Fluids Cha

By
Charity T. Trestiza, MD
IMH PEDIATRIC RESIDENT
Water Overview
•Water comprises
about 60% -70% of the
total body weight
•Varies with
•age
•weight
•gender
Normal Composition in Average Man
•When a person loses more than 10% of his

total body fluids,he can DIE!!!
Functions of Water in the Body
Facilitating cellular metabolism and proper cellular
chemical functioning.
Transporting nutrients to cells and wastes from cells
Facilitating digestion and promoting elimination
Acting as a solvent for electrolytes and

non-electrolytes.
Acting as a tissue lubricant and cushion.
Helping maintain normal body temperature

WATER LOSS
Routes Of Water Loss
- SENSIBLE - INSENSIBLE
Urine Lungs
Feces Sweat
REGULATORS OF FLUID BALANCE
Insensible Water Losses
1. Skin - estimated loss of 300-400 ml/day, by diffusion thru

perspiration 1.5-3.5 L/hour depending on environment or
temp.
2. Lungs - estimated loss of 300-400 ml through expired air (
saturated with vapor).
3. GIT - 200 ml of water lost per day in the feces
1. Kidneys - excretes 120-1500 ml/day in the adult excretion

is proportional to fluid ingested and amount of waste or
solute excreted.
Causes of Increased Causes of Increased
Water Loss Water Gain
• Fever •Increased sodium

• Diarrhea intake
• Diaphoresis •Increased sodium
• Vomiting retention
• Gastric suctioning • Excessive intake of
• Tachypnea water
• Excess secretion of
ADH
MAINTENANCE ELECTROLYTES
Electrolyte meq/kg/24h
Sodium 2-3meq/kg/24h
Potassium 1-2meq/kg/24h
REGULATION OF BODY FLUID COMPARTMENTS
Regulation of Body Fluid Compartments
Tonicity - is the ability of solutes to cause osmotic

driving forces
Filtration - is the movement of water and solutes

from an area of high hydrostatic pressure to an
area of low hydrostatic pressure
Regulation of Body Fluid Compartments
Osmolality - reflects the concentration of fluid that

affects the movement of water between fluid
compartments by osmosis.
Osmotic pressure - is the amount of hydrostatic

pressure needed to stop the flow of water by
osmosis
Fluid Volume Deficit
Involves either volume or distribution of water
or electrolytes:
•Hypovolemia - deficiency in amount of water

and electrolytes in ECF with near normal
water/electrolyte proportions
•Dehydration - decreased volume of water and

electrolyte change
•Third-space fluid shift - distributional shift of

body fluids into potential body spaces
Fluid Volume Excess
Hypervolemia - excessive retention of water
and sodium in ECF
Overhydration - above normal amounts of

water in extracellular spaces
Edema - excessive ECF accumulates in tissue

spaces
Interstitial-to-plasma shift - movement of fluid

from space surrounding cells to blood
TYPES OF IV SOLUTIONS
ISOTONIC solution has the same osmolality as the
extracellular fluid.
Examples: D5W ; Normal Saline
HYPERTONIC solutions have a higher concentration of

solute and are more concentrated than extracellular fluids.
Net movement intracellular to extracellular
Examples : 3% saline; 5% saline
HYPOTONIC solutions have a lower concentration of

solutes and is more dilute than extracellular fluid .Net
movement extracellular to intracellular
Examples :1/2 Normal Saline; 1/3 Normal Saline
Lactated Ringer’s Solution contains Potassium
Isotonic Solution- No potassium content
ELECTROLYTE IMBALANCE
ELECTROLYTE IMBALANCE
SODIUM (Na+)  135-145 mEq/L
Functions
•Maintains osmolality
•Participates in active transport
•Helps regulate body fluids
•Participates in the action potential
Hyponatremia: serum sodium level falls below 130

mEq/L.Cells become swollen.
Hyperkalemia: serum value of >6 mEq/L
Nervous System : Paraesthesia
Neuromuscular: Muscle twitching, muscle weakness, paralysis
Cardiovascular : Bradycardia, Cardiac arrest
DEHYDRATION
defined as "the excessive loss of water

and electrolytes from the body“
Dehydration can be caused by losing too
much fluid, not drinking enough water or
fluids, or both.
• Infants and children are more susceptible to
dehydration than adults because of their smaller body
weights and higher turnover of water and electrolytes.
• So are the elderly and those with illnesses
DEHYDRATION: ASSESSMENT
In order to diagnose the

