PEDIATRIC NURSING- EXAM TWO STUDY GUIDE
CHAPTER 23-FLUID AND ELECTROLYTE BALANCE
• Dehydration (types, degree/level, clinical manifestations, therapeutic management, quality patient
outcomes)
o Extracellular Fluid:
▪ Contains intravascular fluid (inside blood vessels), interstitial fluid, and water follows
Sodim in and out of cells
• So where sodium concentration is greater, water is going
o Peds specific ECF:
▪ Newborn- 50% body fluid is ECF- this predisposes them too quick to dehydration
▪ Toddler- 30% body fluid is ECF
o Kids are more vulnerable to changes in fluid/electrolyte balance
▪ The younger they are, the more fluids they need, this is due to:
• Greater fluid intake and output relative to size
• Body surface area (BSA)
• Metabolic rate
• Kidney function- is not mature until 2 years of age
• Immature and inefficient in excreting waste
o Need to know electrolyte values:
▪ Serum Sodium level- 135-145- indicates neuro check
• Hyponatremia can cause seizures
▪ Serum Potassium levels- 3.5-5.5- indicates watching cardiac functioning
▪ Serum calcium levels- 8.8-10.8- watch muscles, reflexes- Trosseu and Chvostek sign
▪ Ph levels- 7.35-7.45
▪ Polyuria- increased urinary output
▪ Oliguria- decrease urinary output
▪ Anuria- no urinary output
▪ 1 mL/kg/hr is the minimum acceptable output for a child
• Newborn- 6-8 wet diapers a day
• EX: kid that weighs 15 kg, should put out 15mL in an hour, 60 mLs in 4 hours
o Types of Dehydration and treatment: occurs whenever the total output of fluid exceeds the total
intake, regardless of the underlying cause- also known as volume depletion
▪ Degree of dehydration is described as a percentage of body weight dehydrated
o Mild Dehydration: less than 3% in older children or less than 5% in infants
▪ Manifestations:
• Normal tears, normal urinary output, normal vital signs, NORMAL LOC,
normal CRT, thirst or cracked lips
▪ Management:
• Oral rehydration solution (ORS)- frequent sips- use syringe or medicine cup,
give 2-5 mls every 2-3 minutes or 5-10mL every 5 minutes
o EX: Pedialyte
o Use if the gut works, this is easy, cheap, and works, is less traumatic
• Zofran for nausea and vomiting
o Moderate Dehydration: 5% to 10% in infants and 3% to 6% in older children
▪ manifestations:
• Decreased tears, decreased urinary output, slight tachycardia, slightly tachypnea,
IRRITABLE, Capillary refill slightly delayed, dry mucous membranes
o First thing that happens is increased HR- tachycardia
o Then decreased tears and decreased urine output (still voiding, might be
at like 0.9mL/kg/hr)
▪ Management:
, • Oral rehydration solution- frequent sips- use syringe or medicine cup, give 2-5
mls every 2-3 minutes or 5-10mL every 5 minutes
• Zofran for nausea and vomiting
o Severe Dehydration: more than 10% in infants and more than 6% in older children
▪ manifestations:
• NO TEARS, no urinary output, tachycardia, irritable-lethargic, Capillary refill
time>4 seconds, tenting, cool, mottled skin, very increased pulse, hyperpnea,
orthostatic to shock blood pressure, intense thirst
• Shock is a common manifestation of severe depletion of ECF volume
▪ Management:
• IVF resuscitation- 20mL/kg of isotonic solution (NS) over 5-20 minutes
o Bolus isotonic solution- usually not dextrose because this will mess
with sugar level
▪ Usually will use normal saline
▪ Ex: 7kg baby that is severely dehydrated, give 7kg x 20mL=
120 mL in 30 minutes, so set pump at 280mL/hr
▪ Patients who usually require IV fluids are those with severe
dehydration, those with uncontrollable vomiting, those who
are unable to drink for any reason (e.g., extreme fatigue,
coma), or those with severe gastric distention
o The daily maintenance fluids to keep at baseline, these fluids will
include dextrose
o Except with hypertonic dehydration due to risk of cerebral edema
o Isotonic dehydration: occurs in conditions in which electrolyte and water deficits are present in
approximately balanced proportions
▪ Used when sodium level is 135-145
▪ Causes include: nausea, vomiting, diarrhea, NPO status, and burns
▪ This is the most common
o Hypotonic: occurs when the electrolyte deficit exceeds the water deficit
▪ Used when sodium level is less than 135
• ICF is more concentrated than ECF
▪ Requires neuro checks- super important
o Hypertonic: results from water loss in excess of electrolyte loss and is usually caused by a
proportionately larger loss of water or a larger intake of electrolytes
▪ Used when the sodium level is greater than 145
▪ Caused by ketoacidosis, excessive sweating, DI, malnutrition
• Caution- too rapid correction of hypernatremia can cause cerebral edema and
seizures
o Too rapid correction causes same risk of hyponatremia
o Nursing Responsibilities:
▪ Know conditions that predispose to fluid/electrolyte imbalance
▪ Accurate patient history
▪ Know the early signs of dehydration- prevent shock
• Tachycardia is early sign of dehydration
o This is followed by dry skin and mucous membranes, sunken fontanels
and signs of circulatory failure (coolness and mottling of extremities)
• Lethargy is late sign- change in LOC is a huge indicator for the nurse
▪ Use proper fitting BP cuff
▪ Check skin tenting- best place in baby is in the abdomen
▪ Weigh baby daily- NAKED- using the same scale
• Best way to determine dehydration status and fluid loss, is daily weight
, • Textbook: Weight is the most important determinant of the percent of total body
fluid loss in infants and younger children
o However, the preillness weight is often unknown
▪ Accurate I&O
▪ Intraosseous therapy?
