Fluid and Electrolytes Jan Bazner-Chandler CPNP, CNS, MSN, RN.

Fluid and ElectrolytesFluid and Electrolytes

Jan Bazner-ChandlerJan Bazner-Chandler

CPNP, CNS, MSN, RNCPNP, CNS, MSN, RN

Alteration in Fluid and Alteration in Fluid and Electrolyte StatusElectrolyte Status

Normal routes of fluid excretion in infants and children.

Lungs

SkinUrine & feces

Ball &Bender

Developmental and Biological Developmental and Biological VariancesVariances

Infants younger than 6 weeks do not Infants younger than 6 weeks do not produce tears.produce tears.

In an infant a sunken fontanel may In an infant a sunken fontanel may indicate dehydration.indicate dehydration.

Infants are dependant on others to meet Infants are dependant on others to meet their fluid needs.their fluid needs.

Infants have limited ability to dilute and Infants have limited ability to dilute and concentrate urine.concentrate urine.

Developmental and BiologicalDevelopmental and Biological

The small the child, the greater the The small the child, the greater the proportion of body water to weight and proportion of body water to weight and proportion of extracellular fluid to proportion of extracellular fluid to intracellular fluid.intracellular fluid.

Infants have a larger proportional surface Infants have a larger proportional surface are of the GI tract than adults. are of the GI tract than adults.

Infants have a greater body surface area Infants have a greater body surface area and higher metabolic rate than adults.and higher metabolic rate than adults.

Developmental and Biologic Developmental and Biologic

Because of immature kidney function, Because of immature kidney function, children lack ability to adjust to major children lack ability to adjust to major changes in sodium and other electrolytes.changes in sodium and other electrolytes.

Normal urine output is 1 mL / kg / hr.Normal urine output is 1 mL / kg / hr. More prone than adults to conditions that More prone than adults to conditions that

affect fluid and electrolyte status (diarrhea, affect fluid and electrolyte status (diarrhea, vomiting, high fever.vomiting, high fever.

Water BalanceWater Balance

Regulated by Anti-diuretic Hormone ADH.Regulated by Anti-diuretic Hormone ADH. Acts on kidney tubules to reabsorb water.Acts on kidney tubules to reabsorb water. The young infant is highly susceptible to The young infant is highly susceptible to

dehydration.dehydration.

Increased Water NeedsIncreased Water Needs

FeverFever Vomiting and DiarrheaVomiting and Diarrhea High-output in renal failureHigh-output in renal failure Diabetes insipidusDiabetes insipidus BurnsBurns ShockShock TachypneaTachypnea

Decreased Water NeedsDecreased Water Needs

Congestive Heart FailureCongestive Heart Failure Mechanical VentilationMechanical Ventilation Renal failureRenal failure Head trauma / meningitisHead trauma / meningitis

Assessment Assessment

Focused Health HistoryFocused Health History Focused Physical Assessment Focused Physical Assessment

Focused Health HistoryFocused Health History

Recent fluid intake including type of fluid Recent fluid intake including type of fluid ingestedingested

How many voids in past 12 to 24 hours.How many voids in past 12 to 24 hours. Recent weight loss Recent weight loss

Focused Physical AssessmentFocused Physical Assessment

How does the child look?How does the child look? Skin:Skin:

• TemperatureTemperature• Dry skin and mucous membranesDry skin and mucous membranes• Poor turgor, tenting, dough-like feelPoor turgor, tenting, dough-like feel• Sunken eyeballs; no tearsSunken eyeballs; no tears• Pale, ashen, cyanotic nail beds or mucous Pale, ashen, cyanotic nail beds or mucous

membranes. membranes. • Delayed capillary refill > 2-3 secondsDelayed capillary refill > 2-3 seconds

Loss of Skin ElasticityLoss of Skin Elasticity

Loss of skin elasticityDue to dehydration.

