Chapter 24: Fluid & Electrolytes, Page 1 of 15
ALTERATION IN FLUID AND ELECTROLYTE STATUS
Many questions based on dehydration.
MAINTENANCE REQUIREMENT/FLUID REQUIREMENT
 Maintenance fluid is the amount of fluid the body need to replace normal daily losses - in kids
these losses occur from the respiratory tract, UO, skin, GI tract.
 A well child usually drinks more than maintenance requirements; if they take in significantly
less than maintenance they will become dehydrated.
 The requirement for maintenance varies depending on the weight of the child. Infants need
more fluid per kg than the older child.
DAILY FLUID REQUIREMENT (24 HOUR PERIOD)
 100ml/kg for 1st 10kg of weight
 + 50ml/kg for the next 10kg
 + 20ml for every kg over 20kg
SAMPLE FLUID CALCULATION
10kg child
10 kg x 100 ml/kg = 1000 ml/ per day
15kg child
10 kg x 100 ml/kg + 5kg x 50 ml/kg =1250 ml /per day
25kg child
10 kg x 100 ml/kg + 10 kg x 50 ml/kg + 5 kg x 10 ml/kg =1600 ml/ per day
PEDIATRIC ELECTROLYTE VALUES
Potassium (K+)
3.5 – 5.0
Sodium (Na+)
135 – 145
BUN
5 – 25
Creatinine
0.5 – 1.5
Calcium (Ca)
8.4 – 11.0
Chloride (CL-)
98 – 107
ELECTROLYTES
 Electrolytes account for approximately 95% of the solute molecules in body water.
 Sodium Na+ is the predominant extracellular cation.
 Potassium K+ is the predominant intracellular cation.
DEVELOPMENTAL AND BIOLOGICAL VARIANCES
 Infants younger than 6 weeks do not produce tears.
 In an infant a sunken anterior fontanel may indicate dehydration.
 Infants are dependant on others to meet their fluid needs.
 Infants have limited ability to dilute and concentrate urine.
 The smaller the child, the greater the proportion of body water to weight and proportion of
extracellular fluid to intracellular fluid.
 Infants have a larger proportional surface are of the GI tract than adults.
Chapter 24: Fluid & Electrolytes, Page 2 of 15
 Infants have a greater body surface area and higher metabolic rate than adults.
INCREASED FLUID NEEDS
DECREASED FLUID NEEDS
Fever
Congestive Heart Failure
Vomiting and Diarrhea
Mechanical Ventilation – due to moisturized O2 and lack
High-output renal failure
of activity
Diabetes insipidus
Renal failure
Burns
Head trauma/meningitis
Shock
Tachypnea
GENERAL APPEARANCE
 How does the child look?
o Skin:
 Temperature
 Skin and mucous membranes
 Turgor, tenting, dough-like feel
 Sunken eyeballs; no tears
 Pale, ashen, cyanotic nail beds or mucous membranes.
 Delayed capillary refill > 3 seconds
Know the difference between mild, moderate, and severe dehydration.
LOSS OF SKIN ELASTICITY
 Due to dehydration.
 In moderate dehydration the skin may have a doughy texture and appearance.
 In severe dehydration the more typical “tenting” of skin is observed.
CARDIOVASCULAR ALTERATIONS IN FLUID SHIFTS
 Pulse rate change:
o Note rate and quality: tachycardia may be subtle—pulse is often the first VS to change
o Rapid, weak, or thready
o Bounding or arrhythmias due to K+ deficit
 Blood Pressure
o Note increase or decrease
o Will be last to change – child is in big trouble at this point
Respiratory Alterations in fluid shifts
 Change in rate or quality
 Hypovolemia
o Tachypnea
o Apnea
o Deep shallow respirations
 Fluid overload
o Moist breath sounds
o Cough
HGB AND HCT ALTERATIONS IN FLUID SHIFTS
Measures hemoglobin, the main component of erythrocytes, which is the vehicle for transporting
oxygen.
Chapter 24: Fluid & Electrolytes, Page 3 of 15
 Hgb and hct will be increased in extracellular fluid volume loss.
 Hgb and hct will be decreased in extracellular fluid volume excess.
