Dehydration 1 Dehydration Common body fluid disturbance in

Dehydration 1

Dehydration • Common body fluid disturbance in infants and children • Occurs whenever total output exceeds total intake – Insensible losses • • Skin Respiratory Increased renal excretion GI tract (vomiting, diarrhea) – Lack of oral intake – DKA – Large burns 2

Fluid Loss; Infants and <2 yr. excretion is via the urine, feces, lungs and skin have greater daily fluid loss than older child more dependent upon adequate intake greater about of skin surface (BSA), therefore greater insensible loss. • respiratory and metabolic rates are higher • therefore, dehydrate more rapidly • • 3

Mechanism to Restore balance • kidney: conserves water, regulates electrolyte excretion – <2 yr kidneys immature – less able to conserve or excrete water and solutes effectively – greater risk for acid/base imbalances – Will use the SG norm: 1. 005 -1. 015 4

Fluid Volume Imbalances • Dehydration: loss of ECF fluid and sodium. – Caused by: vomiting, diarrhea, hemorrhage, burns, NG suction. – Manifested by wt loss, poor skin turgor, dry mucous membranes, VS changes, sunken fontanel • Fluid overload: excess ECF fluid and excess interstitial fluid volume with edema. – Causes: fluid overload, CHF. – Manifested by wt. gain, puffy face and extremities, enlarged liver. 5

Nursing Considerations • How can the nurse determine if the child is mildly dehydrated vs. moderately dehydrated? 6

Mild Dehydration: by history • hard to detect because the child may be alert, have moist mucous membranes and normal skin turgor. • Wt loss may be up to 5% of body weight. • The infant might be irritable; the older child might be thirsty • vital signs will probably be normal • Capillary refill will most likely be normal • Urine output may be normal or slightly less 7

Moderate Dehydration • dry mucous membranes; delayed cap refill >2 sec; Wt loss 6 -9% of body weight • irritable, lethargic, unable to play, restless • decreased urinary output: <1 ml/kg/hr; dark urine with SG > 1. 015 (in child >2 yr) • Sunken fontanel • HR increased, BP decreased. Postural vital signs 8

Severe Dehydration • wt loss > 10% body weight • lethargic/comatose • rapid weak pulse with BP low or undetectable; RR variable and labored. • dry mucous membranes/parched; sunken fontanel • decreased or absent urinary output. • Cap refill >4 sec 9

Degree of Dehydration Factors Mild < 5% Moderate 5 -10% Severe >10% General Condition Well, alert Restless, thirsty, irritable Drowsy, cold extremities, lethargic Eyes Anterior fontanelle Tears Mouth + tongue Skin turgor Pulse (N=110120 beat/min) Normal Sunken Very sunken, dry Normal depressed Very depressed Present Absent Moist Sticky Dry Slightly decrease Decreased Very decreased Slightly increase Rapid, weak Rapid, sometime impalpable BP (N=90/60 mm Hg) Respiratory rate Urine output Normal Deceased, may be unrecordable Slightly increased Increased Deep, rapid Normal Reduced Markedly reduced 10

Types of Dehydration and Sodium Loss • Sodium may be: – Low – High – Normal 11

Isotonic Dehydration or Isonatremic Dehydration • Loss of sodium and water are in proportion • Most of fluid lost is from extracellular component • Serum sodium is normal (130 -150 m. Eq/L) Harriet Lane Handbook, 2000. – Most practitioners consider below 135 and above 148 a more conservative parameter (138 -148) – Most common form of dehydration in young children from vomiting and diarrhea. 12

Hypotonic or Hyponatremic Dehydration • Greater loss of sodium than water • Serum sodium below normal • Compensatory shift of fluids from extracellular to intracellular makes extracellular dehydration worse. • Caused by severe and prolonged vomiting and diarrhea, burns, renal disease. • By treatment of dehydration with IV fluids without electrolytes. 13

Hypertonic or Hypernatremic Dehydration • Greater loss of water than sodium • Serum sodium is elevated • Compensatory shift from intracellular to extracellular which masks the severity of water loss (dehydration) delaying signs and symptoms until condition is quite serious. • Caused by concentrated IV fluids or tube feedings. 14

Types of dehydration Isotonic (isonatremic) Hypertonic (hypernatremic) Hypotonic (hyponatremic) Loses H 2 O = Na H 2 O > Na H 2 O < Na Plasma osmolality Normal Increase Decrease Serum Na Normal Increase Decrease ECV ICV Decrease maintained Decrease +++ Increase Thirst ++ +/- ++ Not lost +++ Mental state Irritable/lethargic Very irritable Lethargy/coma shock In severe cases Uncommon Common Skin turgor

