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N105: Pediatric Nursing - Fluid and Electrolytes

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christine ceblano

on 20 August 2015

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Transcript of N105: Pediatric Nursing - Fluid and Electrolytes

NI105: Nursing Care for Pediatric Patients with
Fluid and Electrolytes Imbalance
Christine A. Ceblano
19 August 2015
#regulatory
mechanism
#manifestation
#priority
#interventions
#outcome
#concern
F&E
Check
Vulnerable to Dehydration
1. Circulation
2. Gastrointestinal
3. Insensible loss (2)
4. Renal
5. Thirst
6. Hormonal->Metab
she's vulnerable...
T
i
i
G
r
H
to f&e imbalance
total body water - more

esophageal sphincter - immature
peristaltic rate - higher

1 BSA compared to mass - exposed
2 RR - faster

ability to acidify urine - little

communicate thirst? - no

metabolic rate - higher (growing, sick)
55-60% H20
35 I: 20 E
35 I: 40 E
>
Am i wrong?
for thinking out the box from where I stay...
1.
irritable

E4 V4 M6
Describe V4?




Interpret the values
2.
T = 37.5
3.
PR = 150, grade 1
4.
RR = 55
5.
BP = 70/37
6.
weight = 5 kg,

8% weight loss
7.
abdominal girth = 32 cm
8.
urine output = 10 cc in 1hr via weebag @9am


9.
(+) sunken anterior fontanelle
When does anterior fontanelle close?
(+) decreased tears/salivation
(+) poor skin turgor, dry skin and oral mucosa

(+) prolonged

CRT = 3s
NEED
My baby
child
Manifestations if Dehydrated
+ tears?
if older than 2-3 months
+dry?
CRT if > 2s
agitated ? restless ? irritable ?
Weight Estimate
(thrice the age) + 7
(half the month) + 4
*(modified PALS)
<1
>1
*(pediatric journals)
BW growth
NB: 1x
5m: 2x
7Y: 9x
10Y: 10x
1Y: 3x
2Y: 4x
5Y: 5x
(Beevi, A. (2012). Pediatric Nursing Care Plans...
Sick:
* fever
* infection
* drainage/extraction
* phototherapy
Let it burn...
(anatomy/ physiology)
color
Diarrhea
Burn
Nephrotic
syndrome

Diabetes Insipidus
Cases
G
I
R
T/H
<3%: <5-10%: >10%:
minimal or no mild to moderate severe dehydration
alert
drinks normally but might refuse
mildly U.O.
restless
irritable/fatigue
thirsty, eager to drink
+ slightly sunken
fontanelle
+ CRT>2s
& concentrated
urine
N
T
R
R
N
T
C
N
lethargic
/unconscious
T
drinks poorly
oliguria
+ sunken anterior fontanelle
+ cold/ mottled skin
+ may have absent tears
+ poor skin turgor
CRT > 2s
C
SEVERITY OF DEHYDRATION
HR RR
BP
may have
HR RR
10. He has _________
(no/mild/moderate/severe) dehydration.
+tears decreased
+ dry skin,
three-month old boy
Urine output
N-I-T > 2-3 cc/kg
P-S > 1 cc/kg
A > 0.5-1 cc/kg
*minimum hourly urine
estimated measurement
3rd to 4th degree burn
1. Describe the pain in this child?
2. Using rule of nines, what is his total BSA affected?




Describe the level of the ff. laboratory findings:
3. serum Na+ = 125
4. serum K+ = 6.2
5. HCT = 60%, ...
6. urine specific gravity = 1.050



7. Which type of shock is common within the emergent phase (first 48h) of burn injuries?
8. During shock state, the shift to anaerobic metabolism may cause production of _____ that is often associated with the finding of this ABG:
pH = 7.52
pCO2 = 30
HCO3 = 10
O2 sat = 80%

Which breath sound is apparent:
9. if the patient has facial and laryngeal edema
10. after the 48 hours/emergent phase of the event

BURN,
Fluid, Electrolytes, Acid-Base Balance
(+/-) pain VAS _/10; (+/-) facial grimace
Wong-Baker FACES Pain Rating Scale
1st
2nd
3th
Degree
4th
five-month old boy
Some Electrolyte Issues
Hs &Ts
esp first 12 hrs
Fluid Requirement
4ml/kg for the first 10kg of body weight
+ 2ml/kg for the second 10kg of body weight
+ 1ml/kg for remaining over 20kg body weight
Target minimum hourly urine for children:
1-1.5 cc/kg minimum hourly urine
Parkland's Formula:
first half
second half
for the first 8-hour infusion
for the next 16-hour infusion
=
Wallace Rule of Nines
Pediatric burns!!
if neonate, infant
if TBSA >10%
if on face, perineum, hand/feet
if electrical, chemical, inhalation
if least 3rd degree
if with trauma or co-morbidity
*source: Arizona Children's Center

