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Nursing Care of the Child with Alterations in Fluid and Electrolyte Imbalance

Ch 17 and 25, 1619-1626
STUDY
PLAY
Who has greater proportions of body water? adults or children
children
Infants/Toddlers have more ________ fluid so water loss occurs more rapidly.
extracellular
What about the body shape makes infants have greater body surface?
They have bigger heads
Infants have difficulty concentrating and diluting urine up until what age?
2 years
_______ is the principal cation in ECF and _______ is the cation in ICF.
Sodium is the principal cation in ECF and Potassium is the cation in ICF.
What is insensible water loss?

Are electrolytes lost during insensible water loss?
refers to invisible, continuous, and passive water loss from the skin and lungs resulting from heat expenditure.

No electrolytes are lost or excreted in insensible water loss
At what age do infants produce tears?
6 weeks
The smaller the child, the greater the proportion of body water to weight and the greater proportion of ________ fluid and ________ fluid.
The smaller the child, the greater the proportion of body water to weight and the proportion of ECF to ICF.
How does the structure of the infant and young child's gastrointestinal tract affect fluid balance?
they have greater GI surface area than adults which makes them more susceptible to to rapid fluid shifts.
What is normal urin output?
approx 1ml/kg/hr
Why do children have the inability to adjust to major changes in levels of sodium and other electrolytes?
because of immature kidney function
What might a sunken fontanelle indicate about fluid status?
it may indicate dehydration
What sodium level classified isotonic dehydration?
130-150 mEq/L
What sodium level classifies hypotonic dehydration?
less than 130 mEq/L
What sodium level classifies hypertonic dehydration?
more than 150 mEq/L
Describe the relationship between the cell wall, sodium and isotonic dehydration
the same amount of salt inside and outside the cell,
Describe the relationship between the cell wall, sodium and hypertonic dehydration.
more salt outside the cell. Caused by losing more water than sodium. Body pulls more water out of cell.
Describe the relationship between the cell wall, sodium and hypotonic dehydration.
less salt outside the cell. Body pulls more water in cell to compensate
Which type of dehydration is associated with diarrhea and vomiting?
isotonic dehydration
Which type dehydration is associated with burns?
hypotonic
Which type of dehydration is associated with diabetes insipidus?
hypertonic
Which type of dehydration is associated with renal disease?
hypotonic
Which type of dehydration is associated with too much IV fluids or tube feedings that are high in electrolytes?
hypertonic
What would happen during to weight during dehyradration?
decreased weight
What might happen to urine specific gravitiy if a child is dehydrated?
High Urine Specific gravity (may not be seen in younger bc they have difficulty concentrating urine)
What type of fluids do you treat hypertonic dehydration with?
isotonic fluids. Slowly over 48 ours
What can happen if you treat hypertonic dehydration with hypotonic fluids?
water will move into brain cells causing cerebral edema, seizures, and profound neurological sequalae
You should do daily weights to assess fluids status. What does a 1 kg change mean?
1 kg change = 1000ml fluid change
What percent body loss indicates...
mild dehydration?
moderate dehydration?
severe dehydration?
mild dehydration - 5%
moderate dehydration - 5 to 9%
severe dehydration - >10%
What happens to level of conciousness in severe dehyrdation?
they may become lefthargic to comatose
What happens to blood pressure when dehydration becomes severe?
low
What happens to heart rate as dehydration occurs?
increases
What happens to pulse when dehyrdation becomes severs?
impalpable
What happens to eyeballs and fontelles in severe dehydration?
sunken
What happens to skin temp during sever dehydration?
cool, mottled, cyanotic
What happens to urine output during severe dehydration?
low, anuric
At what rate do you give Oral Hydration Therapy?
75ml/kg over 4 hours
How should give the child the ORT?
offer a teaspoon every 1 to 2 minutes. If emesis occurs wait 5 to 10 minutes and continue with a teaspoon every 2 to 3 minutes.
Should you continue to breastfeed during ORT?
Yes
What should you remember when trying to to figure if the doctor ordered a proper amount of replacement fluids for a patient?
for every kg loss 1000ml needs to be replaced over 24 hours
How do you come up with the total number of replacement needs over 24 hours for a child who has lost weight from dehydration?
you have to calculate maintenance and replacement fluid needs and add them together.
What are common causes of extracellular edema in children?

fluids?
Diseases?
Medications?
Excessive isotonic IV Fluids
Diseases such as CHF or Renal Disease
Medications such as prednisone
What are the nursing interventions for a child with extracellular edema?
Strict I and O
Daily Weights
Fluid Restrictions
Frequent Respiratory Assessment
Elevate edematous body parts
Diuretics
Measure abdominal girth
Meticulous Skin Care
Is fluid restricted for a child with excess fluid retention? What is a nursing intervention for this?
Yes, give them Popsicles, they last longer.
If a child has edematous right arm what should you do to that extremity?
elevate it
What are the symptoms of Extracellular Fluid Excess?
Weight Gain
Edema
Respiratory Crackles
Respiratory Distress
What are common isotonic solutions given to children to rehydrate them?
lactate Ringers, normal saline, 1/2 normal saline, 1/4 normal saline
To avoid serious cardiac problems associated with hyperkalemia, potassium should not be added to IV fluids to rehydrate a patient until what has occurred?
until the child has urinated, thus demonstrating adequate renal function
Which electrolyte occurs due to the following?

excessive water intake, excessive ADH, excessive hypotonic IVF (D5W), irrigation with water instead of normal saline
hyponatremia
Which electrolyte occurs due to the following?

Caused by not enough drinking water, undiluted formula, diarrhea or vomiting
hypernatremia
Which electrolyte occurs due to the following?