HYPERKALEMIA
Potassium level above 5.5 mEq / L
Significant dysrhythmias and cardiac arrest may result when potassium levels rise above 6.0 mEq/L
Clinical manifestations:
 Nausea
 Irregular heart rate (only on monitor)
 Pulse slow / irregular
Causes of:
 Acute or chronic renal failure/glomerulonephritis
 ↓ circulatory volume/volume depletion
 Rapid infusion of K+
 Blood transfusion (older blood products)
 ↑ cell breakdown
 Rhabdomyolisis-tissue and muscle breakdown, tumor lysis, starvation
 Medications: NSAIDs, ace inhibitors, β blockers
 Metabolic acidosis
 Hypoglycemia
HYPOKALEMIA
Potassium level below 3.5 mEq / L – child should be on a cardiac monitor.
Before administering supplemental K+ make sure child is producing urine.
 A child on potassium wasting diuretics (furosemide) is at risk for hypokalemia.
Clinical manifestations
 Neuromuscular:
o diminished bowel sounds
o truncal weakness
o limb weakness,
o lethargy
o abdominal distention.
CAUSES OF HYPOKALEMIA
 Metabolic Acidosis
 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
Chapter 24: Fluid & Electrolytes, Page 4 of 15
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
Dehydration
Meds: Diuretics, aminoglycocides, β agonists, insulin, caffeine
TREATMENT OF HYPOKALEMIA
 If patient is dehydrated: rehydrate with K+ containing fluid or ORT (pedialyte)
o Mild-moderate hypokalemia (2.5-3.5) oral usually works
o Severe (<2.5) - IV diluted, SLOWLY no faster than 1mg/kg over 4h. Can require
repeated infusion to bring level up to acceptable range
o Check Mg level, hypokalemia may not be correctable until Mg level is corrected. If
you raise one you have to raise the other as well.
o Treat underlying cause
o Increase dietary K+
Extreme caution is needed with the administration of K+. There is no margin of error.
K+ overdose = death
Na+



Normal values: 135 to 145 mEq / L
Sodium is the most abundant cation and chief base of the blood; helps conduct nerve impulses
The primary function is to chemically maintain osmotic pressure and acid-base balance and to
transmit nerve impulses.
HYPONATREMIA
Serum levels below 130 mEq / L
 Causes: net sodium loss or water excess
 Sodium loss resulting from gastrointestinal output, diuretics, excessive diaphoresis, and intake
of large amounts of water with decreased sodium intake.
Clinical manifestations:
 Excess fluid will shift into the cerebral compartment, which produces increased intracranial
pressure: seizures, coma, respiratory arrest and brain damage.
 Hyponatremia is the most common cause of seizures.
HYPERNATREMIA
Serum level above146 mEq / L
 Causes: insufficient fluid intake or excessive fluid losses.
 Excessive salt intake or insufficient sodium excretion
 Altered thirst
 Increased insensible loss, increase in GI output, watery diarrhea, profuse vomiting)
 Excessive solute intake (incorrectly diluted formula)
 Kidney disease
 Diabetes insipidus
Clinical manifestations:
 Increased irritability with stimulation or high-pitched cry.
Chapter 24: Fluid & Electrolytes, Page 5 of 15
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Lethargy
Seizures
Coma
MEDICAL MANAGEMENT OF THE CHILD WITH HYPERNATREMIA
 Children with hypernatremia are almost always dehydrated.
o Determine cause
o Correct cause
o Fluid resuscitation:
 Replace fluids with hypotonic fluid- SLOWLY over 48 hours
 Too rapid an attempt at correction will result in H2O shift in brain causing
cerebral edema
CLINICAL FEATURES OF DEHYDRATION
Mild 5%
Moderate 10%
Severe >15%
HR
WNL
Slightly ↑
Tachycardic, weak
Systolic BP
WNL
WNL to orthostatic
(>10mm/Hg change)
Hypotensive
UO
↓
Moderate ↓, ↑SG
Markedly ↓, Anuria
Mucus Membranes
Slightly dry
Very dry
Parched
Ant. fontanel
WNL
WNL to sunken
Sunken
Tears
+
↓, eyes sunken
Absent, eyes sunken
Skin turgor
WNL
Decreased turgor
Tenting
Overall condition
Well, alert
Restless, irritable
Lethargic, floppy
Thirst
WNL
Drinks eagerly
Unable to drink
Skin perfusion
WNL
<2sec
Slow 2-4sec, skin cool
to touch
Very delayed >4sec,
skin cool, mottled,
cyanotic
ORAL REHYDRATION THERAPY
(ORT) is a specific procedure intended to rehydrate the moderately dehydrated infant or toddler. Its
advantages over parenteral therapy include fewer complications, lower cost, lower hospitalization
rate, and minimizing the risk of hypernatremia or hyponatremia. Only for child with moderate
dehydration – not severe dehydration. Pedialyte is the most commonly used ORT in the U.S.
