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Na+ = 2-3 meq / kg / day K+ = 1-2 meq / kg / day Notice: Daily fluid maintenance in pediatrics: 0.18% saline ( 30 meq Na+ ) + 2 meq kcl / 100 cc
Diagnostic Evaluation
1. Physical assessment (V/S) 2. Type of dehydration Nursing Therapeutic management of fluid loss Oral rehydration therapy Parenteral fluid therapy Meet ongoing daily loss Replace previous deficit Replace ongoing abnormal losses
IV fluids
Lactated Ringers 0-10 gram glucose/100cc Na 130 meq/L NaHCO3 28 meq/L as lactate K 4 meq/L 273 mOsm/L Amino acid 8.5 % 8.5 gm protein/100 cc 880 mOsm/L
Albumin 25% (salt poor) 25 gm protein/100 cc Na 100-160 meq/L 300 mOsm/L Intralipid 2.25gm lipid/100cc 284 mOsm/L
Type of Dehydration
1. Isotonic (affect ECF ,Na = 135meq /l) 2. Hypotonic ( loss in ECF 2 correct ICF, Na = less than 135meq/l ) 3. Hypertonic ( sever loss in ICF ,Na = more than 150meq/l
Correction of Dehydration
Moderate to severe dehydration: IV push 10-20 cc / Kg Normal saline (5 % albumin) May repeat. Half deficit over 8 hours, and half over 16 hours. If hypernatremic dehydration, replace deficit over 48 hours (evenly distributed).
Estimate Fluid Deficit (% :- Mild, Moderate, Severe). Find Type of Dehydration (Isonatremic, Hyponatremic, Hypernatremic). Give daily Maintenance. Give Deficit as follows: Half volume over 8 hours, half volume over 16 hours (Exception: in Hypernatremic Dehydration, replace deficit over 48 hours).
Nursing Intervention
1. Assessment 2. History 3. Clinical observation 4. Intake & output measurement 5. Replace orally or IVF ( 1g wet diaper wt =1 ml urine )
Monitors the response of the fluids. Considering the fluid volume. Content of fluid. Patient clinical status.
1. Isotonic fluids:
-Have a total osmolality close to that of extra cellular fluids (ECF) and don't cause RBCs to shrink or swell. - 3 L of isotonic solutions are needed to replace 1 L of blood, so pt should be carefully monitored for signs of fluid overload. Examples of Isotonic fluids: D5W: has a serum osmolality of 252 mosm/L. D5W s mainly used supply water and to correct an increased serum osmolality
Normal Saline Solution NS (0.9% Sodium chloride with TO of 308 NS osmolality is contributed by electrolytes - So the solution remains within ECF. - NS is used to treat ECF deficit. - Ringer's solutions: Contains Ca, K and NaCl
2. Hypotonic Fluids
- The purpose of hypotonic fluids is to replace cellular fluids, because it is hypotonic as compared with plasma. - It also used to provide free water for excretion of body wastes. - It may used to treat hypernatramia (hypotonic Na solutions). Examples of hypotonic solutions: 0.45% Nacl Half-strength saline.
Complications of excessive use of hypotonic solutions include: Intravascular fluid depletion. Decreased blood pressure. Cellular edema. Cell damage
3.Hypertonic Solutions
Hypertonic solutions exert an osmotic pressure greater than that of ECF Examples * High concentrations of dextrose such as 50% dextrose in water are used to help meet caloric requirements. These hypertonic solutions must be administered into control veins so that they can be diluted by rapid blood flow.
Saline solutions are also available in osmolar pressures greater than that of ECF and cause cells to shrink. If administered rapidly or in large quantities, they may cause an extra cellular volume excess and cause circulatory overload and dehydration.
*Management and Nsg Care for certain fluid and electrolyte balance disturbances
1-Water depletion - Provide replacement of fluid. -Determine and correct cause depletion. - Measure intake and output. - Monitor V/S
of
water
2- Water Excess: - Limit fluid intake. - Administer diuretics. - Monitor V/S - Determine and treat cause. - Analyze laboratory electrolyte measurement frequently
3- Hyponatremia - Determine and treat cause - Administer I.V fluids with appropriate saline concentration 4- Hypernatramia: - Determine and treat cause. Administer fluids as prescribed. - Measure intake and output. - Monitor lab. Data.
