This document discusses fluid and electrolyte balance in infants and children. It covers normal fluid regulation, increased and decreased fluid needs, signs of dehydration and fluid overload, diagnostic tests including electrolyte levels, treatment for dehydration including oral and IV rehydration, and acid-base imbalances including causes and management of respiratory and metabolic acidosis and alkalosis.

1. Fluid and Electrolytes
Infants and children

2. Alteration in Fluid and
Electrolyte Status
Lungs
Ball &
Bender
Urine & faeces Skin
Normal routes of fluid excretion in infants and children.

3. Developmental and Biological
Variances
Infants younger than 6 weeks do not
produce tears.
In an infant a sunken fontanel may
indicate dehydration.
Infants are dependant on others to meet
their fluid needs.
Infants have limited ability to dilute and
concentrate urine.

4. Developmental and Biological
Smaller the child, greater proportion of
body water to weight and proportion of
extracellular fluid to intracellular fluid.
Infants larger proportional surface area of
GI tract than adults.
Infants greater body surface area and
higher metabolic rate than adults.

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

6. Increased Water Needs
Fever / sepsis
Vomiting and Diarrhoea
High-output in renal failure
Diabetes insipidus
Burns
Shock
Tachypnea

7. Decreased Water Needs
Congestive Heart Failure
Mechanical Ventilation
Renal failure
Head trauma / meningitis

8. General Appearance
How does the child look?
Skin:
• Temperature
• Dry skin and mucous membranes
• Poor turgor, tenting, dough-like feel
• Sunken eyeballs; no tears
• Pale, ashen, cyanotic nail beds or mucous
membranes.
• Delayed capillary refill > 3 seconds

9. Loss of Skin Elasticity
Loss of skin elasticity
Due to dehydration.
Whaley & Wong Text

10. Cardiovascular
Pulse rate change:
Note rate and quality
Rapid, weak, or thready - inappropriate
Bounding or arrhythmias
Blood Pressure (poor indicator)
Note increase or decrease

11. Respiratory
Change in rate or quality
Dehydration of hypovolemia
Tachypnea
Apnea
Deep shallow respirations
Fluid overload
Moist breath sounds
Cough

12. Diagnostic Tests
Make sure free flowing specimen is
obtained, a hemolysed or clotted blood
specimen may give false values.

13. Hemoglobin and Hematocrit
Measures hemoglobin, main component of
erythrocytes, vehicle for transporting
oxygen.
Hb and hct will be increased in extracellular
fluid volume loss.
Hb and hct will be decreased in extracellular
fluid volume excess.

14. Electrolytes
Electrolytes account for approximately
95% solute molecules in body water.
Sodium Na+ predominant extracellular
cation.
Potassium K+ is the predominant
intracellular cation.

15. Potassium
High or low values can lead to cardiac
arrest.
With adequate kidney function excess
potassium is excreted in the kidneys.
If kidneys are not functioning, the
potassium will accumulate in the
intravascular fluid

16. Potassium
Adults: 3.5 to 5.3 mEq /L
Child: 3.5 to 5.5 mEq / L
Infant: 3.6 to 5.8 mEq / L
Panic Values:
< 2.5 mEq /L or > 7.0 mEq / L

17. Hyperkalemia
Potassium level above 5.0 mEq / L
Significant dysrhythmias and cardiac
arrest may result when potassium levels
arise above 6.0 mEq/L
Adequate intake of fluids to insure
excretion of potassium through the
kidneys.

18. CM: Hyperkalemia
Nausea
Irregular heart rate
Pulse slow / irregular

19. Causes of Hyperkalemia
Acute renal failure
Chronic renal failure
Glomerulonephritis

20. Diagnostic tests:
Serum potassium
ECG
Bradycardia
Heart block
Ventricular fibrillation

21. Hypokalemia
Potassium level below 3.5 mEq / L
Before administering make sure child is
producing urine.
A child on potassium wasting diuretics is
at risk – Lasix

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

23. Causes of Hypokalemia
Vomiting / diarrhea
Malnutrition / starvation
Stress due to trauma from injury or
surgery.
Gastric suction / intestinal fistula
Potassium wasting diuretics
Ingestion of large amounts of ASA

24. Foods high in potassium
Apricots, bananas, oranges,
pomegranates, prunes
Baked potato with skin, spinach, tomato,
lima beans, squash
Milk and yogurt
Pork, veal and fish

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

26. Sodium
Sodium is the most abundant cation and
chief base of the blood.
The primary function is to chemically
maintain osmotic pressure and acid-base
balance and to transmit nerve impulses.
Normal values: 135 to 148 mEq / L

27. Treatment Modalities
Peripheral IV

28. IV Therapy
Ball & Bender

29. Intraosseous Therapy
Intraosseous needle in place for emergency vascular access.

30. Central Venous Catheter

31. Total Parental Nutrition
A tunneled catheter should have
Whaley & Wong An occlusive dressing in place.

32. TPN Therapy
TPN provides complete nutrition for
children who cannot consume sufficient
nutrients through gastrointestinal tract to
meet and sustain metabolic requirements.
TPN solutions provide protein,
carbohydrates, electrolytes, vitamins,
minerals, trace elements and fats.

