CH 23 - fluid/electrolyte imbalance

chronic diarrhea compared to fluid loss

- Increaseed freq + increase in water content for more than 14 days. - causes: Malabsorption syndromes, inflammatory bowel disease, cystic fibrosis, celiac, food allergy, lactose tolerance •Good nursing assessment and history help to diagnosis type of diarrhea- Foreign travel? •Stool culture is taken to culture of causative agent •Stool for ova and parasite maybe taken if suspect intestinal parasitic disease

how do you treat mild-mod dehydration

-1st 4-6 hours: ORS with 75-90 mMol Na+/ 111-139 mMol glucose (e.g., WHO solution, Pedialyte RS) -18-24 hr: ORS with 30-60 mMol Na+/ 111-139 mMol glucose (e.g., Pedialyte, Infalyte) -Give 45-60 ml/kg with frequent feedings -Older children—give 30-60 ml q h -Amount and rates are determined from body weight and severity of dehydration

why are fluids different in kids

-metabolic rates are 2-3 times that of adults -kidney are immature...insufficient in excreting waste cannot concentrate/dilute urine as well or excrete sodium/acids -Infants ingest and excrete a greater amount of fluid per kg of body weight than do older children.

s/s of dehydration in order of occurances:

1. tachycardia 2. dry skin and mucous membranes 3. sunken fontanels 4. signs of circulatory failure (coolness and mottling of extremities) 5. loss of skin elasticity 6. delayed capillary filling time

interventions for a child w dehydration caused by diarrhea or vomitting

ORS - 10/L/kg extra for loss b/c of diarrhea popsicles/flavored ice, IV bolus short term if child isnt drinking, NGT possible w infalye or pedialyte Give antiemetics for vomiting, antidiarrheals avoid: high cal. thick juices,

Hypodynamic stage

Progressive deterioration of cardiovascular function, hypothermia, cold extremities, weak pulses, hypotension

Edema formation can be caused by which of the following? a. Decreased venous pressure b. Alteration in capillary permeability c. Increased plasma proteins d. Increased tissue tension

b. Alteration in capillary permeability

The nurse would expect which of the following conditions to produce an increased fluid requirement? a. Heart failure b. High intracranial pressure c. Mechanical ventilation d. Tachypnea

b. High intracranial pressure

Clinical manifestations of lowering blood pressure, pronounced tachycardia, narrowed pulse pressure, poor capillary filling, and increased confusion would suggest which of the following? a. Compensated shock b. Hypotensive (decompensated shock) c. Irreversible shock

b. Hypotensive (decompensated shock)

What is the primary goal in treating any pediatric patient with allergies? a. Have Benadryl available for use immediately for any contact b. Obtaining a thorough and complete health history c. Prevention of a reaction d. Prevention of anaphylaxis

c. Prevention of a reaction

What is the chief solute in extracellular fluid (ECF) and the primary determinant of ECF? a. Potassium b. Calcium c. Sodium d. Water

c. Sodium

An infant with moderate dehydration has what clinical signs? a. Mottled skin color, decreased pulse and respirations b. Decreased urinary output, tachycardia, and fever c. Tachycardia, oliguria, capillary filling within 2 to 4 seconds d. Tachycardia, bulging fontanel, decreased blood pressure

c. Tachycardia, oliguria, capillary filling within 2 to 4 seconds

Normodynamic stage of shock

Duration of only a few hours; cool skin, normal pulses and blood pressure, decreased

The sudden development of high fever, vomiting and diarrhea, profound hypotension, shock, oliguria, and an erythematous macular rash with subsequent desquamation are clinical signs of: a. anaphylaxis. b. irreversible shock. c. C. difficile infections. d. toxic shock syndrome.

d. toxic shock syndrome.

