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Balance and Imbalance of Body Fluids

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Green bilious. Bowel obstruction. Curdled. Delayed emptying. Fever and diarrhea ... Progressive non bilious projectile vomiting. Usual age of onset is 3 weeks ... – PowerPoint PPT presentation

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Title: Balance and Imbalance of Body Fluids


1
Balance and Imbalance of Body Fluids
  • Nurs 309
  • Spring 2006

2
Distribution of body fluids
  • Total body fluids (TBF)
  • Intracellular fluids (ICF)
  • Extracellular (ECF)
  • Water is the major constituent of body tissues
    ranging from 45 to 75

3
Distribution of body fluids
  • ICF refers to the fluid within the cells
  • ECF
  • Intravascular
  • Interstitial
  • Transcellular

4
Water balance in infants
  • Infants and small children have greater need for
    water
  • Infants have a greater fluid intake relative to
    size
  • Water and electrolyte disturbances occur more
    frequently and more rapidly

5
Water balance in infants
  • The fluid compartment varies from the adults
  • The ECF accounts for more than 50 of TBW
  • The ECF compartment remains larger than the
    adults until age two

6
Water balance in infants
  • Fluid loss is divided between insensible, urinary
    and fecal
  • 2/3 of the loss is insensible and 1/3 respiratory
  • Insensible loss is influenced by
  • Heat
  • Humidity
  • Body temperature
  • Respiratory rate

7
Water balance in infants
  • Infants and young children have an increased
    tendency for fevers
  • Fevers increase insensible losses by 7mg/kg/24
    hours for every degree rise over 37.2C (99F)
  • Increase body surface are related to volume

8
Water balance in infants
  • There is an increase in insensible loss due to
    increased body surface area
  • The metabolic rate is higher in infants resulting
    in increase metabolic waste
  • Immature kidneys at birth potentiates dehydration
    or over hydration

9
Dehydration
  • Dehydration occurs whenever total output exceeds
    intake
  • Dehydration can be due to decreased fluid intake
  • Dehydration is children is usually due to water
    loss associated with vomiting or diarrhea

10
DehydrationIsotonic
  • Primary form seen in children
  • Water and electrolytes are lost in same
    proportion
  • Loss is from the ECF
  • Hypovolemic shock is greatest threat
  • Severe diarrhea or vomiting

11
DehydrationHypotonic
  • Electrolyte loss exceeds water loss
  • Fluid shifts from ECF to ICF for osmotic
    equilibrium
  • This shift increases ECF deficit
  • Shock is a frequent result
  • Usually due to increased intake of free water

12
DehydrationHypertonic
  • Water loss exceeds electrolyte loss
  • Fluids shift from ICF to ECF
  • May occur infants with diarrhea who have been fed
    concentrated formula
  • Neurologic disturbances are more common

13
Dehydration
14
Clinical signs of dehydration
  • Tachycardia
  • Dry skin and mucus membranes
  • Sunken fontanels
  • Cool mottled skin
  • Loss of elasticity of the skin
  • Delayed capillary refill time

15
Degrees dehydrationMild
  • Fluid volume loss lt50 ml/kg
  • Skin color pale
  • Skin elasticity decreased
  • Mucus membranes dry
  • Urinary output decreased
  • Blood pressure normal
  • Pulse
    normal-increased
  • Capillary refill lt 2 sec

16
Degrees dehydrationmoderate
  • Fluid volume loss 50-90 ml
  • Skin color gray
  • Skin elasticity poor
  • Mucus membranes very dry
  • Urinary output oliguria
  • Blood pressure normal-low
  • Pulse increased
  • Capillary refill 2-3 sec

17
Degrees dehydrationsevere
  • Fluid volume loss gt100 ml
  • Skin color
    mottled
  • Skin elasticity very
    poor
  • Mucus membranes parched
  • Urinary output oliguria/azotemia
  • Blood pressure lowered
  • Pulse
    rapid/thready
  • Capillary refill gt3
    sec

18
Dehydration management
  • Mild cases may be treated at home
  • Oral rehydration therapy consists of rapid fluid
    replacement
  • Replacement of continued losses
  • Provision of maintenance fluids