CardiovascularCardiovascular

Pulse rate change:Pulse rate change: Note rate and quality: rapid, weak, or threadyNote rate and quality: rapid, weak, or thready Bounding or arrhythmiasBounding or arrhythmias TachycardiaTachycardia #1 sign that something is wrong #1 sign that something is wrong Increased HR may be first subtle sign of hypovolemiaIncreased HR may be first subtle sign of hypovolemia

Blood PressureBlood Pressure Note increase or decrease (remember it takes a 25% Note increase or decrease (remember it takes a 25%

decrease in fluid or blood volume for change to occur)decrease in fluid or blood volume for change to occur)

RespiratoryRespiratory

Change in rate or qualityChange in rate or quality Dehydration or hypovolemiaDehydration or hypovolemia

Tachypnea Tachypnea ApneaApnea Deep shallow respirationsDeep shallow respirations

Fluid overloadFluid overload Moist breath soundsMoist breath sounds CoughCough

Diagnostic TestsDiagnostic Tests

Make sure free flowing specimen is Make sure free flowing specimen is obtained, a hemolyzed or clotted obtained, a hemolyzed or clotted specimen may give false values.specimen may give false values.

Hemoglobin and HematocritHemoglobin and Hematocrit

Measures hemoglobin, the main Measures hemoglobin, the main component of erythrocytes, which is the component of erythrocytes, which is the vehicle for transporting oxygen.vehicle for transporting oxygen. Hgb and hct will be Hgb and hct will be increasedincreased in extracellular in extracellular

fluid volume loss.fluid volume loss.

Hgb and hct will be Hgb and hct will be decreaseddecreased in extracellular in extracellular fluid volume excess.fluid volume excess.

ElectrolytesElectrolytes

Electrolytes account for approximately Electrolytes account for approximately 95% of the solute molecules in body 95% of the solute molecules in body water.water.

Sodium Na+ is the predominant Sodium Na+ is the predominant extracellular cation.extracellular cation.

Potassium K+ is the predominant Potassium K+ is the predominant intracellular cation.intracellular cation.

PotassiumPotassium

High or low values can lead to cardiac High or low values can lead to cardiac arrest.arrest.

With adequate kidney function excess With adequate kidney function excess potassium is excreted in the kidneys.potassium is excreted in the kidneys.

If kidneys are not functioning, the If kidneys are not functioning, the potassium will accumulate in the potassium will accumulate in the intravascular fluidintravascular fluid

PotassiumPotassium

Adults: 3.5 to 5.3 mEq /LAdults: 3.5 to 5.3 mEq /L Child: 3.5 to 5.5 mEq / LChild: 3.5 to 5.5 mEq / L Infant: 3.6 to 5.8 mEq / LInfant: 3.6 to 5.8 mEq / L

Panic Values Panic Values

< 2.5 mEq /L or > 7.0 mEq / L< 2.5 mEq /L or > 7.0 mEq / L

HyperkalemiaHyperkalemia

Defined as potassium level above 5.0 mEq Defined as potassium level above 5.0 mEq / L/ L

Significant dysrhythmias and cardiac Significant dysrhythmias and cardiac arrestarrest

Adequate intake of fluids to insure Adequate intake of fluids to insure excretion of potassium through the excretion of potassium through the kidneys.kidneys.

Causes of HyperkalemiaCauses of Hyperkalemia

Acute renal failureAcute renal failure Chronic renal failureChronic renal failure GlomerulonephritisGlomerulonephritis

Diagnostic tests:Diagnostic tests:

Serum potassiumSerum potassium ECGECG

BradycardiaBradycardia Heart blockHeart block Ventricular fibrillationVentricular fibrillation

HypokalemiaHypokalemia

Potassium level below 3.5 mEq / LPotassium level below 3.5 mEq / L Before administering make sure child is Before administering make sure child is

producing urine.producing urine. A child on potassium wasting diuretics is A child on potassium wasting diuretics is

at risk – Lasix at risk – Lasix

CM: HypokalemiaCM: Hypokalemia

Neuromuscular manifestations are: neck Neuromuscular manifestations are: neck flop, diminished bowel sounds, truncal flop, diminished bowel sounds, truncal weakness, limb weakness, lethargy, and weakness, limb weakness, lethargy, and abdominal distention. abdominal distention.

