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Differences between Adults and Children
- Greater % of body weight that is fluids
- Body surface area is much greater in children compared to adults
- Increased metabolic rate compared to adults
- Kidney function (under 2 years) immature
- Greater daily fluid requirement
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Greater % of Body Weight that is Fluids
- 75-80% - infants
- 65-70% - children
- 60% - adults (usually around 15 years old)
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Body Surface Area is Much Greater in Children Compared to Adults
- Preemie has 5x greater than an adult
- Newborn has 2-3x greater than an adult
- Larger loss of fluids through skin
- More susceptible to dehydration and fluid overload
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Increased Metabolic Rate Compared to Adults
- Growing: uneven pattern throughout childhood
- More physically active
- Fever: increases fluid loss approximately (7ml/kg/24 hours for every 1 degree F)
- Inability to shiver or sweat to control temperature
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Kidney Function (under 2 years) Immature
- Inability to concentrate or dilute urine due to immature homeostatic regulation (this effects ability to conserve or excrete sodium or calcium)
- Inability to acidify urine
- For adequate hydration the minimum output is: 1-2 ml/kg/hr
- Acidifying urine is important because it helps fight infections
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Greater Daily Fluid Requirement
- Little reserve and body water must be replenished
- Fluids needs are often linked with caloric needs
- 3-10 kgs = 100 ml/kg
- 10-20 kgs = 1000 ml + 50 ml/kg for each over 10 kg
- >20 kgs = 1000 ml + 20 ml/kg for each over 20 kg
- Changes with specific disorders such as: fever, diarrhea, vomiting, burns, tacypnea
Only takes 5% fluid loss before they become dehydrated
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Intracellular Fluid (ICP)
- The fluid inside the cell
- High is proteins and potassium
- Low in sodium
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Extracellular Fluid (ECP)
- All the fluid outside of the cellular walls
- Proteins are high in intravascular but low in interstitial
- High in sodium
- Low in potassium
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Extracellular Fluid Volume Deficit (Dehydration)
- Most common with children
- Shifts between water and electrolytes
- Common causes: vomiting, diarrhea, not taking enough fluids
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Dehydration Manifestations
- Tachycardia
- Tachypnea
- Decreased B/P (often later sign)
- Sunken Fontanels
- Dry skin and mucus membranes, no tears
- Cool or mottling of extremities
- Loss of skin elasticity (poor skin turgor)
- Decrease or lack of urine output
- Weight loss
- Fatigue or lethargic
- Thirst
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Complications from Dehydration
- Hypovolemic Shock: compensated, decompensated (low B/P, high HR)
- Shifts in Acid-Base Status: metabolic acidosis, metabolic alkalosis
- Shifts in Electrolyte Status (esp. Na+ and K+): for every 0.1 until fall in pH, serum K+ increases by 0.5 mEQ/L
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Dehydration Goals
- Improve circulatory function:
- Oral/NG replacement fluids
- IV solutions (NS/LR)
- Blood/plasma
- Electrolyte balance
- Acid-Base balance
ASSESS AND REASSESS
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Edema
- Interstitial fluid volume excess
- Movement of fluids by:
- filtration (pressure)
- osmotic pressure (concentration)
- hydrostatic pressures (pump)
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Edema Manifestations
- Increased Blood Hydrostatic Pressure
- Decreased Blood Osmotic Pressure
- Increased Interstitial Fluid Osmotic Pressure
- Blocked Lymphatic Drainage
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Increased Blood Hydrostatic Pressure
- Extracellular fluid volume excess
- Increased fluid volume in the vascular compartment
- Fluid moves from greater pressure to less which is the insterstial compartments: increased capillary flood flow (local infection); venous congestion (right side heart failure)
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Decreased Blood Osmotic Pressure
- Normally, albumin and other plasma proteins pulls fluids into the capillaries
- Increased albumin excretion (ex. nephrotic syndrome)
- Decreased albumin synthesis (ex. liver disease, starvation)
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Increased Interstitial Fluid Osmotic Pressure