Isotonic dehydration

dehydration occurs when electrolyte and water deficits are present in balanced proportion -most common type

Hypotonic dehydration

dehydration occurs when the electrolyte deficit exceeds the water deficit, higher loss in ECF Na+ less than 130 mEq/L == cell is going to swell (loss of salt, excess water)

Hypertonic dehydration

dehydration results from water loss in excess of electrolyte loss. large loss of water or a large intake of electrolytes. Na+ is greater than 150 mEq/L. == cell is going to shrink because the water is rushing out (loss of water, excess salt)

when is there a decreased need for fluids? (excess)

CHF Mechanical ventilation After surgery Oliguric renal failure Increase intracranial failure

Hyperdynamic stage of shock

Warm, flushed skin with normal blood pressure, chills, fever, and normal urinary output

Which of the following describes the most common initial signs of anaphylaxis? a. Cutaneous signs of flushing and urticaria and complaint of feeling warm b. Bronchiolar constriction with wheezing c. Vasodilation and hypotension d. Laryngeal edema and stridor

a. Cutaneous signs of flushing and urticaria and complaint of feeling warm

Which of the following drugs used to improve cardiac function in the pediatric patient with shock also improves renal function? a. Dopamine b. Lasix c. Vasopressin d. Epinephrine

a. Dopamine

The nurse recognizes which of the following individuals as having the least water content in relation to weight? a. Obese adolescent female b. Thin adolescent female c. Obese adolescent male d. Thin adolescent male

a. Obese adolescent female

A common cause of respiratory failure in the pediatric population after severe burns is: a. bacterial pneumonia. b. pneumothorax. c. pulmonary edema. d. restriction of chest wall as a result of edema and inelastic eschar formation.

a. bacterial pneumonia.

Sepsis and septic shock

a. caused by an infectious organism and the patient's immune, inflammatory, and coagulation responses to the infecting organism i. Evaluation/interventions: monitor labs, ABG, vital signs, lactate, I/O, kidney levels, give vasodilators, fluids (crystalloid, colloids), broad-spectrum antibiotics, *watch for fever, tachycardia, tachypnea for early s/s of septic shock and prevention*

Cardiogenic shock

a. impaired cardiac muscle function that leads to decreased cardiac output. seen after cardiac surgery and in children with acute dysrhythmias, congestive heart failure, trauma, or cardiomyopathy.

Anaphylaxis

a. is the acute clinical syndrome resulting from the interaction of an allergen and a patient who is hypersensitive TREAT: administer epinephrine IM 0.1mg FIRST LINE interventions: remove or stop spread of offending allergen (stop IV if from that), CPR if necessary, administer oxygen, airway patency *IF CAUSE NOT DETERMINED: slow spread by D/C IV or dye infusion; IF CAUSE DETERMINED stat IV ASAP*

Hypovolemic shock

a. reduced size of vascular compartment, falling BP, poor cap refill, low CVP—causes: hemorrhage(trauma), plasma loss(burns, peritonitis), extracellular fluid loss (vomit/diarrhea)

To obtain relevant information from the parents of a child with fluid and electrolyte disturbances, the nurse should question the parents about: a. the type and amount of the child's intake and output. b. the child's general appearance. c. the child's weight over the past month. d. whether they have taken the child's temperature within the past 24 hours.

a. the type and amount of the child's intake and output.

Diagnostic evaluation of dehydration to initiate a therapeutic plan includes: i. serum electrolytes. ii. acid-base imbalance determination. iii. physical assessment to determine degree of dehydration. iv. type of dehydration based on pathophysiology.

all of the above

Joan, age 3 years, is admitted for fluid and electrolyte disturbances. The nurse's assessment should include: i. general appearance observation. ii. vital signs. iii. intake and output measurements. iv. daily weights. v. assess capillary filling time.

all of the above

Early signs of shock

apprehension, irritability, normal BP, narrowing pulse pressure (difference between diastolic and systolic BP), thirst, pallor, diminished urinary output, unexplained mild tachycardia, and decreased perfusion of the hands and feet.

. A gram-negative organism that is commonly found on the burn wound surface on the third day after burn and is responsible for wound sepsis is: a. C. difficile. b. Pseudomonas aeruginosa. c. group B streptococci. d. Haemophilus influenzae.

b. Pseudomonas aeruginosa.

