Fluids and Electrolytes – Case Study #1 Notes
advertisement
Learning Products & Programs Pediatric Learning Solutions Fluids & Electrolytes: Dehydration Case Studies Learner Guide Introduction These case studies are intended for facilitated group discussions. Learners (e.g., class attendees) should complete the assigned prerequisite Fluids and Electrolytes Series web-based courses and then proceed to reviewing and completing the associated case studies prior to attending the class session. Included in the Learner Guide are Fluids and Electrolytes Formula Tables to assist in determining the degree of dehydration and fluid replacement needs. Agenda Welcome and Introduction Review of Course Objectives and Class Schedule Fluids and Electrolytes Case Studies 1. Collin 2. Suzette 3. Jerome 4. Lori 5. James Course Objectives By the end of the course, you will be able to: Recognize assessment parameters that indicate an alteration in fluid or electrolyte status. Recognize abnormal lab values indicative of alterations in fluid or electrolyte status and implement appropriate interventions. Calculate weight loss and degree of dehydration in patients experiencing alterations in fluid status. Calculate maintenance and deficit replacement of fluids and maintenance electrolytes for patients experiencing isotonic, hypotonic and hypertonic dehydration, water intoxication and fluid shifts. Implement appropriate interventions for patients with assessment findings indicating alterations in fluid and/or electrolyte status. Fluids and Electrolytes Formula Tables Maintenance Fluid Needs Weight (pre-illness weight) Maintenance Fluid Need/24 Hours Newborn (0-72 hours) 60-100 mL/kg 0-10 kg (0-22 lbs) 100 mL/kg >10-20 kg (24-44 lbs) 1000 mL + (50 mL/kg) x (every kg above 10 kg) >20 kg (>44 lbs) 1500 mL + (20 mL/kg) x (every kg above 20 kg) Percent of weight loss: Pre-illness weight (kg) – current weight (kg) = Difference (Difference/ pre-illness weight (kg)) X 100= % Weight Loss Degree of Dehydration Degree Infant and Young Children Older Children and Adolescents Mild Percent of Weight Loss <5% Percent of Weight Loss 3-5% Moderate 5-10% 6-8% Severe 11-15% 9% Assessment of Dehydration Mild Moderate Severe Area of Assessment Infant 5% loss Children 3% loss Infant 10% loss Children 6% loss Infant 15% loss Children 9% loss Thirst Slight Moderate Intense Anterior Fontanel Flat Depressed Very sunken Skin Pale, cool Grayish Cool, pale, mottled* Blood Pressure Normal Decreased Low* Pulse Slightly increased Increased, weak Tachycardia (rapid, thready, feeble)* Respirations Normal Normal to rapid Deep and rapid Skin Turgor Decreased Loss of elasticity Very poor Mucous Membranes Normal to dry Dry Dry, cracked Eyes Normal Somewhat depressed Grossly sunken Tears Present Decreased Absent Urine Output Decreased Oliguria Prerenal azotemia Behavior Normal, alert, possibly some restlessness Irritable, restless or lethargic Hyperirritable to lethargic, limp * Key symptoms of circulatory shock Dehydration Type of Dehydration Serum Sodium Value Isotonic 130-150 mEq/L Hypotonic <130 mEq/L Hypertonic 150-160 mEq/L Fluid deficit Calculation: (Percent weight loss*) X 10 mL/kg (pre–illness weight) = Fluid deficit Fluid Deficit Replacement Calculation: (Pre-illness weight (kg) X percent of weight loss*) X 10ml (Pre-illness weight (kg) X percent of weight loss*) X 20ml *Percent of weight loss is written as a whole number for these calculations Fluids and Electrolytes Formula Tables Electrolyte Maintenance Formulas Using Weight Electrolyte Daily Maintenance Need Sodium 2-4 mEq/kg*/24 hours Potassium 2-3 mEq/kg*/24 hours For practice purposes, use value of 3 mEq sodium/kg and 2 mEq potassium/kg *Pre-illness weight Electrolyte Maintenance Formulas Using Fluid Replacement Volume Electrolyte Daily Maintenance Need Sodium 2-4 mEq/100mL water Potassium 2-3 mEq/100mL water For practice purposes, use value of 3 mEq sodium per 100mLs fluid and 2 mEq potassium per 100mLs fluid Fluids and Electrolytes Formula Tables Standard Intravenous Fluid Composition per liter Type of Fluid Sodium Chloride Normal Saline (0.9%) 154 mEq 154 mEq 5% Dextrose in Water Ringer’s lactate Glucose 278 mmol/L 130 mEq 109 mEq Critical Thinking Exercises for Dehydration Case Study #1, Collin Collin is a 6-year-old male brought into the ED with a chief complaint of “fever and vomiting.” It is the middle of January (flu season) and the waiting room is packed. You are the triage nurse assessing Collin. His vital signs are: Temp: 100.9 Heart rate: 160 Respirations: 24 Blood pressure: 100/60 Current weight: 44 lbs (20 kg) As you proceed with your assessment, you note that Collin is fully alert and responsive, his mucous membranes are dry, but his lips are pink and smooth and his skin is pale and cool. Collin’s mother states that he weighed 47 lbs (21.4kg) on his last pediatric appointment, which was two weeks ago. The last time that she is certain he voided was the previous evening. The physician ordered a chemistry panel on Collin. The initial results have just been reported: Na = 150 Glucose = 60 K = 3.1 Total Ca = 9 Cal = 115 Mg = 1.6 CO2 = 20 BUN = 30 Creat = 0.9 Fluids and Electrolytes – Case Study #1 Notes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Critical Thinking Exercises for Dehydration Case Study #2, Suzette Suzette, age one month, is admitted to your unit from the ED with a history of seizures of unknown origin. She is currently postictal. Her admission lab work is: Na = 120 Glucose = 45 K = 4.2 Total Ca = 10.0 Cl = 85 Mg = 2.0 CO2 = 28 BUN = 5.0 Creat = 0.2 Suzette’s mom reports that she started vomiting