Causes of HypokalemiaCauses of Hypokalemia

Vomiting / diarrheaVomiting / diarrhea Malnutrition / starvationMalnutrition / starvation Stress due to trauma from injury or Stress due to trauma from injury or

surgery.surgery. Gastric suction / intestinal fistulaGastric suction / intestinal fistula Potassium wasting diureticsPotassium wasting diuretics Ingestion of large amounts of ASAIngestion of large amounts of ASA

Foods high in potassiumFoods high in potassium

Apricots, bananas, oranges, Apricots, bananas, oranges, pomegranates, prunespomegranates, prunes

Baked potato with skin, spinach, tomato, Baked potato with skin, spinach, tomato, lima beans, squashlima beans, squash

Milk and yogurtMilk and yogurt Pork, veal and fishPork, veal and fish

Monitor Potassium LevelsMonitor Potassium Levels

A child with a nasogastric tube in place that is set to suction,needs to have potassium levels monitored.

SodiumSodium

Sodium is the most abundant cation and Sodium is the most abundant cation and chief base of the blood. chief base of the blood.

The primary function is to chemically The primary function is to chemically maintain osmotic pressure and acid-base maintain osmotic pressure and acid-base balance and to transmit nerve impulses.balance and to transmit nerve impulses.

Normal values: 135 to 148 mEq / LNormal values: 135 to 148 mEq / L

HyponatremiaHyponatremia

Reflects an abnormal rate of sodium to Reflects an abnormal rate of sodium to water and is defined as a serum sodium water and is defined as a serum sodium concentration less than 135 mEq/L.concentration less than 135 mEq/L.

Results from retention of water secondary Results from retention of water secondary to impairment in free water excretion.to impairment in free water excretion.

PathophysiologyPathophysiology

When sodium levels drop in the fluids When sodium levels drop in the fluids outside the cells, water will sweep into the outside the cells, water will sweep into the cells in an attempt to balance the cells in an attempt to balance the concentration of salt outside the cells.concentration of salt outside the cells.

Cells will swell as the result of the excess Cells will swell as the result of the excess water.water.

Brain cells cannot accommodate – Brain cells cannot accommodate – symptoms of hyponatremia result from symptoms of hyponatremia result from brain swelling brain swelling

Early ManifestationsEarly Manifestations

Anorexia, nausea, lethargy and apathyAnorexia, nausea, lethargy and apathy More advanced symptoms: disorientation, More advanced symptoms: disorientation,

agitation, seizures, depressed reflexes, agitation, seizures, depressed reflexes, focal neurological deficits focal neurological deficits

Severe: coma and seizures: sodium Severe: coma and seizures: sodium concentration less than 120 mEq/Lconcentration less than 120 mEq/L

HypernatremiaHypernatremia

Serum sodium greater than 150 mEq/L is Serum sodium greater than 150 mEq/L is caused by conditions that produce an caused by conditions that produce an excessive gain of sodium or excessive excessive gain of sodium or excessive loss of water that is greater than the loss loss of water that is greater than the loss of sodium.of sodium.

Clinical PearlClinical Pearl

Most infant with severe dehydration have Most infant with severe dehydration have a history of lethargy, listlessness, and a history of lethargy, listlessness, and decreased responsiveness; those with decreased responsiveness; those with hypernatremia dehydration tend to be hypernatremia dehydration tend to be irritable and fussy. irritable and fussy.

Hypernatremia Hypernatremia

Inadequate fluid intake – 75%Inadequate fluid intake – 75% Gastrointestinal losses – 44% Gastrointestinal losses – 44% Occurs primarily in infants with diarrhea Occurs primarily in infants with diarrhea

dehydrationdehydration Diabetes insipidus was major reason for Diabetes insipidus was major reason for

excessive urinary outputexcessive urinary output Loss from high fever, environmental Loss from high fever, environmental

temperatures and hyperventilation temperatures and hyperventilation

Primary Sodium ExcessPrimary Sodium Excess

Improperly mixed formula or re-hydration Improperly mixed formula or re-hydration solutionsolution

Ingestion of sea waterIngestion of sea water Hypertonic saline IVHypertonic saline IV High breast milk sodiumHigh breast milk sodium