ORT
Indications for use of ORT
 Children between 3 mos. and 5 years of age with acute diarrheal illness with or w/o vomiting
 Children with mild to moderate dehydration
 Patient is able to tolerate oral intake
 Normal bedside glucose
Chapter 24: Fluid & Electrolytes, Page 6 of 15
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
Parental ability and willingness to comply with procedure.
Shock
Contraindications:
 Altered mental status
 Severe dehydration
 Parental limitations/ Unreliable home situation
 Excessive vomiting / Uncontrolled diarrhea
 Abdominal distention or absent bowel sounds
 Abnormal bedside glucose
 (Adjusted) Age 3 months or less
 Complicated medical history (premature, cardiac anomalies, AIDS, etc.)
RE-HYDRATION THERAPY for mild to moderate dehydration
 Increase po fluids if diarrhea increases.
 Give po fluids slowly if vomiting.
 Stop ORT when hydration status is normal
 Start on BRAT diet
o Bananas
o Rice
o Applesauce (whole apples NOT apple juice)
o Toast
TREATMENT OF MILD TO MODERATE DEHYDRATION
 ORT (oral re-hydration therapy)
o 1-2 oz per pound divided into frequent feedings of:
 infant: 3-4 oz qh
 child: 1-2 oz qh
o Non-carbonated soda, jell-o, fruit juices, ice pops.
o Commercially prepared solutions are the best: Pedialyte
PARENT TEACHING
 Call PNP/MD
o If diarrhea or vomiting increases
o No improvement seen in child’s hydration status.
o Child appears worse.
o Child will not take fluids.
o NO URINE OUTPUT
o If child is very irritable or any other change in neurologic function
MODERATE TO SEVERE DEHYDRATION: IV Therapy is needed
FLUID REPLACEMENT
 Isotonic fluids initially:
o Normal Saline 0.9%
Chapter 24: Fluid & Electrolytes, Page 7 of 15
o Followed by: Dextrose 5% in 0.45% NS
Potassium is added only after child has voided.
NURSING INTERVENTIONS
 Assess child’s hydration status
 Accurate intake and output (weigh diapers/sheets) 1g of wet diaper = 1mL
 Daily weights
o most accurate way to monitor fluid levels
 Hourly monitoring of IV rate and site of infusion.
o Increase fluids if increase in vomiting or diarrhea.
o Decrease fluids when taking po fluids or signs of edema.
 A severely dehydrated child will need more than maintenance to replace lost fluids. 1½-2
times maintenance.
 Adding potassium to IV solution.
 Never add in cases of oliguria/anuria or if urine output is < 0.5 mg/kg/hour
 Never give IV push
 If adding K+ to IVF double check dosage/amount drawn up with another RN EVEN if this is
NOT your institutions policy. There is no margin of error
K+ overdose = DEATH
FLUID OVERLOAD
 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.
S/S FLUID OVERLOAD
 Tachypnea
 Dyspnea
 Cough
 Moist breath sounds
 Weight gain from edema
 Jugular vein distention
IV THERAPY IN PEDIATRICS
 Use small bags of fluid (250mL/500mL) and buretrol to control fluid volume.
 Check IV solution against physician orders.
 Always use infusion pump so that the rate can be programmed and monitored.
 There are only (2) exceptions to not using an infusion pump in Peds:
o Adolescent who is almost “adult” size (>120lbs)
o Massive trauma with severe hypovolemia (in ER / PICU only)
 Mechanical pumps can fail, IV’s can “blow” ,
o IV bag, site, pump and rate must be checked hourly.
