FLUID &ELECTROLYTES

BALANCE IN
GASTROINTESTINAL TRACT

PEDRIATRIC HEALTH NURSING

 •NIMRA
PRESENTER: MEHREEN
 OBJECTIVES:
At the end of this presentation learner will be able to:
I. Discuss fluid and electrolyte balance.
II. Discuss Distribution of body fluids.
III. Explain in fluid volume related to growth.
IV. Understand about water balance in infants.
V. Describe the disturbances of fluid and electrolyte balance.
 Fluid and electrolyte balance :
 Total body water in an individual ranges from 75%(in term newborns) to 45% ( in late
adolescence) of total body weight.
 Body fluids are distributed between the intracellular fluid

 (ICF) and extracellular fluid (ECF) compartments.

 The ICF compartment consists of fluid contained within all of

 the billions of cells in the body. The remaining one third of body water is in the ECF

 compartment, which contains all the fluids outside the cells,

 including those in the interstitial or tissue spaces and blood vessels.

 In the newborn ,about 50% of body fluid is contained within the ECF where as 30% in
toddlers .
Daily Maintenance Fluid Requirements

Body weight Amount of Fluid per Day

1 to 10 kg 100 ml/kg

11 to 20 kg 1000 ml plus 50 ml/kg for each kg >10 kg

>20 kg 1500 ml plus 20 ml/kg for each kg >20 kg

Sodium 130 -150 meq/L
concentration

Potassium 3.5-5.5 meq/L

concentration
Nurses should be alert for altered fluid
requirements in various conditions:
Increased requirements:
• Fever (add 12% per rise of 1° C)
• Vomiting, diarrhea
• High-output kidney failure
• Diabetes insipidus
• Diabetic ketoacidosis
• Burns
• Shock
• Radiant warmer (preterm infant)
• Tachypnea
• Decreased requirements:
• Heart failure
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• Mechanical ventilation
• After surgery
• Oliguria renal failure
• Increased intracranial pressure
Changes in Fluid Volume Related to Growth

• Maintenance fluids contain both water and electrolytes and can be

estimated from the child's age , body weight, degree of activity, and body
temperature. Basal metabolic rate (BMR) is derived from standard tables
and adjusted for the child's activity, temperature, and disease state.
• As the organism grows and develops, a progressive decrease occurs in
TBW, with the fastest rate of decline taking place during fetal life. The
changes in water content and distribution that occur with age reflect the
changes that take place in the relative amounts of bone, muscle, and fat
making up the body. At maturity, the percentage of TBW is somewhat
higher in the male than in the female and is probably a result of the
differences in body composition, particularly fat and muscle content.
Water Balance in Infants

• Compared with older children and adults, infants and young children have a
greater need for water and are more vulnerable to alterations in fluid and
electrolyte balance. Infants have a greater fluid intake and output relative
to size. Water and electrolyte disturbances occur more frequently and
more rapidly, and children adjust less promptly to these alterations.
Body Surface Area

• The infant's relatively greater body surface area (BSA) allows larger
quantities of fluid to be lost through the skin. It is estimated that the BSA of
preterm neonates is five times more, and that of newborns is two to three
times more, than that of older children or adults. The proportionately
longer gastrointestinal (GI) tract in infancy is also a source of fluid loss,
especially from diarrhea.
Basal Metabolic Rate

• The rate of metabolism in infancy is significantly higher than in adulthood

because of the larger BSA in relation to the mass of active tissue.
Consequently, infants have a greater production of metabolic wastes that
the kidneys must excrete. Any condition that increases metabolism causes
greater heat production, insensible fluid loss, and an increased need for
water for excretion. The BMR in infants and children is higher to support
cellular and tissue growth.
Kidney Function

• The infant's kidneys are functionally immature at birth and are therefore
inefficient in excreting waste products of metabolism. Of particular importance for
fluid balance is the inability of the infant's kidneys to concentrate or dilute urine,
to conserve or excrete sodium, and to acidify urine. Therefore, the infant is less
able to handle large quantities of solute-free water than older children and is more
likely to become dehydrated when given concentrated formulas or overhydrated
when given excessive water or dilute formula.
Fluid Requirements:

• Infants ingest and excrete a greater amount of fluid per kilogram of body
weight than do older children. Because electrolytes are excreted with water
and infants have a limited ability for conservation, maintenance
requirements include both water and electrolytes. The daily exchange of
ECF in infants is much greater than that of older children, which leave
infants with little fluid volume reserve in dehydrated states. Fluid
requirements depend on hydration status ,size ,environmental factors, and
underlying disease.
Disturbances of Fluid and Electrolyte Balance:

