI Loss Renal Loss Endocrine
Poor intake Diarrhea Renal tubular acidosis Insulin therapy
IVF low in K Vomiting Chronic renal disease Glucose therapy
Anorexia Malabsorbtion Fanconi's syndrome DKA
Intestinal fistula Gentamicin, Hyperaldosteronism
Laxatives Amphotericin Adrenal adenomas
Enemas Diuretics Mineralocorticoids
Bartter's syndrome

Bartter’s syndrome: Hypereninemia and hyperaldosteronism

Hypokalemia
 Management:
 Cardiac Arrhythmias or Muscle Weakness
 KCl IV (cardiac monitor)
 PO K - Depend of etiology
 Hypophoshatemia = KPO4
 Metabolic acidosis = KCl
 Renal tubular acidosis = K citrate
 Hyperkalemia

Differential Diagnosis
 Pseudohyperkalemia - from blood hemolysis
 Metabolic Acidosis
 Chronic Renal Failure
 Congenital Adrenal Hyperplasia
 Females = Usually Dx at birth - Ambiguous Genitalia
 Males = Dehydration, hyponatremia, hyperkalemia

 Medications
 ACE inhibitors and NSAID’s
Hyperkalemia
 Diagnosis:
 Symptoms
 Cardiac Arrhythmias
 Paresthesias
 Muscle weakness or paralysis

 ECG
 Peaked T waves
 Short QT interval (K>6 mEq)
 Depressed ST segment
 Wide QRS (K>8 mEq)
 Hyperkalemia

 Management
 Close cardiac monitoring
 Life -threatening hyperkalmia
 Intravenous
Calcium - rapid onset, duration< 30 min
 NaHCO3 or glucose and insulin

 Ion exchange resins

 Sodium polystyrene sulfonate (Kayexelate)
 PO or Enema

 Hemodyalisis