Fluid and Electrolytes & Burns

Homeostasis body’s attempt to maintain equilibrium.

Body fluids, electrolytes, and acid base buffers – release or absorption of hydrogen ions to maintain a stable blood ph.


Acidosis – blood ph < 7.35
Alkalosis – blood ph > 7.45

Fluids:
Intracellular – fluid inside cells

Extracellular-
fluid between the cells and outside the blood and lymph vessels (primarily saline)

Intravascular – within vessels and lymph

Electrolytes affect formation and retention of water in the body.
Sodium –
136-146 mEq/L newborns
139 – 146 mEq/L infants
135 – 148 mEq/L child
135 – 146 mEq/L adult

Potassium –
3.0 – 6.0 mEq/L newborns
3.5 – 5 mEq/L infants – adults

Chloride –
97 – 110 mEq/L infant
98 – 111 mEq/L child
95 – 106 mEq/L adult


Infants (70-75% of weight) have a higher percentage of body water than adults (50-60% of body weight), so they require higher fluid intact and are more susceptible to dehydration.

During illness (vomiting, diarrhea, hemorrhage)
Extracellular fluid is lost first. Infants have a higher proportion of fluid in extracellular areas so easily dehydrated.
Infants have > body surface area lose more insensible water loss through skin and lungs
Infants have a higher metabolic rate
Infants immature kidneys cannot concentrate urine.

Nurse Actions:
Measure Intake and Output
Assess lab values
Assess vital signs
Monitor urine specific gravity
Examine history
Either calculate replacement needs or limit fluids and administer diuretics

Causes of electrolyte imbalance:

Hypo-natremia –
Excessive sodium bicarbonate or baking soda
Diarrhea, vomiting, n/g suctioning,
Diuretics, water intoxification,
Malnutrition, DKA
Excessive sweating, burns
Renal disease, cystic fibrosis

Hyper-natremia –
Excessive intake of sodium or increased water loss
(Normally causes ADH release which stimulates thirst)

Hypo- kalemia
Decreased dietary intake, loss of gastric fluid
Excessive renal secretion, sweating

Hyperkalemia
Crushing injuries, burns, tissue necrosis
Hemolysis
Renal failure
Severe dehydration
Too rapid infusion of IV potassium

Potassium:
Never push
Never give more than 40mEq/kg/hr
Rate not to exceed 1 mEq/kg/hr


Hormones affecting fluid balance:
Antidiuretic hormone and secreted by the posterior pituitary causing renal tubules to reabsorb water. Secreted when hypovolemic – increases vascular volume and decreases urine output
Aldosterone – mineralcorticoid secreted by adrenal cortex causes body to reabsorb Na and secrete K. *It is excreted when the body needs to retain fluids.


IV fluids
Hypertonic solutions: Used to pull fluid into the vascular space from intracellular. Causes fluid shift, cells to venous. This causes cells to shrink. Can be used for cerebral edema. Mannitol is a common hypertonic solution.
10% glucose in water or D10W
Dextrose 5% in normal saline or D5 0.9% NaCl
Dextrose 5% in 0.45 NS
Dextrose 5% in RL

Isotonic solutions: Used to replace fluid losses to expand intravascular volume. No fluid shift.
Ringers lactate (RL)
Normal saline (NS)
Dextrose 5% in water
Dextrose 5% in 0.2% NS

Hypotonic solutions: Used to dilute extracellular fluid and rehydrate cells. Fluid shifts from ECF to cells. These fluids are often used for dehydration.
Water
0.45% sodium chloride or 0.45% NS
0.33% NaCl

Replacement Intake for 24 hours:
1-10 kg – 100 ml/kg –
2.5 kg infant = 250 ml
10 kg infant 1,000 ml

10-20 kg – 1,000 ml for first 10 kgs then + 50 ml/kg
11 kg infant = 1,050 ml
13 kg infant = 1,150 ml
20 kg infant = 1,500 ml

>20 kg – 1,500 ml + 20ml/kg
21 kg infant = 1,520 ml
30 kg infant = 1,700 ml

Minimum Urine output
Infant 2 ml/kg/hr
Children 1 ml/kg/hr
Adults ½ ml/kg/hr

*Dehydration can cause a hyper concentration of electrolytes
*Fluid overload can cause a hypo concentration of electrolytes

Respiratory Acidosis:
Caused by any condition that decreases respiratory effort:
Slowed respirations = increase in CO2 = increase in carbonic acid - increase CO2 = decrease ph
Causes:
Chronic respiratory disease
CNS depression
Pneumothorax
Neuromuscular disease

Respiratory Alkalosis:
When CO2 is too low = decrease in CO2 (decrease carbonic acid) = increase in ph
Causes:
Hyperventilation
Anxiety
Sepsis
Heart failure
Hepatic failure
Fever or hypermetabolic states
Salicylate poisoning

