Miss. Wafa Saleh 1

Miss : kamlah 2

Miss : kamlah 3

Case study

• Omar is 10 months old. Several days ago he developed vomiting & diarrhea. His parents tried to get him to eat, but he had little appetite. He drank a little water & few sips of juice, but the next morning he would not drink anything. the diarrhea continued.

• Omar’s mother brought him to the ER, he was irritableon arrival, & his mother reported that he has been alternatively irritable & lethargic. His mucus membranes & tongue appear dry, & skin turgor over the abdomen is slightly decreased. He had two wet diapers per day. And his urine is dark in color.

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• The mother also reported that his weight in the last week was 12 kg. however, when the nurse weighted him, the scale read only 11 kg.

• By assessment, the pulse found to be: 140 b/min apically , blood pressure: 90/50 mmHg on left leg, temperature: 36.5 C axillary, respiratory rate: 35 breath/min. The anterior fontanel is depressed, capillary refill is slow.

• The doctor order to administer him to pediatric floor. Daily weighting, administer I.V,F, monitor V/Ss every four hours, enhance oral intake, measure intake/ output chart. Assess signs of dehydration.

• Also he asked for several blood sampling; CBC, serum electrolytes (K, Na, Cr, urea, glucose).

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Anatomy & physiology

• Fluid in the body is in a dynamic state.It is located in two major compartments:

• Extracellular: fluid outside the cells. Fluid could be within blood vessels (intravascular) or interstitial (between cells). It accounts for one third of the body fluid. It is rich in sodium ions. Fluid move between them by filtration.

• Intracellular: fluid within cells. It accounts for two third of body fluid. It is rich in potassium ions. Fluid move into & out the cells be osmosis.

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Continue…

## Total body fluid ( TBF) expressed as a percentage of body weight that is varies with age .

Newborn infant Child/

adolescent

TBF 75 % 65 % 50 %

ECF 45 % 25 % 5 10-15 %

ICF 30 % 30- 40 % 40 %

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Increase requirement

• Vomiting\diarrhea (increase fluid loss from gastrointestinal system). • renal diseases can influence the rate of fluid excretion. • Burns, fluid evaporation. • Shock, blood loss. • Phototherapy, increase evaporation of body fluid. • Increase Respiratory rate, leads to excessive water loss from lungs.• Fever: increase in metabolic rate which will increase water demand ( each Celsius increase above 37 degrees, 0.42 ml/kg/hr of additional fluid is needed.

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Decreased requirement

• Congestive heart failure, overload on heart.• Syndrome of inappropriate antidiuritic hormone

(SIAH).

• Mechanical ventilation• Post operatively

• Oliguric renal failure • Increased intracranial pressure .

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Assessment guide lines for fluid balance

Assessment focus

Assessment guidelines

Body weight Is the weight decreases since last measurement?

Skin & mucus membrane

What are temp, turgor, moisture of skin?

Cardiovascular & respiratory

What are pulse, respiratory & B/P?, capillary refill.

Gastrointestinal Does child has vomiting, nausea, diarrhea?

Urinary system What is the child urinary output, specific gravity?

Musculoskeletal Describe muscle tone & symmetry?

Neurological system

What is level of consciousness?

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Fluid Volume Imbalances

• When fluid intake & output is not balanced, fluid imbalance occur rapidly.

• The major types of fluid imbalances are:

Extracellular fluid volume deficit (dehydration).

Extracellular fluid volume excess

Interstitial fluid volume excess (edema)

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• ECF deficit occur when there is not enough fluid in the extracelluar compartments (vascular & interstitial).

• Depending on he cause of dehydration, sodium may be normal, low or high, in which dehydration is classified.

Isotonic or isonatremic dehydration.

Hypotonic or hyponatremic dehydration.

Hypertonic or hypernatremic dehydration.

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Hypotonic Isotonic Hypertonic

Na loss > water loss.

Na levels in ECF is low

Fluid shifts from ECF to ICFincrease dehydration

Occur with sever prolonged diarrhea, vomiting, burns, renal diseases.

Na loss = water loss

Na levels in ECF is normal

No shifts of fluid

Occur with diarrhea, vomiting.

Na loss < water loss

Na levels in ECF is high

Fluid shifts from ICF to ECF delay dehydration

Occur with administration of hypertonic IVF

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Causes

• All situations that require increase fluid requirements are consider causes for dehydration.

• Mainly Vomiting & diarrhea.

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Many child with vomiting are suffering from a mild gastroenteritis ( infection) caused by a viral or bacterial organism .

It important that vomiting be described correctly.

