fluid and electrolyte imbalance 2a

8/3/2019 Fluid and Electrolyte Imbalance 2A

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Fluid and electrolyte

imbalanceSamah Suleiman

18/4/2006


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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)


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Pediatric Fluid Therapy PrinciplesPediatric Fluid Therapy Principles

Maintenance H2O needs:

Weight in Kg H 2O fluid needs

1-10 100cc /kg /day

11-20 1000+50cc/kg/day

> 20 1500 + 20cc/kg/day

Add 12 % for every 0C


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Na+

& K+

Daily Needs

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


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Nursing requirements of FLUID

Increased requirement :

Fever

Vomiting

Renal failure Burn

Shock

Tachypnea

Gastroenteritis

Diabetes (Insipidus, mellitus - DKA)

Cystic fibrosis


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Decreased requirement

CHF

Postoperatively

oliguric ( RF )

Increase ICP


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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


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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/L300-500cc/M2/day

Less in patients on the ventillator


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CompositionofBody 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/L5. 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/cc9. 8.4% NaHCO3 (1 meq/cc Na & HCO3)

2000 mOsm/L


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IVfluids

Lactated Ringers

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


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Albumin 25% (salt poor)

25 gm protein/100 cc

Na 100-160 meq/L300 mOsm/L

Intralipid

2.25gm lipid/100cc 284 mOsm/L


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Pediatric Fluid Therapy PrinciplesPediatric Fluid Therapy Principles

Assess water deficit by:

1. weight:

weight loss (Kg) = water loss (L)

OR

2. Estimation of water deficit by physicalexam:

Mild moderate severeInfants < 5 % 5 - 10 % >10 %

Older children < 3 % 3 - 6 % > 6 %


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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


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Physical Signs ofDehydration

Signs & sympt. MILD Moderate Severe

General Thirsty, allert,

restless

Thirsty, irritable,

or drowsy

Drowsy limp,

skin cold / sweaty

Radial pulse Normal rate Rapid, weak Rapid, feeble

Respiration Normal Deep Deep & rapidAnterior font. Normal Sunken Very sunken

Skin turgor Pinch retracts

immediately

Retracts slowly Poor

Eyes Normal Sunken Grossly sunken

Tears Present Absent AbsentMucous memb. Moist Dry Very dry

Urine flow Normal Dark &

decreased

Oliguria / anuria


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CorrectionofDehydration

Moderate to severe dehydration:

IV push

10-20 cc / Kg Normal saline

(5 % albumin)

May repeat.

Half deficit over8 hours, and half over16

hours. If hypernatremic dehydration, replace

deficit over48 hours (evenly distributed).


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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 Plasma PH Plasma PCO2 Plasma HCO3

Respiratory

Acidosis

Respiratory

Alkalosis

Metabolic

Acidosis

Metabolic

Alkalosis


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Nursing Intervention

1. Assessment

2. History

3.C

linical observation4. Intake & output measurement

5. Replace orally orIVF

( 1g wet diaper wt =1 ml urine )


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Types of I.V solutions

Solutions are three types

- Isotonic it's total osmolality (TO) = TO of blood

-H

ypotonic:It's

TO

TOof blood

- Hypertonic: it's TO TO of blood.

*Electrolyte solutions considered isotonic

If total electrolyte content (

TEC) } 310m

Eq/L.and hypotonic ifTEC 250 meq/L and

hypertonic ifTEC 375 Meq/L


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When administrating I.Vfluid nurse should

Monitors the response of the

fluids.

Considering the fluid volume.

Content of fluid.

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 ofblood, so pt should be carefully monitored for signs

of fluid overload.

Examples ofIsotonic fluids:

D5W: has a serum osmolality of 252 mosm/L.

D5W s mainly used supply water and to correct an

increased serum osmolality


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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:C

ontainsC

a, K and NaC

l


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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.


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Complications of excessive use of

hypotonic solutions include:

Intravascular fluid depletion. Decreased blood pressure.