type of dehydration,
you need to know the
History and you must do
a thorough physical
examination
We classify type of
dehydration depending
on the amount of water
and electrolytes lost.
1. Diminished
sensorium (lethargy)
2. Lack of urine output
3. Cool moist
extremities
4. A rapid and feeble
pulse
5. Decreased BP
6. Peripheral cyanosis
7. DEATH.
Look at
*Lethargic or
:condition* Well , alert *restless,irritable
unconscious;floppy
Eyes Normal sunken
very sunken & dry
Tears Present absent
absent
Mouth and Moist dry
very dry
tongue Drinks *thirsty,drinks
*drinks poorly or not
Thirst normally,not eagerly
able to drink *
Thirsty
*goes back
Feel skin pinch Goes back quickly *Goes back very slowly
slowly*
If the patient has 2

or more signs, If the patient has 2 or
The patient has
including at least more signs, including at
Decide no sign of
1 *signs*, there is least 1 *sign* , there is
dehydration
Some Severe Dehydration
Dehydration
Poor Skin Turgor
Summary of Management According to
Degree of Dehydration
Degree of Amount of Fluid Type of Fluid Feeding
Dehydration
None Vol per vol Suitable home Usual diet or
replacement or fluids (not salty formula,
after each diarrheic or highly continue
stool: sweetened), breastfeeding
50-100 ml (1/4-1/2 ORS, rice water,
cup) if < 2yrs; 100- vegetable or
200 ml (1/2 -1 cup) chicken soup
if 2-10 yrs; ad
libitum for older
children
Summary of Management According to
Degree of Dehydration
Degree of Signs Fluids Feeding
Dehydration
Mild Slightly dry ORS, 30-50 Breastfeeding,
mucus memb., ml/kg in 4-6 hrs full-strength
increased thirst, cow milk or
slightly reduced lactose-contg.
urine flow formula, undil.
lactose-free
formula
Moderate Sunken eyes, ORS, 60-90 Same as above
sunken ml/kg in 4-6 hrs
fontanelle, loss
of skin turgor,
dry mucus
Do not give:
• Very sweet tea, soft drinks, and sweetened
fruit drinks.
• These are often hyperosmolar (high sugar
content).
• Can cause osmotic diarrhea, worsening
dehydration and hyponatremia.
ASSESSMENT OF DIARRHEA PATIENTS FOR DEHYDRATION
A B C
Look at:
CONDITION Well, Alert Restless, Lethargic or unconscious
EYES Normal Irritable Sunken
THIRST Drinks normally, Sunken Drinks poorly, or not able to
not thirsty Thirsty drinks drink
eagerly
FEEL:
SKIN Goes back Goes back slowly Goes back very slowly
PINCH quickly
DECIDE The patient has If the patient has If the patient has two or
NO SIGNS OF two or more more signs in C, there is
DEHYDRATION. signs in B, there SEVERE DEHYDRATION.
is SOME
DEHYDRATION.
TREAT Use treatment Weigh the Weigh the patient and use
Plan A patient, if treatment Plan C.
possible and use
treatment Plan
ESTIMATE THE FLUID DEFICIT
ASSESSMENT FLUID DEFICIT AS % FLUID DEFICIT IN

OF BODY WEIGHT Ml/kg BODY
WEIGHT
No dehydration <5% <50mL/kg
Some dehydration 5-10% 50-100L/kg
Sever dehydration >10% >100mL/kg

TREATMENT PLAN A NO DEHYDRATION
Rule 1. Give the Child more fluids than usual to

prevent dehydration.
Rule 2. Give Supplemental zinc for 10-14 days

TREATMENT PLAN B SOME DEHYDRATION
Amount of ORS required:

Patient’s weight in kg x 75 and give for 4 hours
TREATMENT PLAN C SEVERE DEHYDRATION
AGE First give 30mL/kg in: Then give 70mL/kg

in:
Infants 1 hour 5 hours

(<12months)
Older 30 minutes 2 ½ hours

(>12months)
Repeat once if radial pulse is very weak or not detectable.
*the duration of treatment for infants is longer.

REPLACEMENT THERAPY
DEGREE OF % Fluid Loss CCLINICAL
DEHYDRATION FEATURES
INFANT CHILD
Mild 5% 3% •Sunken eyes
•Depressed anterior
Fontannels
•Dry skin, lips and
tongue
•Mild oliguria
Moderate 10% 6% •Early shock
•Loss of skin
elasticity
•CRT >2 SECS
•Unstable v/s with
marked Oliguria
DEGREE OF % Fluid Loss CCLINICAL
DEHYDRATION FEATURES
INFANT CHILD
Severe 15% 9% •Late shock
REHYDRATION PHASE
Degree of Manner of Fluid to administer
Dehydration and Administration
Volume Fluid
Mild First 6 hours D50.3 Nacl