Primary Water Deficit Primary Water Deficit

Diabetes InsipidusDiabetes Insipidus Diabetes MellitusDiabetes Mellitus Gastroenteritis (water loss greater than Gastroenteritis (water loss greater than

solute loss)solute loss) Inadequate breast feedingInadequate breast feeding Withholding of water: handicapped Withholding of water: handicapped Increased insensible loss – premature Increased insensible loss – premature

infantinfant

Additional Lab ValuesAdditional Lab Values

Arterial blood gas to determine acid-base Arterial blood gas to determine acid-base statusstatus

Urine specific gravity: measures kidney’s Urine specific gravity: measures kidney’s ability to dilute and concentrate urine.ability to dilute and concentrate urine. normal values 1.001 to 1.020normal values 1.001 to 1.020 Low specific gravity may indicate fluid excess Low specific gravity may indicate fluid excess

of kidney disease.of kidney disease. High specific gravity may indicate fluid deficit.High specific gravity may indicate fluid deficit.

Treatment ModalitiesTreatment Modalities

Peripheral IV with IVhouse.

Intraosseous TherapyIntraosseous Therapy

Intraosseous needle in place for emergency vascular access.

Central Venous CatheterCentral Venous Catheter

Total Parental NutritionTotal Parental Nutrition

Whaley & Wong

A tunneled catheter should haveAn occlusive dressing in place.

Complications of TPNComplications of TPN

Sepsis: infectionSepsis: infection Liver dysfunctionLiver dysfunction Respiratory distress from too –rapid Respiratory distress from too –rapid

infusion of fluidsinfusion of fluids

TPN TherapyTPN Therapy

TPN provides complete nutrition for TPN provides complete nutrition for children who cannot consume sufficient children who cannot consume sufficient nutrients through gastrointestinal tact to nutrients through gastrointestinal tact to meet and sustain metabolic requirements.meet and sustain metabolic requirements.

TPN solutions provide protein, TPN solutions provide protein, carbohydrates, electrolytes, vitamins, carbohydrates, electrolytes, vitamins, minerals, trace elements and fats.minerals, trace elements and fats.

TPN: care reminderTPN: care reminder

caREminder:caREminder: The TPN infusion rate should remain fairly The TPN infusion rate should remain fairly

constant to avoid glucose overload. The constant to avoid glucose overload. The infusion rate should never be abruptly infusion rate should never be abruptly increased or decreased.increased or decreased.

DehydrationDehydration

Significant depletion of body water. Signs Significant depletion of body water. Signs and symptoms include thirst, lethargy, dry and symptoms include thirst, lethargy, dry mucosa, decreased urine output, and as mucosa, decreased urine output, and as the degree of dehydration progresses, the degree of dehydration progresses, tachycardia, hypotension, and shock. tachycardia, hypotension, and shock.

Cause of DehydrationCause of Dehydration

Most common cause is fluid loss in the GI Most common cause is fluid loss in the GI tract from vomiting, diarrhea or both.tract from vomiting, diarrhea or both.

Hypovolemic Shock Hypovolemic Shock = second most = second most common cause of cardiac arrest in common cause of cardiac arrest in infants / childreninfants / children Loss of FluidsLoss of Fluids Loss of blood volumeLoss of blood volume

DiarrheaDiarrhea

Most common cause of diarrhea in infant / Most common cause of diarrhea in infant / child is Rotoviruschild is Rotovirus

WHO recommends immunization against WHO recommends immunization against Rotovirus to decrease infant deaths world Rotovirus to decrease infant deaths world wide.wide.

3 Types of Dehydration3 Types of Dehydration

Isotonic DehydrationIsotonic Dehydration Hyponatremic DehydrationHyponatremic Dehydration Hypernatremic DehydrationHypernatremic Dehydration

Isotonic DehydrationIsotonic Dehydration

Sodium and water are lost in proportional Sodium and water are lost in proportional amountsamounts

Reduction in circulating blood volumeReduction in circulating blood volume

Hyponatremic DehydrationHyponatremic Dehydration

Hypotonic dehydration: results from water Hypotonic dehydration: results from water retention or sodium loss.retention or sodium loss.

Two causes:Two causes: Formula is diluted with water beyond Formula is diluted with water beyond

manufacturer recommendationmanufacturer recommendation Fluid loss is replaced with electrolyte-free Fluid loss is replaced with electrolyte-free

water.water.