• Water Intoxication
o This causes cells to swell leading to cerebral edema and seizures
▪ This is one of the leading causes of seizures in healthy babies- usually due to watering
down or diluting formula
• So do not give babies under 6 months any extra water
▪ Textbook: Fluid intoxication can occur during acute IV water overloading, too-rapid
dialysis, tap water enemas, feeding of incorrectly mixed infant formula, or excess water
ingestion, or with too rapid reduction of glucose levels in diabetic ketoacidosis
• Textbook and Mrs.Hall: A number of clinicians have reported water intoxication
in infants after swimming lessons
• Calculation of daily and hourly maintenance fluid requirements
o Maintenance fluid requirements are based on child’s weight in kg
▪ 100-50-20 formula (24 requirement)
• Allow 100 mL/kg for the first 10 kg
• Allow 50 mL/kg for the second 10 kg
• Allow 20 mL/kg for remaining body weight
• To determine hourly rate, then divide by 25
▪ Ex: if baby weighs 22 kg, then (100 x10kg= 1000) +(50 x 10kg= 500) + (20 x 2kg= 40)=
1540/25= 61.6= 62 mL/hr
▪ 4-2-1 formula (hourly rate)
• 4mL/kg for the first 10 kg
• Add 2 mL/kg for second 10 kg
• Add 1 mL/kg for remaining body weight
▪ Ex: so if baby weighs 7 kg, then 7kg x 4 mL= 28mL/hr
▪ Ex: so if baby weights 22 kg, then (10kg x 4 mL= 40mL) + (10 kg x 2mL=20mL)+ (2 kg
x 1mL)= 62mL/hr
• Shock (Hypovolemic, Distributive):
o Is a critical condition of inadequate tissue perfusion and end-organ perfusion
▪ Results in a failure to meet metabolic requirements of O2 nutrient delivery and waste
removal (CO2, lactate, etc)
▪ is a complex clinical syndrome characterized by inadequate tissue perfusion to meet the
metabolic demands of the body, resulting in cellular dysfunction and eventual organ
failure- is a result of hypovolemia, altered peripheral vascular resistance, or pump failure
o s/sx:
▪ Tachycardia, tachypnea, decreased perfusion (decreased O2 saturation), delayed capillary
refill time, cool/mottled skin, change in LOC, oliguria
• Hall emphasized how signs of severe dehydration are really close to signs of
shock
o Pathophysiology:
▪ Reduced blood flow resulting in low cardiac output, hypotension, and low central venous
pressure (CVP)
▪ There is a large release of catecholamines, which produces vasoconstriction and reduces
blood flow to the skin, kidneys, muscles, and splanchnic viscera- skin feels cold and
clammy
o Compensated vs Hypotensive Shock:
▪ BP is determining factor
, • If all signs of shock, but bp is the normal/unchanged, then this is compensated
shock, so call provider, and ask for them to come to bedside
o Early clinical signs are subtle and include apprehension, irritability,
normal BP, narrowing pulse pressure, thirst, pallor, and diminished
urinary output
o Textbook- Unexplained mild tachycardia and a decrease in perfusion of
the hands and feet are differentiating features of compensated shock
• Hypotension is a late sign!! Need to know BP for exam-is based on age- another
clinical sign of hypotensive shock is a change in level of consciousness as brain
perfusion declines
o Neonates systolic <60
o Infants (1-12 months) systolic <70
o Children (1-10 years) systolic <70 +(2x age in years)
▪ So if child is 5 years of age, then minimum systolic is 80
o Children (>10 years) systolic <90
o Textbook emphasis: Hypotension is a late and poor prognostic sign of
shock, so signs of shock must be recognized and appropriate
interventions implemented before hypotension is evident
o With the progression of hypotensive shock there is damage to vital
organs of such magnitude that the entire system is disrupted regardless
of therapeutic intervention
▪ Irreversible (or terminal) shock is cardiac arrest.