19
Dehydration management
  • Parenteral fluid therapy
  • Replace deficits
  • Replace ongoing losses
  • Provide normal physiologic needs
  • IV therapy is initiated immediately
  • Normal saline or lactated Ringers

20
Dehydration management
  • First phase
  • Bolus of 20 to 30ml/kg repeatedly
  • Second phase
  • Deficit and maintenance therapy
  • Third phase
  • Return to normal and begin oral feedings

21
Edema
  • Abnormal accumulation of interstitial fluid
  • Any factor that causes sodium retention will
    cause or augment edema
  • Can be due the sodium retaining qualities of
    steroids

22
Edema
  • Alteration in cell membrane permeability
  • A decrease in plasma protein will decrease
    vascular osmotic pull
  • Obstruction of venous return

23
Edema
  • Assessment
  • Can occur in any part of the body
  • Daily weights are sensitive indicators in
    children
  • Abdominal girths are good indicators
  • Pitting edema may be present
  • Management
  • Treatment of the underlying cause
  • Recognition is primary role for nurses

24
Edema
25
Disturbances in acid base balanceRespiratory
acidosis
  • Inadequate pulmonary ventilation causing a rise
    in plasma CO2
  • Increase levels of hydrogen and carbonic acid and
    subsequent rise in pH
  • Correction of primary problem and normalizing CO2
  • Oxygen and mechanical ventilation may be needed

26
Respiratory acidosis
  • Depression of respiratory center
  • Head injury, depressant drugs, CNS infection
  • Lung disease
  • Pulmonary disease, pneumonia, pulmonary edema
  • Chest wall function
  • Chest wall trauma, skeletal disease or deformity

27
Respiratory alkalosis
  • Increased rate and depth of pulmonary ventilation
  • CO2 is blown off causing a decrease in pH
  • Causes are associated with extreme emotions,
    congestive heart failure
  • Ventilated patients
  • Treatment is rebreathing

28
Metabolic acidosis
  • Lowered plasma concentrations of HCO3 with
    subsequent decrease in pH
  • Immediate pulmonary compensation
  • Kussmaul respirations
  • Associated with diabetic ketoacidosis, starvation
  • Treatment directed at correcting HCO3 deficit

29
Metabolic alkalosis
  • Elevation of plasma pH with reduction of H
    concentration
  • Associated with hydrochloric acid loss
  • Treatment is aimed at alleviation of acid losses

30
Nursing responsibilities Assessment
  • Electrolyte imbalance can occur rapidly in
    children
  • Diarrhea and vomiting
  • Fever and sweating
  • Cardiac anomalies
  • Renal disease
  • Medications
  • Trauma surgery burns

31
Assessment and history
  • General observation
  • Toxic appearing
  • Loss of appetite
  • Irritable
  • History
  • Estimation of all output
  • Estimation of all intake

32
Clinical observations
  • Tachycardia
  • Dry mucus membranes
  • Lack of tears
  • sunken fontanel
  • Loss of skin elasticity
  • Prolonged capillary refill time
  • Weight change

33
Intake and output in children
  • Careful weighing of diapers and pads
  • 1gm 1 ml
  • Urine, stool, vomitus
  • Insensible loss due to radiant warmers or bili
    lights
  • At home note number of voids
  • Number of diapers

34
The child who is NPO
  • Signs
  • On the door
  • At the bedside
  • On the child
  • Monitor
  • Sinks
  • Fountains
  • Toilets
  • Appropriate nursing care

35
Venous access devices in pediatrics
  • Peripherally inserted central catheters (PICCS)
  • One week to three months
  • Silastic catheter threaded into SVC
  • Parenteral infusions
  • Blood draws
  • Infection rate lt 2

36
Peripherally inserted central catheters (PICCS)
37
Peripherally inserted central catheters (PICCS)
38
Long term venous access devices
  • Long term venous access devices (VADS) include
    tunneled and implanted ports
  • Single of multiple lumens
  • Tunneled from the subclavian to superior vena
    cava or right atrium
  • Strict aseptic technique is used whenever the
    device is entered