• Disturbances of fluids and their solute concentration are closely

interrelated. Alterations in fluid volume affect the electrolyte component,
and changes in electrolyte concentration influence fluid movement.
Because intracellular water and electrolytes move to and from the ECF
compartment , any imbalance in the ICF is reflected by an imbalance in the
ECF. Disturbances in the ECF involve either an excess or a deficit of fluid or
electrolytes. Of these, fluid loss occurs more frequently.
Disturbances of Select Fluid and
Electrolyte Balance
The fluid imbalance conditions are:
1. Water Depletion
2. Water Excess
Electrolytes imbalance conditions :
3. Sodium Depletion (HYPONATREMIA)
4. Sodium Excess (HYPERNATREMIA)
5. Potassium Depletion (HYPOKALEMIA)
6. Potassium Excess(HYPERKALEMIA)
 ADH, Antidiuretic hormone;
 BMR, basal metabolic rate;
 BUN , blood urea nitrogen;
 CNS, central nervous system;
 DKA, diabetic ketoacidosis;
 ECG, electrocardiogram;
 GI, gastrointestinal;
 IV, intravenous;
 IWL, insensible water loss;
 NG, nasogastric
The fluid imbalance conditions their clinical manifestations and nursing interventions are given as :

Water Depletion
 Failure to absorb or reabsorb water
 Complete or sudden cessation of intake or prolonged diminished intake:
 Neglect of intake by self or caregiver—confused, psychotic,
 unconscious, or helpless
 Loss from GI tract—vomiting, diarrhea, NG suction, fistula
 Disturbed body fluid chemistry:
 Inappropriate ADH
 secretion
 Excessive renal excretion: Glycosuria (diabetes)
 Loss through skin or lungs:
 Excessive perspiration or evaporation—
febrile states,
 hyperventilation, increased ambient
temperature, increased
 activity (BMR)
 Impaired skin integrity—transudate from
injuries
 Hemorrhage
 Iatrogenic:
 Overzealous use of diuretics
 Improper perioperative fluid replacement
 Use of radiant warmer or phototherapy
 Clinical manifestations:
• General symptoms depend to some extent on proportion of electrolytes lost with
water:


Thirst
Variable temperature—increased (infection) Laboratory findings:
 Dry skin and mucous membranes • High urine specific gravity
 Poor skin turgor • Increased hematocrit
 Poor perfusion (decreased pulse, prolonged • Variable serum electrolytes
capillary refill • Low serum bicarbonate (HCO3)
 time) Weight loss • Variable urine volume
 Fatigue • Increased BUN
 Diminished urinary output • Increased serum osmolality
 irritability and lethargy
 Tachycardia
 Tachypnea
 Altered level of consciousness, disorientation
 Management and Nursing Care
 provide replacement of fluid losses commensurate with
volume depletion.
 Provide maintenance fluids and electrolytes.
 Determine and correct cause of water depletion.
 Measure fluid intake and output.
 Monitor vital signs. Monitor urine specific gravity.
 Monitor body weight
 . Monitor serum electrolytes.
 WATER EXCESS
Water intake in excess of output:
• Excessive oral intake
• Hypotonic fluid overload
• Plain water enemas
Failure to excrete water in presence of normal intake:
• Kidney disease
• Syndrome of inappropriate syndrome of inappropriate anti-
diuretic hormone
• Heart failure
• Malnutrition
 Clinical manifestations:
Edema: Laboratory findings:
• Generalized • Low urine specific gravity
• Pulmonary (moist rales or • Decreased serum electrolytes
crackles) • Decreased hematocrit
• Intracutaneous (noted especially • Variable urine volume
in loose areolar tissue)
Elevated central venous pressure
Hepatomegaly
Slow, bounding pulse Weight gain
Lethargy
Increased spinal fluid pressure
CNS manifestations (seizures,
coma)
 Management and Nursing Care
 Limit fluid intake.
 Administer diuretics.
 Monitor vital signs.
 Monitor neurologic signs as necessary.
 Determine and treat cause of water
excess.
 Analyze serum electrolyte measurements.
 Implement seizure precautions.
Electrolyte Imbalance:
 Sodium Depletion (Hyponatremia)