Rotavirus • • Common viral form of diarrhea All ages but 3 mo-2 yrs most common Fecal/oral route Virus remains active; – 10 days on hard, dry surfaces – 4 hrs on human hands – 1 wk on wet areas 16

Rotavirus (cont. ) • Incubation period 1 -3 days • Symptoms: mild/mod fever, stomach ache, frequent watery stools (20/day) • Treatment: prevention! Hand washing and isolation of the infected child. • Fluid rehydration for diarrhea, advanced to bland diet for older children • Breast milk for the infant who BF 17

Clinical Management for Dehydration • Blood may be drawn to assess electrolytes, BUN and Creatinine levels • an IV may be placed the same time • Oral Rehydration Solution is the treatment of choice for mild-moderate dehydration – 1 -3 tsp of ORS every 10 -15 min to start (even if vomits some) – 50 ml/Kg/Hr is the goal for rehydration. 18

Why are drinks high in glucose avoided during rehydration? • Simple sugars increases the osmotic effect in the intestine by pulling water into the colon, thereby increasing diarrhea and subsequent fluid/electrolyte loss • Drinks high in glucose: apple juice, sodas, jello water. 19

Recommended foods during rehydration progression: • Starches, cooked fruits & vegetables, soups, yogurt, formula, breast milk. • BRAT diet used to be recommended, but recent research has shown no difference than return to normal diet with some attention to lactose containing foods, depending upon the child’s response. 20

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Management Ø Non-specific Ø Oral Rehydration Solution (ORS): • Effective in all types & all degrees of dehydration. • Can prevent dehydration if given early in the disease. • Cheap, easy to administer; can be given by mother at home. • No chance of overhydration or electrolyte overdose. Ø Methods of administration: spoon, cup, dropper, syringe, nasogastric tube or IV

ORS Composition Ø Sodium Chloride Ø Tri-Sodium Citrate (bicarbonate) Ø Potassium Chloride Ø Glucose

Types of ORS Solution Glucose g/dl Na m. Eq/L K meq/L Cl meq/L WHO 2. 0 90 20 80 Rehydralyte 2. 5 75 20 65 Pedialyte 2. 5 45 20 35 Infalyte 2. 0 50 20 40

IV Therapy • Used for severe dehydration or in the child who will not/cannot tolerate ORS (Oral Rehydration Solution) • Half 24 hr maintenance plus replacement given within first 6 -8 hr (in ER) to rapidly expand the intravascular space. Usually a normal saline bolus. • slower IV rate for the remainder of the first 24 hrs • nurse records IV volume infused hourly 25

Which of the following IV solutions replaces Sodium? • • D 5 W Lactated Ringers Normal Saline D 5 ½ NS 26

Rehydration and IV solution • Why is the child initially rehydrated with a normal saline bolus and not an IV solution with potassium? • Potassium is only added to an IV after the patient has voided to avoid hyperkalemia in a child with little or no urinary output 27

Daily Maintenance Fluid Requirements • Calculate child’s weight in kg • Allow 100 ml/kg for first 10 kg body weight • Allow 50 ml/kg for second 10 kg body weight • Allow 20 ml/kg for remaining body weight 28

Example #1 of Daily Fluid Calculation • Child weighs 32 kg • 100 x 10 for first 10 kg of body weight = 1000 ml • 50 x 10 for second 10 kg of body weight = 500 ml • 20 x 12 for remaining body weight = 240 ml • 1000 + 500 + 240 = 1740 ml/24 hr 29

Example #2 of Daily Fluid Calculation • Child weighs 8. 5 kg • 100 x 8. 5 for first 10 kg of body weight = 850 ml • No further calculations • 850 ml/24 hr 30

Example #3 of Daily Fluid Calculation • Child weighs 14 kg • 100 x 10 for first 10 kg of body weight = 1000 ml • 50 x 4 for second 10 kg of body weight = 200 ml • No further calculations • 1000 + 200 = 1200 ml/24 hr 31

Example of Maintenance Fluid Calculation • Your patient is a 10 yr old weighing 35 Kg. You want to determine this patient’s 24 hr maintenance fluid needs: • for the first 10 Kg give 100 ml/Kg = 1000 ml • for the second 10 Kg: 50 ml/Kg = 500 ml • for the remaining 15 Kg (35 -20 Kg) , replace at 20 ml/Kg = 20 (15) = 300 ml • 1000 + 500+ 300= 1800 ml/day. 32