Hypernatremic DehydrationHypernatremic Dehydration

Marked by elevated sodium levelsMarked by elevated sodium levels

DehydrationDehydration

General AssessmentGeneral Assessment

Loss of weight Loss of weight Level of consciousnessLevel of consciousness

Alert to irritable Alert to irritable Restless to lethargic Restless to lethargic Lethargic to coma Lethargic to coma

Vital SignsVital Signs

The heart rate is the most sensitive The heart rate is the most sensitive indicator of dehydration / hypovolemia.indicator of dehydration / hypovolemia.

HR will be elevated in an attempt to HR will be elevated in an attempt to compensate for fluid loss.compensate for fluid loss.

Blood pressure will only drop as child is Blood pressure will only drop as child is severely dehydrated (>10%). severely dehydrated (>10%).

Skin TurgorSkin Turgor

In moderate dehydration the skin may In moderate dehydration the skin may have a doughy texture and appearance.have a doughy texture and appearance.

In severe dehydration the more typical In severe dehydration the more typical “tenting” of skin is observed.“tenting” of skin is observed.

Skin TurgorSkin Turgor

WeightWeight

CaREminder; one kilogram of body weight CaREminder; one kilogram of body weight equals the weight of 1 L of water, thus, the equals the weight of 1 L of water, thus, the amount of fluid gain or loss can be calculated amount of fluid gain or loss can be calculated from weight gain or loss.from weight gain or loss.

Nursing intervention: compare daily weight Nursing intervention: compare daily weight with previous measurement and note with previous measurement and note trends.trends.

Urine OutputUrine Output

Normal urine output is 1-2 mL/kg/hrNormal urine output is 1-2 mL/kg/hr In mild dehydration urine output may be low – In mild dehydration urine output may be low –

parent may report decrease in voiding parent may report decrease in voiding Moderate dehydration urine output would be low Moderate dehydration urine output would be low

and concentrated (oliguric) with elevated specific and concentrated (oliguric) with elevated specific gravity.gravity.

Severe dehydration would by (anuric) very low – Severe dehydration would by (anuric) very low – very concentrated urine with high S.G.very concentrated urine with high S.G.

Treatment of Mild to ModerateTreatment of Mild to Moderate

ORT – oral re-hydration therapyORT – oral re-hydration therapy 50 ml / kg every 4 hours50 ml / kg every 4 hours Increase to 100 ml / kg every 4 hoursIncrease to 100 ml / kg every 4 hours No carbonated soda, jell-o, fruit juices or tea.No carbonated soda, jell-o, fruit juices or tea. Commercially prepared solutions are the Commercially prepared solutions are the

best.best.

Re-hydration TherapyRe-hydration Therapy

Increase po fluids if diarrhea increases.Increase po fluids if diarrhea increases. Give po fluids slowly if vomiting.Give po fluids slowly if vomiting. Stop ORT when hydration status is normalStop ORT when hydration status is normal Start on BRAT dietStart on BRAT diet

BananasBananas RiceRice ApplesauceApplesauce ToastToast

Teaching / Parent InstructionTeaching / Parent Instruction

Call PMDCall PMD If diarrhea or vomiting increasesIf diarrhea or vomiting increases No improvement seen in child’s hydration No improvement seen in child’s hydration

status.status. Child appears worse.Child appears worse. Child will not take fluids.Child will not take fluids. NO URINE OUTPUTNO URINE OUTPUT

Moderate to Severe DehydrationModerate to Severe Dehydration

IV Therapy needed

Fluid ResuscitationFluid Resuscitation

Crystalloid Solution: used for volume Crystalloid Solution: used for volume resuscitation to expand the interstitial resuscitation to expand the interstitial volume rather that the plasma volume.volume rather that the plasma volume. Isotonic Saline is the prototype crystalloid Isotonic Saline is the prototype crystalloid

fluid. 0.9% NaCl or normal saline.fluid. 0.9% NaCl or normal saline. Lactated Ringers contains potassium and Lactated Ringers contains potassium and

calcium. calcium.