• Damage to vital organs, such as the heart or brain, is of such magnitude that the
entire organism will be disrupted regardless of therapeutic intervention.
• Death occurs even if cardiovascular measurements return to normal levels with
therapy.
• Early detection of shock prevents cardiac arrests
o Hypovolemic shock
▪ Example causes: pyloric stenosis, trauma (massive loss of blood, burns, DKA,
vomiting/diarrhea)
▪ Characteristics= falling blood pressure, poor capillary filling, low CVP
▪ follows a reduction in circulating blood volume related to blood loss (e.g., trauma, major
bleeding), plasma losses (e.g., burns, peritonitis), or extracellular fluid losses (e.g.,
diarrhea, dehydration) beyond the child's physiologic ability to compensate
▪ Treat with blood fast
o Distributive shock
▪ Examples: anaphylactic and septic shock and neurogenic shock
▪ results from a vascular abnormality that produces maldistribution of blood supply
throughout the body
▪ characteristics: reduction in peripheral vascular resistance, profound inadequacies in
tissue perfusion, increased venous capacity and pooling, acute reduction in return blood
flow to the heart, and diminished cardiac output
o Septic shock: are caused by an infectious organism and the patient's immune, inflammatory, and
coagulation responses to the infecting organism
• Sepsis-systemic inflammatory response syndrome caused by infection
• Septic shock- sepsis with organ dysfunction and hypotension
▪ Early s/sx: warm skin, fever, flushed, bounding pulses, BP and urinary output normal
• vasodilation with increased cardiac output, which results in warm, flushed skin
that reflects vascular tone abnormalities and hyperdynamic, warm, or
hyperdynamic-compensated responses
▪ Second stage: cool, decreased urinary output and level of consciousness, BP is ok
CHAPTER 23-FLUID AND ELECTROLYTE BALANCE
• Dehydration (types, degree/level, clinical manifestations, therapeutic management, quality patient
outcomes)
o Extracellular Fluid:
▪ Contains intravascular fluid (inside blood vessels), interstitial fluid, and water follows
Sodim in and out of cells
• So where sodium concentration is greater, water is going
o Peds specific ECF:
▪ Newborn- 50% body fluid is ECF- this predisposes them too quick to dehydration
▪ Toddler- 30% body fluid is ECF
o Kids are more vulnerable to changes in fluid/electrolyte balance
▪ The younger they are, the more fluids they need, this is due to:
• Greater fluid intake and output relative to size
• Body surface area (BSA)
• Metabolic rate
• Kidney function- is not mature until 2 years of age
• Immature and inefficient in excreting waste
o Need to know electrolyte values:
▪ Serum Sodium level- 135-145- indicates neuro check
• Hyponatremia can cause seizures
▪ Serum Potassium levels- 3.5-5.5- indicates watching cardiac functioning
▪ Serum calcium levels- 8.8-10.8- watch muscles, reflexes- Trosseu and Chvostek sign
▪ Ph levels- 7.35-7.45
▪ Polyuria- increased urinary output
▪ Oliguria- decrease urinary output
▪ Anuria- no urinary output
▪ 1 mL/kg/hr is the minimum acceptable output for a child
• Newborn- 6-8 wet diapers a day
• EX: kid that weighs 15 kg, should put out 15mL in an hour, 60 mLs in 4 hours
o Types of Dehydration and treatment: occurs whenever the total output of fluid exceeds the total
intake, regardless of the underlying cause- also known as volume depletion
▪ Degree of dehydration is described as a percentage of body weight dehydrated
o Mild Dehydration: less than 3% in older children or less than 5% in infants
▪ Manifestations:
• Normal tears, normal urinary output, normal vital signs, NORMAL LOC,
normal CRT, thirst or cracked lips