Which symptoms would the nurse expect in a child with hypocalcemia? a. Abdominal cramps, oliguria b. Tingling of nose, ears, fingertips, and toes; neuromuscular irritability; tetany c. Thirst, low urine specific gravity d. Flushed, mottled extremities and weight gain

b. Tingling of nose, ears, fingertips, and toes; neuromuscular irritability; tetany

In infants and young children, the most accurate means of describing dehydration or fluid loss is: a. as a percentage. b. by milliliters per kilogram of body weight. c. by the amount of edema present or absent. d. by the degree of skin elasticity.

b. by milliliters per kilogram of body weight.

Rapid fluid replacement is contraindicated in which of the following types of dehydration? a. Isotonic b. Hypotonic c. Hypertonic

c. Hypertonic - bc of risk of water intoxication

Johnny, age 13 months, is being admitted for parenteral fluid therapy because of excessive vomiting. The nurse would recognize which of the following as most essential in implementing care for Johnny? a. Give Johnny oral fluids until the parenteral fluid therapy can be established. b. Question the provider's order for parenteral fluid therapy of 0.9% sodium chloride. c. Withhold the ordered potassium additive until Johnny's renal function has been verified. d. Replace half of Johnny's estimated fluid deficit over the first 24 hours of parenteral fluid therapy.

c. Withhold the ordered potassium additive until Johnny's renal function has been verified.

The position of choice for the child in shock is: a. Trendelenburg. b. head-down with feet straight. c. flat with the legs elevated. d. semi-Fowler.

c. flat with the legs elevated.

Infants and young children are at high risk for fluid and electrolyte imbalances. Which of the following factors contributes to this vulnerability? a. Decreased body surface area b. Lower metabolic rate c. Mature kidney function d. Increased extracellular fluid volume

d. Increased extracellular fluid volume

Which of the following instructions for treating the child with mild dehydration is not correct? a. Administer 2 to 5 ml of oral rehydration solution (ORS) by syringe or small medication cup every 2 to 3 minutes until the child is able to tolerate larger amounts. b. Oral administration of ondansetron (Zofran) to the child with acute gastroenteritis and vomiting may prevent the need for intravenous (IV) therapy. c. ORS management consists of replacement of fluid loss over 4 to 6 hours. d. ORS should not be started until after all vomiting has stopped.

d. ORS should not be started until after all vomiting has stopped.

Toxic shock syndrome (TSS) is caused by the toxins produced by: a. C. difficile bacteria. b. human papillomavirus. c. Streptococcus bacteria. d. Staphylococcus bacteria.

d. Staphylococcus bacteria.

when is there an increased need for fluids? (deficit)

fever High output kidney failure or DKA Vomiting and diarrhea Shock, burns Tachypnea

how do you treat severe dehydration

fluid therapy IV or intraosseous infusion -Initial rehydration maybe by 0.9% sodium chloride or -Lactated Ringers which are both close to body's serum osmolality. 20ml/kg over 20 minutes and may repeat. This is called giving "a bolus" or "fluid challenge" -Common IV in kids is 5% Dextrose in 0.2 NaCL with 20meq of potassium chloride

Water intoxication can occur in children from: i. excessive intake of electrolyte-free formula. ii. administration of inappropriate hypotonic solutions. iii. dilution of formula with water. iv. isotonic dehydration. v. vigorous hydration with water following a febrile illness. vi. fluid shifts from intracellular to extracellular spaces.

i. excessive intake of electrolyte-free formula. ii. administration of inappropriate hypotonic solutions. iii. dilution of formula with water. v. vigorous hydration with water following a febrile illness.

anasarca

severe generalized edema in all body tissues

treating shock overalll

ventilation (o2, 100%, fluid replacement, inotropes/vasopressors for cardiac support, child flat w legs raised above heart, warm and calm, and pain is kept under control.

s/s of fluid volume deficit:

• Moist mucous membranes • Sodium and potassium within normal limits • Voiding (>1 ml/kg/hr) • Capillary refill of 2 seconds or less • Skin turgor brisk • Fluid intake and output balanced

what alternatives can you offer to kids to replace fluids?

•Popsicles •Jell-O •Whatever they want to drink, even pop without caffeine •Small amounts in fun cups