1. By
Hidayatullah khan
KMU
Fluids & Electrolytes
imbalance

2. Composition of Body Compartments
 Total Body Water (TBW)= 50-75% of Total Body Mass
 TBW = Intracellular Fluid (ICF) + Extracellular Fluid (ECF)
 ICF = 2/3 of TBW
 ECF = 1/3 of TBW -- 25% of body weight
 ECF = Plasma (intravascular) + Interstitial fluid
Fluid % in child body ( 75%-80%)

3. Regulation of Body Fluids and Electr
olytes
 Anti-Diuretic Hormone (ADH)
 Thirst
 Aldosterone
 Atrial Natriuretic Factor

4. Daily Maintenance Requirements
Add 12 % for every
0
C

5. 4cc, 2cc, 1cc rule
 4 cc for the first 10 kg
 2 cc for the next 10 kg
 1 cc for each kg after
 Example:
 27 kg child
 4 cc for the first 10 kg = 40cc
 2 cc for the next 10 kg = 20cc
 1 cc for each kg after = 7 cc
67 cc/hr

6. Estimation of Dehydration

7. Nursing requirements of FLUID
Increased requirement :
 Fever
 Vomiting
 Renal failure
 Burn
 Shock
 Tachypnea
 Gastroenteritis
 Diabetes (Insipidus, mellitus - DKA)
 Cystic fibrosis

8. Decreased requirement
 CHF
 Postoperatively
 oliguric ( RF )
 Increase ICP

9. Dehydration
 Classification
 Isotonic
 Serum Sodium 130-150 mEq
 Hypotonic
 Serum Sodium < 130 mEq
 Hypertonic
 Serum Sodium >150 mEq

10. 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

11. Management of Dehydration
 General Principles:
 Supply Maintenance Requirements
 Correct volume and electrolyte deficit
 Replace ongoing abnormal losses

12. Management of Dehydration
 Oral Rehydration:
 Effective for mild and some moderate dehydrations
 Child may be able to tolerate PO intake
 Small aliquots as tolerated
 Mild: 50 cc/kg over 4 hours
 Moderate: 100 cc/kg over 4 hours
 2 types of oral solution
 Maintenance
 Rehydration

13. Composition of Body fluids
1. D5W (5 g sugar/100 ml)
2. D10W (10 g sugar/100 ml)
3. NS (0.9% NaCl) 9 gm NaCl/L
4. 1/2 NS (0.45% NaCl) 4.5gm/L
5. D5 .18 NS 1.80gm/L
6. 3% NaCl 30gm/L

14. IV fluids
Lactated Ringer’s
0-10 gram glucose/100cc
Na 130 meq/L
NaHCO3 28 meq/L as lactate
K 4 meq/L

15. Pediatric Fluid Therapy Principles
Assess water deficit by:
1. weight:
weight loss (Kg) = water loss (L)
OR
2. Estimation of water deficit by physical exam:
Mild moderate severe
Infants < 5 % 5 - 10 % >10
%
Older children < 3 % 3 - 6 % > 6 %

16. Physical Signs of Dehydration
Signs&sym
pt. M
IL
D M
oderate Severe
G
eneral T
hirsty, allert,
restless
T
hirsty, irritable,
ordrow
sy
D
row
sy–lim
p,
skincold/ sw
eaty
R
adial pulse N
orm
al rate R
apid, w
eak R
apid, feeble
R
espiration N
orm
al D
eep D
eep&rapid
A
nteriorfont. N
orm
al Sunken V
erysunken
Skinturgor P
inchretracts
im
m
ediately
R
etractsslow
ly P
oor
E
yes N
orm
al Sunken G
rosslysunken
T
ears P
resent A
bsent A
bsent
M
ucousm
em
b. M
oist D
ry V
erydry
U
rineflow N
orm
al D
ark&
decreased
O
liguria/ anuria

17. Correction of Dehydration
 Mild dehydration: increase oral intake
 Moderate to severe dehydration:
IV push
10-20 cc / Kg Normal saline
May repeat.
 Half deficit over 8 hours, and half over 16 hours.
 If hypernatremic dehydration, replace deficit over 48
hours .

18. Disturbance of acid based balance
Disturbance Plasma PH Plasma PCO2 Plasma HCO3
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic A
cidosis
Metabolic Al
kalosis

19. 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 )

20. When administrating I.V fluid nurse
should
 Monitors the response of the
fluids.
 Considering the fluid volume.
 Content of fluid.
 Patient clinical status.

21. Hyponatremia
 Predisposing Factors
 Diabetes mellitus (hyperglycemia)
 Cystic fibrosis
 Gastroenteritis
 Excessive water intake (formula dilution)
 Diuretics (thiazides and furosemide)
 Renal disease

22.  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.

