Fluid & Electrolytes

1. Fluid & Electrolytes Care of Children Instructor: Crystal Jensen

2. Oral Rehydration Therapy • IV Fluid Replacement Dehydration

3. Extracellular Edema • IV fluid overload: ( vs dx process • Sudden weight gain (grams), neck vein distention • Dependent edema (Rt side heart failure) ankles or sacrum • Tx diuretics • Weigh pt, I/O, weigh diapers (milliliters) • Tx successful: output > intake • Complication: Pulmonary Edema (crackles, increased RR) • Pain, restricted movement • Inflammatory edema: tx w/ice • Elevation of extremities Edema

4. Hypernatremia • Because of certain physiologic characteristics, infants are predisposed to dehydration. They have a large surface area in relation to their height or weight compared with adults and have relatively large evaporative water losses. In infants, hypernatremia usually results from diarrhea and sometimes from improperly prepared infant formula or inadequate mother-infant interaction during breastfeeding. • The group most affected is intubated, critically ill patients. Most cases result from a failure to freely administer water to patients. The incidence of breastfeeding-related hypernatremia is 1-2%. Sodium Imbalance

5. In children with acute hypernatremia, mortality rates are as high as 20%. Neurologic complications related to hypernatremia occur in 15% of patients. The neurologic sequelae consist of intellectual deficits, seizure disorders, and spastic plegias. In cases of chronic hypernatremia in children, the mortality rate is 10%. When dehydration is severe, skin turgor is reduced, and the skin develops a characteristic doughy appearance.

6. Patients in certain situations or with certain conditions are at risk for hypernatremia: Hospitalized patients who receive exclusive intravenous fluids Patients with coma Newborns Toddlers Patients with diabetes insipidus Patients receiving alkali therapy Patients with diarrhea Patients with fever Patients with renal disorders (eg, dysplasia, medullary cystic disease, polycystic kidney disease, tubulointerstitial disease) Patients with obstructive uropathy Patients with electrolyte disturbances (eg, hypokalemia, hypercalcemia) Patients with heat stroke or excessive hypotonic fluid loss

7. Signs and symptoms of hypernatremia include the following: Irritability High-pitched cry or wail Periods of lethargy interspersed with periods of irritability Altered sensorium Seizures Increased muscle tone Fever Rhabdomyolysis[2, 3] Oligoanuria Excessive diuresis

8. Hypotnatremia: Case study Sodium Imbalance

9. A first-time mother gave birth to a 5-pound girl. The baby is full-term, but the mother has been concerned that the baby is small. The mother has decided to feed formula, and so received instructions in the hospital prior to discharge about proper formula preparation and storage. Five days after the birth, the nurse in the pediatric clinic received a call from the mother, who was concerned because the baby was lethargic and was not feeding well. The mother was instructed to bring the baby in to the clinic immediately. Upon questioning, it was learned that the mother had mixed "strong" formula by adding less water than directed to a powder formula, in an attempt to have the baby gain weight more rapidly. What assessments of the baby are critical? What instructions does the mother need? What follow-up is required? Fill in the appropriate steps of the Care Plan below. Class Activity

10. Hyperkalemia • Hypokalemia • Word Document Potassium Imbalance

11. Hypocalcemiais a laboratory and clinical abnormality that is observed with relative frequency, especially in neonatal pediatric patients. • The concentration of calcium in the serum is critical to many important biologic functions, including the following: • Calcium messenger system by which extracellular messengers regulate cell function • Activation of several cellular enzyme cascades • Smooth muscle and myocardial contraction • Nerve impulse conduction • Secretory activity of exocrine glands hypocalcemia produces a wide range of peripheral and CNS effects, including paresthesias, tetany (ie, contraction of hands, arms, feet, larynx, bronchioles), seizures, and even psychiatric changes in children. Calcium Imbalance

12. Hypocalcemia continued: Cardiac function may also be impaired because of poor muscle contractility. • One of the most common causes of hypocalcemia is renal failure • History • In patients with hypocalcemia, the history varies depending on age. In newborns, patient history can include the following: • Possibly no symptoms • Lethargy • Poor feeding • Vomiting • Abdominal distension • History in children can be as follows: • Seizures • Twitching • Cramping • Laryngospasm, a rare initial manifestation Calcium Imbalance