Renal insufficiency, too much K+ in IVF, Blood transfusions
hyperkalemia
Which electrolyte occurs due to the following?

no K+ in IVF, Loss of Gastric secretions, diuretics, low K+ diet
hypokalemia
What complications can rapid occurring hyponatremia cause?
May lead to cerebral edema, seizures, coma, respiratory rest
What types of fluids can be given to patients with hyponatremia?
Isotonic (.9NS) or hypertonic (D5LR) IVF may be given
Which electrolyte imbalance is NG suctioning likely to cause?
hyponatremia, and hypokalemia
What do you use to flush when your giving medications oral route through a tube? What about when you are performing irrigation?
tube feedings: use water to flush
irrigation: use saline solution
What sodium serum concentration indicate hypernatremia?
High sodium serum concentration (greater than 148 mmol/L)
Where do the symptoms of hypernatremia come from? What are they?
Symptoms from shrinking and tearing of brain cells- confusion, seizures, coma, lethargy with with irritability on stimulation
What is the typical management for hypernatremia?
Management - hypotonic IV fluids
Resolve the problem slowly, if you do it quickly the water will go into the brain cells quickly and you will get increased intraventricular pressure. Typically you do it over 48 hours
Is boiled skim milk high or low in solute concentration?
high solute concentration
What serum pottasium level indicates hypokalemia?
hyperkalemia?
hypokalemia is less than 3.5 mEq/L
Hyperkalemia is more than 5.8 mEq/L (book says 5.0)
What are the symptoms of hyperkalemia?
Symptoms -weakness, Increased GI motility, Tachycardia/arrhythmias, oliguria, anuria
What are the symptoms of hypokalemia?
Symptoms - muscle weakness, respiratory distress, decreased cardiac output, dysrythmias
How do we manage hypokalemia?
Management - high K+ diet, IVF with K+, monitor Urine output, Cardiac and respiratory function
How do we manage hyperkalemia?
Management - Prevention, IVF, Monitor cardiac, musculature, renal and GI system
What could cause a false high pottasium reading in a lab?
Sometimes the procedure to collect blood can cause blood hemolysis can cause a false high in the sample
Most post op patient's, especially those with GI surgery are getting what electrolyte in their fluids?
potassium
Would you most likely see hypokalemia or hyperkalemia in a child who has oliguria or anuria?
hyperkalemia
How can having diabetes cause hypokalemia?
hyperglycemia typically produces osmotic diuresis and high urine output, resulting in in potassium loss.
How can potassium loss occur through the integumentary system?
sweat and burns
What are common causes of respiratory acidosis?
Respiratory illness
Trauma
Muscular disorders
What are common symptoms of respiratory acidosis?
Increased Pco2
CNS depression
Tachycardia
What are the common causes of respiratory alkalosis?
Anxiety
Pain
Mechanical overventilation
Salicylate poisoning
What are common symptoms of respiratory alkalosis?
Low Pco2, high pH
Confusion
Parasthesia
Muscle cramping
What are the common causes of metabolic acidosis?
Acid poisoning
(including aspirin)
Starvation
Diabetic ketoacidosis
Diarrhea
What are the common symptoms of metabolic acidosis?
Symptoms
Decreased pH, HCO3
Kussmaul respirations
Cardiac arrhythmias, hypotension
What are the common causes of metabolic alkalosis?
Common Causes
Baking Soda poisoning
Bicarbonate antacid poisoning
Vomiting
Nasogastric suction
What are the common symptoms of metabolic alkalosis?
Symptoms
Elevated pH, bicarbonate and Pco2
Increased respiratory rate
Neuromuscular irritability
CNS depression
What type of acid base imbalance from a child eating a bottle of tums?
metabolic alkalosis
The nurse is asked why infants are more prone to fluid imbalances than adults. The response is:
A. Adults have a greater body surface area.
B. Adults have a greater metabolic rate
C. Infants have functionally immature kidneys
D. Infants ingest a lesser amount of fluid per kilogram
C. Infants have functionally immature kidneys
An 8 month old is admitted with severe dehydration. Fluid therapy is initiated. Which observation best indicates an improvement in the infants status?
A. Fontanels are depressed
B. Infant has gained 3 oz. since yesterday
C. Skin remains pulled together after being gently pinched and released
The infant's hematocrit is greater today than yesterday
B. Infant has gained 3 oz. since yesterday
A school nurse has provided an instructional session about impetigo to parents. Which parent statement indicates need for further instructions?
A. "It is most common in humid weather"
B. "It begins in an area of broken skin, such as an insect bite"
C. "It is extremely contagious"
D. " Lesions most often are located on the arms and chest"
D. " Lesions most often are located on the arms and chest"
A child has sustained a severe burn. Place in order of what would be done for this child when the health care team arrives on the scene.

A. Start intravenous fluids
B. Provide for relief of pain
C. Establish an airway
CAB
A 2-year old is treated for burns to the chest when grabbing hot coffee off the kitchen counter. Which statement made by the parents at discharge indicates an understanding of safety measures?
A. "I guess my child needs to understand what the word hot means"
B. " We will install a safety gate as soon as we get home so my child cannot get into the kitchen"
C. " We will be sure that our child stays in her room when we work in the kitchen"
D. " We will not leave hot liquids unattended."
D. " We will not leave hot liquids unattended."
Which should a school nurse include in a take home care instruction sheet for children with pediculosis capitis?
A. Use anti-lice sprays on all bedding and furniture.
B. Have all beddings and linens dry cleaned.
C. Soak combs and brushes in warm water.
D. Vacuum floors, play areas, and furniture to remove hairs that might carry live nits.
D. Vacuum floors, play areas, and furniture to remove hairs that might carry live nits.