Chapter 15: Fluid Imbalance
• Dehydration: Infants
• Subject to greater evaporation of water from skin
• Rapid respirations increase fluid loss
• When diarrhea is present, additional fluid is lost
• Immature infant kidneys = poor water conservation
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Fluid Imbalance
• Classification of dehydration is based on serum
sodium levels
– Isotonic
– Hypotonic
– Hypertonic
• Maintenance therapy vs. deficit therapy
– Adjusted continually for patient’s condition
• Oral fluids
• Parenteral fluids
– Given by route other than digestive tract
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Fluid Imbalance
• Overhydration
– Body receives more fluid than it can excrete
– Can occur in patients with normal kidneys who receive
intravenous fluids too rapidly
– Can also occur in a patient receiving acceptable rates
of fluid, especially when the patient’s illness is related
to disorders of fluid movement
– Edema: presence of excess fluid in the interstitial
spaces
• Edema in infants may first be seen about the eyes and
in the presacral, occipital, or genital areas
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Urinary Tract Infection
• Description
– Bacterial invasion of the upper urinary tract (kidney
and ureters) or lower urinary tract (bladder and
urethra)
• Vesicoureteral reflux
– Primary contributing factor to upper UTIs
• Rated I-V
– Malfunctioning valve at the junction of the ureter and
bladder lets urine reflux up the ureters toward the kidney
– Bacteria from urine can cause pyelonephritis and renal
damage
– Diagnosed via ultrasound and voiding cystourethrogram
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Urinary Tract Infection
• Signs and symptoms
– Poor feeding, fussiness, delayed growth, foulsmelling urine, and incontinence (in a child who
has been previously trained)
– Many adolescent girls exhibit classic signs of UTI
(frequency, urgency, pain on urination, blood in
the urine) after the first episode of sexual
intercourse
– High fever, chills, flank pain, and abdominal pain
can indicate kidney infection (pyelonephritis)
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Urinary Tract Infection
• Treatment and nursing care
– 7- to 14-day course of an appropriate antibiotic,
generally sulfamethoxazole-trimethoprim (Bactrim,
Septra)
• Penicillins and cephalosporins may also be ordered
– Nurses need to teach proper hygiene
• No bubble baths or irritating diaper wipes
• Wiping from front to back
– Other preventive measures include wearing cotton
underwear, adequate fluid intake, encouraging
children to not put off going to the bathroom when the
urge is felt, investigating and treating signs of
intestinal parasites (pinworms)
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Acute (Post-streptococcal)
Glomerulonephritis
• Description
– Occurs as an immune reaction caused by a Group A
beta-hemolytic streptococci
• Signs and symptoms
– Urine is smoky brown in color or bloody
– Periorbital edema in the morning; edema spreads to
the abdomen and extremities due to gravity
– The child may have fatigue, headache, abdominal
discomfort, and vomiting
Oliguria: Decreased urine output, often caused by
sodium/fluid retention
Anuria: body’s suppression of urine formation; may
necessitate dialysis
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Acute (Poststreptococcal)
Glomerulonephritis
• Treatment and nursing care
– Prevent the child from becoming overtired,
chilled, or exposed to infection
– A low-sodium diet may be ordered
– Furosemide (Lasix) if significant edema and fluid
overload are present and renal failure is not
severe
– Penicillin is given if the streptococcal infection
persists, but it usually does not alter the course of
the disease
– Persistent anuria may necessitate dialysis
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Nephrotic Syndrome (Nephrosis)
• Refers to a number of different types of kidney
conditions that are distinguished by the presence of
marked amounts of protein in the urine
• Signs and symptoms
– The characteristic symptom of nephrosis is
edema
– The edema shifts with the position of the child
during sleep
– The urine appears dark and frothy
– Urine output can be decreased
– Vomiting and diarrhea may also be present
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Nephrotic Syndrome (Nephrosis)
• Treatment and nursing care
– Control of edema—steroids, diuretics, and
albumin
– Diet—well-balanced; high protein; salt
restricted
– Fluid balance—the patient’s urine must be
carefully measured; weight pt daily
– Care of the skin—good skin care is especially
important during periods of marked edema
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Nephrotic Syndrome (Nephrosis)
• Treatment and nursing care (continued)
– Positioning— repositioned frequently to
prevent respiratory infection and skin
breakdown
– Infection prevention—assessment for and
protection from infection is critical
– Emotional support—parental guidance,
education and support should be given by all
members of the nursing team
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Enuresis
• Bed-wetting
– Primary: child has never been dry for an extended
period of time
– Secondary: bed-wetting after the child has been dry