Fluid ReplacementFluid Replacement

Standard Orders:Standard Orders: Normal Saline or 0.9% NaCl at 20 mL / kg Normal Saline or 0.9% NaCl at 20 mL / kg Followed by Dextrose 5% in 0.45 normal Followed by Dextrose 5% in 0.45 normal

salinesaline Followed by Dextrose 5% in 0.45 normal Followed by Dextrose 5% in 0.45 normal

saline with 20 mEq KCL per 1000 mLsaline with 20 mEq KCL per 1000 mL Potassium is only added to the IV when there Potassium is only added to the IV when there

is documentation of voiding.is documentation of voiding.

Nursing InterventionsNursing Interventions

Assess child’s hydration statusAssess child’s hydration status Accurate intake and outputAccurate intake and output Daily weights Daily weights

most accurate most accurate way to monitor fluid levelsway to monitor fluid levels

Hourly monitoring of IV rate and site of infusion.Hourly monitoring of IV rate and site of infusion. Increase fluids if increase in vomiting or diarrhea.Increase fluids if increase in vomiting or diarrhea. Decrease fluids when taking po fluids or signs of Decrease fluids when taking po fluids or signs of

edema.edema.

Care ReminderCare Reminder

A severely dehydrated child will need A severely dehydrated child will need more than maintenance to replace lost more than maintenance to replace lost fluids. 1 ½ to 2 times maintenance.fluids. 1 ½ to 2 times maintenance.

Adding potassium to IV solution.Adding potassium to IV solution. Never add in cases of oliguria / anuriaNever add in cases of oliguria / anuria

• Urine output less than 0.5 mg/kg/hourUrine output less than 0.5 mg/kg/hour Never give IV pushNever give IV push Double check dosageDouble check dosage

Over hydrationOver hydration

Occurs when child receives more IV fluids Occurs when child receives more IV fluids that needed for maintenance.that needed for maintenance.

In pre-existing conditions such as In pre-existing conditions such as meningitis, head trauma, kidney shutdown, meningitis, head trauma, kidney shutdown, nephrotic syndrome, congestive heart nephrotic syndrome, congestive heart failure, or pulmonary congestion.failure, or pulmonary congestion.

Signs and SymptomsSigns and Symptoms

TachypneaTachypnea DyspneaDyspnea CoughCough Moist breath soundsMoist breath sounds Weight gain from edemaWeight gain from edema Jugular vein distentionJugular vein distention

Safety Precautions Safety Precautions

Use small bags of fluid or buretrol to control fluid Use small bags of fluid or buretrol to control fluid volume.volume.

Check IV solution infusion against physician Check IV solution infusion against physician orders.orders.

Always use infusion pump so that the rate can Always use infusion pump so that the rate can be programmed and monitored.be programmed and monitored.

Even mechanical pumps can fail, so check the Even mechanical pumps can fail, so check the intravenous bag and rate frequently.intravenous bag and rate frequently.

Record IV rate q hourRecord IV rate q hour

Acid – Base ImbalancesAcid – Base Imbalances

Acidosis:Acidosis: Respiratory acidosis Respiratory acidosis

is too much carbonic is too much carbonic acid in body.acid in body.

Metabolic Acidosis is Metabolic Acidosis is too much metabolic too much metabolic acid.acid.

Alkalosis.Alkalosis. Respiratory alkalosis Respiratory alkalosis

is too little carbonic is too little carbonic acid.acid.

Metabolic alkalosis is Metabolic alkalosis is too little metabolic too little metabolic acid.acid.

Respiratory AcidosisRespiratory Acidosis

Carbonic acid excess: CO2 is retained and Carbonic acid excess: CO2 is retained and pH decreasespH decreases

Caused by the accumulation of carbon Caused by the accumulation of carbon dioxide in the blood.dioxide in the blood.

Acute respiratory acidosis can lead to Acute respiratory acidosis can lead to tachycardia and cardiac arrhythmias.tachycardia and cardiac arrhythmias.

Causes of Respiratory AcidosisCauses of Respiratory Acidosis

Any factor that interferes with the ability of Any factor that interferes with the ability of the lungs to excrete carbon dioxide can the lungs to excrete carbon dioxide can cause respiratory acidosis.cause respiratory acidosis.

Aspiration, spasm of airway, laryngeal Aspiration, spasm of airway, laryngeal edema, epiglottitis, croup, pulmonary edema, epiglottitis, croup, pulmonary edema, cystic fibrosis, and edema, cystic fibrosis, and Bronchopulmonary dysplasia.Bronchopulmonary dysplasia.