39
Long term venous access devices
40
Port-a-cath
41
Long term venous access devices
  • Central line sepsis is a major complication
  • Line access should be minimized
  • Dressing changes are sterile and follow hospital
    protocols
  • Family teaching
  • Line access
  • Trouble shooting line breaks and/or occlusions

42
Total parenteral nutrition (TPN)
  • Hyperalimentation provides total nutrition
  • Chronic bowel obstruction
  • Sepsis
  • Short bowel
  • Prematurity
  • Concentrated glucose, proteins, vitamins and
    minerals
  • Intralipids are IV fats
  • Peripheral IV infusion is contraindicated

43
Total parenteral nutrition (TPN)
44
Gastrointestinal disorders Diarrhea
  • Estimated 1.3 Billion cases of childhood diarrhea
    each year
  • 24 of childhood deaths attributed to diarrhea
  • Diarrhea is present when there is an increase in
    stool frequency and water content
  • Diarrhea varies in severity and duration

45
Acute diarrhea
  • Sudden increase in the frequency and consistency
    of the stools
  • Usually caused by an infectious agent
  • Usually self limiting (lt14 days)
  • Usually no specific treatment needed if there is
    no dehydration

46
Acute diarrhea
  • Most cases are spread by the fecal oral route
  • Overcrowding, lack of clean water, poor hygiene
    contribute to the spread of diarrhea
  • The increase incidence in infants is an age
    related susceptibility

47
Rotavirus
  • The most common pathogen in the U.S. is Rotavirus
  • Rotavirus is a major killer worldwide
  • In the U.S. it is responsible for 60,000 hospital
    admissions per year and 20 deaths per year

48
Rotavirus
  • Epidemics late fall through early spring
  • Fecal oral person to person
  • Family spread is common
  • The virus is very environmental hardy

49
Rotavirusclinical features
  • Begins with fever an vomiting followed by
    diarrhea
  • Typically there is 1o to 20 bowel movements per
    day
  • Diarrhea usually lasts between 3 to 8 days
  • Vomiting is limited to the first 24 hours and
    occurs 80 to 90 of the time

50
Rotaviruscontrolling transmission
  • The most important measure is good handwashing
  • Handwashing alone removes only 75 of virus
  • Agents containing alcohol are most effective
  • Wash hands and then apply alcohol containing hand
    rub
  • Wipe down surfaces and then apply alcohol
    disinfectant

51
Acute diarrhea
  • Virus
  • Norwalk
  • Bacteria
  • Salmonella ,Shigella, E-Coli
  • Parasites
  • Giardia
  • Other causes
  • Laxatives, foods containing Sorbitol or fructose,
    antibiotics

52
Acute diarrheaevaluation
  • History of current medications, possible
    ingestions, and family history
  • Questions regarding onset of diarrhea
  • Character of the stools
  • Watery explosive
  • Large foul smelling greasy
  • Onset in relation to introduction of foods

53
Acute diarrhealab evaluation
  • Neutrophils or red blood cells
  • Bacterial infection
  • Eosinophils
  • Parasitic infection
  • C-difficile
  • If treated with antibiotics
  • Other labs
  • CBC, electrolytes, BUN, creatinine, urine
    specific gravity

54
Acute diarrheamanagement
  • Assessment of fluid and electrolyte balance
  • Rehydration
  • Maintenance of fluid therapy
  • Reintroduction of adequate diet

55
Acute diarrheamanagement
  • Oral rehydration therapy (ORT)
  • Pedialyte, Rehydralyte, Infalyte
  • Reduce vomiting, diarrheal losses and shorten the
    duration of the illness

56
Acute diarrheamanagement
  • After initial rehydration ORT can be used as part
    of maintenance program
  • Formula, breast feeding, regular diet
  • ORT replacement 11 10mg/kg or ½ to 1 cup per
    diarrheal stool
  • Continued feeding or early reintroduction
    beneficial

57
Assessment
  • Urinary output
  • Poor turgor
  • Fontanel
  • Mucus membranes
  • Tears
  • Prolonged CRT
  • Elevated heart rate

