Pediatric Fluid Balance

Which statement correctly compares blood plasma and interstitial fluid? • Both contain the same kind of ions • Plasma exerts lower osmotic pressure than does interstitial fluid. • Plasma contains slightly more ions • The main cation in plasma is sodium, whereas the main cation in interstitial fluid is potassium

Both contain the same kind of ions, That is related to the fact that blood plasma and interstitial fluid are both part of the extracellular fluid and are of the same ionic composition, the osmotic pressure is the same, the composition is the same, and the main cation of both of the extracellular fluids is sodium, so it is all the same

Which assessment data would the nurse anticipate when admitting a client with extracellular fluid volume excess? • distended neck veins • elevated hematocrit • increased serum sodium • rapid, thready pulse

Distended neck veins, Think what are the things that would give me signs of fluid overload? (Edema in bilateral LE, crackles, I&O (how positive are they? 1-2 liters positive is normal, 8 is something to investigate), Kidneys (BUN and creatinine), slower bounding pulse, BP will be up. The other 3 options are for fluid deficit

Dextrose 10%

Hypertonic *Purpose* • When some nutrition with glucose is required. (great for NPO) • To provide water replacement. • Highest sugar concentration you can put through an IV *Precautions* • Monitor pt glucose levels when using Dextrose 10% • Dextrose is toxic to peripheral vessels

Hypotonic Solutions

Never bolus with hypotonic, only with isotonic, and it shouldn't have an electrolyte in it • 0.45% NS

When fluid is in the wrong compartment in the body, there is some kind of issue with:

• *Problems with the Oncotic Pressure* • *Fluid shift*: Major shifting because of fluid resuscitation, like with sepsis or burns, so the body is trying to figure out where to put all this extra fluid and it just shifts because its so overwhelming • *Lymphatics blocking up*

When do fluid and electrolyte imbalances typically happen?

• Common in most patients with major illness or injury i. Directly caused by illness or disease (burns or heart failure) • Result of therapeutic measures (IV fluid replacement or diuretics) i. Go back and check the urine output and BP ii. Always evaluate • Perioperative patients are at risk for the development of fluid and electrolyte imbalances because of restriction of oral intake, gastrointestinal preparation, blood volume loss, or fluid shifts.

Hypovolemia (fluid deficit) Signs and Symptoms

• Dry tenting skin, decreased skin turgor • Dry mucosa, no sweat • Headache, dizzy • BP ↓, HR ↑ (thready), temp ↑, BUN ↑, creat ∼ • Urine output ∼ 30ml/hr, decreased • Look at total fluid • Weight loss • *Orthostatic Hypotension*

ECF to ICF → (decreased ECF)

• ECF → ICF leads to water excess (↓ ECF) • The primary symptoms are neurologic and result from brain cell swelling as water shifts into the cells.

What would tell me that this is a fluid overload?

• Edema (peripheral and pulmonary) • Weight gain • Crackles in and out • JVD • ↑ BP, ↑ HR (bounding), ↑RR, ↓O₂Sat • Dyspnea • UA: Volume, ↓ BUN, ↑Creatinine

Purpose of IV Fluids

*Maintenance when oral intake is not adequate* • Range of 50 -100 mL an hour is normal maintenance *Replacement when losses have occurred* • Burn patients and Neuro (Diabetes Insipidus) i. Loss in urine output and insensible loss

Body fluid movements

*Osmosis* (water): Fluid moves from ↑concentrate → ↓concentrate *Diffusion* (solute and electrolytes): Particles move from ↑concentrate → ↓concentrate *Active Transport*: solutes move from ↑concentrate → ↓concentrate (Na- K pump)

Hypomagnesemia

*S/Sx* • Hyperactive DTRs • ∆ CNS • Major ∆ ECG *Tx* • Oral: med, diet (yogurt, sardines, dark leafy greens) • LR Most susceptible are alcohol addicts, substance abuse

Hypermagnesemia

*S/Sx* • No deep tendon reflexes (DTRs) • ↓ (depression) of CNS • ↓ neuromuscular function *Tx* • Decrease intake Mg • *Calcium Gluconate* • Lasix • Hemodialysis

Hypernatremia

*S/Sx* • Thirsty • ↓ Urination • Lethargy • Seizures *Tx* • Monitor I&O • Monitor LOC • Monitor Ca (↑Na→↓Ca) • Seizure Precautions • Hypotonic Fluids (D5W, ½NS, ¼NS)