- Normally there is a low osmotic pressure in the interstitial fluid
- A shift occurs in the capillary permeability
- Increased capillary permeability: burns, hypersensitivity reactions, septic shock, distributive shock
- Distributive Shock: hot and warm; vasodilation and increase in cardiac output as a reaction to foreign substances (septic or anaphylaxis)
- Distributive Shock S/S: fever, tachycardia, tachypnea, BP and urine are normal in compensated shock, flush face, chills
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Blocked Lymphatic Drainage
- Lymph vessels normally drain small proteins and excess fluids from the interstitial to the blood vessels
- Ex. tumors, bruising
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Goals in Edema Care
- Improve Circulatory Function
- maintain perfusion
- monitor edema
- abdominal girth
- monitor behavior and neurological changes
- daily weight
- I&O
- specific gravity
- Maintain Positive Body Image
- Manage Pain
- Maintain Skin Integrity
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Nephrotic Syndrome
- Not a disease, unsure of cause
- There is an alteration in the glomeruli permeability due to the fusion of the glomeruli membrane surface in the kidneys
- Not enough albumin
- Can be secondary (ex. w/lupus) or rare (congenital)
- Three basic types: congenital (rare); secondary, often associated with lupus; minimal change or idiopathic
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Minimal Change Nephrotic Syndrome
- Usually males (2:1) ages 1-8 years especially preschoolers
- 4 Major Characteristics
- Proteinuria: losing albumin in urine
- Edema: low levels of protein in intravascular change osmotic pressure so fluid in interstitial tissue
- Low Serum Albumin: activates liver for protein loss
- Hyperlipidemia: high cholesterol levels to compensate for low hypoalbuminemia
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Nephrotic Syndrome Manifestations
- Loss of appetite yet weight gain
- Diarrhea
- Skin pallor, fatigued/lethargic
- Edema: abdomen and eyes
- Decreased volume of urine
- Protein in urine dipstick; high specific gravity
- Low B/P due to decreased volume
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Treatment in Nephrotic Syndrome
- Rest
- No fluid restriction (if primary cause)
- High dose steroids or immunosuppressants b/c trying to turn off immun system and stop attacking own body
- Albumin and Lasix-give first albumin to pull fluid back into vascular space and then give lasix
- Skin Care
- Body Image, psychosocial for distorted body image
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Urinary Tract Infections
- Greatest Risk Factor: Stasis of Urine
- Other risk Factors:
- girls
- hygiene habits
- sexual activity
- clothing
- structural risks (neurologic bladder; VUR-Vesicoureteral reflux/reflex)
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UTI Clinical Manifestations
- Incontinence in toilet trained child
- Strong smelling urine
- Frequency and/or urge to void
- Persistent diaper rash
- Temperature (complications-hydronephrosis, pyelonephritis)
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Complications of UTI
- Hydronephrosis
- Pyelonephritis
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Goals in Urinary Infections
- Maintain integrity of urinary tract system
- Teaching, prevention
- Oral intake
- Medications
- Surgical interventions
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Epispadias
Urethra located on the dorsal (or superior) surface of penis
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Hypospadias
- Urethra located on the underside (ventral surface) of penis
- 1:300
- Treatment: straighten penis for pscho-social-sexual reasons; foreskin used for repair
- Urethra works without surgery
- Surgery needs to be done in first 1-2 years to decrease psychological problems
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Hypospadias Considerations
- No circumcision-foreskin is used for repair
- Pain (bladder spasms; constipation)
- Maintain surgical repair (double diaper)
- Home care (stents or foleys/limited mobility)
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Cyptorchidism
- Undescended Testes
- 3 Major Factors: low birth weight, prematurity, hypospadias
- Bilateral or unilateral
- 3-4% normal births
- 30% of preterm babies
- 75% descend spontaneously by 3 months
- Orchiopexy done usually close to 1 year
- Boys can also often have inguinal hernias with cryptorchidism
- There is 20-40% increase risk for testicular cancer if history of cryptorchidism
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