– Family history
• Child should never be punished
• Time is usually all that is needed; out grow it
• Therapy includes medications, fluid restriction
after evening meal, waking a child to void, bladder
training, bed pad alarms upon initiation of voiding
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Hydrocele
• An excessive amount of fluid in the sac that
surrounds the testicle; causes the scrotum to
swell
• Common in the neonate, and in many cases,
the condition corrects itself as the baby grows
• If a chronic hydrocele persists in the older
child, it is corrected with surgery
• Routine postoperative nursing care is given
• Same-day or outpatient surgery may be
arranged
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Undescended Testes (Cryptorchidism)
• Description
– One or both testes fail to descend into the scrotum
• Because the testes are warmer in the abdomen
than in the scrotum, the sperm cells begin to
deteriorate
• Treatment and nursing care
– Occasionally, spontaneous descent of the testis or
testes occurs during the first 6 months of life
– If this does not happen, treatment is recommended at
9 to 15 months
– The testis or testes can be brought down to the
scrotum with a surgical intervention called orchiopexy
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Hypospadias and Epispadias
• Description
– Hypospadias—the urinary meatus appears on
the ventral or underside of the penis’ shaft
– Epispadias—the urethral opening is on the
dorsal or upper surface of the shaft
• Treatment and nursing care
– Surgical repair is usually performed between
6 and 12 months of age using the foreskin
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Dysmenorrhea (Primary)
• Description
– Painful menstruation; denotes pain associated
with the menstrual cycle in the absence of
organic pelvic disease
– Secondary dysmenorrhea: Patient may have
an underlying condition such as
endometriosis, PID, ovarian cysts, adhesions,
congenital abnormalities
– Mittelschmerz: Midcycle pain during
ovulation
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Dysmenorrhea (Primary)
• Signs and symptoms
– Cramping, abdominal discomfort, and leg aches, all of
which begin at the onset of menses
– Systemic symptoms such as nausea, vomiting,
dizziness, diarrhea, backache, and headache
– Premenstrual syndrome: symptoms overlap with
dysmenorrhea, but include weight gain, breast
tenderness, irritability, and insomnia
• Treatment and nursing care
– Ibuprofen or naproxen should be taken every 4 hours;
usually 2 to 3 days of medications are required
– Warm heating pad applied to the lower abdomen
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Sexually Transmitted Diseases
• Chlamydia infection
– Most common STD in the U.S.
– Often asymptomatic
• Gonorrhea
– Anaerobic bacterium
– GC, clap, a dose, strain, the drip
– Men: Symptoms within 2-7 days of contact
• Painful urination, pus discharge, inflamed scrotum
– Women: 80-90% asymptomatic
• Mild burning in genital area, possible yellow discharge, swelling
of Bartholin glands, abdominal discomfort. Can cause PID.
– Minors can receive free, confidential treatment without
parental consent from the city/state health department, or
most physicians
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Sexually Transmitted Diseases
• Syphilis
– Caused by spirochete Treponema pallidum
– Can be passed to unborn children
– Incubation period: 10-90 days
• Stages of syphilis symptoms
– Primary: chancre sores where spirochete enters the
body
– Secondary: begins 4 weeks to 6 months after
infection. Disease enters a latent period if left
untreated
– Tertiary: After the fourth year. Spirochetes attack
heart, blood vessels, brain, spinal cord
• Insanity and blindness, crippling or paralysis, death
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Sexually Transmitted Diseases
• Genital herpes
– Herpes simplex virus (HSV) type II frequency
among teenagers is increasing
– Lesions can persist for 3-6 weeks
– Fever, headache, malaise, anorexia
– HSV Type II can be passed to infants via the
birth canal
• Cesarean section is generally performed
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Sexually Transmitted Disease
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Sexually Transmitted Diseases
• Treatment and nursing care
– Hospitalization is uncommon
– Nurses need to create a comfortable
environment and approach teenagers without
judgment
– The reporting of sexual contacts, required by
law, often prevents patients from seeking
help; assuring confidentiality is important
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Acquired Immunodeficiency Syndrome
(AIDS)
• Signs and symptoms
• Failure to thrive, chronic diarrhea, repeated respiratory
infections, oral candidiasis, and enlargement of the liver
and spleen
• Treatment and nursing care
– There is no cure for AIDS
– Several antiviral drugs are being used for treatment in
children
– Assessment for signs of infection, including vital signs, and
observation of the skin and general condition of the child
should be done routinely
– Due to immune suppression, signs of inflammation/
infection may be suppressed
– Psychological support of the child and family is critical
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