after her feedings three to four days after her twoweek well baby appointment. She checked for a fever, but Suzette was never febrile. The amount (small amount after each feeding) and frequency of vomiting hasn’t changed over time, but her mom was concerned that she was not getting enough nutrients and fluids, so she was giving her bottles of water between feedings. She had made an appointment to see the pediatrician this afternoon. Suzette appears lethargic. Her skin is gray, slightly mottled and cool to touch. Her capillary refill is 5 to 6 seconds and her heart rate is 220. Her skin tents when pinched. According to records at the pediatrician’s office, she weighed 8 pounds (3.6 kg) at her two-week check-up. Fluids and Electrolytes – Case Study #2 Notes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Critical Thinking Exercises for Dehydration Case Study #3, Jerome Jerome, age 4 months, was brought in by his father. According to his father, Jerome has had vomiting and diarrhea for three days. Today, Jerome has been irritable when awake. His father says he has had very little intake of formula – one or two sucks and then he does not want any more. He has not shown interest in any of his toys; he just wants to be held. He had two small stools early this morning, both of which were liquid green with some red flecks. He has not had any urinary output in the last four hours, although his diaper was wet when he woke up this morning. On her assessment of Jerome, the pediatric nurse practitioner notes that Jerome’s weight is 11.4 lbs (5.2 kg). Clinic records indicate his last weight two weeks ago was 13 lbs (5.9 kg). His skin is cool, dry and slightly grayish in appearance. Some tenting is present. His mucous membranes are dry and his anterior fontanel is slightly depressed. Jerome’s heart rate is 150/minute, his respirations are 45/minute, and his temperature is 99.6°F (36.6°C). Blood was drawn to check Jerome’s electrolytes. Fluids and Electrolytes – Case Study #3 Notes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Critical Thinking Exercises for Dehydration Case Study #4, Lori Lori, age 3, had been suffering with diarrhea for 72 hours at the time her parents took her to the pediatrician. According to her parents, she had at least 8 to 10 liquid, yellow to green stools each of the past three days. They did not give her any solids or milk products, on the advice of the pediatrician. The only clear fluids they had available were weak tea and water, to which they added a little sugar. When Lori was brought in, she appeared very dehydrated. Her skin and mucous membranes were dry and the skin on her abdomen tented when pinched. Her eyes appeared dull and gray. She was lethargic, though she responded to questions. Her parents were uncertain if she had voided during the past 12 hours. Her weight at the time of admission was 13.6 kg. According to records at the pediatrician’s office, she weighed 32 pounds (14.5 kg) at her last visit, two weeks previous. Lori’s physician admitted her to the hospital. Intravenous fluids of 5% Dextrose/0.2% NS with 20 mEq KCl/L were started, to run at 50 mL/hr. Fluids and Electrolytes – Case Study #4 Notes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Critical Thinking Exercises for Dehydration Case Study #5, James James is an 11-month-old infant who has been in good health since birth. Although he has had liquid stools for the past four days, he has continued to ingest his powdered formula with seemingly little change in pattern. For this reason, his parents felt that there was little cause for worry. However, this morning the parents have brought James to the emergency room. They said he was acting very irritable, cried and fussed constantly, and could not be consoled. He refused all offers of formula. His mother said the area around his eyes looked “dark and funny” and she thought his skin felt “heavy.” She also said that the skin over the opening on top of his head had gone inward. James’ extremities appear rigid even at rest, and his father said he saw James’ right arm and leg twitching. Frightened by all of these changes, the parents decided to bring James to the emergency room. Your assessment of James confirms grayish skin with a doughy feel, dark eyes, sunken fontanel and irritability. His extremities are warm and the pulses are strong and equal bilaterally. The extremities are rigid with occasional twitching. His weight is 8.6 kg. His vital signs are slightly elevated above the normal ranges. James has not voided in the past four hours. Fluids and Electrolytes – Case Study #5 Notes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Learner Feedback Name and Hospital ___________________________________________ Date ___________________________________________ Directions: Answer how well you agree with the following statements using the rating scale listed below. Add comments to more fully explain your answers. 1. Strongly Disagree 2. Somewhat Disagree 3. Somewhat Agree 4. Strongly Agree The online courses provided content that I found useful/relevant to this facilitated session. 1 2 3 4 Comments: Having a live, facilitated session following the online course was helpful to me. I feel confident about applying this knowledge. 1 2 3 4 Comments: The content of this class was clear and easy to understand. 1 2 3 4 Comments: Learner Feedback The length of the class was appropriate for the content presented. 1 2 3 4 Comments: My organization provided me with sufficient time to take this class. 1 2 3 4 Comments: Suggestions for improving this class: Give this completed form to your class facilitator.