if >30% TBSA - colloid replacement
1. Resuscitation Period
TBSA burned x mass(kg) x 4
2. Maintenance Period
(preferred solution - PLR,
4cc x 15
#childabuse?
60 x 8 x 4
= 2560
IVF: PLR 1280 cc x 8 h
to ff same of 1280 x 16 h
% kg 4
Sample:
IVF volume
Infusion rate (in cc/hr)
4 * 8
= 32
duration of each half:
IVF: PLR x 32 cc/hr
Recalculate volume at Hour: 4, 8, 12 -- 18, 24 -- 36
Note:
G26
G24
G22
Dextrose 5% Normosol
Replacement
D5NM
D5IMB
D5NR
PNSS
D5 0.9NaCl
PLR
Mannitol
Dextran 40
D5LR
D5W
D5050
TPN
How to save a life?
Drowning
Give potential cause of hypervolemia?
1. Circulation
2. Gastrointestinal
3. i- Respiration
4. Renal
5. Thirst
6. Hormone
C
G
R
T
Gastric lavage
Child: 10-15 cc/kg of PNSS
7. In blood transfusions, what medication(s) is sometimes given during or after the procedure?
Hemodialysis
Peritoneal dialysis
i
H
(Idrees, 2005)
Correcting Hypocalcemia
usual: 200-500mg/kg/dose continuous
or divided in 4 divided doses
tetany: 100-200mg/kg/dose x 10 min
Fluid Intoxication
D.R. 3y/o M from Ermita, Manila
(+) difficulty waking up and persistent vomiting with blood streak
no known allergies
no known vaccination
past medical history: (+)ascariasis during school deworming (Aug 2014)
last intake 15 hours ago of ~30 cc milk formula
1 month PTA, pt started eating fish balls served near the daycare area
1 week PTA, pt had episode of passing out worm per orem and anus; (-) consult
2 days PTA, pt ate a serving of left-over canned beans which was left opened
2 days PTA, pt was noted to start having BM of 6x a day of yellow watery stool; (-)management
1 day PTA, pt was reported to have increased skin temperature according to mother although Temp unrecorded;
temporarily self-medicated with Paracetamol 1/2 tablet p.o. (-)consult
2 hour PTA, (+) vomit three times (~2 cups each of 30 min interval
10 min PTA, persistence of fever, vomiting with streak of blood, and
difficulty waking up prompted this consult
(+) stuporous, on stretcher
E2 V2 M4
T = 38.5
PR = 140, grade 1
RR = 60
BP = 60/40
O2 sat = 93%
wt = 9kg; mother verbalized weight loss (unknown %)
tricep skin fold

(+) pallor, (+) face flushing, (+) skin warm to touch
(+) dry skin and oral mucosa, (+) poor skin turgor, CRT = 3s
(+) prominent ribs
(+) wasting
abdominal girth = 55cm
(+) shifting dullness
(+) yellowish watery stool c Bristol scale of Type 7
(+) bipedal edema grade 2
(+) oliguria: U.O. = 4cc turbid dark yellow urine
(last urination 10 hours ago)
elevated IgM anti-HAV
elevated IgE
(+) Salmonella typhi in the blood
hyponatremia: Na+ = 128 (date)
WBC = 15 (date)
RBC = 2 , Hgb HCT
(+) FOBT
ABG: pH = 7.35
pCO2 = 46
HCO3 = 18
pO2 = 95% (with O2 support of 10Lpm via FM)
B.R.N. three-month M from Taguig City

(+) scalding burn
brought to hospital ER by aunt (father's sister)
no known allergy
no know past medical history
family dynamics: youngest of two siblings
parents separated, under father's custody (living under grandparents' roof)
father with history of drug addiction since 2011 (according to aunt)
16 hours PTA, pt was seen crying on the floor with beside a large pan of boiling soup by aunt;
noted with burn injuries at head upper extremities, and abdominal area
then rinse off the soup with pouring tap water for 30 minutes
15 hour 50 min PTA, pt was immediately brought to local health center for first aid;
assessed and advised to be sent to nearest hospital
15 hours PTA, immediately sent to ER department at this hospital
(+) lethargic
E4V3M5
(+) facial grimace of pain VAS 4/10
(+) 2nd to 3rd degree burn injuries:
TBSA affected = 36%
T = 37.8 C
PR = 148
RR = 51
BP = 62/33
wt = 6 kg

(+) poor skin turgor, (+) skin mottling
O2 sat = 95%
(+) anuria

c IVF of D5LR 1L x _____cc/hr into (L) cephalic vein
c O2 support of 4Lpm via n.c.
c intact and dry foley catheter draining no urine
serum Na = 130
serum K = 5.6
HCT=__, RBC =__, Hgb = ___

ABG = ___________
Nephri A.S. 5 y/o F from Pembo, Makati City

admitted for AVF creation for hemodialysis
diagnosed with congenital nephrotic syndrome (May 2011)
allergic to seafoods
no other known comorbidities
last oral intake: breadstick and water at 3pm
(+)anuria; no urine output since two days ago (date)
2 yrs PTA, pt was detected to have increased RBC and protein in urinalysis; additional laboratory examination showed inc BUN, Crea, LDL, triglyceride and decreased GFR,
and serum albumin
1 yrs 11 months PTA, pt's renal biopsy showed findings of nephrotic syndrome
(+) conscious, coherent, oriented to time, person & place
(+) anasarca
(+) papilledema
(+) facial edema
on orthopneic position
(+) shifting dullness
abdominal girth = 65 cm
weight = weight gain (~5%);
(+) anorexia
(+) bipedal edema grade 2
(+) non-productive cough
(+) minimal fine crackles at (L) costophrenic angle
(-)ANA
(-)IgM anti-HAV and anti-HBV
(+)foamy urine
urine sp gravity = 1.035 (date)
albumin = __, Ca = ___ (date)
GFR = 55 (date)
BUN, Crea, LDL, PO4-3 (date)
WBC = 11 (date)

ABG = ________ (date)
#normal GFR = 90-120 mL/min/1.73 m2
CKD if <60 x 3 mos
Acute Glomerulonephritis
elevated ESR
elev ASO titer
enlarged kidney in KUB UTZ
(+) proteinuria, microscopic hematuria
(+) azotemia: elev BUN, Crea
*bedrest if active
*possible recovery
*maynotneedwaterrestriction
(+) extreme thirst
(+) polyuria of
2-20 L/day
(+) nocturia

(+) irritability
(+) vomiting
(+) weight loss
Thank you.
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