Because different conditions are marked by different forms of vomiting , and correct description of the child ‘s actions can aid greatly in diagnosis.

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Its consider the major cause of infant mortality in developing countries, 5 million children die from dehydration related to diarrhea allover the world.

Diarrhea is defined as an increase in the fluidity, volume & number of stools relative to the usual habits of each individual, however it is the consistency rather than the number of stools that is the most important. It could be acute or chronic.

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Normal stool Diarrhea stool

Frequency 1 – 3 daily Unlimited number

Color Yellow Green

Effort Needs effort Effortless

Ph > 7, Alkaline < 7, Acidic

Odor Odor or odorless

Sweet or foul

Presence of blood

Negative occult blood

Positive or negative

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Is differentiated from chronic diarrhea by the fact that it last fewer than 3 weeks in children or 4 weeks in infants. It caused by:

Rotavirus is the most common cause of acute nonbacterial diarrhea ( gastroenteritis)

Bacterial cause include salmonella and shigella(invasive, include damage of intestinal mucosa, occult blood present). Protozoa infections ( Entameba Histolitica). Other infection ( UTI), secondary infection Exposure to enteric pathogens (weaning or picking contaminated objects). Excess sugar or fat in formula.

Acute watery diarrhea

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Usually associated with one or more of the following :-

1- malabsorption.2- anatomic defects3- allergic reaction4- lactose intolerance5- inflammatory process 6- immunodeficiency7- endocrine disorder

Diarrhea may persists more than 14 weeks, it is not chronic but recurrent.

chronic diarrhea

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• Bacteria, protozoa or viruses invade the GIT, will stimulate fluid and electrolyte secretion from the mucosal cells, that will destroy intestinal epithelial and mucosal cells, that results in decreased capacity for fluid and electrolyte absorption due to a smaller intestinal surface area.

Pathophysiology of Diarrhea

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mild diarrhea :-

1- low grade fever.2- irritable3- appear unwell 4- 2-10 times ( loose, watery)5- dry mucous membrane6- normal urine out put7- rapid pulse8- normal skin turgor9- skin feel warm

Clinical manifestations

sever diarrhea :-

1- high grade fever.2- irritable3- appear lethargic4- time of diarrhea every few minutes (liquid green, mixed with blood or mucous)5- dry mucous membrane6- concentrated urine7-Skin cool8- Depressed fontanel, sunken eyes

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If any of the causes listed previously including vomiting or diarrhea become sever or prolonged or associated with more than one cause, it could lead to dehydration.

Dehydration can be mild, moderate or sever.

Each category has different sign and symptoms.

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Clinical assessment

Mild Moderate Sever

Wt loss 5%

(40-50ml/kg)

6-9%

(60-90ml/kg)

10% or more

(100ml/kg)

Consciousness Alert, restless Irritable, lethargic, alert

Lethargic to comatose

Blood pressure Normal Normal or low Low to undetectable

Pulse Normal Normal or rapid Tachycardia or bradycardia

Skin turgor Normal poor Very poor

Mucus membrane

Moist Dry Parched

Urine Normal Decreased output, dark

color, increased specific gravity

Very decreased, or

oliguric

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Clinical assessment

Mild Moderate Sever

Thirst Slightly increased

Moderately increased

Greatly increased

Fontanel Normal Sunken Sunken

Extremities Warm Cool Cool, discolored

Respiration Normal Normal to rapid Changing rate

Eyes Normal slightly sunken deeply sunken

Tears normal decreased absent

Capillary refill normal delayed ( >2sec) absent

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Diagnostic tests

• Clinical observation listed previously, especially weight loss).

• Serum Cr, Glucose, Na, Ca, K,

• BUN ( > 17mg/dl). • ABGs: decrease Ph, low

Bicarbonate (acidosis)• Urine specific gravity (as

fluid level decreased it increased).

• CBC, increase hematocrit.

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Treatment

• Medical management depend on the identification of the degree of dehydration, and acts accordingly.

• Also, identify the cause of dehydration and treat it.

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Continue…

• Identify the cause of diarrhea (stool culture) to find out the pathogen are viral, bacterial or protozoa.

• Bacterial infections are associated with presence of Neutrophile, occult blood (gross blood; shigella).

• Administer broad spectrum antibiotic.

• Treating extracelluar fluid volume deficit is by oral hydration and administration of IVF.

• Oral rehydration therapy (ORT) is used for children with diarrhea and having mild to moderate dehydration.

• Solution contains water, carbohydrate (glucose), sodium, potassium, chloride, & lactate.

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Continue…

• IVF administration in moderate or sever dehydration.