Hypercalcemia

*S/Sx*: • Muscle weakness • Hypoactivity • Hypotension • Thirst, polyuria • ↓CNS *Tx* • Avoid CA foods • Promote excretion (lasix & oral fluid intake) • *Calcitonins*: phosphorus and biphosphate

Hypocalcemia

*S/Sx*: • Tetany • Laryngospasm • Chvestek's (face spasm) • Trusseu's (swan hand) • Muscle twitching • Hyperexcitability • ∆ECG • Hypotension • ∆CNS *Tx*: • PO: dietary (milk, avocado, banana, and spinach) • IV: LR • Ca↓ = Albumin ↓ • Ca↓ = Phosphorus ↑

Hyperkalemia

*S/Sx*: • Weakness • ∆CNS • Chest pain, palpitations • vFibb • ∆ECG (tall T wave) • ↑Creatinine *Tx*: • Telemonitor • Hold LR • 5- 5.9: is a little ↑, stop potassium and get an IV • 6-6.5: is moderately ↑ get away with kayexalate (binds K and excretes in poop) • >7 dangerous/emergent, treated with insulin (drives K into the cells and out of vascular system) and calcium (treats symptoms) • >10-12 fatal

Hyponatremia

*S/Sx*: • Sleepy • Edema • Lethargy • Seizures *Tx*: • Strict I&O • Daily weight • ↑Na Diet (milk, eggs, salt tabs) • Seizure precautions • NS • 3% NS (when hand tremors)

The RN is aware that fluid volume deficit can be most accurately assessed by: • appearance of wrinkling skin • a decrease in blood pressure • cracked lips • a change in body weight

A change in body weight, Dehydration is more accurately assess by serial assessment and body weight is actually the most important, 1 liter of fluid = 2.2 pounds. Dry skin is associated with dehydration, but it is also due to aging. Cracked lips are also a general sign. Drop in BP can also happen with dehydration, so if you're concerned about dehydration you need to be concerned with orthostatic BP's (applied question, most helpful in assessing patient safety)

Tests for Hypocalcemia

A, Chvostek's sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. B, Trousseau's sign is a carpal spasm induced by C, inflating a blood pressure cuff above the systolic pressure for a few minutes.

An 87 yo s/p hip pinning has a BP of 80/50 with a heart rate of 80. Urine output is 15 ml over the last hour. PMH includes CHF, HTN, and hypothyroidism. The nurse should: a. Document these normal findings. b. Administer 250 ml NS over 15 minutes then check VS and lung sounds. c. Draw labs to check Na and K before selecting IV fluids. d. Give 1 liter LR as fast as possible, then check VS, neck circumference and labs.

B, administer 250ml NS over 15 minutes then check VS and lung sounds. This is a heart patient so follow up and make sure the fluid is staying in the right place

Isotonic Solutions

Dextrose (D₅W) Normal Saline 0.9% (NSS) Lactated Ringers (LR)

A pt in rehab has tube feeds running at goal (75ml/hr). This morning's labs include Na 148, K 4.2, creatinine 1.2, glucose 145. Which recommendation would you give the MD as part of your SBAR communication? a. Do you want me to turn the feeding rate down? b. Do you want me to start a D5W IV? c. Do you want me to give intermittent tap water down the feeding tube? d. Do you want me to see if there is a more concentrated formula available?

Don't turn down feeding tube because you want to make sure there is nutrition, don't start D₅W, we already have glucose, it is high, he doesn't need more. We don't want anything more concentrated. The tap water (C) will dilute the hypernatremia out using the most natural and least invasive route as possible.

Which IV fluid is used to correct fluid loss from excessive perspiration, vomiting, or to prevent alkalosis? • Plasma Expanders • 5%DW • NaCl • Lactated Ringers • D5NS

D₅NS, Don't see a lot of this, usually they go to D₅ 0.45NS

Which IV solution is used to correct dehydration, ketoacidosis, hypernatremia, and provides 170 calories per liter? • Plasma Expanders • D₅W • NaCl • Lactated Ringers • D5NS

D₅W, When we have too much sodium or chloride in the system, you have to go to a dextrose solution and get away from normal saline

A 19 yo trauma pt in the ER has a BP of 80/50, with a heart rate of 130. a. Give 1 liter of D₅W as fast as possible IV b. Give 1 liter NS as fast as possible IV. c. Start an additional large bore IV as saline lock. d. Calculate the anion gap before selecting IV fluid.