DEHYDRATION
Chapter 24: Fluid & Electrolytes, Page 8 of 15
The excessive loss of water from body tissues. It is a very common occurrence in the pediatric
population whenever total fluid intake is less than total fluid output.
Dehydration is classified by degree and type:
DEGREE
mild, moderate, or severe
TYPE
isotonic, hypertonic, or hypotonic
The main causes of dehydration in the pediatric population are:
 Vomiting
 Diarrhea
 Increased BMR
 Decreased intake
 Diabetic ketoacidosis
 Severe burns
 Prolonged high fever
 Hyperventilation
DEHYDRATION
Physical assessment findings and lab values make the diagnosis of dehydration.



Na+ can ↓ or stay WNL
K+ can ↓ or stay WNL
Cl- level ↓
ASSESSMENT OF THE CHILD WITH DEHYDRATION
Clinical manifestations will depend on the degree of dehydration
 Thirst
 Fatigue
 Weight loss
 Dry MM
 ↓ or absent tear production
 Poor skin turgor
 ↑ capillary refill time
 Depressed fontanel (infant only)
 ↓ UO
 Tachycardia/ Tachypnea
Lab Studies:
 UA with ↑ SG (>1.030)
 CBC: ↑ HCT,  HgB, ↑ BUN
 Alterations in Na+, K+, ClTYPES OF DEHYDRATION
Isotonic:
 Major fluid loss involves extracellular components and circulating blood volume
 Na+ WNL or ↓
Chapter 24: Fluid & Electrolytes, Page 9 of 15

K+ WNL or ↓
Hypertonic:
 Excessive loss of H2O (as compared to electrolytes) fluid shifts from intracellular to
extracellular compartment. Child is at risk for neurological complications.
 Na+ ↓, K+ level varies, and Cl- ↑.
 Highest mortality is associated with this type
Hypotonic:
 H2O shifts from extracellular to the intracellular compartments in an attempt to establish
equilibrium, this shift further increase loss of extra cellular fluid and can lead to shock/
 Na ↓, CL- ↓ and K+ varies.
ISOTONIC DEHYDRATION
Most common type in Pediatric Patients. The major fluid loss involves extracellular components and
circulating vascular volume, this puts the child at risk for hypovolemic shock
Causes:
 Hemorrhage
 GI losses: vomiting, NG drainage, diarrhea
 Fever; diaphoresis
 Burns
 Diuretics
 Third spacing of fluid
Serum Na+ level usually stays normal (130-150)
HYPOTONIC DEHYDRATION (water intoxication)
More fluid is gained - causes an excess of fluid as compared to electrolytes  electrolyte loss
exceeds water loss.
Water shifts from the extracellular to the intracellular compartments, which further increase the loss
of extracellular fluid and commonly results in hypovolemic shock.
Causes:
 Plain water enemas, plain water NG or bladder irrigation
 Overuse of hypotonic IVF or infused too rapidly
 Increased water intake (water gets replaced but not electrolytes - frequently happens with
athletes)
 In young kids/infants occurs frequently when parents add too much water to commercial
infant formula
Serum Na+ decreases (less than 130)
ISOTONIC IV FLUID
 Has approximately the same concentration (osmolatity) as that of extracellular fluid
Chapter 24: Fluid & Electrolytes, Page 10 of 15

Are given to expand ECF volume
Types of isotonic fluid
 Normal saline (0.9 NaCL)
 Lactated Ringers (LR)
 Dextrose 5% in water (D5W)
HYPERTONIC IV FLUID
 Concentration (osmolatity) is higher than that of serum plasma
 Are given to increase the ECF volume and decrease cellular swelling
 Causes cells to shrink and contributes to ECF volume overload.
Types of hypertonic fluid
 5% dextrose in 0.9 % NaCl (D5NS)
 10% dextrose in water (D10W)
 0.3 NaCl
 5% dextrose in water with 0.3 NaCL (D5W 0.3 NaCl)
MILD-MODERATE DEHYDRATION
 Oral rehydration with Pedialyte (or its equivalent) in small quantities (1-2 oz/hr) Pedialyte
promotes reabsorption of Na, H2O and reduces vomiting and diarrhea.
o If child has diarrhea without dehydration, give Pedialyte + normal diet for age
o If child is vomiting give very small amounts of Pedialyte (1-2 teaspoons) q5-10min as
tolerated for 1 hour, increase as child's vomiting subsides.
