Dehydrationpure (tissue) water loss and hypovolemiato sodium loss and thus loss of bloodvolume.Loss of water from the extracellular fluidvolume, vascular and interstitial fluids.It is literally the removal of water ordeficiency of fluid within an organism.Extracellular Fluid Volume Deficit(ECFVD) Intracellular fluid VolumeDeficit (ICFVD)
Losses can be :1. Mild – loss of 1 to 2 L of water (2% ofbody weight is lost).2. Moderate – loss of 3 to 5 L of water (5% ofbody weight is lost).3. Severe – loss of 5 to 10 L of water (8% ofbody weight is lost).Fluids are normally found in three spaces: Inside the cells (Intracellular) Around the cells (Interstitial) In the bloodstream (Intravascular)
PathophysiologyDehydration is seen when the normalcompensation for fluid in the bloodstreamcannot be corrected by stored fluid elsewhere.When fluids are lost from the intravascularspaces because of lack of intake or excess loss,interstitial fluids move in to restore vascularvolume. Because the actual volume of fluid inthe interstitial space limited, othercompensation systems are initiated to restorefluid volume.If the dehydration is not corrected, fluid isshifted from the cells into the vascular system.
Cellular DehydrationThe loss of cellular fluid is dangerous because thecells need fluid for cellular function. Intracellular fluid Volume Deficit (ICFVD) Less fluid is available for temperature regulation viasweating, and lowered blood volume decreases thebody’s ability to transport core heat to theperiphery for conducive loss. There is cerebrospinal fluid and less fluid in fat padsaround the eyes. If cerebral cells becomedehydrated, thought processes may be impaired.
Causes of dehydration in childrenCommon viral infections causing vomiting and diarrhea includerotavirus or winter vomiting disease (norovirus).Common bacterial infections include Salmonella, E coli,Campylobacter and C.difficile.Parasitic infections such as Giardia lamblia cause the conditionknown as giardiasis.Dehydration can be caused by losing too much fluid, notdrinking enough water or fluids, or both.Your body may lose too much fluids from:Excessive sweatingExcessive urine outputFeverVomiting or diarrheaExercise during high heat and humidity
Clinical Manifestations of DehydrationClinicalManifestationsMildDehydrationModerateDehydrationSevere DehydrationLevel ofconsciousnessAlert Lethargic ObtundedCapillary refill time 2 seconds 2-4 secondsGreater than 4 seconds,cool limbsMucous membranes Normal Dry Parched, crackedHeart rateSlightincreaseIncreased Very increasedRespiratory rate Normal IncreasedIncreased andhyperpneaBlood pressure NormalNormal, butorthostaticDecreasedPulse Normal Thready Faint or impalpableSkin turgor Normal Slow TentingEyes Normal Sunken Very sunkenUrine output Decreased Oliguria Oliguria/anuria
√ Three types of dehydration based on serum sodiumlevels:1.hypotonic or hyponatremic (referring to this as primarilya loss of electrolytes, sodium in particular)2.hypertonic or hypernatremic (referring to this asprimarily a loss of water)3.isotonic or isonatremic (referring to this as equal loss ofwater and electrolytes).Differential Diagnosis:External or stress-related causesInfectious diseasesMalnutrition
Signs :dry or sticky mouthfew or no tears when cryingeyes that look sunken into the headsoft spot (fontanels) on top of head that looks sunkenlack of urine or wet diapers for 6 to 8 hours in an infant (or onlya very small amount of dark yellow urine)lack of urine for 12 hours in an older child (or only a very smallamount of dark yellow urine)dry, cool skin (poor skin turgor)Symptoms:excessive loss of fluid from vomiting or diarrhea if the child refuses to eat or drink.lethargy or irritabilityfatigue or dizziness in an older childthirst and discomfortloss of appetite
Skin turgor assessment – thisassessment can be done on theforearm. Skin that does not flattenimmediately after release is called“tenting”, an example of fluidvolume deficit. Dry and cracked lipsSunken eyes Thirst and discomfort
Examinations and testsDelayed capillary refillLow blood pressurePoor skin turgor -- the skin may not be as elastic as normaland sag back into position slowly when the health careprovider pinches it up into a fold (normally, skin springs rightback into place)Rapid heart rateShock (hypovolemic)Complete blood count (CBC)Blood chemistries (to check electrolytes, especiallysodium, potassium, and bicarbonate levels)Blood urea nitrogen (BUN)CreatinineUrine specific gravityOther tests may be done to determine the cause of thedehydration (for example, blood sugar level to check fordiabetes).