•Infants (50ml/kg)
•Children (30ml/kg)
Moderate 1st 2 hours D5 LR

•Infants (100ml/kg) ¼ of total
Next 5-6 hours D50.3 Nacl

¾ or remainder
deficit
Degree of Manner of Fluid to administer
Dehydration and Administration
Volume Fluid
Severe First 2 hours D5LR

•Infants (150ml/kg) 1/3 of total
Next 5-6 hours

2/3 or
remainder
deficit
<20kg= D50.3 Nacl

>20kg=D5LR
MAINTENANCE THERAPY
DAILY MANTENANCE FLUID VOLUME
(HOLIDAY-SEGAR METHOD)
0-10kg 100ml/kg
11-20kg 1,00ml+50ml/kg for each >10kg

Or 50ml/kg >10kg
>20kg !,500ml/kg for each >20kg
Or 20ml/kg
<20kg= D5IMB
>20kg=D5NM
Practice Case
A 3 year old boy was admitted at the ER because of diarrhea for 3
days duration, non bloody, non mucoid with 3-4 episodes per day,
each episode amounting to about 30-50cc/ episode
P.E
Wt- 13kg
BP= 90/60mm/Hg
Dry lips and tongue
Sunken Eyeballs
CBS, Tachycardic
Diagnosis? Mild Dehydration

What Fluid to use?
D5 0.3 Nacl
D50.3 Nacl at 30cc/kg(patient is a child) for 6 hours

30ccx 19 cc=390 cc(30cc/kgx13kg) for 6 hours= 65cc/H
Upon re-assessment of the patient: Patient hydration

status improved and with improved appetite, thus put
on Maintenance therapy. What Maintenance fluid will
you start for a 13 kg child?
D5IMB (Using Holiday Segar Method)

1st 10kg= x 100cc 1st 10-1000
2nd 10 kg-150
2nd 10 kg=50cc 1150/24h=47.9 or 48cc/h
THANK YOU
Fluids and Electrolytes Practice Quiz
1. The nurse monitoring a trauma patient

who has a crushing leg wound should
be alert for signs of:
a. Tachycardia
b. Hypernatremia
c. Hypercalcemia
d. Hyperkalemia
60
1. Correct D
Whole blood contains lots of potassium, and

persons with crushing wounds or multiple
trauma may have had K+ released when cells
walls were ruptured.
61
2. When monitoring fluid and electrolytes the

nurse should realize that the major cation
regulating extracellular osmolality is:
a. Sodium
b. Potassium
c. Calcium
d. Magnesium
62
2. Correct A
Sodium is the major cation in extracellular fluid

and regulates extracellular osmolality.
Potassium is the major intercellular cation and

regulates intercellular osmolality. The amount
of Potassium and Sodium with the cells is
regulated by the Sodium-Potassium pump,
located on the cell wall.
63
3. Hypokalemia is a dangerous condition
because it increases the risk of:
a. Dysrhythmia
b. Hyperventilation
c. Seizures
d. Renal shutdown
64
3. Correct A
Potassium has a direct effect on the excitability

of muscle tissue and can alter cardiac
conduction and heart rhythm.
65
4. When apatient is prescribed a low-
potassium diet, they should be taught to
avoid:
a. Whole wheat bread

b. Melons and oranges
c. Green beans and carrots
d. Pears and cranberry juice
66
4. Correct B
Fruit such as Melons, oranges, and bananas are

high in potassium; the other foods listed are
relatively low in potassium.
67
5. When IV fluids
are being administered to a
patient, which of the following assessments
require prompt action by the nurse?
a. Increased urine output

b. Dry hacking cough
c. Moist crackles in the lungs
d. One-side headache with nausea
68
5. Correct C.
Moist crackles in the lungs could be indicative

of pulmonary edema or fluid overload and
should be reported to the physician
immediately. The IV should be slowed to a
"keep open" rate.
69
6. The nurse assesses the patient who is
severely dehydrated and going into shock.
What changes in vital signs are noted?
a. Decreasing blood pressure, decreasing pulse

b. Decreasing blood pressure, increasing pulse
c. Increasing blood pressure, increasing pulse
d. Increasing blood pressure, decreasing pulse
70
6. Correct B.
The early signs of shock that are seen in vital

signs are a drop in blood pressure and an
increase in pulse.
71
7. For a patient in hypovolemic shock,
which is the highest priority nursing
action?
a. Check vital signs every five minutes
b. Start IV fluids
c. Apply a cardiac monitor
d. Administer epinephrine Sub-q
72
7. Correct B.
The first measure in most patients with shock is to replace fluids.