Give 1-liter NS as fast as possible IV then start an additional large bore IV

A pt with CHF has the following assessment findings: 2+ pedal edema, JVD, bilateral basilar crackles, UO 1.2 liters/24hr, BP 145/88, Na 129. Which treatment is indicated? a. Fluid restriction b. Salt tablets c. NS IV d. 3% sodium chloride IV

He looks like fluid overload. Sodium is low because there is too much fluid (diluted out), don't give him salt tablets because that will have him hold onto more water by bringing the sodium up. We don't want to do that, we want to get rid of water. We don't want to give him more fluid. We want to restrict his fluids because he is fluid overloaded, so A (Fluid Restriction)

The RN is administering and IV solution of 0.45% Sodium chloride. With respect to human blood cells this solution is: • Isotonic • Isometric • Hypotonic • Hypertonic

Hypotonic, They are less concentrated, so the fluid is going to move out of the plasma and into the cell. Give to a patient after surgery when they are dehydrated to get fluid to those cells

ICF to ECF → (increased ECF)

ICF → ECF leads to water deficit (↑ ECF) • Associated with symptoms that result from cell shrinkage as water is pulled into vascular system. • For example, neurologic symptoms are caused by altered central nervous system (CNS) function as brain cells shrink.

The weight of extracellular body fluid is approximately 20% of the total body weight on an average individual. The component of the extracellular fluid that contributes the greatest portion to this amount is the: • Plasma fluid • Interstitial fluid • Fluid in dense body tissue • Fluid in body secretions

Interstitial fluid, The interstitial fluid constitutes about 60% of body weight, which is 10-12 liters in adults. Plasma is 4% of body weight, so that's in your actual blood vessels. Fluid in body tissues and secretions is actually very small at about 20%. So most of that is in the interstitial space and in the vascular place

Lactated Ringers (LR)

Isotonic *Purpose* • For acute blood loss • To treat *burns* • Dehydration i. Marathon runner, chronic dysentery • To treat third spacing • To treat lower GI fluid loss. • *Think OR and OB* *Precautions* • Similar to plasma in content but does not contain Mg2+ • Don't use in renal pts to avoid hyperkalemia. • Don't use in pts with liver failure because pts cannot metabolize lactate. • Don't use in pts with PH > 7.5

Normal Saline 0.9% NSS

Isotonic *Purpose* • Used most commonly, "go to IV fluid", everybody can have it, 80% of time • With blood transfusion, same osmolarity as our serum • *Fluid replacement* • *Think blood* • Fluid challenge • *Bolus* (neuro) • Fluid replacement with DKA • To treat hypercalcemia • To treat hyponatremia • To treat metabolic alkalosis • To treat shock *Precautions* • Used as replacement for ECF • Do not use in pts with heart failure, edema or hypernatremia to avoid fluid overload.

Dextrose (D₅W)

Isotonic *Purpose*: To replace fluid loss & dehydration To treat hypernatremia *Precautions* • Initially isotonic then hypotonic • Use cautiously with cardiac & renal pts. • Don't use for resuscitation to avoid hyperglycemia. • Does not provide enough daily calories

Hypokalemia

K+ < 3.5 mEq/l *S/Sx*: • Weakness • Bradycardia • Shallow respirations • ∆ECG ( U- Wave) • ∆CNS • ↑ UO *Tx*: • K- Lor (with food) (oral if mild, IVPB if mod-severe) • LR • Telemonitor • Hold Lasix

Which IV fluid contains Na, Cl, K, Ca, and Lactate, and is used to correct extracellular fluid shifts? • Plasma Expanders • 5%DW • NaCl • Lactated Ringers • D5NS

Lactated ringers, Typically use when people come in preoperatively, they come in NPO and you want to make sure that they have replacement of these electrolytes. Switch to D₅ about 24 hours after surgery because you may be building up NaCl and you want to pump up your cells with the dextrose

Given the appropriate IV fluids that were order after your SBAR call to the Physician, which of the following labs should be trended for our trauma/head injured patient? (Select All the Apply) A. Daily chem 7 B. Albumin every 6 hours C. Daily CBC D. Na level every 6 hours E. K level every 4 hours F. Daily ALT AST