13. Hypocalcemia: Physical Examination- • Children’s symptoms include the following: • Lethargy • Cyanosis • Tremulousness • Seizures • Apnea • Tetany and signs of nerve irritability, such as the Chvostek sign, carpopedal spasm, the Trousseau sign, and stridor • Abdominal distension • Prematurity, birth asphyxia, or congenital heart disease (features associated with infants of mothers with diabetes mellitus) Calcium Imbalance

14. Hypercalcemiais defined by a high calcium level in the blood. Calcium is important for bone formation, but is also vital for normal cell function in all cells. • High levels of parathyroid hormone or vitamin D cause hypercalcemia. Excessive dietary intake of Vitamin D or Vitamin A will cause hypercalcemia. • The most common cause of high parathyroid hormone levels in children comes from a complication of chronic kidney disease. • Kidney stones are a major complication of hypercalcemia that can cause blood in the urine or severe pain in the back, flank or lower abdomen. Stomach pain and psychiatric issues also may occur when blood calcium levels are too high.  • Sometimes, children with hypercalcemia develop a severe acute illness with intense stomach pain and dehydration. Calcium Imbalance

15. Hypermagnesemia • Hypermagnesemia is an uncommon clinical finding, and symptomatic hypermagnesemia is even less common. This disorder has a low incidence of occurrence, because the kidney is able to eliminate excess magnesium • The most common cause of hypermagnesemia is renal failure. Other causes include the following[3, 4] : • Excessive intake • Hypothyroidism • Addison disease • Familial • Milk alkali syndrome • Depression Magnesium Imbalance

16. Hypermagnesemia • In patients with acute renal failure, hypermagnesemia usually presents during the oliguric phase; the serum magnesium level returns to normal during the diuretic phase. If a patient receives exogenous magnesium during the oliguric phase, severe hypermagnesemia can result, especially if the patient is acidotic. • One of the earliest symptoms of hypermagnesemia is deep-tendon reflex attenuation. Facial paresthesias also may occur at moderate serum levels. • Muscle weakness is a more severe manifestation, occurring at levels greater than 5 mmol/L. This manifestation can result in flaccid muscle paralysis and depressed respiration and can eventually progress to apnea. • Magnesium is also cardiotoxic and, in high concentrations, can cause bradycardia. Occasionally, complete heart block and cardiac arrest may occur at levels greater than 7 mmol/L. Magnesium Imbalance

17. hypomagnesemia, can result in disturbances in nearly every organ system and can cause potentially fatal complications (eg, ventricular arrhythmia, coronary artery vasospasm, sudden death) • The main controlling factors in magnesium homeostasis appear to be gastrointestinal absorption and renal excretion. • Plentiful in green vegetables, cereal, grain, nuts, legumes, and chocolate. Vegetables, fruits, meats, and fish • Food processing and cooking may deplete magnesium content, thus accounting for the apparently high percentage of the population whose magnesium intake is less than the daily allowance. Magnesium Imbalance

18. Hypomagnesemia- disorders that cause magnesium and potassium losses, include diuretic therapy and diarrhea • The classic sign of severe hypomagnesemia (< 1.2 mg/dL) is hypocalcemia • Hypomagnesemia is now recognized to cause cardiac arrhythmia • At-risk patients include acutely ill patients in the intensive care unit Magnesium Imbalance

19. Neuromuscular irritability, including tremor, fasciculations, tetany, Chvostek and Trousseau signs, and convulsions, have been noted with hypomagnesemia • Other manifestations include the following: • Convulsions • Apathy • Muscle cramps • Hyperreflexia • Acute organic brain syndromes • Depression • Generalized weakness • Anorexia • Vomiting Magnesium deficiency has also been linked to chronic fatigue syndrome, sudden death in athletes, impaired athletic performance, and sudden infant death syndrome. Magnesium Imbalance

20. Causes of hypomagnesemia related to decreased magnesium intake include the following[4] : • Starvation • Alcohol dependence • Causes related to the redistribution of magnesium from extracellular to intracellular space include the following: • Alcohol withdrawal syndromes • Refeedingsyndrome • Acute pancreatitis • Causes related to gastrointestinal magnesium loss include the following: • Diarrhea • Vomiting and nasogastric suction • Gastrointestinal fistulas and ostomies • Diuretics - Loop diuretics, osmotic diuretics, and chronic use of thiazides

21. Class Activity: • Create a table to include the following: • Normal range lab values for children (Calcium, Potassium, Magnesium, Sodium) • Include a column for critical lab values • The last column should provide information r/t nursing management Lab Values