How much fluid should this patient get per hour? • 1800 ml / 24 hrs = 75 ml/hr. • Therefore, if the patient were NPO and not taking in fluids from any other source, the IV should be running at 75 ml/hr. • If there is a deficit that also needs to be replaced, the IV rate may be slightly higher for a defined period of time. • If the patient is receiving fluids from other sources, these need to be accounted as well 33

Practice Problems for Calculating 24 hr Fluid Maintenance and the hourly IV rate for: • • • A 9 yr old patient who weighs 20 Kg. 1500 ml/day A 6 mo old baby who weighs 8 Kg. 800 ml/day An 24 mo old toddler who weighs 18 Kg 1400 ml/day A 3 yr old preschooler who weighs 28 Kg 1660 ml/day An 18 yr old who weighs 50 Kg 2100 ml/day Adult > 50 Kg= 2 -3 L/day 34

Prevention Ø “Wash your hands frequently, especially after using the toilet, changing diapers. ” Ø “Wash your hands before and after preparing food. ” Ø “Wash diarrhea-soiled clothing in detergent and chlorine bleach. ” Ø “Never drink unpasteurized milk or untreated water. ”

Points to Remember Ø Gastroenteritis is acute self-limited illness. Ø Diarrhea and vomiting in infancy and childhood is usually due to viral gastroenteritis. Ø Fluid replacement with ORS is the mainstay of management. Ø Breast feeding should be continued, but formula feeding should cease until recovery. Ø Antibiotics and antiemetics agents are contraindicated.

Electrolyte Imbalance 37

Fluid Overload: Edema • Increased capillary blood flow: inflammation, infection • venous congestion: ECF excess, R sided heart failure, muscle paralysis. • • Increased albumin excess: Nephrotic Syndrome Decreased albumin synthesis: Kwashiorkor, liver cirrhosis increased capillary permeability: inflammation/ burns blocked lymphatic drainage: tumors/surg. 38

Clinical Assessment/Management of Edema assess dependent limbs if ambulating or sacrum if lying ascites; periorbital edema; rings too tight pitting edema for degree of swelling daily wt and strict I and O elevation/change position Q 2 hr/ protect skin against breakdown • distraction to deal with discomfort and limitations of edema. • • • 39

Electrolyte Imbalances • Electrolytes usually gained and lost in relatively equal amounts to maintain balance • Imbalance caused by: – Abnormal route of loss (vomiting/diarrhea) can disturb electrolyte balance – Disproportionate IV supplementation – Disease states: renal dis. 40

Hypernatremia • Excess serum sodium in relation to water • Causes: – – – – Too concentrated infant formula Not enough water intake Clinical manifestations: thirst, lethargy, confusion Seizures occur when rapid or is severe. SG concentrated 1. 020 -1. 030 Lab test: serum sodium Treatment: hypotonic IV solution 41

Hyponatremia • Excess water in relation to serum sodium • Most common sodium imbalance in children • Causes: – Infants vulnerable to water intoxication: dilute form, excess pool water, poorly developed thirst mechanism so cont to drink and can’t excrete excess water. 42

Hyponatremia has been repeatedly reported in the press as a major hazard of infant swimming lessons. 43

Hyponatremia (cont) • Clinical manifestation: decreased level of consciousness d/t swelling of brain cells. – Anorexia, headache, muscle weakness, decreased DTR’s, lethargy, confusion or coma. – Seizures occur when rapid or severe. – SG dilute: 1. 000 -1. 0005 – Lab tests: serum sodium • Treatment: hypertonic solution. 44

Hyperkalemia • Excess serum potassium • Causes: – excess K intake from IV overload, blood transfusion, rapid cell death (hemolytic crisis, large tumor destruction from chemo tx, massive trauma, metabolic acidosis from prolonged diarrhea and in DM when insulin levels are low • Insulin drives K back into the cells – decreased K loss from Renal insufficiency 45

Hyperkalemia (cont) • Clinical manifestation: all are related to muscle dysfunction: hyperactivitiy of GI smooth muscle: intestinal cramping and diarrhea. – Weak skeletal muscles – Lethargy – Cardiac arrhythmias (tachycardia, prolonged QRS, peaked T waves: also AV block and VTach). – Lab test: serum potassium – Treatment: correct underlying condition (take K out of the IV) – dialysis (peritoneal or hemo), Kayexalate (PO or enema), K wasting diuretics, IV calcium, bicarbonate, insulin and glucose. – Low potassium diet. 46