 DO NOT give fruit juice, soda, sports drinks, chicken or beef broth. They are all very high in
Na+ and glucose and will make the diarrhea and vomiting worse.
MODERATE- SEVERE DEHYDRATION
Restoration and maintenance of adequate hydration and electrolyte balance is the priority goal
of the RN
 Initial fluid replacement consists of fluid boluses of an isotonic fluid at a rate of 20-30mL/kg
(contraindicated in hypertonic dehydration due to the risk of water intoxication)
 Subsequent therapy is used to replace fluid & electrolyte losses. The fluid of choice is usually
a saline solution with 5% dextrose (D5 ½ NS, D5 1/3 NS with or without K+). The selection
of fluid is based on the probable cause of dehydration.
NURSING PROCESS FOR THE CHILD WITH DEHYDRATION:
Nursing Diagnoses:
 Fluid volume deficit
 Fluid volume excess
 Fluid volume imbalance
 Tissue perfusion, altered
 Urinary elimination, altered
Chapter 24: Fluid & Electrolytes, Page 11 of 15

Altered tissue perfusion
NURSING INTERVENTIONS FOR FLUID VOLUME DEFICIT
 Administer O2 as needed
 Monitor VS for hypotension/tachycardia/RR
 Continual assessment of LOC, muscle weakness
 Identify and correct underlying cause
 Identify medications that could be contributing to fluid loss, obtain orders to discontinue,
decrease or change medication
 Weigh daily (same time/same scale)
 Careful evaluation and monitoring of I & O
 IV fluids as ordered
 Encourage po intake
 Monitor hydration status (MM/UO/skin turgor)
 Provide/encourage meticulous oral hygiene
 Monitor electrolytes (serum & urine)
 Monitor color & SG of urine
NURSING INTERVENTIONS FOR FLUID VOLUME EXCESS
 Monitor breath sounds, SaO2 and RR
 Administer O2 as needed
 Monitor neurological status, ability to ambulate, weakness
 Identify and correct underlying cause
 Identify medications, IVF that may be contributing to fluid gains: obtain orders to discontinue
or decrease dose/rate.
 Weigh daily (same time/same scale)
 Careful evaluation & monitoring of I&O
 Monitor for edema
 Administer diuretics as prescribed
 Restrict fluid and Na+ intake
 IV fluids as ordered, monitor IV site
 If child has diarrhea, meticulous care of perineum
 Maintenance of Foley catheter
Parent teaching:
 Anti-diarrheal agents (lopermide) are not for use in children, their use can be fatal
 Reassurance and support
 Teach parents that acute diarrhea may produce temporary lactose intolerance. Avoid lactose
for about 1 week after resolution.
NURSING INTERVENTIONS FOR THE CHILD WITH DEHYDRATION:
RESTORATION and maintenance of adequate hydration and electrolyte balance are the
priority goals of the RN

Initial replacement consists of fluid boluses of an isotonic fluid at a rate of 20-30ml/kg.
Chapter 24: Fluid & Electrolytes, Page 12 of 15
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
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Subsequent therapy is used to replace fluid and electrolyte losses. Usually D5 NS
Correction of the condition that caused the dehydration
Oral rehydration (Pedialyte) in small quantities
o (1-2oz/hr), pedialye promotes reabsorption of Na + H20 (also reduces the amount and
frequency of vomiting and diarrhea)
Chapter 24: Fluid & Electrolytes, Page 13 of 15
DIARRHEA/ACUTE GASTROENTERITIS
 Diarrhea is the passage of frequent, watery, loose stools and is actually a symptom and not a
disease.
 An increase in intestinal motility and rapid bowel emptying results in impaired absorption,
this decrease in absorption causes inflammation of the bowel and a decrease in surface area
for absorption.
 Diarrhea can be acute, chronic, inflammatory, viral or bacterial in nature.
