Fluids & Electrolytes (Peds)

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Fluids & Electrolytes (Peds)
2012-02-27 13:49:07

Fluids & Electrolytes (Peds)
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  1. Differences between Adults and Children
    • Greater % of body weight that is fluids
    • Body surface area is much greater in children compared to adults
    • Increased metabolic rate compared to adults
    • Kidney function (under 2 years) immature
    • Greater daily fluid requirement
  2. Greater % of Body Weight that is Fluids
    • 75-80% - infants
    • 65-70% - children
    • 60% - adults (usually around 15 years old)
  3. Body Surface Area is Much Greater in Children Compared to Adults
    • Preemie has 5x greater than an adult
    • Newborn has 2-3x greater than an adult

    • Larger loss of fluids through skin
    • More susceptible to dehydration and fluid overload
  4. Increased Metabolic Rate Compared to Adults
    • Growing: uneven pattern throughout childhood
    • More physically active
    • Fever: increases fluid loss approximately (7ml/kg/24 hours for every 1 degree F)
    • Inability to shiver or sweat to control temperature
  5. Kidney Function (under 2 years) Immature
    • Inability to concentrate or dilute urine due to immature homeostatic regulation (this effects ability to conserve or excrete sodium or calcium)
    • Inability to acidify urine
    • For adequate hydration the minimum output is: 1-2 ml/kg/hr
    • Acidifying urine is important because it helps fight infections
  6. Greater Daily Fluid Requirement
    • Little reserve and body water must be replenished
    • Fluids needs are often linked with caloric needs
    • 3-10 kgs = 100 ml/kg
    • 10-20 kgs = 1000 ml + 50 ml/kg for each over 10 kg
    • >20 kgs = 1000 ml + 20 ml/kg for each over 20 kg
    • Changes with specific disorders such as: fever, diarrhea, vomiting, burns, tacypnea

    Only takes 5% fluid loss before they become dehydrated
  7. Intracellular Fluid (ICP)
    • The fluid inside the cell
    • High is proteins and potassium
    • Low in sodium
  8. Extracellular Fluid (ECP)
    • All the fluid outside of the cellular walls
    • Proteins are high in intravascular but low in interstitial
    • High in sodium
    • Low in potassium
  9. Extracellular Fluid Volume Deficit (Dehydration)
    • Most common with children
    • Shifts between water and electrolytes
    • Common causes: vomiting, diarrhea, not taking enough fluids
  10. Dehydration Manifestations
    • Tachycardia
    • Tachypnea
    • Decreased B/P (often later sign)
    • Sunken Fontanels
    • Dry skin and mucus membranes, no tears
    • Cool or mottling of extremities
    • Loss of skin elasticity (poor skin turgor)
    • Decrease or lack of urine output
    • Weight loss
    • Fatigue or lethargic
    • Thirst
  11. Complications from Dehydration
    • Hypovolemic Shock: compensated, decompensated (low B/P, high HR)
    • Shifts in Acid-Base Status: metabolic acidosis, metabolic alkalosis
    • Shifts in Electrolyte Status (esp. Na+ and K+): for every 0.1 until fall in pH, serum K+ increases by 0.5 mEQ/L
  12. Dehydration Goals
    • Improve circulatory function:
    • Oral/NG replacement fluids
    • IV solutions (NS/LR)
    • Blood/plasma
    • Electrolyte balance
    • Acid-Base balance

