ADMINISTRATION OF IV FLUIDS

PROCEDURE

SUBMITTED TO: MRS SHAILAJA MADAM

ASST.PROFESSOR,

CHILD HEALTH NURSING

SUBMITTED BY: BUSHRA JABEEN

MSC (N), CHN, 1ST YR

SUBMITTED ON: 24-0 -2019.

INTRODUCTION

Water is the largest single component of the body comprising approximately 75% of total body
weight in the term newborn Total Body Water (TBW) fall during early infancy to about 60% of
body weight by 4 to 6 months of age. A more gradual reduction in TBW then occurs approaching
adult values of 50 to 60% at puberty

CLINICAL ASSESSMENT FOR DEHYDRATION

 Clinical assessment therefore comprises some of the following indicators of dehydration:

Loss of body weight:

 Normal: no loss of body weight.

 Mild dehydration: 5-6% loss of body weight.
 Moderate: 7-10% loss of body weight.
 Severe: over 10% loss of body weight.

Clinical features of mild-to-moderate dehydration; 2 or more of:

 Restlessness or irritability.
 Sunken eyes (also ask the parent).
 Thirsty and drinks eagerly.

Clinical features of severe dehydration; 2 or more of:

 Abnormally sleepy or lethargic.

 Sunken eyes.
 Drinking poorly or not at all.
 Pinch test (skin turgor): the sign is unreliable in obese or severely malnourished children.
 Normal: skin fold retracts immediately.
 Mild or moderate dehydration: slow; skin fold visible for less than 2 seconds.
 Severe dehydration: very slow; skin fold visible for longer than 2 seconds.
 Other features of dehydration include dry mucous membranes, reduced tears and
decreased urine output.
 Additional signs of severe dehydration include circulatory collapse (e.g. weak rapid
pulse, cool or blue extremities, hypotension), rapid breathing, sunken anterior fontanelle.
MAINTENANCE THERAPY

Maintenance fluid requirements are the quality of fluid and electrolytes necessary to achieve zero
water and electrolytes balance water loss occurs from two main sources:

1. Insensible (evaporative)

2. Urine

Approximately two thirds of evaporative fluid losses occur through the skin, with the remainder
being lost through the respiratory tract. Infants and children on mechanical ventilators or in mist
tents do not lose water through respiratory tract and actually receive water while inspiring
humidifies air. On the other hand, hyperventilation or hyperthermia will increase insensible losses.
Under normal conditions, insensible losses comprise 30 to 40% of maintenance fluid requirements.
Evaporative water loss increase by approximately 12% per degree of fever above 38C. The factor
known to influence insensible water losses are hyperthermia, increased activity, hyperventilation,
radiant warmers and phototherapy.

BODY FLUIDS

Stable internal environment is maintained by the balance of body water and electrolytes
disturbances in the fluid and electrolytes balance is very common problem usually found in
association with several disease conditions. Growing children are more susceptible to disturbances
of fluid and electrolytes balance during their illness correction of imbalance and maintenance of
fluid and electrolyte balance are the prime importance for the management of any disease
conditions.

Water is the largest component of human body. Total Body Water (TBW) in full term neonates
is approximately 73 to 80% of body weight and gradually reduces to 60% by one to two years of
age.

Total body water consists of two compartments- intercellular fluids(ICF) and extracellular fluids
(ECF) and two minor compartments- transcellular fluid (TCF) and slowly exchangeable fluid
(SEF) compartments. ICF volume represents 35 - 40% of body weight and is the sum total of fluids
from the cells in different locations, ECF volume represents 20-25% of body weight and consists
plasma water and interstitial water. TCF volume represents about 2% body weight; its most
important components being gastrointestinal secretions', urine in kidney and lower urinary tract,
CSF, aqueous, humor and synovial, pleural and peritoneal fluids. SEF volume represents 8-10%
of body weight and is combined in bones, dense connective tissues and cartilages

Sodium and chloride are the principal electrolytes in the ECF, while potassium and phosphates
are the principal electrolytes in the ICF.

HYPOTONIC SOLUTIONS

It provides more water than electrolytes diluting the ECF. Osmosis than produces a movement
of water from the ECF to the ICF For example 0.45% Nacl.

ISOTONIC SOLUTIONS

Administration of isotonic solution expands only the ECF. There is no net loss or gain from the
ICF An isotonic solution is the ideal fluid replacement from a patient with an ECF volume deficit.
For example, 0.9% Nacl,RL. These solutions have sodium concentration somewhat higher than
plasma and chloride concentration.

HYPERTONIC SOLUTIONS

These solutions initially raise the osmolality of ECF and expand it. It is useful in the treatment of
hypovolemia and hyponatremia. For example,10% dextrose solutions, 5% DNS.

MANAGEMENT OF DEHYDRATION

In severe dehydration rapid expansion of intravascular volume is required to maintain vital

functions. This is achieved by rapid intravenous infusion of 100-120 mL/kg of isotonic iso-
osmotoic solution. Ringer lactate or normal saline (or) plasma.

DEHYDRATION
 It is the fluid imbalance due to excessive loss of body water. Dehydration can be hypotonic,
isotonic or hypertonic. The common type is isotonic dehydration with proportion loss of water and
solutes from ECF. The ICF volume remains intact as there is no redistribution of fluid.