23. Hyponatremia
 Hyponatremic Dehydration
 Hypovolemic Hyponatremic Dehydration
 High urine output and Na excretion
 Increase in atrial natriuretic factor
 Hypervolemic Hyponatremic Dehydration
 Edematous disorder (nephrotic syndrome, CHF, cirrhosis)

24. Hyponatremia
 Acute Hyponatremia (<24 hours)
 Early Onset (Serum Sodium <125 meq/L)
 Nausea
 Vomiting
 Headache
 Later or Severe (Serum Sodium <120 meq/L)
 Seizure
 Coma
 Respiratory arrest

25. Hyponatremia
 Chronic Hyponatremia (>48 hours)
 Lethargy
 Confusion
 Muscle cramps
 Neurologic Impairment

26. Hyponatremia
 Management
 Na Deficit:
 Na Deficit = (Na Desired - Na observed) x 0.6 x body weight(kg)
 Replace half in first 8 hours and the rest in the following
16 hours
 Rise in serum Na should not exceed 2 mEq/L/h to
prevent Central Pontine Myelinolysis
 In cases of severe hyponatremia (<120 mEq) with CNS
symptoms:
 3% NaCl 3-5 ml/kg IV push for hyponatremia induced seizures
 6 ml/kg of NaCl will raise serum Na by 5 mEq/L

27. Hypernatremia
 Hypernatremia leads to hypertonicity
 Increase secretion of ADH
 Increase thirst
 Patients at risk
 Inability to secrete or respond to ADH
 No access to water

28. Hypernatremia
 Etiology
 Pure water depletion
 Diabetes insipidus (Central or Nephrogenic)
 Sodium excess
 Salt poisoning (PO or IV)
 Water depletion exceeding Na depletion
 Diarrhea, vomiting, decrease fluid intake
 Pharmacologic agents
 Lithium, Cyclophosphamide, Cisplatin

29. Hypernatremia
 Signs and symptoms
 Disturbances of consciousness
 Lethargy or Confusion
 Neuromuscular Irritability
 Muscle twitching, hyperreflexia
 Convulsions
 Hyperthermia
 Skin may feel thick

30. Hypernatremia
 Management
 Normal Saline or Ringer lactate to restore volume
 Hypotonic solution (D5 1/5 NS) to correct calculated
deficit over 48 hours
 Water Deficit
 Normal body H20 - Current body H20
 Current body water
 0.6 x body weight (kg) x Normal Na/Observed Na
 Normal Body water
 0.6 x body weight (kg)
 Decrease Na concentration at a rate of 0.5 mEq/hr or
~ 10 mEq/day: Faster correction can result in
Cerebral Edema

31. Potassium
 Most abundant intracellular cation
 Normal serum values 3.5-5.5 mEq
 Abnormalities of serum K are potentially life-
threatening due to effect in cardiac function

32. Hypokalemia
 Diagnosis
 Symptoms
 Arrhythmias
 Neuromuscular excitability (hyporreflexia, paralysis)
 Gastrointestinal (decreased peristalsis or ileus)
 Serum K < 3mEq/L
 ECG:
 Flat T waves
 Short P-R interval and QRS
 U waves

33. Hypokalemia
Nutritional GI Loss Renal Loss Endocrine
Poor intake Diarrhea Renal tubular acidosis Insulin therapy
IVF low in K Vomiting Chronic renal disease Glucose therapy
Anorexia Malabsorbtion Fanconi's syndrome DKA
Intestinal fistula Gentamicin, Hyperaldosteronism
Laxatives Amphotericin Adrenal adenomas
Enemas Diuretics Mineralocorticoids
Bartter's syndrome
Bartter’s syndrome: Hypereninemia and hyperaldosteronism

34. Hypokalemia
 Management:
 Cardiac Arrhythmias or Muscle Weakness
 KCl IV (cardiac monitor)
 PO K - Depend of etiology
 Hypophoshatemia = KPO4
 Metabolic acidosis = KCl
 Renal tubular acidosis = K citrate

35. Hyperkalemia
 Differential Diagnosis
 Pseudohyperkalemia - from blood hemolysis
 Metabolic Acidosis
 Chronic Renal Failure
 Congenital Adrenal Hyperplasia
 Females = Usually Dx at birth - Ambiguous Genitalia
 Males = Dehydration, hyponatremia, hyperkalemia
 Medications
 ACE inhibitors and NSAID’s

36. Hyperkalemia
 Diagnosis:
 Symptoms
 Cardiac Arrhythmias
 Paresthesias
 Muscle weakness or paralysis
 ECG
 Peaked T waves
 Short QT interval (K>6 mEq)
 Depressed ST segment
 Wide QRS (K>8 mEq)

37. Hyperkalemia
 Management
 Close cardiac monitoring
 Life -threatening hyperkalmia
 Intravenous Calcium - rapid onset, duration< 30 min
 NaHCO3 or glucose and insulin
 Ion exchange resins
 Sodium polystyrene sulfonate (Kayexelate)
 PO or Enema
 Hemodyalisis