ManagementMild and Moderate Dehydration:1. Fluid Restoration Oral Rehydration› Oral Rehydration Solution “ORS”› Standard home solutions Intravenous Rehydration Monitoring for complications of fluidrestoration Monitor Intake and Output for fluidreplacement Nutritious food and supplements
Severe Dehydration:1. Laboratory evaluation and intravenous rehydrationare required. The underlying cause of thedehydration must be determined and appropriatelytreated. Phase 1 focuses on emergency management. Severedehydration is characterized by a state ofhypovolemic shock requiring rapid treatment.o IV fluido Tachycardia, capillary refill, urine output, and mental statusall should improve. Phase 2 focuses on deficit replacement, provision ofmaintenance fluids, and replacement of ongoinglosses. Maintenance fluid requirements are equal tomeasured fluid losses
Solution Contents Uses CommentsHypotonic5% dextrose in water(D5W)50g dextroseNo electrolytesReplaces deficits oftotal body water.Not used alone toexpand ECF volumebecause dilution ofelectrolytes can occur.Supplies 170 kcal/L and freewaterDistilled water cannot be givenIV because it would causehemolysis of RBCs.Dextrose is metabolized on firstpass through liver, leaving asolution of water but withouthemolytic problems.Isotonic0.9% NaCl (normal salineolution, NS, 0.9% NS)154 mEq/L Na and Cl ECF deficits in clientswith low serum levelsof Na or Cl andmetabolic alkalosisBefore and afterinfusion of bloodproductsNot used for routineadministration of IV fluidsbecause it contains moresodium than ECFExpands plasma and interstitialvolume and does not enter cellsLacteted RingersSolution (LR)130 mEq/L Na4 mEq/L K3 mEq/L Ca109 mEq/L Cl28 mEq/L lactateECF deficits, such asfluid loss with burnsand bleeding anddehydration from lossof bile or diarrheaSolution is roughly isotonic toplasma but does not containmagnesium or phosphateLactate is equivalent tobicarbonate and solution can beused to treat many forms ofacidosisCannot be used in people withalkalosisIntravenous Water and Electrolyte Solutions
HypertonicLactated Ringer’sSolution with 5% dextrose(D5/LR)5o g dextrose130 mEq/L Na4 mEq/L K3 mEq/L K109 mEq/L Cl28 mEq/L lactateFCF deficits, such as fluidloss with burns andbleeding and dehydrationfrom loss of bile ordiarrheaProvides modest calories(170 kcal)Solution hypertonic because it iscombination of two solutions(D5W and LR)5% dextrose and normalsaline (D5/o.9 NS)50g dextrose154 mEq/L Na and ClECF deficits in clientswith low serum levels ofNa or Cl and metabolicalkalosisBefore and after infusionof blood productsProvides modest calories(170 kcal)Solution is hypertonic because itis combination of two solutions(D5W and NS)5% dextrose and 0.45%normal saline (D5/0.45 NS;D5/1/2 NS)50g dextrose77 mEq/L Na and ClCan be used as an initialfluid for hydrationbecause it provides morewater than sodiumProvides modest calories(170 kcal)Commonly used as a maintenancefluid5% dextrose and 0.225%normal saline(D5/0.2 NS; D5/1/4 NS)50g dextrose34 mEq/L Na and ClCan be used as an initialfluid for hydrationbecause it provides morewater than sodiumProvides modest calories(170 kcal)Commonly used as a maintenancefluid
Nursing ManagementKeep fresh water or other fluids in an easilyaccessible location.Provide fluids of choiceEncourage family members to assist theclientProvide oral care every 2 hours to helpdecrease discomfort from dry mucousmembranesRecord intake and Output of the clientEducate client how to self-care at homeMonitor for signs of Hypovolemic shock
Preventive measures Even when you are healthy, drink plenty of fluids everyday. Drink more when the weather is hot or you areexercising. Carefully monitor someone who is ill. If you believe thatthe child is getting dehydrated, call your health careprovider before the person becomes dehydrated. Beginfluid replacement as soon as vomiting and diarrheastart -- DO NOT wait for signs of dehydration. Always encourage a child who is sick to drink fluids.Remember that fluid needs are greater with a fever,vomiting, or diarrhea. The easiest signs to monitor areurine output (there should be frequent wet diapers ortrips to the bathroom), saliva in the mouth, and tearswhen crying. Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.
TreatmentOral re-hydration solutions (ORS)Fluid replacementIntravenous rehydration therapyAlternative therapiesProper food intakeAdequate rest and sleep patternMonitor intake and outputSevere cases: IVF/ NGTMedical treatment:In cases of severe dehydration, admission tohospital may be required. Fluid may be giventhrough a tube through the nose or saline dripintravenously.
ComplicationsUntreated severe dehydration may leadto:DeathPermanent brain damage Seizures Cholera Gastroenteritis Shigellosis Fever Electrolyte disturbanceHypernatremia (also caused by dehydration)Hyponatremia, especially fromrestricted salt diets