In hypotonic dehydration, the depletion of solutes in ECF is much more than the water losses.
Hypotonicity of ECF leads to shift of water from EDF to ICF causing further contraction of ECF
and shock

In hypertonic dehydration , excess loss of water proportionate to the solutes causing

movement of water from the cells in the ICF- leading to intercellular dehydration

ELECTROLYTE IMBALANCE

Hyponatremia is termed when serum sodium level is less than 130mEd/L. It occur due to water
retention, sodium loss or both.

MANAGEMENT

Administering 3% solution of sodium chloride (saline),10 mL/kg body weight at the rate of 1ml
per minute intravenously to correct the sodium deficit. Calculated extra sodium should be
administered slowly in 24 to 48 hours.

HYPERNATREMIA

When serum sodium is more than 150 mEq/L. It results from deficit of water with respect to
sodium stores due to water loss in diarrhea, vomiting, dieresis, burns or excessive sodium intake.

MANAGEMENT

Hypernatremia should be treated promptly with rapid intravenous infusion of ringer lactate or
saline to correct hypovolemia.

HYPOKALEMIA

The serum potassium level less than 3.5 mEq/L.

MANAGEMENT

Slow administration of potassium over 24-28 hours. Potassium infusion should be given using
infusion pump at the rate of 0.3 - 0.35 mEq/kg/h till the ECG become normal. Infusion rate should
not exceed 0.6 mEq/kg/h. Infusion fluid should not contain more than 40 mEq/l of potassium.
Higher rates and contractions may cause cardiac depression. Potassium should be administered
only when urinary flow is established.

HYPERKALEMIA
Serum potassium level is more than 5.5 mEq/L .

MANAGEMENT

Mild hyperkalemia (5.5 - 6 mEq/L) is managed by stopping the potassium intake. Moderate
hyperkalemia (6 - 8 mEq/L) is managed with glucose insulin infusion or sodium bicarbonate
infusion and additional supportive measures along with discontinuation of potassium intake.

BURNS MANAGEMENT

Fluid replacement is done promptly on the basis of TBSA burnt and body weight of the child. The
parkland formula is the most commonly used.

Parkland formula: (4 mL/kg body wt x % of body surface area) + Maintenance requirement of

1500mL/m²

 Of the total 50% is given within the first 8 hours.

 Remaining over next 16 hours.
 Ringers lactate is preferred on 1st day. Subsequently fluids may be given as N/2 in 5%
dextrose.
 Fluids should be reduced to 50% after the 1st day.
 Colloids can be administered if the serum albumin levels are less than 2 g/dl or fluid
requirement is in excess of 300 mL/m²/h

In case of very sick child, Parental route is used. Intravenous fluid therapy refers to the infusion
of fluid directly in to venous system which may be accomplished through the use of needle,
cannula, or venous cut down.

PURPOSE

 To restore fluids
 To reduce electrolyte deficit.

MAINTENANCE REQUIREMENTS OF FLUID AND ELECTROLYTES:

For infants and older children fluid requirements in 24 hours are:

 Upto 10 kg - 1000 mL.

 10 - 20 kg - 1000mL + 50 mL/kg increase in body weight beyond 10 kg.
 20 - 30 kg - 1500 mL + 20 mL/kg increase in body weight above 20 kg
 30 - 40 kg - 60 mL/kg/day.

MAINTENANCE OF ELECTROLYTES REQUIREMENTS IS:

Sodium 3 mmol/kg/day
Potassium 2 mmol/kg/day

Chloride 3 mmol/kg/day

EXAMPLE:

Calculation of fluid requirement in 24 hours for a child weighing 12 kg:

10-20 kg 100 + 50 mL/kg increase in body weight beyond 10 kg.

12 kg: 1000 + 50 x 2 = 1100 mL ( child is 2 kg more than 10 kg).

1100mL is fluid requirement

Calculation of flow rate:

The calculation of rate of fluids is main responsibility to facilitate administration of correct

amount of fluid in right duration of time.

The formula to complete the flow rate is:

Volume of solution
------------------------- x Drops factor = Drop
Time intervals in minutes

Drop factor for microdrip set = 60

Volume of solution - 125 mL

Drop factor - 60

Time interval in minutes - 60 x 60

= 125x60 = 20.83
6 x 60

The rate of flow to be regulated is 20 - 21 drops/min

VEINS USED FOR INFUSION IN NEWBORN AND INFANCY

Scalp veins - Frontal, Superficial temporal vein,umbilical veins- (during first few days of life).

Superficial veins- Of the hands, wrist, arm and foot

OLDER CHILDREN: On the basis of accessibility of veins, for right handed children left hand is
preferred.
NURSING MANAGEMENT

 During parenteral fluid therapy, clinical and biochemical indicators of water and
electrolytes status should be monitored closely.
 The pulse rate, blood pressure, capillary refill time and sensorium ashould be monitored.
 Intake and output chart should be maintained.
 Laboratory tests should be done daily to adjust intake of water and electrolytes.
 Body weight should be recorded daily.

BIBLIOGRAPHY:

 A padmaja “ma procedure manual of pediatric nursing”, 1st edition (2014),

published by jaypee brothers publishers ltd, india, page no-58- 2.
 https://litfl.com/paediatric-dehydration-assessment/
 www.rch.org.au
 www.slideshare.net