33. Complications of TPN
Sepsis: infection
Liver dysfunction
Respiratory distress from too –rapid
infusion of fluids

34. TPN: care reminder
The TPN infusion rate should remain fairly
constant to avoid glucose overload. The
infusion rate should never be abruptly
increased or decreased.

35. Dehydration

36. Skin Turgor
In moderate dehydration the skin may
have a doughy texture and appearance.
In severe dehydration the more typical
“tenting” of skin is observed.

37. Skin Turgor

38. Treatment of Mild to Moderate
ORT – oral re-hydration therapy
50 ml / kg every 4 hours
Increase to 100 ml / kg every 4 hours
Non carbonated soda, jelly, fruit juices
Commercially prepared solutions are the
best.

39. Re-hydration Therapy
Increase po fluids if diarrhea increases.
Give po fluids slowly if vomiting.
Stop ORT when hydration status is normal
Start on BRAT diet
Bananas
Rice
Applesauce
Toast

40. Teaching / Parent Instruction
Call H/S
If diarrhea or vomiting increases
No improvement seen in child’s hydration
status.
Child appears worse.
Child will not take fluids.
NO URINE OUTPUT

41. Moderate to Severe Dehydration
IV Therapy
needed

42. Fluid replacement
Isotonic fluids initially:
Normal Saline 0.9%
Potassium is added only after child has voided.

43. Nursing Interventions
Assess child’s hydration status
Accurate intake and output
Daily weights
most accurate way to monitor fluid levels
Hourly monitoring of IV rate and site of infusion.
Increase fluids if increase in vomiting or diarrhea.
Decrease fluids when taking po fluids or signs of
odema.

44. Care Reminder
A child with severe dehydration will need
more than maintenance to replace lost
fluids. 1 ½ to 2 times maintenance.
Adding potassium to IV solution.
Never add in cases of oliguria / anuria
• Urine output less than 0.5 mg/kg/hour
Never give IV push
Double check dosage

45. Over hydration
Occurs when child receives more IV fluids
that needed for maintenance.
In pre-existing conditions such as
meningitis, head trauma, kidney shutdown,
nephrotic syndrome, congestive heart
failure, or pulmonary congestion.

46. Signs and Symptoms
Tachypnea
Dyspnea
Cough
Moist breath sounds
Weight gain from edema
Jugular vein distention

47. Congestive Heart Failure
Ball & Bender

48. Safety Precautions
Use buretrol to control fluid volume.
Check IV solution infusion against physician
orders.
Always use infusion pump so that the rate can
be programmed and monitored.
Even mechanical pumps can fail, so check the
intravenous bag and rate frequently.
Record IV rate hourly

49. Acid – Base Imbalances
Acidosis: Alkalosis.
Respiratory acidosis Respiratory alkalosis
is too much carbonic is too little carbonic
acid in body. acid.
Metabolic Acidosis is Metabolic alkalosis is
too much metabolic too little metabolic
acid. acid.

50. Respiratory Acidosis
Caused by the accumulation of carbon
dioxide in the blood.
Acute respiratory acidosis can lead to
tachycardia and cardiac arrhythmias.

51. Causes of Respiratory Acidosis
Any factor that interferes with the ability of
the lungs to excrete carbon dioxide can
cause respiratory acidosis.
Aspiration, spasm of airway, laryngeal
odema, epiglottitis, croup, pulmonary
odema, cystic fibrosis, and
Bronchopulmonary dysplasia.
Sedation overdose, head injury, or sleep
apnoea.

52. Medical Management
Correction of underlying cause.
Bronchodilators: asthma
Antibiotics: infection
Mechanical ventilation
Decreasing sedative use.

53. Ventilation Assist
Ball & Bender

54. Respiratory Alkalosis
Occurs when the blood contains too little
carbon dioxide.
Excess carbon dioxide loss is caused by
hyperventilation.

55. Causes of hyperventilation
Hypoxemia
Anxiety
Pain
Fever
Salicylate poisoning: ASA
Meningitis
Over-ventilation

56. Management
Stress management if caused by
hyperventilation.
Pain control.
Adjust ventilation rate.
Treat underlying disease process.

57. Metabolic Acidosis
Caused by an imbalance in production and
excretion of acid or by excess loss of
bicarbonate.

58. Causes:
Gain in acid: ingestion of acids, oliguria,
starvation (anorexia), DKA or diabetic
ketoacidosis, tissue hypoxia.
Loss of bicarbonate:
diarrhea, intestinal or pancreatic fistula, or
renal anomaly.

59. Ingestion of large doses of Aspirin

60. Management
Treat and identify underlying cause.
IV sodium bicarbonate in severe cases.
Assess rate and depth of respirations and
level of consciousness.

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

62. Causes:
Gain in bicarbonate:
Ingestion of baking soda or antacids.
Loss of acid:
Vomiting, nasogastric suctioning, diuretics
massive blood transfusion

63. Clinical Manifestations
Hypertonicity or tetany
Management: Correct the underlying
condition