• Start with isotonic solution (Lactated Ringer) then or accompanied with hypotonic solutions (half saline of fifth saline).

• Electrolyte balance.• Intake output chart. • Daily weight. • Monitor V/S every 4

hours unless baby with high grade fever, monitor each ½ hour.

• Monitor sign of dehydration.

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Nursing Management

1- prevent dehydration:

• Weight daily using the same scale, compare weight with previous reading, calculate weight loss.

• Assess signs of dehydration.

• Educate parents about signs of dehydration.

• Measure pulse, level of consciousness, skin turgor, mucus membrane moisture, respiratory rate, B/P, urine specific gravity.

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2- provide oral rehydration:

• Give frequent small amounts (1-3 tea spoon every 10-15 min).

• If the child vomits, instruct the parents to give the child (1 tea spoon) every 2 – 3 min.

• Advise the parents to continue the

child’s normal diet in addition to

providing rehydration therapy solution.

• Tell parents to avoid simple sugar

including juices, jell-O.

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3- Monitor IVF:

• Be sure that the amount of fluid administered corresponds with the child level of dehydration.

• Rapid infusion of 20-30ml/kg is needed over the

1-2 hours then oral rehydration.

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• Fluid volume deficit.

• Risk for ineffective peripheral tissue perfusion related to hypovolemia.

• Risk for injury related to postural hypotension.

• Knowledge deficit (parents) related to causes of dehydration.

• Activity intolerance.

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Occur when too much fluid in the extracelluar compartment, it called saline excess too.

It caused by either IVF overload or by over secretion of the aldesterone hormone from adrenal cortex due to tumors, CHF, liver cirrhosis & chronic renal failure.

Which will lead the kidneys to retain saline (sodium & water) in the body.

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• It characterized by weight gain, bounding pulse, distended neck veins, hepatomegaly, dyspnea, oerthopnea, and lung crackles.

• Treatment started with treating the underlying cause;

• e.g. child with CHF should be given medication to strength the heart ability to contract,

• Diuretics may be given to remove fluid from the body, thus reducing extracelluar fluid volume.

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Nursing Management

• Weight daily. • Measure intake/output, it must

negative balance.• Assess pulse characteristics. • Monitor signs of pulmonary edema

(lung crackles)• Observe edema. • Monitor the child on isotonic

solution to prevent overload. • Provide low sodium diet. • Provide skin care if edema presents.

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• Increase fluid accumulation in the interstitial space leads to edema.

• It has several etiologies. To know it, a view of the normal fluid movement at the capillary level is needed.

• There are main two forces control the movement of fluid in the extracelluar compartments:

1- the hydrostatic pressure.

2- the osmotic or oncotic pressure.

• Hydrostatic pressure moves fluid away (blood hydrostatic pressure moves fluid from capillaries into the interstitial compartment.

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Interstitial Osmotic pressure

Blood Hydrostatic pressure

Blood Osmotic pressure

Interstitial Hydrostatic pressure

1- increase 2- decrease

3- increase

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• Osmotic pressure moves fluid toward it, blood osmotic pressure pull fluid from interstitial into capillaries.

• Any disruption of these forces, will lead to edema.

1- increase in blood hydrostatic pressure :

Occur when increase fluid volume in EC compartmentleads to vein congestion and leads fluid to enters the interstitial compartment Edema.

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2- decrease in blood osmotic pressure:

Any condition (nephrotic syndrome) leads to decrease the plasma proteins leads to decrease the oncotic pressureincrease fluid shift from capillaries into the interstitial compartment Edema.

3- Increase interstitial fluid osmotic pressure:

Entering of large amounts of proteins into the interstitial compartments will leads to increase oncotic or osmotic pressure leading to pulling the fluid in interstitial space Edema.

4- Blocked lymphatic drain:

Normally protein & extra fluid in the interstitial space drain into the lympatic vessels, when blocked (tumor) increase fluid accumelation in the interstitial space Edema.

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Clinical manifestations:

• Edema: ankles if child walk, sacral if the

child supine at bed.

• Shiny, thin skin.

Medical management:

Treat the underlying cause.

Nursing Management:

• observe presence of pitting edema: which is a concave indentation that remains after pressing down ward on an edematous area.

• Daily weight.

• intake/output cart.

•Monitor skin integrity, keep skin clean, dry.

• change position every 2 hours.

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1. Classify the subjective & objective data?

2. List four nursing diagnosis according to the data (prioritized) ?

3. List three nursing interventions in regard education to the parents about the case?

4. What do you expect the results of the serum test the doctor ask to perform? Tests highlighted in the case with underlying line.