▪ Management:
• Oral rehydration solution (ORS)- frequent sips- use syringe or medicine cup,
give 2-5 mls every 2-3 minutes or 5-10mL every 5 minutes
o EX: Pedialyte
o Use if the gut works, this is easy, cheap, and works, is less traumatic
• Zofran for nausea and vomiting
o Moderate Dehydration: 5% to 10% in infants and 3% to 6% in older children
▪ manifestations:
• Decreased tears, decreased urinary output, slight tachycardia, slightly tachypnea,
IRRITABLE, Capillary refill slightly delayed, dry mucous membranes
o First thing that happens is increased HR- tachycardia
o Then decreased tears and decreased urine output (still voiding, might be
at like 0.9mL/kg/hr)
▪ Management:
, • Oral rehydration solution- frequent sips- use syringe or medicine cup, give 2-5
mls every 2-3 minutes or 5-10mL every 5 minutes
• Zofran for nausea and vomiting
o Severe Dehydration: more than 10% in infants and more than 6% in older children
▪ manifestations:
• NO TEARS, no urinary output, tachycardia, irritable-lethargic, Capillary refill
time>4 seconds, tenting, cool, mottled skin, very increased pulse, hyperpnea,
orthostatic to shock blood pressure, intense thirst
• Shock is a common manifestation of severe depletion of ECF volume
▪ Management:
• IVF resuscitation- 20mL/kg of isotonic solution (NS) over 5-20 minutes
o Bolus isotonic solution- usually not dextrose because this will mess
with sugar level
▪ Usually will use normal saline
▪ Ex: 7kg baby that is severely dehydrated, give 7kg x 20mL=
120 mL in 30 minutes, so set pump at 280mL/hr
▪ Patients who usually require IV fluids are those with severe
dehydration, those with uncontrollable vomiting, those who
are unable to drink for any reason (e.g., extreme fatigue,
coma), or those with severe gastric distention
o The daily maintenance fluids to keep at baseline, these fluids will
include dextrose
o Except with hypertonic dehydration due to risk of cerebral edema
o Isotonic dehydration: occurs in conditions in which electrolyte and water deficits are present in
approximately balanced proportions
▪ Used when sodium level is 135-145
▪ Causes include: nausea, vomiting, diarrhea, NPO status, and burns
▪ This is the most common
o Hypotonic: occurs when the electrolyte deficit exceeds the water deficit
▪ Used when sodium level is less than 135
• ICF is more concentrated than ECF
▪ Requires neuro checks- super important
o Hypertonic: results from water loss in excess of electrolyte loss and is usually caused by a
proportionately larger loss of water or a larger intake of electrolytes
▪ Used when the sodium level is greater than 145
▪ Caused by ketoacidosis, excessive sweating, DI, malnutrition
• Caution- too rapid correction of hypernatremia can cause cerebral edema and
seizures
o Too rapid correction causes same risk of hyponatremia
o Nursing Responsibilities:
▪ Know conditions that predispose to fluid/electrolyte imbalance
▪ Accurate patient history
▪ Know the early signs of dehydration- prevent shock
• Tachycardia is early sign of dehydration
o This is followed by dry skin and mucous membranes, sunken fontanels
and signs of circulatory failure (coolness and mottling of extremities)
• Lethargy is late sign- change in LOC is a huge indicator for the nurse
▪ Use proper fitting BP cuff
▪ Check skin tenting- best place in baby is in the abdomen
▪ Weigh baby daily- NAKED- using the same scale
• Best way to determine dehydration status and fluid loss, is daily weight
, • Textbook: Weight is the most important determinant of the percent of total body
fluid loss in infants and younger children
o However, the preillness weight is often unknown
▪ Accurate I&O
▪ Intraosseous therapy?