5- Hypokalemia:
- Monitor V/S and ECG. - Administer supplemental K. - Assess for adequate renal output before administration. IV: administered slowly. Oral: after high K fluids and foods.
6- Hyperkalemia - Determine and treat cause. Monitor V/S and ECG - Administer I.V fluids if prescribed. - Monitor serum potassium levels. 7- Hypocalcaemia: - Determine and treat cause. - Administer calcium supp. as prescribed and administered slowly. - Monitor serum calcium levels. - Monitor serum protein level
8- Hypocalcaemia: - Determine and treat cause. - Monitor serum Ca levels. - Monitor ECG.
SODIUM
Na+ are very important for regulating blood and interstitial fluid pressures as well as nerve and muscle cell conduction of electrical currents. Aldosterone causes retention of Na+.
a. HYPONATREMIA:Vomiting, diarrhea, sweating, and burns cause Na+ loss. Dehydration, tachycardia and shock (see above) can result. Intake of plain water worsens the condition. Pedialyte is a better fluid to drink. Explain this. b. HYPERNATREMIA Severe water deprivation, salt retention or excessive sodium intake causes this. Increased Na+ draws water outside of cells, resulting in tissue dehydration. Thirst, fatigue and coma result.
CHLORIDE
Cl- anion is necessary for the making of HCl, hyper polarization of neurons, regulating proper acid levels, and balancing osmotic pressures between compartments.
a. HYPOCHLOREMIA Excessive vomiting causes chloride loss, resulting in blood and tissue alkalosis, and a depressed respiration rate. b. HYPERCLOREMIA Dehydration or chloride gain can result in renal failure or acidosis (increases in Cl- are accompanied by increases in H+).
POTASSIUM
K+ is important in the intracellular fluid. Aldosterone causes excretion of K+. a. HYPOKALEMIA Caused by diarrhea, exhaustion phase of stress, excessive aldosterone secretions in adrenal cortical hyperplasia and some diuretics. K+ loss from cells contributes to tissue dehydration and acidosis. Flattened T waves, bradycardia, muscle spasms, a lengthened P-R, and mental confusion can also result.
b. HYPERKALEMIA Caused by eating large amounts of "light salt" (KCl), kidney failure, and decreased aldosterone secretions in Addison's Disease; resulting in elevated T waves and fibrillation of the heart. The movement of K+ into cells accompanies tissue alkalosis.
CALCIUM
Calcium Ca++ cations are needed for bone, muscle contraction, and synaptic transmission.
a. HYPOCALCEMIA Excessive calcitonin, inadequate PTH, decreased Vita. D, or reduced Ca++ intake results in muscle cramps, and convulsions. b. HYPERCALCEMIA Increased PTH, Vita. D or calcium intake can cause kidney stones, bone spurs, and lethargy.
RESPIRATORY ACIDOSIS
Increased pCO2 and pH below 7.35 due to hypoventilation, emphysema etc. Compensation occurs in the kidney through increased H+ excretion and HCO3reabsorption. Bicarbonate/carbonic acid ratio is 10-15:1.
RESPIRATORY ALKALOSIS
Hyperventilation due to O2 deficiency, CVA, or anxiety are causes of respiratory alkalosis. Renal compensation occurs by decreasing H+ excretion and HCO3reabsorption. H+ is reabsorbed. Bicarbonate/carbonic acid ratio is 30-40:1.
METABOLIC ACIDOSIS
Due to loss of HCO3- by diarrhea, ketoacidosis, keto acids from a high protein diet, high stomach acidity, anaerobic fermentation, and renal disease. Compensation occurs by an increase in respiration rate. Bicarbonate/carbonic acid ratio is 10-15:1.
METABOLIC ALKALOSIS
Increased intake of antacids, low protein/high vegetable diet, and vomiting/loss of HCl are common causes. Compensation is by hypoventilation. Bicarbonate/carbonic acid ratio is 35:1.
7. % of protein binding & fat distributions 8. Drug half life 9. Excretion 10. Gastric empty time 11. Eating habits 12. Exercise pattern 13.sexual development
* Calculation
of medication
* 6 medication right