Pediatric Dehydration - 2 Nursing CEs

Author: Kelly Miller-Martin, RN, MSN, MA Written: January 22, 2005 COURSE OBJECTIVES At the end of this session, the nurse will be able to: 1. Describe the differences in the pediatric patient that affects their ability to adapt to fluid changes. 2. Identify common gastrointestinal disorders of infants and children. 3. Assess for dehydration in the pediatric client. 4. Plan nursing care for the dehydrated pediatric client. 5. Develop outcomes and goals specific to the pediatric population. 6. Identify ways to include family in plan of care. 7. Integrate existing nursing knowledge of fluid and electrolyte imbalance, dehydration, and diarrhea, with newly learned information for the pediatric client to implement safe and appropriate nursing care for the pediatric patient. 8. Evaluate pediatric specific outcomes for effectiveness. WATER BALANCE DIFFERENCES Infants and young children have a greater need for water Greater I & O relative to size Larger extracellular compartment Greater body surface area Higher basal metabolic rate Immature kidney function EXTRACELLULAR FLUID COMPARTMENT Constitutes more than half total body water at birth Contains greater content of extracellular sodium and chloride Has greater ECF until about age 2 Greater and more rapid water loss during this age WATER LOSS 60% fluid lost from ECF, 40% ICF 2/3 of insensible water loss is through skin 1/3 through respiratory tract Insensible fluid loss is increased by heat, humidity, temperature and respiratory rate Infants and toddlers tend to be more highly febrile Fever increases fluid loss by 7ml/kg/24hrs for each degree in temp above 37.2C or 99F BODY SURFACE AREA BSA of premature newborn is 5 times that of an older child/adult Full term newborn BSA is 2-3 times as great Proportionately longer GI tract Can lose relatively large amounts of water from insensible perspiration through skin or from GI tract due to diarrhea BASAL METABOLIC RATE

Rate is higher due to larger BSA in relation to mass of active tissue Higher to support growth Greater production of metabolic waste must be excreted by kidneys Any condition that causes increased metabolism causes greater heat production, insensible fluid loss, and an increased need for water excretion KIDNEY FUNCTION Kidneys are functionally immature and inefficient in excreting waste products of metabolism Unable to concentrate or dilute urine Cannot conserve or excrete sodium or acidify urine Less able to handle large amounts of solute free water Become dehydrated when given concentrated formula Become overly hydrated when given excessive water or dilute formula CLINICAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS IN PEDIATRIC PATIENTS Failure to thrive Spitting up or regurgitation Nausea, Vomiting, projectile vomiting Constipation Diarrhea Bowel sound changes Abdominal distention Abdominal pain Bleeding Jaundice Fever Dysfunctional swallow due to structural defects or CNS changes DEHYDRATION Distribution of water between ECF and ICF spaces depends on active transport of potassium into and sodium out of cells Sodium is the main solute in ECF Potassium is mainly intracellular When ECF volume is reduced in acute dehydration, total body sodium is almost always reduced, regardless of serum values Sodium replacement should always be included in fluid volume replacement TYPES OF DEHYDRATION Isotonic Hypotonic (hyponatremic) Hypertonic (hypernatremic, hyperosmotic) ISOTONIC DEHYDRATION Primary form of dehydration in children Water and salt are lost in equal amounts No osmotic force between ICF and ECF Major loss is from ECF Reduction in plasma volume, circulating volume, Shock is greatest threat to life Child will display characteristic symptoms of hypovolemic shock Serum sodium remains normal (130-150 meq/L) HYPOTONIC (HYPONATREMIC) DEHYDRATION Electrolyte deficit exceeds water deficit

Because ICF is more concentrated than ECF, water moves from ECF to ICF to establish osmotic equilibrium Movement further increases ECF volume loss Shock is frequent finding Physical signs tend to be more severe with small losses due to greater proportional loss of ECF Serum sodium is less than 130 mEq/L HYPERTONIC DEHYDRATION Fluid shifts from ICF to ECF Water loss exceeds electrolyte loss Most dangerous Requires specific rehydration therapy Serum sodium is greater than 150 mEq/L Greater water loss for same intensity of physical signs More neurological signs: altered consciousness, poor ability to focus, lethargy, increased muscle tone with hyperreflexia, hyperirritability Cerebral changes are serious and can result in permanent damage Usually caused by giving highly concentrated, high protein fluids that cause excessive solute load on kidneys LEVELS OF DEHYDRATION MILD MODERATE SEVERE MILD DEHYDRATION Weight loss-infants 5% Weight loss-children 3-4% Pulse & BP Normal Normal Behavior Slight thirst Normal Mucous membranes Tears present Normal anterior fontanel External jugular vein visible when supine Cap refill is normal Urine specific gravity greater than 1.020 MODERATE DEHYDRATION Weight loss-infants 10% Weight loss-children 6-8% Slightly increased pulse Normal to orthostatic BP Irritable, more thirsty Dry mucous membranes Decreased tears Anterior fontanel normal to sunken External jugular is not visible except with supraclavicular pressure Slowed CRT (2-4 seconds), decreased turgor Urine spec. grav. Greater than 1.020, oliguria SEVERE DEHYDRATION Weight loss- infants 15% Weight loss-children 10%