Metabolic Acidosis:
Loss of bicarbonate in stools or increase in ketones = decrease in ph
Causes:
DKA
Alcoholic ketoacidosis
Increase intake acids, salicylate acid
Diarrhea
Renal failure
Starvation
Shock

Metabolic Alkalosis:
Decreased body acids = Increase in ph
Causes:
Vomiting
Prolonged NG suctioning
Overuse of antacids
Hypokalemia
Diuretics

Degrees of dehydration:
Minimal < 3% loss of body weight
Moderate 3-9% loss of body weight, lethargic, thirsty, eager to drink
Severe - >9% loss of body weight, lethargic, unconscious, drinks poorly or unable to drink

Nursing assessment for Fluid and electrolyte imbalance:
General appearance
Illness – lethargic, pale, increase cap refil
Increase respirations
I&O, wet diaper, voiding
Weight loss *(1 kg of body weight = 1 liter of water, so 1 kg loss = 1000 ml fluid loss)
Vital signs
Skin turgor either skin tenting or edematous
Fontanelles sunken or bulging
Mucous membranes, Tears?
Urine specific gravity (wet diaper urine concentration)
Labs

Dehydration causes
Gastroenteritis – most common cause (rotavirus most common)
Diarrhea
Stomatitis
Pharyngitis, Tonsilitis
Burns
Cystic fibrosis
Diabetes Insipidus
Hemorrhage

Oral Rehydration Solution (ORS) is the first recommended action
Pedialyte, Lytren, Infalyte, Resol,
Diluted fruit juices or soft drinks 1 part drink to 4 parts water

Can rehydrate through NG tube, IV or intraosseous IO
Boluses of 20ml/kg are recommended




Nursing Diagnosis
Fluid volume deficit
Risk for injury
Knowledge deficit

Outcomes:
Fluid loss replacement
Adequate hydration
No injuries from lethargy
Knowledge understanding

Edema:
Heart failure, renal failure, nephrotic syndrome, Burns, allergic reactions
+0 - no edema
+1 - ¼ “ mild edema
+2 – ¼ - ½ “ – moderate
+3 – ½ - 1 “ - severe
+4 - > 1 – very severe

Nursing Assessment/Interventions:

Assess edema, daily weights, meticulous I&O
Elevate edematous extremities, turn q 2 hours
Concerns for body image concerns
Assess respiratory status
Med administration
Lab values monitored
Treatment:
Diuretics, fluid and sodium restriction, dietary supplementation
Must monitor potassium since diuretics cause K loss


Burns:


In 1940 children with burns over 30% of their body died
In 2000 children with burns on up to 59% of their body lived

Initially, early stabilization cool burn, cool not ice cold water = less tissue damage
Prevent further burn and contamination, no toothpaste, butter or honey
Stabilization of airway, breathing, circulation and pain management
11th leading cause of death in children age 1-9
Culturally loose fitting clothing/cooking

Burn type
Thermal (most common), scalds, contact
Electrical, inserting items in outlets, chewing on wires
Chemical, household items
Radiation, sun

What is a blister? The body's bandaid!

Degree
Superficial – first degree, epidermis, sunburn, healing 48-72 hours
Superficial partial – Second degree, blister, moist painful, healing 1-3 weeks
Deep partial thickness – Second degree, white, sensation diminished, healing in 3-4 weeks
Full – Third degree, white, black, brown, do not heal spontaneously, heal with contraction
Full – Fourth degree, lethal extend into muscle, fascia, bone.

Measuring burns:
Rule of Nines
*Total Body Surface Area (TBSA)

Step 1: Cool, protect
Step 2: Respiratory management
Step 3: Fluid resuscitation with Lactated Ringers, Parkland formula
Step 4: Close the wound either through healing secondary intention or surgical grafts
Step 5: Debridement hydrotherapy, painful
Step 6: Cleaned and antimicrobial cream Silvadene



Skin graphs
Homographs – cadaver graphs
Heterographs – pig graphs, synthetic skin
Temporary graphs speed healing by increasing granulation tissue

Parkland Formula:
4ml LR solution x kg of body weight x % total body surface area burned
½ of total given in the first 8 hours
¼ is given in the second 8 hours
¼ is given in the third 8 hours

Burn Case:



Interstitual fluid
https://youtu.be/B658Yn3INYc

Fluids
https://youtu.be/4r1G_oLH-Pw

Oral rehydration therapy
https://youtu.be/bN-ipx3LZVM

Burns
https://youtu.be/2f0-Dx09RWs

Care plan
https://youtu.be/BDBXO9fmpmw

Zoni's Burn
https://youtu.be/IqdT1hfZBl0