58
Plan
  • The child will maintain hydration
  • The child will maintain appropriate nutrition
  • The child will not spread infection
  • The family will receive support and education
    especially for home care

59
Implementation
  • Hygiene, handwashing, diaper disposal, changing
    table hygiene
  • Caregiver taught to monitor child for signs of
    dehydration.. number of wet diapers, or voids,
    fluid intake patterns
  • Continuation of oral intake with ORT for improved
    nutrition and fluid status
  • BRAT diet no longer recommended

60
Implementation
  • When the child is hospitalized, strict IO
  • Attention to hygiene, handwashing, crib, changing
    table
  • Appropriate skin care and protection, (zinc oxide
    or 1-2-3 cream)

61
Evaluation
  • Monitor fluid losses, strict I0
  • Monitor food intake
  • Observe for evidence of complications e.g. fluid
    and electrolyte disturbances
  • Observe and interview family for effectiveness
    of teaching and outcome care of patient

62
Vomiting
  • Forceful ejection of the gastric contents from
    the mouth
  • Nausea and retching
  • Regurgitation is more passive
  • Common in childhood and self limiting

63
Vomitingetiology
  • Green bilious
  • Bowel obstruction
  • Curdled
  • Delayed emptying
  • Fever and diarrhea
  • infection
  • Localized pain
  • Appendicitis
  • Change in level of consciousness
  • CNS involvement

64
Vomitingevaluation
  • History
  • When does it occur
  • How much
  • How often
  • Associated with diarrhea or pain
  • Is it forceful
  • Dizziness, blurred vision or headache

65
Vomitingevaluation
  • Hydration status
  • Abdominal pain
  • Lab work
  • Urine analysis
  • CBC
  • Electrolytes
  • Abdominal imaging
  • Imaging of the head

66
Vomitingmanagement
  • Assessment
  • Appearance, amount, frequency and behaviors
  • Maintenance of hydration paramount
  • Anti emetics to break the cycle
  • Continued fluid support with progression to
    regular diet

67
Hypertrophic pyloric stenosis
68
Hypertrophic pyloric stenosispathophysiology
69
Hypertrophic pyloric stenosisclinical
manifestations
  • Progressive non bilious projectile vomiting
  • Usual age of onset is 3 weeks
  • Initially the infant is hungry and irritable
  • With progression the infant become dehydrated
    with weight loss
  • Ultimately failure to thrive

70
Hypertrophic pyloric stenosisdiagnostic
evaluation
  • The diagnosis is based on history of projectile
    vomiting
  • Olive like mass palpated in upper abdomen
  • The diagnosis is confirmed with ultra sound
  • Elevated BUN and creatinine
  • Low sodium and potassium

71
Hypertrophic pyloric stenosis
72
Hypertrophic pyloric stenosisnursing
considerations
  • Pre operative
  • Rehydration and restoration of electrolyte
    balance
  • NPO with NG decompression
  • IOs with attention to overall status
  • NG function and patency
  • Parental support, education and reassurance

73
Hypertrophic pyloric stenosisnursing
considerations
  • Post operative
  • IV management, frequent vital signs, pain
    management
  • Reassurance of the family
  • Gradual progression of feeds an tolerated
  • Post operative wound observation and care

74
The Child with Renal Dysfunction
  • Creatinine
  • Is a produced at a constant rate
  • Any that is filtered by the glomerulus is lost
  • Production is to excretion
  • As the GFR declines the serum creatinine
    increases proportionately
  • Creatinine is a good indicator of GFR
  • Normal values 0.6 to 1.2 mg/dl

75
The Child with Renal Dysfunctionlab values
  • BUN (Blood urea nitrogen)
  • Reflects glomerular filtration
  • BUN levels rise as glomerular filtration drops
  • Normal values are 10 to 20 mg/dl
  • Specific gravity
  • The ability of the kidney to concentrate urine
  • Normal value are 1.001- 1.035

76
Urinary tract infection(UTI)
  • Significant number of bacteria in the urinary
    tract
  • Peak incidence between ages 2 and 6 yrs
  • Females 10 to 30 times greater risk than boys

