Alterations in Child’s Fluid, Electrolyte and Acid-Base

Balance

HOMEOSTASIS General Concepts

• the maintenance of normal volume and normal

• Intake = Output = Fluid Balance
composition of the extracellular fluid is vital to life.
• Sensible losses
• the various physiologic arrangements which serve to
restore the normal state, once it has been disturbed;  Urination
 Defecation
 Fluid balance  Wound drainage
 Electrolyte balance
 Osmotic balance • Insensible losses
 Acid-base balance
 Evaporation from skin
General Principles  Respiratory loss from lungs
• Diffusion: movement of the particles in a solution
from the area of high concentration to the area of
Fluid Compartments
lower concentration.
• Electrolyte: inorganic substance that dissociates
into ions. • INTRACELLULAR

• Osmosis: diffusion of solvent molecules (water) into  40% of body weight

region in which there is a higher concentration of a • EXTRACELLULAR
solute (electrolyte) to which the membrane is
impermeable.  20% of body weight
 Two types
• Osmotic pressure: the pressure necessary to prevent
solvent migration. • INTERSTITIAL (between)

• Osmol: concentration of osmotic active particles. • INTRAVASCULAR (inside)

• Osmolarity : number of osmoles per liter of solution.
• Osmolality: number of osmoles per kilogram of
Age-Related Fluid Changes
solvent.
• Tonicity: effective osmolality of a solution relative to
plasma. • Full-term baby - 80%
• Lean Adult Male - 60%
• Colloids: high molecular weight particles (> 20000 D) • Aged client - 40%
• Oncotic pressure (colloid osmotic pressure): the
pressure necessery to prevent diffusion of solvent
molecules (water) into region in which there is a
higher concentration of a colloid to which the
membrane is impermeable
 Alterations in Child’s Fluid, Electrolyte and Acid-Base
Balance
Types of Fluid/Solution

Isotonic Solution Hypotonic Solution Hypertonic Solution

• No fluid shift because solutions • Lower solute concentration • Higher solute concentration •
are equally concentrated Fluid is drawn into the
• Fluid shifts from hypotonic solution hypertonic solution to create a
• Normal saline solution (0.9% into the more concentrated solution to balance (cells shrink)
NaCl) create a balance (cells swell)
• 5% dextrose in normal saline
• Half-normal saline solution (0.45% (D5/0.9% NaCl)
NaCl)

Fluid Balance

• The main way to regulate body water gain is by adjusting the volume of water intake, mainly by
drinking more or less fluid. The thirst center in the hypothalamus governs the urge to drink.
• Although increased amounts of water and solutes are lost through sweating and exhalation during
exercise, loss of excess water or excess solutes depends mainly on regulating excretion in the urine.
• The extent of urinary Na (and Cl) loss is the main determinant of body fluid volume, whereas the
extent of urinary water loss is the main determinant of body fluid osmolarity

Disturbances of fluid homeostasis

• Disturbance of fluid balance Diagnosis Fluid Imbalances

(intake≠output)
• Physical signs: skin turgor, oedema,
 Dehydraton, Overhydration mucous membranes, neck veins, puls,  Dehydration
(hyperhydration) liver, level of consciousness, capillary  Hypovolemia
refill, fontanel (children)  Hypervolemia
• Disturbance of osmolarity (electrolyte
intake≠water intake) • Vital signs: blood pressure; heart  Water intoxication
rate; (respiratory rate); body
 Isonatremic (isotonic)
temperature; CVP; urine output;
 Hyponatremic
serum and urine Na, osmolarity; Htk;
(hypotonic)
serum total protein
 Hypernatremic
(hypertonic)
 Alterations in Child’s Fluid, Electrolyte and Acid-Base
Balance
Dehydration

• Signs: increased thirst (except: advanced age, hypotonic dehydration), weakness, decreased skin turgor,
dry mucous membranes, empty neck veins, decreased urine output, elevated Htk, fever, tachycardia,
hypotension, decreased CVP,lethargy, stupor, coma
• Mild (loss: 4% of body weight): decresed skin turgor, sunken eyes, dry mucous membranes
• Moderate (loss: 5-8 % of body weight): + oliguria, orthostatic hypotension, tachycardia
• Severe (loss: 8-10 % of body weight): + hypotension, decreased level of consciusness, stupor

• Loss of body fluids increased concentration of solutes in the blood and a rise in serum Na+ levels.
• Fluid shifts out of cells into the blood to restore balance.
• Cells shrink from fluid loss and can no longer function properly

Clients at Risk Signs and Symptoms Management

 Confused  Irritability • Fluid Replacement - oral or IV over

 Confusion 48 hrs.
 Comatose
 Dizziness • Monitor symptoms and vital signs
 Bedridden  Weakness
• Maintain I&O
 Infants  Extreme thirst
  urine output • Maintain IV access
 Elderly
 Fever • Daily weights
 Enterally fed  Dry skin/mucous • Skin and mouth care
membranes
 Sunken eyes
 Poor skin turgor
 Tachycardia
 Alterations in Child’s Fluid, Electrolyte and Acid-Base
Balance
Hypovolemia

Management
 Isotonic fluid loss from the Signs and Symptoms
extracellular space.
• Fluid replacement
 Can progress to hypovolemic shock • Mental status deterioration
• Albumin replacement
• Thirst
Caused by: • Blood transfusions for
• Tachycardia
hemorrhage
• Delayed capillary refill
– Excessive fluid loss (hemorrhage) • Dopamine to maintain BP
• Orthostatic hypotension
– Decreased fluid intake • MAST trousers for severe
• Urine output < 30 ml/hr shock
– Third space fluid shifting
• Cool, pale extremities • Assess for fluid overload with
treatment
• Weight loss

Hypervolemia
Signs and Symptoms
• Excess fluid in the extracellular compartment as a result of fluid or
sodium retention, excessive intake, or renal failure. • Tachypnea • Increased CVP,
pulmonary artery
• Occurs when compensatory mechanisms fail to restore fluid balance. • Dyspnea pressure and
• Crackles pulmonary artery
 Leads to CHF and pulmonary edema wedge pressure
• Rapid, bounding (Swan-Ganz)
Edema Management pulse
• JVD
• Hypertension
• Fluid is forced into tissues by • Fluid and Na+ restriction  Acute weight gain
the hydrostatic pressure • S3 gallop
• Diuretics • Edema
• First seen in dependent
areas • Monitor vital signs, include
breath sounds
• Anasarca - severe • Elevate HOB and give O2 as ordered
generalized edema • Hourly I&O
• Maintain IV access
• Pitting edema • Monitor ABGs and labs
• Skin & mouth care
• Pulmonary edema • Daily weights
 Alterations in Child’s Fluid, Electrolyte and Acid-Base
Balance

Water Intoxication

Causes: Signs and symptoms of

increased intracranial
pressure
– Early:
– SIADH
 change in LOC,
– Rapid infusion of hypotonic solution  N/V,
– Excessive tap water NG irrigation or  muscle weakness,
enemas  twitching,
 cramping
– Psychogenic polydipsia
– Late:

 bradycardia,
 widened pulse
 pressure,
 seizures,
 coma

Management

• Prevention is the best treatment

• Assess neuro status
• Monitor I&O and vital signs
• Fluid restrictions
• IV access
• Daily weights
• Monitor serum Na+
• Seizure precautions