  13. Edema
    • Interstitial fluid volume excess
    • Movement of fluids by:
    • filtration (pressure)
    • osmotic pressure (concentration)
    • hydrostatic pressures (pump)
  14. Edema Manifestations
    • Increased Blood Hydrostatic Pressure
    • Decreased Blood Osmotic Pressure
    • Increased Interstitial Fluid Osmotic Pressure
    • Blocked Lymphatic Drainage
  15. Increased Blood Hydrostatic Pressure
    • Extracellular fluid volume excess
    • Increased fluid volume in the vascular compartment
    • Fluid moves from greater pressure to less which is the insterstial compartments: increased capillary flood flow (local infection); venous congestion (right side heart failure)
  16. Decreased Blood Osmotic Pressure
    • Normally, albumin and other plasma proteins pulls fluids into the capillaries
    • Increased albumin excretion (ex. nephrotic syndrome)
    • Decreased albumin synthesis (ex. liver disease, starvation)
  17. Increased Interstitial Fluid Osmotic Pressure
    • Normally there is a low osmotic pressure in the interstitial fluid
    • A shift occurs in the capillary permeability
    • Increased capillary permeability: burns, hypersensitivity reactions, septic shock, distributive shock
    • Distributive Shock: hot and warm; vasodilation and increase in cardiac output as a reaction to foreign substances (septic or anaphylaxis)
    • Distributive Shock S/S: fever, tachycardia, tachypnea, BP and urine are normal in compensated shock, flush face, chills
  18. Blocked Lymphatic Drainage
    • Lymph vessels normally drain small proteins and excess fluids from the interstitial to the blood vessels
    • Ex. tumors, bruising
  19. Goals in Edema Care
    • Improve Circulatory Function
    • maintain perfusion
    • monitor edema
    • abdominal girth
    • monitor behavior and neurological changes
    • daily weight
    • I&O
    • specific gravity
    • Maintain Positive Body Image
    • Manage Pain
    • Maintain Skin Integrity
  20. Nephrotic Syndrome
    • Not a disease, unsure of cause
    • There is an alteration in the glomeruli permeability due to the fusion of the glomeruli membrane surface in the kidneys
    • Not enough albumin
    • Can be secondary (ex. w/lupus) or rare (congenital)
    • Three basic types: congenital (rare); secondary, often associated with lupus; minimal change or idiopathic
  21. Minimal Change Nephrotic Syndrome
    • Usually males (2:1) ages 1-8 years especially preschoolers
    • 4 Major Characteristics
    • Proteinuria: losing albumin in urine
    • Edema: low levels of protein in intravascular change osmotic pressure so fluid in interstitial tissue
    • Low Serum Albumin: activates liver for protein loss
    • Hyperlipidemia: high cholesterol levels to compensate for low hypoalbuminemia
  22. Nephrotic Syndrome Manifestations
    • Loss of appetite yet weight gain
    • Diarrhea
    • Skin pallor, fatigued/lethargic
    • Edema: abdomen and eyes
    • Decreased volume of urine
    • Protein in urine dipstick; high specific gravity
    • Low B/P due to decreased volume
  23. Treatment in Nephrotic Syndrome
    • Rest
    • No fluid restriction (if primary cause)
    • High dose steroids or immunosuppressants b/c trying to turn off immun system and stop attacking own body
    • Albumin and Lasix-give first albumin to pull fluid back into vascular space and then give lasix
    • Skin Care
    • Body Image, psychosocial for distorted body image
  24. Urinary Tract Infections
    • Greatest Risk Factor: Stasis of Urine
    • Other risk Factors:
    • girls
    • hygiene habits
    • sexual activity
    • clothing
    • structural risks (neurologic bladder; VUR-Vesicoureteral reflux/reflex)
  25. UTI Clinical Manifestations
    • Incontinence in toilet trained child
    • Strong smelling urine
    • Frequency and/or urge to void
    • Persistent diaper rash
    • Temperature (complications-hydronephrosis, pyelonephritis)
  26. Complications of UTI
    • Hydronephrosis
    • Pyelonephritis
  27. Goals in Urinary Infections
    • Maintain integrity of urinary tract system
    • Teaching, prevention
    • Oral intake
    • Medications
    • Surgical interventions
  28. Epispadias
    Urethra located on the dorsal (or superior) surface of penis
  29. Hypospadias
    • Urethra located on the underside (ventral surface) of penis
    • 1:300
    • Treatment: straighten penis for pscho-social-sexual reasons; foreskin used for repair
    • Urethra works without surgery
    • Surgery needs to be done in first 1-2 years to decrease psychological problems
  30. Hypospadias Considerations
    • No circumcision-foreskin is used for repair
    • Pain (bladder spasms; constipation)
    • Maintain surgical repair (double diaper)
    • Home care (stents or foleys/limited mobility)
  31. Cyptorchidism
    • Undescended Testes
    • 3 Major Factors: low birth weight, prematurity, hypospadias
    • Bilateral or unilateral
    • 3-4% normal births
    • 30% of preterm babies
    • 75% descend spontaneously by 3 months
    • Orchiopexy done usually close to 1 year
    • Boys can also often have inguinal hernias with cryptorchidism
    • There is 20-40% increase risk for testicular cancer if history of cryptorchidism