High pulse Orthostatic to shock BP Hyperirritability to lethargic Intense thirst Parched mucous membranes Absent tears, sunken eyes Sunken anterior fontanel External jugular are not visible even with supraclavicular pressure Very delayed cap refill and tenting, Skin cool, acrocyanotic or mottled Oliguria or anuria PEDIATRIC ASSESSMENT Infant Posterior fontanel should close by 3 months Anterior fontanel should close by 18 months Should have 6-8 wet diapers/day Assess for difficulties feeding/breastfeeding Toddler Able to drink from cup and use straw Speaks in small sentences Preschool Should have 20 teeth, assess for poor dentition and dental care Speech should be comprehensible School age Starts to lose deciduous teeth Pre adolescent Physical and social maturity vary greatly May see emergence of eating disorders Some are beginning sexual activity Drug and alcohol abuse is also a possibility With any suspicion of any of the above behaviors, interview child in private away from parents

With any suspicion of any of the above behaviors, interview child in private away from parents Adolescent Same factors as with pre-adolescent, although seen more frequently Assess for fad diets, poor nutritional choices FAMILY DYNAMICS Ascertain who has custody of child or legal power of medical consent Caregiver will be primary individual giving information Depending on the state, issues of reproductive nature cannot be revealed to parent. Give minor information with appropriate resources DIARRHEA Symptom that results from disorders of digestive, absorptive and secretory functions Caused by abnormal intestinal water and electrolyte transport Affects 500 million children worldwide per year

20% of all pediatric deaths in developing countries are due to dehydration and diarrhea GASTROENTERITIS FACTS Diarrhea is a major cause of infant mortality world-wide Gastroenteritis is the #1 cause of dehydration world-wide Rotavirus is #1 cause of gastroenteritis Gastroenteritis variables: abrupt onset, fever, N/V, URI, diarrhea, highly contagious, can cause severe dehydration REHYDRATION Can be oral or intravenous Oral is easier in pediatrics due to limited vein access and maintenance Oral rehydration may also include nasogastric or orogastric tubes Infants may be given an electrolyte solution (Pedialyte, Rehydrolyte), breastmilk, or strength formula Older children may be given a commercial carbohydrate-electrolyte solution (Gatorade) IV solution is saline or dextrose/saline. No potassium until after child voids IV gauge is either 24g or 22g Infusion pump is necessary Hourly checks on site and fluid infusion CALCULATION OF IV RATE 100ML/KG for first 10kg 50ml/kg for every kg between 11-20kg 20ml/kg for every kg over 20kg Total amount is divided by 24 for hourly rate EXAMPLE #1 Child weighs 4kg 100ml x 4kg = 400ml 400ml/24hr = 16.6 or 17ml/hr

EXAMPLE #2 Child weighs 15kg 100ml x 10kg = 1000ml 50ml x 5kg = 250ml 1000ml + 250ml = 1250ml 1250ml/24hr = 52ml/hr EXAMPLE #3 Child weighs 25kg 100ml x 10kg = 1000ml 50ml x 10kg = 500ml 20ml x 5kg = 100ml 1000ml + 500ml + 100ml = 1600ml 1600ml/24hr = 66.6 or 67ml/hr PRIMARY PREVENTION FOR DEHYDRATION Good hand washing Proper formula dilution No free water for infants

Offer small frequent meals after loose stools to prevent dehydration Proper food storage Keep animals away from play areas Keep shoes on List of NANDA Approved Nursing Diagnoses This list is representative, not all-inclusive. Fluid Volume: Deficient Ineffective Infant Feeding Pattern Ineffective Breastfeeding Caregiver Role Strain, Risk For Compromised Family Coping Risk for Delayed Development Diarrhea Interrupted Family Process Fear Risk for Imbalanced Fluid Volume Risk for Infection Transmission Deficient Knowledge Nausea Noncompliance Imbalanced Nutrition Pain Impaired Parenting Parental Role Conflict Risk for Impaired Parent-Infant Attachment Disturbed Sleep Pattern

References
Holliday, Malcolm A., Isotonic Saline Expands Extracellular Fluid and is Inappropriate for Maintenance Therapy. Pediatrics January 2005, Volume 115, Issue 1. Mezzacappa, Elizabeth Sibolboro, Breastfeeding and Maternal Stress and Health. Nutrition Reviews, July 2004, Vol. 62 Issue 7 Nager, AL, Wang, VJ, Comparison of Nasogastric and Intravenous Methods of Rehydration of Pediatric Patients with Dehydration. Pediatrics 2002;109, 566-572. Issue 9. Pace, Brian; Glass, Richard M.; Molter, Jeff., Feeding Your Newborn. JAMA: Journal of the American Medical Association, 3/1/2000, Vol. 283

Wathen, Joe E., Mackenzie, Todd, Bothner, Joan P. Usefulness of Serum Electrolyte Panel in the Management of Pediatric Dehydration Treated with Intravenously Administered Fluids. Pediatrics. Vol. 11 No. 5, November 2004