Fluid balance

Side effect of ventolin

Beta-2

bronchodilation + increase hr -> tachycardia

Could have parkinson effects -> tremors

Lower potassium (pulls glucose into cells with K+)

List reasons why children are considered at greater risk for fluid volume imbalance (1-4 important)

1. High BSA (insensible loss)

2. Increased metabolic demand

3. Immature kidney function (can't concentrate solutes)

4. Intracellular allocation (high ECF)

5. Skin differences

6. Infants/small kids can't verbalize thirst

7. Toddlers -> physiological anorexia (picky eaters)

Sensible fluid loss

Urine and bowels

Insensible fluid loss

skin and respirations

Most common cause dehydration

Gastroenteritis

Viral causes of gastroenteritis

Rota, Adenovirus (conjuctivitis/fever), Norovirus

Rota virus prevention

PO vaccine @ 2, 4, 6 months

Called R5

Is a live attenuated vaccine and requires teaching regarding hand washing 10 days post adminstration

R5 complications of intussusception

Bacterial causes of gastroenteritis

E. Coli, Shigella, Salmonella, Campylobacter

Ova and parasite causes of gastroenteritis

Giardia

Occult gastroenteritis

HUS

Ask if on iron supplement as it could cause false + on occult

Other causes of diarrhea

Antibiotics (ampicillin)

Cows milk protein allergy

Juice

Extracellular fluid volume deficit

dehydration

Euvolemia

Most common

Extracellular fluid volume excess

Saline excess related to IV fluid overload, aldosterone, or glucocorticoids

Interstitial fluid volume excess

Edema related to ECF volume excess

Causes of fluid volume imbalance

Vomiting, diarrhea, poor oral intake, infants of low-birth weight in warmers

Excessive activity in heat (BSA), ineffective sweat capability

Isotonic dehydration

Equal loss of Na to water in ECF

Causes of isotonic dehydration

Acute emesis, diarrhea, hemorrhage

Hypotonic dehydration

ECF Na loss with osmotic shift to ICF

Causes and treatmentof hypotonic dehydration

Prolonged gastric loses, burns, furosemide, nephrotic syndrome, hypo-based fluids

Replace slowly to reduce central pontine myelinolysis

Hypertonic dehydration

water loss in higher proportion to Na loss

Causes of hypertonic dehydration and treatment

diabetes insipidus, DKA, prolonged diarrhea, fever, younger infants

Remember to repair slowly to reduce cerebral edema (ICP)

Mild dehydration

loss of

S/S of mild dehydration

Restlessness (infant cry)

thirst (hypothalamus)

Urea upper normal range

MM may be sticky

Urine output will be less frequent

Pulse, resp, BP, skin turgor, tears, fontanel, specific gravity, pH all normal

Moderate dehydration

loss of 6-9% of body weight

Moderate dehydration S/S

Tachcardia

Increased respirations

Decreased BP

U/O

Specific gravity in moderate dehydration

1.020- 1.030

Blood pH in moderate dehydration

7.3 - 7.10

Severe dehydration

>10% body weight loss

S/S of severe dehydration

Rapid, weak pulse

Grunting rapid respirations

Hypotension

Anuria

Tenting skin

Very dry MM

Absent tears

Concave fontanel

Mental status stuporous or coma

Very sunken eyeballs

Urea high

Specific gravity in severe dehydration

>1.030

Blood pH in severe dehydration

7.10

Normal urine output (if less than 12)

1-5 ml/kg/hr

Normal urine output (if >12y)

>0.5ml/kg/hr (same as adults)

Serious potential consequence of dehydration

Hypovolemic shock

First intervention for dehydration (if mild)

Oral rehydration (ex: pedialyte)

Intervention for moderate-serious dehydration

IV fluid administration and electrolytes

Use of antiemetics and antidiarrheals?

Don't use antidiarrheals - gets rid of virus and don't want to cause constipation.

If vomiting give antiemetic (ondansetron)

differences of preterm, sepsis, and SGA infants

Decreased glycogen stores, decreased adipose tissue, immature metabolic pathways (gluconeonegesis), and increased metabolic demands

Gluconeogensis vs. glycogenolysis

Gluconeogenesis creates new glucose from non-carbohydrates like amino acids and glycerol

Glycogenolysis breaks down stored glycogen into glucose

Isotonic fluid solution

NS (NaCl 0.9%)

When is NS used

Vascular resuscitation (shock)

D5W

Technically hypotonic (uncommonly used by itself)