At the onset of shock, the peripheral circulation diminishes,
blood pressure drops, and heart rate increases.
IV fluids help raise the circulatory volume and thereby increase

blood pressure.
73
8. A patient asks the nurse why he needs to be on
I&O. The nurse tells the patient that his fluid
balance is important because:
a. Too little fluid leads to decreased cardiac output

b. Too little fluid causes dehydration; too much,
pulmonary edema
c. Too much fluid causes peripheral edema
d. Too little fluid causes oliguria, which can result in
renal shutdown.
74
8. Correct B
The patient should get about 2,000 ml a day to

prevent dehydration and pulmonary edema.
75
9. A nurse assess hypocalcemia in a post-

operative patient. One sign to look for is:
a. Headache
b. Pallor
c. Tetany
d. Blurred vision
76
9. Correct C
When calcium is low, increased excitability

of the nervous system leads to tetany.
77
10. What change in vital signs would a nurse

assess if a patient developed postural
hypotension?
a. Increase in blood pressure, drop in pulse
b. Increase in blood pressure, increase in pulse
c. Drop in blood pressure, increase in pulse
d. Drop in blood pressure, drop in pulse
78
10. Correct C
Blood pressure drops as the volume of

circulating blood decreases. The pulse rate
increases as the heart attempts to increase
the amount of circulating blood by
pumping faster.
79
11. The physician orders tap water enemas
until clear. The nurse should restrict the
total to three enemas because tap water
enemas can cause electrolyte imbalance.
Which imbalance is of most concern?
a. Hypercalcemia
b. Hypocalcemia
c. Hyperkalemia
d. Hypokalemia
80
11. Correct D
Tap water enemas lead to decreased sodium

and potassium, and can lead to water
intoxication.
More problems are caused by small changes in
potassium levels than by changes in the other
electrolytes.
81

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•When a person loses more than 10% of his

Transporting nutrients to cells and wastes from cells

Facilitating digestion and promoting elimination

Acting as a solvent for electrolytes and

Acting as a tissue lubricant and cushion.

Helping maintain normal body temperature

Routes Of Water Loss

1. Skin - estimated loss of 300-400 ml/day, by diffusion thru

1. Kidneys - excretes 120-1500 ml/day in the adult excretion

• Fever •Increased sodium

Tonicity - is the ability of solutes to cause osmotic

Filtration - is the movement of water and solutes

Osmolality - reflects the concentration of fluid that

Osmotic pressure - is the amount of hydrostatic

•Hypovolemia - deficiency in amount of water

•Dehydration - decreased volume of water and

•Third-space fluid shift - distributional shift of

Overhydration - above normal amounts of

Edema - excessive ECF accumulates in tissue

Interstitial-to-plasma shift - movement of fluid

HYPERTONIC solutions have a higher concentration of

HYPOTONIC solutions have a lower concentration of

Hyponatremia: serum sodium level falls below 130

defined as "the excessive loss of water

In order to diagnose the

If the patient has 2

ASSESSMENT FLUID DEFICIT AS % FLUID DEFICIT IN

No dehydration <5% <50mL/kg

Some dehydration 5-10% 50-100L/kg

Sever dehydration >10% >100mL/kg

Rule 1. Give the Child more fluids than usual to

Rule 2. Give Supplemental zinc for 10-14 days

Amount of ORS required:

AGE First give 30mL/kg in: Then give 70mL/kg

Infants 1 hour 5 hours

Older 30 minutes 2 ½ hours

Repeat once if radial pulse is very weak or not detectable.

*the duration of treatment for infants is longer.

Mild First 6 hours D50.3 Nacl

Moderate 1st 2 hours D5 LR

Next 5-6 hours D50.3 Nacl

Severe First 2 hours D5LR

Next 5-6 hours

<20kg= D50.3 Nacl

11-20kg 1,00ml+50ml/kg for each >10kg

Diagnosis? Mild Dehydration

D50.3 Nacl at 30cc/kg(patient is a child) for 6 hours

Upon re-assessment of the patient: Patient hydration

D5IMB (Using Holiday Segar Method)

1. The nurse monitoring a trauma patient

Whole blood contains lots of potassium, and

2. When monitoring fluid and electrolytes the

Sodium is the major cation in extracellular fluid

Potassium is the major intercellular cation and

Potassium has a direct effect on the excitability

a. Whole wheat bread

Fruit such as Melons, oranges, and bananas are

a. Increased urine output

Moist crackles in the lungs could be indicative

a. Decreasing blood pressure, decreasing pulse

The early signs of shock that are seen in vital

The first measure in most patients with shock is to replace fluids.

IV fluids help raise the circulatory volume and thereby increase