• Water Intoxication
o This causes cells to swell leading to cerebral edema and seizures
▪ This is one of the leading causes of seizures in healthy babies- usually due to watering
down or diluting formula
• So do not give babies under 6 months any extra water
▪ Textbook: Fluid intoxication can occur during acute IV water overloading, too-rapid
dialysis, tap water enemas, feeding of incorrectly mixed infant formula, or excess water
ingestion, or with too rapid reduction of glucose levels in diabetic ketoacidosis
• Textbook and Mrs.Hall: A number of clinicians have reported water intoxication
in infants after swimming lessons
• Calculation of daily and hourly maintenance fluid requirements
o Maintenance fluid requirements are based on child’s weight in kg
▪ 100-50-20 formula (24 requirement)
• Allow 100 mL/kg for the first 10 kg
• Allow 50 mL/kg for the second 10 kg
• Allow 20 mL/kg for remaining body weight
• To determine hourly rate, then divide by 25
▪ Ex: if baby weighs 22 kg, then (100 x10kg= 1000) +(50 x 10kg= 500) + (20 x 2kg= 40)=
1540/25= 61.6= 62 mL/hr
▪ 4-2-1 formula (hourly rate)
• 4mL/kg for the first 10 kg
• Add 2 mL/kg for second 10 kg
• Add 1 mL/kg for remaining body weight
▪ Ex: so if baby weighs 7 kg, then 7kg x 4 mL= 28mL/hr
▪ Ex: so if baby weights 22 kg, then (10kg x 4 mL= 40mL) + (10 kg x 2mL=20mL)+ (2 kg
x 1mL)= 62mL/hr
• Shock (Hypovolemic, Distributive):
o Is a critical condition of inadequate tissue perfusion and end-organ perfusion
▪ Results in a failure to meet metabolic requirements of O2 nutrient delivery and waste
removal (CO2, lactate, etc)
▪ is a complex clinical syndrome characterized by inadequate tissue perfusion to meet the
metabolic demands of the body, resulting in cellular dysfunction and eventual organ
failure- is a result of hypovolemia, altered peripheral vascular resistance, or pump failure
o s/sx:
▪ Tachycardia, tachypnea, decreased perfusion (decreased O2 saturation), delayed capillary
refill time, cool/mottled skin, change in LOC, oliguria
• Hall emphasized how signs of severe dehydration are really close to signs of
shock
o Pathophysiology:
▪ Reduced blood flow resulting in low cardiac output, hypotension, and low central venous
pressure (CVP)
▪ There is a large release of catecholamines, which produces vasoconstriction and reduces
blood flow to the skin, kidneys, muscles, and splanchnic viscera- skin feels cold and
clammy
o Compensated vs Hypotensive Shock:
▪ BP is determining factor
, • If all signs of shock, but bp is the normal/unchanged, then this is compensated
shock, so call provider, and ask for them to come to bedside
o Early clinical signs are subtle and include apprehension, irritability,
normal BP, narrowing pulse pressure, thirst, pallor, and diminished
urinary output
o Textbook- Unexplained mild tachycardia and a decrease in perfusion of
the hands and feet are differentiating features of compensated shock
• Hypotension is a late sign!! Need to know BP for exam-is based on age- another
clinical sign of hypotensive shock is a change in level of consciousness as brain
perfusion declines
o Neonates systolic <60
o Infants (1-12 months) systolic <70
o Children (1-10 years) systolic <70 +(2x age in years)
▪ So if child is 5 years of age, then minimum systolic is 80
o Children (>10 years) systolic <90
o Textbook emphasis: Hypotension is a late and poor prognostic sign of
shock, so signs of shock must be recognized and appropriate
interventions implemented before hypotension is evident
o With the progression of hypotensive shock there is damage to vital
organs of such magnitude that the entire system is disrupted regardless
of therapeutic intervention
▪ Irreversible (or terminal) shock is cardiac arrest.
• Damage to vital organs, such as the heart or brain, is of such magnitude that the
entire organism will be disrupted regardless of therapeutic intervention.
• Death occurs even if cardiovascular measurements return to normal levels with
therapy.
• Early detection of shock prevents cardiac arrests
o Hypovolemic shock
▪ Example causes: pyloric stenosis, trauma (massive loss of blood, burns, DKA,
vomiting/diarrhea)
▪ Characteristics= falling blood pressure, poor capillary filling, low CVP
▪ follows a reduction in circulating blood volume related to blood loss (e.g., trauma, major
bleeding), plasma losses (e.g., burns, peritonitis), or extracellular fluid losses (e.g.,
diarrhea, dehydration) beyond the child's physiologic ability to compensate
▪ Treat with blood fast
o Distributive shock
▪ Examples: anaphylactic and septic shock and neurogenic shock
▪ results from a vascular abnormality that produces maldistribution of blood supply
throughout the body
▪ characteristics: reduction in peripheral vascular resistance, profound inadequacies in
tissue perfusion, increased venous capacity and pooling, acute reduction in return blood
flow to the heart, and diminished cardiac output
o Septic shock: are caused by an infectious organism and the patient's immune, inflammatory, and
coagulation responses to the infecting organism
• Sepsis-systemic inflammatory response syndrome caused by infection
• Septic shock- sepsis with organ dysfunction and hypotension
▪ Early s/sx: warm skin, fever, flushed, bounding pulses, BP and urinary output normal
• vasodilation with increased cardiac output, which results in warm, flushed skin
that reflects vascular tone abnormalities and hyperdynamic, warm, or
hyperdynamic-compensated responses
▪ Second stage: cool, decreased urinary output and level of consciousness, BP is ok