Na level every 6 hours, daily chem7, and daily CBC

Hypertonic Solutions

Never bolus with hypertonic solutions, only with isotonic, and it shouldn't have an electrolyte in it • D₅W in 0.45 NSS • *D₅W in 0.9% NSS* • Dextrose 10% • Hypertonic 3% Saline • Plasma Expanders

Magnesium

Norm: 1.7 - 2.3 Critical: <1 or >9 Magnesium is important for many processes in the body, including regulating muscle and nerve function, blood sugar levels, and blood pressure and making protein, bone, and DNA Think Conduction

Sodium (Na)

Norm: 135-145 Critical: <130, >155 Seizure: <125, >155 Think Brain

Potassium (K)

Norm: 3.3 - 5.0 Critical: <3, >6 Think Heart

Calcium

Norm: 8.6 - 10.5 Critical: <7 or >12 Think Muscle

What would be the most appropriate nursing intervention with a K level of 6.0?

Notify physician of abnormal labs, request kayexalate and a change of IV fluids. Maintain pt on cardiac monitoring and recheck the lab.

The RN is assessing a patient in the ER who has been vomiting for 24 hours at home and is dizzy on rising. The patients skin is pale and moist, BP 103/67. On assisting the patient to the bathroom the RN should assess for which of the following: • Hyperkalemia • Hypoglycemia • Orthostatic Hypotension • Fluid overload

Orthostatic hypotension, A drop of 20-30mmHg from supine to sitting up is often indicative of hypovolemia and dehydration

Which IV fluid is used to manage fluid losses and acts as a bolus fluid for low BP? • Plasma Expanders • 5%DW • NaCl • Lactated Ringers • D5NS

Pick NaCl because it is isotonic and has the same electrolyte concentration as the intracellular

Which IV fluid increases blood volume: albumin, plasma, and dextran? • Plasma Expanders • 5%DW • NaCl • Lactated Ringers • D5NS

Plasma expanders, Plasma expanders give us our oncotic pressures

The most important electrolyte of intracellular fluid is: • Sodium • Calcium • Chloride • Potassium

Potassium, The concentration of potassium is greater inside the cell and is important in establishing membrane potential via the sodium potassium pump

The two body systems that interact with the bicarbonate buffer system to preserve the normal body fluid pH of 7.4 are the • Respiratory and urinary systems • Skeletal and nervous systems • Muscular and endocrine systems • Circulatory and urinary systems

Respiratory and urinary systems, Kidneys make bicarb and bicarb uses our serum CO₂ to make that bicarbonate buffer. Your serum CO₂ is your big buffering bank, when your kidneys need to make bicarb, they pull from this bank, make the bicarbonate, and then buffers up. That total Serum CO₂ should not be confused with the PaCO₂ on the ABG's, it is different. The PaCO₂ on an ABG is an acid because it is measured in a gas state. A drop in serum CO₂ should tell you that your body is in an acidotic state and is trying to make bicarbonate to buffer.

The nurse is aware that the body's attempts to compensate for excessive fluid losses associated with diarrhea are evident in increased: • Ammonia levels • Urine Specific Gravity • Temperature • Serum Potassium

Urine specific gravity, Specific gravity increases, urine becomes more concentrated by the body's attempts to conserve water. Ammonia levels are related to liver function, temp is related to SIRS and the serum potassium is something you should check because it would be decreased

This same trauma/head injured patient remains somnolent and agitated on day 3. She is NPO. Since admit, her I+O balance is +2 liters. VS stable. Lungs are clear. Today her Na+ is 133, K+ is 3.8. Which IV solution is most appropriate? A. 3% NaCl at 50 ml/hr, with NS w/20meq KCl at 75/hr B. D5½ NS w/40KCl at 50 ml/hr. C. D5W at 200/hr D. D5 .45 NS w/40KCl at 50/hr, with 3% NS at 100 ml/hr

When I think neuro I think NS, keep the fluid in the vascular space and pull fluid from the vascular space in the brain to decrease that edema. A is the best (3% NaCl at 50 ml/hr, with NS w/20meq KCl at 75/hr)

Orthostatic BP

a drop of 20-30 mmHg from supine to sitting up is often indicative of hypovolemia and *dehydration*

At the arterial end of the capillary

capillary hydrostatic pressure exceeds plasma oncotic pressure, and fluid is moved into the interstitium.

At the venous end of the capillary

the capillary hydrostatic pressure is lower than plasma oncotic pressure, and fluid is drawn back into the capillary by the oncotic pressure created by plasma proteins.