77
Urinary tract infectionEtiology
  • E-Coli accounts for 80 of all UTIs
  • Structural anatomy of females attributed to
    higher incidence
  • Urinary stasis
  • Incomplete bladder emptying
  • Obstruction due to constipation

78
Urinary tract infectionEtiology
  • Indwelling catheters
  • Tight clothing
  • Poor hygiene
  • Infestations
  • Sexual intercourse

79
Urinary tract infectionclinical manifestations
  • Frequency
  • Urgency
  • Dysuria
  • Foul smelling urine
  • Daytime enuresis
  • Fever

80
Diagnostic evaluation
  • Urine appears cloudy, thick with visible strands
    of mucus or pus
  • The diagnosis is confirmed by culture
  • Collection methods
  • Bag urine
  • Clean catch
  • Suprapubic cath
  • Straight cath

81
Diagnostic evaluation
  • Urine dip sticks are useful screens while culture
    is pending
  • The presence of nitrates is highly predictive of
    infection
  • The absence of nitrates and leukocyte esterase
    have a negative predictive value

82
UTImanagement
  • Antibiotic therapy is the mainstay of treatment
    for UTI
  • Therapy is guided by the culture and sensitivity
  • Penicillin, sulfonamides, cephalosporin's,
    nitrofurantoin
  • VCUG is recommended after the first UTI

83
Nursing considerations
  • Obtaining all specimens
  • Preparation of family and child for all
    procedures
  • Educate the family regarding antibiotic therapy
  • Timing of administration
  • Possible side effects
  • Give all that is prescribed

84
Nursing considerationsprevention
  • Adequate fluid intake (100ml/kg or 50ml/lb/day)
  • Proper perineal hygiene
  • Avoid tight clothing, diapers cotton underwear
  • Promote urination to children too busy playing
  • Increase fiber and water to avoid constipation

85
Vesicouretral Reflux(VUR)
  • Retrograde flow of urine up the ureters
  • Reflux potentiates bladder and kidney infection
  • Primary reflux is associated with congenital
    anomaly
  • Secondary is acquired
  • Primary form is highly familial

86
Vesicouretral Reflux(VUR)
87
Vesicouretral Reflux(VUR)
88
Vesicouretral Reflux(VUR)
  • Grade one Grade two

89
Vesicouretral Reflux(VUR)
  • Grade three Grade four

90
Vesicouretral Reflux(VUR)
  • Grade five

91
Vesicouretral Refluxmanagement
  • Grades one and two have an 80 chance of
    spontaneous remission
  • Grades four and five require surgical
    reimplantation of the ureters
  • Grade three is managed similarly to grade one and
    two unless there are complications

92
Hemolytic uremic syndrome(HUS)
  • HUS triad
  • Renal failure
  • Hemolytic anemia
  • Thrombocytopenia
  • Occurs in children 6 months to 3 years
  • Usually follows a GI or URI

93
HUSpathophysiology
  • Damage to the lining of the arterioles of the
    glomerulus
  • Platelet aggregation at the damage site causes
    obstruction
  • RBC damaged in narrowed vessels
  • Removal of RBCs in spleen

94
HUSmanifestations
  • The hemolytic process persists for several days
    to two weeks
  • Anorexia, irritable and lethargic
  • Marked pallor with bruising and purpura
  • Severe cases will be anuric
  • All cases will have azotemia

95
HUSevaluation
  • HUS triad is sufficient for diagnosis
  • Azotemia
  • Elevated creatinine and BUN w/ hematuria
  • Low serum hemoglobin and hematocrit
  • Elevated reticulocyte levels

96
HUSmanagement
  • Normalization of electrolytes and acid base
    balance
  • Early hemodialysis
  • Blood transfusions
  • Adequate nutrition enteral or parenteral

97
HUSnursing considerations
  • Monitoring fluid and electrolyte therapy
  • Frequent vital signs
  • IO
  • Hemodialysis
  • Blood transfusion
  • Monitoring level of consciousness
  • Family support
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