D10W

Treatment of hypoglycemia

Most common IV fluid used

0.9%NaCl D5W with additive 20mmol/L K+

Treatment of resuscitation of shock

Delivery of fluid bolus

10-20ml/kg (IV or IO)

Often give 10 if congenital heart defect

What to assess for fluid bolus

Cap refil, auscultate lungs, vitals will react quickly (~15 mins)

Potential complications with fluid bolus

Increased ICP]

Peripheral and pulmonary edema (if weak heart, kidneys)

lb to kg conversion

1 kg = 2.2 lb

A drop in BP is a ___ sign of shock in infants

Late

Shock definiton

Inadequate cardiac output and insufficient oxygenation of tissues to meet metabolic demands

Key intervention for developing shock

Oxygen administration

Early oxygen prevents rapid deterioration and supports CO.

Start on O2 even if spO2 is till high

Method of O2 delivery during shock

Nasal cannula if spO2 is still high

Non-rebreather if low

2 types of distributive shock (vasodilation)

Septic shock

Anaphylactic shock

Hypovolemic shock patho

Fluid loss -> decreased circulating blood volume -> D preload -> compensatory mechanisms of I hr and redistribution of blood (peripheral vasoconstriction; RAAS; ADH)

Ineffective interventions lead to myocardial dysfunction, ischemia, organ failure and death

two stages of hypovolemic shock

early - compensated

Late - uncompensated or hypotensive

Symptoms of compensated hypovolemic shock

BP normal with narrow pulse pressure

I hr

I RR

Pale or mottled skin

Normal or prolonged CRT

Normal or weak peripheral pulses with strong central pulses

Cool extremities

LOC - may be irritable

Normal or decreased U/O

Symptoms of uncompensated (hypotensive) shock

Decreased systolic BP

Absent or D peripheral/central pulses

Lactic acidosis

Prolonged CRT

LOC - lethargy

Anuria

Nursing care goals for hypovolemic shock

Improve tissue perfusion - fluid bolus (vascular resuscitation)

oxygen/glucose (maintain or restore pH)

6 interventions for hypovolemic shock

1. Reposition (high fowlers or trendelenburg if loosing blood), suction and apply O2

2. Initiate IV and resuscitate with isotonic fluids

3. Monitor and frequent assessments (q15)

4. Consider Rx medications and interventions

5. Consider DI, labs (CBC, electrolytes), tests

6. Subspecialty consult (maybe STEP team)

What lab values would be important for hypovolemic shock

Coags, hbg, hct, lactate, BUN/Cr ratio, K (elevated in acidosis related hypoxia vs. low in prolonged gastric losses)

Septic shock pathophysiology

Body's response to infection -> decrease SVR -> maldistribution of blood flow to extremities (cytokine dump) -> warm phase -> SVR increases -> cold phase

Nursing care goals with septic shock

1. Improve tissue perfusion, O2/glucose delivery to restore pH (vascular resuscitation)

2. Hemodynamic stability / prevent end-organ failure

3. Investigate and treat cause

Two phases of septic shock

Early - warm phase - compensated

Late - cold phase - decompensated

S/S of warm phase septic shock

Tachycardia

Tachypnea

Fever

Warm extremities

Bounding pulses

Normal CRT

Normal or increased systolic BP

Wide pulse pressure (20-30 mm Hg over normal)

Normal U/O

Fussy, irritable

Normal coagulation

Neonates/young infants temperature in septic shock

Neonates and young infants may be hypothermic in septic shock (no fever)

S/S of cold phase of septic shock

Tachycardia

Respiratory depression

Hypothermia

Cool, pale extremities

Decreased pulses

Prolonged CRT

hypotension

Narrow pulse pressure (10-20)

Oliguria (

Nursing care interventions for septic shock

Reposition, O2, fluid resuscitation, monitor frequently, start antibiotics (broad spectrum until C/S comes back), watch labs (CBC, clotting/coags, lactate, differential)

Anaphylactic shock

Manifested by hypotension (early sign), generalized urticaria, angioedema, and laryngeal edema

Vasodilation due to loss of vasomotor tone and capillary leak resulting from the release of mediators from tissue cells in an immediate hypersensitivity reaction

maculopapular

rash or hives (flat red area covered with small raised bumps)

Order of treatment for anaphylactic shock

1. O2 (non-rebreather) + epinephrine

2. Ventolin (only if having resp compromise)

3. IV fluids

4. Corticosteroids (for biphasic reaction)

5. Certirizine (antihistamine - long acting)

If hr > 60 but < 100

Provide ventilation/oxygen support, no compressions yet

If hr < 60 with poor perfusion despite effective ventilation

Begin CPR (compressions + breaths)