Sedation overdose, head injury, or sleep Sedation overdose, head injury, or sleep apnea.apnea.

AssessmentAssessment

Respiratory distressRespiratory distress CNS depression: disorientation, comaCNS depression: disorientation, coma Hypoxia: restlessness, irritability, Hypoxia: restlessness, irritability,

tachycardia, arrhythmiastachycardia, arrhythmias Muscle weaknessMuscle weakness

Medical ManagementMedical Management

Correction of underlying causeCorrection of underlying cause Bronchodilators: asthmaBronchodilators: asthma Antibiotics: infectionAntibiotics: infection Mechanical ventilationMechanical ventilation Decreasing sedative useDecreasing sedative use

Respiratory AlkalosisRespiratory Alkalosis

Carbonic acid deficit; not enough CO2 is Carbonic acid deficit; not enough CO2 is retained, and pH increases.retained, and pH increases.

Excess carbon dioxide loss is caused by Excess carbon dioxide loss is caused by hyperventilation.hyperventilation.

Causes of hyperventilationCauses of hyperventilation

HypoxemiaHypoxemia AnxietyAnxiety PainPain FeverFever Salicylate poisoning: ASASalicylate poisoning: ASA MeningitisMeningitis Over-ventilationOver-ventilation

AssessmentAssessment

DizzinessDizziness Numbness or paresthesias of fingers and Numbness or paresthesias of fingers and

toestoes TetanyTetany ConvulsionsConvulsions UnconsciousnessUnconsciousness

ManagementManagement

Stress management if caused by Stress management if caused by hyperventilation.hyperventilation.

Pain control.Pain control. Adjust ventilation rate.Adjust ventilation rate. Treat underlying disease process.Treat underlying disease process. Have child slow respirations, breathe into Have child slow respirations, breathe into

paper bagpaper bag

Metabolic AcidosisMetabolic Acidosis

Bicarbonate deficityBicarbonate deficity

Causes:Causes:

Gain in acidGain in acid: ingestion of acids, oliguria, : ingestion of acids, oliguria, starvation (anorexia), DKA or diabetic starvation (anorexia), DKA or diabetic ketoacidosis, tissue hypoxia.ketoacidosis, tissue hypoxia.

Loss of bicarbonateLoss of bicarbonate::diarrhea, intestinal or pancreatic fistula, or diarrhea, intestinal or pancreatic fistula, or renal anomaly.renal anomaly.

AssessmentAssessment

Kussmaul respirationsKussmaul respirations SOB on exertionSOB on exertion WeaknessWeakness Drowsiness to stuporDrowsiness to stupor When pH is < 7.2 cardiac contractility is When pH is < 7.2 cardiac contractility is

reduced – BP will decreasereduced – BP will decrease

ManagementManagement

Treat and identify underlying cause.Treat and identify underlying cause. IV sodium bicarbonate in severe cases.IV sodium bicarbonate in severe cases. Provide low-protein, high-calorie dietProvide low-protein, high-calorie diet Position to facilitate ventilationPosition to facilitate ventilation

Metabolic AlkalosisMetabolic Alkalosis

A gain in bicarbonate or a loss of A gain in bicarbonate or a loss of metabolic acid can cause metabolic metabolic acid can cause metabolic alkalosis.alkalosis.

Causes:Causes:

Gain in bicarbonate:Gain in bicarbonate:

Ingestion of baking soda or antacids.Ingestion of baking soda or antacids.

Loss of acid:Loss of acid:

Vomiting, nasogastric suctioning, diuretics Vomiting, nasogastric suctioning, diuretics massive blood transfusionmassive blood transfusion

AssessmentAssessment

Signs similar to dehydrationSigns similar to dehydration TachycardiaTachycardia HypoventilationHypoventilation Muscle hypertonicityMuscle hypertonicity Confusion, irritability, comaConfusion, irritability, coma

TreatmentTreatment

Administer fluid containing sodium and Administer fluid containing sodium and potassiumpotassium

Avoid antacidsAvoid antacids Management: Correct the underlying Management: Correct the underlying

conditioncondition