Cellular edema.

Cell damage


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3.Hypertonic Solutions

Hypertonic solutions exert an osmotic

pressure greater than that ofECF

Examples

* High concentrations of dextrose such as

50% dextrose in water are used to help meet

caloric requirements.

These hypertonic solutions must beadministered into control veins so that they

can be diluted by rapid blood flow.


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*Management and Nsg Care for certain

fluid and electrolyte balance disturbances

1-Water depletion

- Provide replacement of fluid.

-D

etermine and correct cause of water depletion.

- Measure intake and output.

- Monitor V/S


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2- Water Excess:

- Limit fluid intake.

- Administer diuretics.- Monitor V/S

- Determine and treat cause.

- Analyze laboratory electrolyte measurementfrequently


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3- Hyponatremia

- Determine and treat cause

- AdministerI.V fluids with appropriate saline

concentration

4- Hypernatramia:


Administer fluids as prescribed.- Measure intake and output.

- Monitor lab. Data.


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5- Hypokalemia:


- 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.


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6- Hyperkalemia


- Monitor V/S and ECG - Administer I.V fluids if prescribed.

- Monitor serum potassium levels.

7- Hypocalcaemia:


- Administer calcium supp. as prescribed and

administered slowly.- Monitor serum calcium levels.

- Monitor serum protein level


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8- Hypocalcaemia:


- Monitor serumC

a levels.- Monitor ECG.


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SODIUM

Na+ are very important for regulating blood

and interstitial fluid pressures as

well as nerve and muscle cell conduction of

electrical currents. Aldosterone causesretention of Na+.


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a. HYPONATREMIA:-

Vomiting, diarrhea, sweating, and burns cause Na+loss. Dehydration, tachycardiaand 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 excessivesodium intake causes this.

Increased Na+ draws water outside of cells,resulting in tissue dehydration.Thirst, fatigue and coma result.


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CHLORIDE

Cl- anion is necessary for the making ofHCl,

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 inCl- are accompanied by increases in H+).


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POTASSIUM

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 accompaniestissue alkalosis.


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CALCIUM

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 cancause kidney stones, bone spurs,

and lethargy.


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RESPIRATORY ACIDOSIS

Increased pCO2 and pH below 7.35 due to

hypoventilation, emphysema etc.

Compensation occurs in the kidney through

increased H+ excretion and HCO3-reabsorption. Bicarbonate/carbonic acid ratio

is 10-15:1.


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RESPIRATORY ALKALOSIS

Hyperventilation due to O2 deficiency, CVA,

or anxiety are causes of respiratory

alkalosis. Renal compensation occurs by

decreasing H+ excretion and HCO3-reabsorption.

H+ is reabsorbed. Bicarbonate/carbonic acid

ratio is 30-40:1.


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METABOLIC ACIDOSIS

Due to loss ofHCO3- 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.


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METABOLIC ALKALOSIS

Increased intake of antacids, low protein/high

vegetable diet, and vomiting/loss of

HCl are common causes. Compensation is

by hypoventilation. Bicarbonate/carbonicacid ratio is 35:1.


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Child vs. Adult inmedication 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


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7. % of protein binding & fat distributions

8. Drug half life

9.E

xcretion10. Gastric empty time

11. Eating habits

12. Exercise pattern

13.sexual development


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Rout of medication administration

1. Orally 2. Rectally 3. Nasal

4. IM 5. IV 6.transdermally

7.T

opical 8.Inhalation

*Calculation of medication1. Bwt 2. Hight 3.G&D

4. Swallowing 5. Past experience

*6medication right


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Steps to give medication

1. Identification the child

2. Oral medication ( infantpreschool school

age)

3. Teach the child how to swallowing ( liqide

need hr ,Tablet (1/2-1hr)

* Safe storage of medication

*Determination of the correct dosage

fluid and electrolyte imbalance 2a

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