 Electrolytes effected: Na+, K+, CL It can affect any part of the GI tract.
 Diarrhea accompanies many childhood diseases including respiratory infections and GI
disorders.
 The younger the child the more severe and the faster the diarrhea will cause electrolyte
imbalances. In young children untreated diarrhea can lead to hypovolemic shock and death.
 Diarrhea is the leading cause of death in children in the world.
DIARRHEA/ACUTE GASTROENTERITIS
Etiology/Pathophysiology:
It can have many different causes; the specific etiology is not always identified.
 Bacterial infection (e.coli/salmonella/shigella)
 Viral infection (rotovirus/adenovirisu)
 Parasitic infection
 Fungal over growth
 Food sensitivity
 Food intolerance
 Lactose intolerance
 Introduction of new foods
 Stress, anxiety, fatigue
 Overeating
 Medications
 Surgical intervention (SBS)
NURSING PROCESS IN THE CARE OF THE CHILD WITH DIARRHEA
Assessment
 Amount, color, consistency and time of stools
 Strict I & O
 Daily weights
 Child's activity level
 Abdominal cramping, fever
 Skin integrity
 Lab: electrolytes with special attention to Na+, K+, CL Diagnostic test: ova & parasites, rotovirus, bacteria, salmonella, shigella, giardia
Nursing Interventions
 Based on the cause of the diarrhea
 Rehydration first then
 Usually a BRAT diet is prescribed by provider.
Chapter 24: Fluid & Electrolytes, Page 14 of 15
PREVENT dehydration, maintain electrolyte balance
DIARRHEA
 Diarrhea without dehydration = Pedialyte + regular diet
 NO fruit juices, sport drinks, chicken or beef broth (Na & gluc)
 Advance to BRAT Diet as tolerated (bananas, rice. apples ,tea or toast)
BRAT diet
 bananas (fresh or baby food)
 rice (white, plain no salt or butter)
 apples (not apple juice or sauce)
 Tea or toast (no butter or jelly)
Advance to BRAT diet when acute diarrhea has subsided and rehydration is achieved.
VOMITING
The forceful ejection of gastric contents through the mouth, it is a well defined complex and
coordinated process that is under the control of the CNS.
Etiology/Pathophysiology:
 VERY common in children and is usually self-limiting.
 Can be associated with infectious process, ICP, toxin ingestion, food intolerance or allergy,
obstruction in the GI tract, metabolic disorders or psychogenic problem.
 Requires NO treatment unless there are complications (dehydration/electrolyte
imbalance/malnutrition/aspiration).
NURSING ASSESSMENT: VOMITING
The child’s age, pattern of vomiting and duration of symptoms help determine the cause/etiology
 Green bilious vomiting - think bowel obstruction
 Curdled stomach contents, mucous or fatty foods that are vomited several hours after eating
suggest poor gastric emptying time.
 Vomitus that looks like coffee grounds is associated with bleeding
NURSING PROCESS IN THE CARE OF THE CHILD WHO IS VOMITING
Assessment:
 Note /document color, consistency, time
 Daily weights
 Strict I & O
 Activity level
 Abdominal cramping
 Fever
 Lab and dx tests (x-ray’s, sono, endoscopy, electrolytes, bun)
Nursing Diagnosis:
 Fluid volume deficit
 Fluid volume imbalance
Chapter 24: Fluid & Electrolytes, Page 15 of 15
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
Alteration in nutrition: less than body requirements
Aspiration: risk for
Electrolyte imbalance
Nursing Intervention:
 Based on the cause of the vomiting very small amts of Pedialyte (1-2 teaspoons) q1-5 min as
tolerated x 1hr, advance as child tolerates
 NO fruit juices, sport drinks, chicken or beef broth (Na & gluc)
Prevention of electrolyte imbalance, dehydration and aspiration are the priority of all nursing
interventions
SYMPTOMS ASSOCIATED WITH VOMITING
 Fever and diarrhea
 Infection
 Constipation
 Obstruction
 Localized abdominal pain
o Appendicitis
o Pancreatitis
o Peptic ulcer
 Headache/change in LOC
o CNS disorder
o Vomiting without nausea = Brain tumor
 Forceful or projectile
o Pyloric stenosis