Hypokalemia • • Decreased serum potassium Causes: diarrhea and vomiting, ingestion of large amts black licorice, diuretics, osmotic diuresis (glucose in urine as in DM), NPO without K replacement in IV, NG Suction, bulimia, insulin. – Also in nephrotic syndrome, cirrhosis, Cushing Syndrome, CHF (to be covered elsewhere) 47

Hypokalemia (cont) • Clinical manifestations: muscle dysfunction • Slowed GI smooth muscle resulting in abdominal distention, constipation and paralytic ileus • Skeletal muscles are weak; may effect respiratory muscles • Cardiac arrhythmias: hypokalemia potentiates Digoxin Toxicity. • Lab test: serum potassium • Treatment: oral and/or IV potassium, diet rich in K. 48

Hypercalcemia • Excess calcium • Needs vit. D for efficient absorption; most of Ca is stored in the bones. • Causes: bone tumors that cause bone destruction, chemo therapy release Ca from the bones; immobilization causes loss from the bones (usually excreted) but if kidneys can’t clear it, hypercalcemia results, increased intake (milk-alkali syndrome). 49

Hypercalcemia (cont) • Clinical manif: Ca imbalances alter neuromuscular irritability with non-specific symptoms – Constipation, anorexia, N/V, fatigue, skeletal muscle weakness, confusion, lethargy. – Renal calculi, cardiac arrhythmias – Hyper. Ca increases Na and K excretion leading to polyuria and polydipsia. – Rx: serum Ca, Ionized Ca, fluids, Lasix, steroids, dialysis. 50

Hypocalcemia • Decreased serum calcium • Causes: decreased intake of Ca and/or Vit D (adolescents are vulnerable d/t fad diets and the deficit cannot be made up later, increasing risk for osteoporosis). – Limited exposure to sunlight, premature infants and dark skinned people at increased risk to inadeq. Vit D and therefore decreased Ca absorption. – Parathyroid dysfunction, multiple transfusion (Citrate binds Calcium), steatorrhea (as in pancreatitis and Cystic Fibrosis) binds Calcium in the stool. 51

Hypocalcemia (cont) • Clinical Manifestations: acute situation related to increased muscular excitability: tetany. +Chvostek’s Sign, + Trousseau’s Sign. • In children: Twitching, cramping, tingling around the mouth or fingers, carpal/pedal spasms. • In infants: tremors, muscle twitches, brief tonicclonic seizures, CHF. • Laryngospasm, seizures and cardiac arrhythmias in severe situations. 52

Hypocalcemia (cont ) • In children and adolescents, chronic hypocalcemia more common, manifestation. By spontaneous fractures. Lab tests: serum Ca; bone density study Rx: oral and/or IV Ca, Ca rich diet 53

Hypermagnesemia • Excess in Mg. • Imbalances characterized by neuromuscular irritability • Causes: impaired renal function, Magnesium Sulfate given parentally to treat eclampsia, increased use of laxatives, enemas, antacids, IV fluid additives. 54

Hypermagnesemia (cont) • Clinical Manifestations: decreased muscle irritability, hypotension, bradycardia, drowsiness, lethargy, weak or absent DTR’s. • Rx: increase fluids, diuretics, dialysis. 55

Hypomagnesemia • Decreased serum Mg. • Stored in cells and bones • Causes: prolonged NPO without replacement, chronic malnutrition, chronic diarrhea, short bowel syndrome, malabsorption syndromes, steatorrhea, multiple transfusions, prolonged NG Suctioning, some medications. 56

Hypomagnesemia (cont) • Clinical manifestations: increased neuromuscular excitability (tetany). Hyperactive reflexes, skeletal muscle cramps, twitching, tremors, cardiac arrhythmias, seizures. • Lab: serum Mg along with Ca and K. • Rx: PO/IV Magnesium admin and treating underlying cause of imbalance. 57

Critical Thinking: Clinical Evaluation of Fluid and Electrolyte Imbalance • How can you evaluate children appropriately for fluid and electrolyte imbalance without thinking through the clinical manifestations of every possible disorder, one after the other? 58

ANSWER v Risk factor assessment v Exam several body systems: cardiovascular, respiratory, neurological v Look for factors that alter intake, retention, and loss of fluids and electrolytes v Consider growth and development to realize problems most common to the age group. v Clinical assessment: wt, fluid balance, vascular volume (BP, HR), interstitial volume (edema? ), mentation, DTR’s, muscle irritability, GI function, cardiac rhythm, assess electrolyte levels. 59