Prolonged low-sodium diet

Decreased sodium intake
Fever
Excess sweating
Increased water intake without electrolytes
Tachypnea (infants)
Cystic fibrosis
Burns and wounds
Vomiting, diarrhea, NG suction, fistulas
Adrenal insufficiency
Renal disease
DKA Malnutrition
 Clinical manifestations:
Associated with water loss:
• Same as with water loss—
Laboratory findings:
dehydration, weakness, • Sodium concentration <130
dizziness, nausea, abdominal mEq/L (may be normal if
cramps, apprehension volume loss)
• Mild—apathy, weakness, • Urine specific gravity depends on
nausea, weak pulse water deficit or excess
• Moderate—decreased blood
pressure, lethargy
 Management and Nursing Care

 Determine and treat cause of sodium

deficit.
 Administer IV fluids with appropriate
saline concentration.
 Monitor fluid intake and output.
 Sodium Excess (Hypernatremia)

 High salt intake—enteral or IV

 Renal disease
 Fever
 Insufficient breast milk intake in neonate (dehydration
 hypernatremia)
 Increased temperature
 Increased humidity
 Hyperventilation
 Diabetes insipidus
 Hyperglycemia
 Clinical manifestations

 Intense thirst Laboratory findings:

 Dry, sticky mucous membranes • Serum sodium concentration ≥150 mEq/L
 Flushed skin • High plasma volume
 Temperature possibly increased • Alkalosis
 Hoarseness
 Oliguria
 Nausea and vomiting
 Possible progression to disorientation,
seizures, muscle
 twitching, nuchal rigidity, lethargy at
rest, hyperirritability
 when aroused
 Management and nursing care:

 Determine and treat cause of sodium excess.

 Administer IV fluids as prescribed.
 Measure fluid intake and output.
 Monitor laboratory data.
 Monitor neurologic status.
 Ensure adequate intake of breast milk and
provide
 lactation assistance with new mother/baby
pair before
 hospital discharge.
 POTASSIUM DEPLETION:
 Starvation
 Clinical conditions associated with poor food intake Malabsorption
 IV fluid without added potassium
 GI losses—diarrhea, vomiting, fistulas, NG suction
 Diuresis
 Administration of diuretics
 Administration of corticosteroids
 Diuretic phase of nephrotic syndrome
 Healing stage of burns
 Potassium-losing nephritis
 Hyperglycemic diuresis (e.g., diabetes mellitus)
 Familial periodic paralysis
 IV administration of insulin in DKA
 Alkalosis
 Clinical manifestations:
s/s Laboratory findings:

 Muscle weakness, cramping, stiffness, paralysis,  Decreased serum potassium concentration ≤3.5
hyperreflexia mEq/L
 Hypotension  • Abnormal ECG—notched or flattened T waves,
 Cardiac arrhythmias, gallop rhythm decreased
 Tachycardia or bradycardia  ST segment, premature ventricular contractions
 Ileus
 Apathy, drowsiness
 Irritability
 Fatigue
 Management and Nursing Care:

 Determine and treat cause of potassium deficit. Monitor vital signs, and ECG.
 Administer supplemental potassium. Assess for adequate
 renal output before administration.
 For IV replacement, administer potassium slowly. Always
 monitor ECG for IV bolus potassium replacement.
 For oral intake, offer high-potassium fluids and foods.
 Evaluate acid-base status.
 POTASSIUM EXCESS:

 Renal disease  Transfusion with old donor blood

 Renal failure  Severe dehydration
 Adrenal insufficiency (Addison disease)  Crushing injuries
 Associated with metabolic acidosis  Burns
 Too rapid administration of IV potassium  Hemolysis
chloride
 Dehydration
 Potassium-sparing diuretics
 Increased intake of potassium (e.g., salt
substitutes)
 CLINICAL MANIFESTATIONS
 Oliguria
 Muscle weakness,
 flaccid paralysis
 Twitching
 Hyperreflexia
 Bradycardia
 Ventricular fibrillation and cardiac arrest
 Apnea—respiratory arrest

Laboratory findings:
• High serum potassium concentration ≥5.5 mEq/L
• Variable urine volume
• Flat P wave on ECG, peaked T waves, widened QRS
complex, increased PR interval
 MANAGEMANT AND NURSING CARE:
 Determine and treat cause of potassium excess. Monitor vital signs, including
ECG.
 Administer exchange resin, if prescribed.
 Administer IV fluids as prescribed.
 Administer IV insulin (if ordered) to facilitate movement of potassium into cells.
Monitor potassium levels.
 Evaluate acid-base status.
Reference:
• WONGS ESSENTIAL OF PEDIATRICS NURSING