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HOLYFAMILY / Physics / PHYS 433 / What are the causes of Hyponatremia?

What are the causes of Hyponatremia?

What are the causes of Hyponatremia?

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Peds Week 10 Notes Alterations in Fluid, Electrolyte, and Acid-Base Balance Lab Values: Review A. What are the normal values (for blood): a. Na: 135-145 b. K: 3.5-5 c. Ca: 8.5-10.5 B. See these the most, most serious seide effects when you have  severe alterations of one or the other and seen more often in  kids C. Something to think about – normally see these lab values BMP  (basic metabolic panel)  the calcium in this is the total calcium  level – can also see calcium in an ABG – not a total calcium –  that’s an ionized calcium (it’s lower) Electrolyte Imbalances A. Na B. Ca C. K Sodium Imbalances Hypernatremia A. Reasons a child could be prone to hypernatremia a. Body fluids are too concentrated in sodium b. From different things – ways you get dehydrated (diarrhea,  vomiting, sweating, etc.) without adequate fluid intake  after c. One thing that is different that is diabetes insipidus – you  have/you are diuresing fluid d. Osmolality is telling you how concentrated it is – this cause it would be elevated B. Clinical manifestations a. Thirsty, small urine output (unless caused by DI),  decreased level of consciousness manifested by confusion,  lethargy, or coma results from shrinking of the brain cells,  seizures can occur when hypernatremia occurs rapidly or is severe C. Treatment a. Sodium is really high = diuretic to drink down levels (be  careful in DI scenario) especially the ones that are better  wasting electrolytes (loop/thiazide diuretic), IV fluids  (because you are dehydrated and want to give you fluid) –  rather than a isotonic solution you will give a hypotonic  solution (lower amounts of sodium) b. Give isotonic first to get normal fluid status and then give  hypotonic to draw sodium out D. What is an example of a hypotonic IV solution? Isotonic? a. Isotonic – 0.9% Normal Saline, Lactated Ringers, D5W b. Hypotonic – 0.45% normal saline Sodium Imbalances Hyponatremia A. Causes: a. Volume overload for different reasons i. Excessive water intake ii. DI – excessive urine output  SIADH (opposite)  hold onto fluid, don’t urinate much and become  hyponatremic from that B. Clinical manifestations (neuro) a. Early: change in mental status, seizures, N/V, headache,  weak muscles, and can progress from there b. Late: unconsciousness, respiratory arrest, etc.  C. Treatment a. We are volume overloaded so we want to give diuretics and sodium replacements (multiple ways to give Na  oral  sodium, IV), fluid restrict them, don’t want them to get  dehydrated especially when using diuretics so – we are  going to give them hypertonic saline  3% normal saline  Potassium Imbalances A. A little about potassium a. What is the main role of potassium in the body i. Muscle contractions (heart), enzyme reactions –  you’ll see symptoms with this  b. What types of food are rich in potassium i. Bananas, potatoes, dark leafy greens, yogurt,  avocados c. What are potential causes of imbalance i. Malnutrition (if going on for a long period of time),  dehydration, treatments that cause alterations –  diuretics (potassium wasting diuretics) HyperkalemiaA. Signs and Symptoms a. Muscle dysfunction b. Dysrhythmias – see two definite things – QRS wider and  peaked T waves (really unique to hyperkalemia) c. Muscle cramping d. GI – colic intestinal cramping, loose stools e. Lethargy  B. Treatment a. Need to be ECG monitor, high potassium down – diuretics – want loop diuretics (don’t have use for potassium sparing),  Kexylate (creates diarrhea – loose stools – to lose  electrolytes) b. Other things:  i. IV calcium to help draw it out to get rid of it ii. Give insulin and glucose together – nothing to do  with glucose – it helps dry out the potassium (giving  them a large amount of insulin – only seen in adult –  it’s very dangerous to do) Hypokalemia A. Many similar Signs and Symptoms of hyperkalemia except: a. Constipation (hyper has loose stools)  b. Abdominal discomfort c. Different arrhythmia – flat wave? B. Nursing implications a. Close monitoring (ECG) b. Potassium replacement  i. Routes to give potassium: PO, IV (K-rider, etc.) ii. IV potassium  BURNS – want to have largest IV  possible (ideally central or PICC line) – NEED to give  it SLOWLY: minimum of 2 hours (have it dilute it??) iii. Oral is ideal – but if given today it takes a day or two  to bring it up – may need IV for instant  c. Assessments i. What will you focus your assessments on? 1. Cardiac (monitor - don’t want to see any signs  of compromise) 2. Renal 3. GI (because of symptoms) Calcium Imbalances A. Calcium a. 98% is stored in bones b. Concentration regulated by parathyroid hormone c. 3 Forms in plasma i. Ionized – bound to ionsii. Free – bound to proteins – don’t measure specifically iii. Total d. Alterations can be caused by: (diet) i. Intake ii. Absorption iii. Distribution iv. Excretion  Hypercalcemia A. Clinical manifestations can be non-specific a. GI upset, diarrhea, N/V (hyperkalemia would be first guess  for a child that’s vomiting), fatigue – can progress with  neurological symptoms – change in mental status,  lethargy, confusion B. Treatment a. Lasix – diuretics is number 1 b. Steroids c. Dialysis – if any electrolyte is too high this is a good way to  spin them off – problem with this is the access – some sort  of big line is needed kids don’t have a fistula – dialysis  catheter – risk for infection, etc.  Hypocalcemia A. Clinical Manifestations a. Tetany – muscle contraction that does not stop (skeletal in nature), laryngospasms, cardiac issues B. Treatment a. Treat the cause – with any imbalance – if caused by diet,  diuretic use, etc. fix/treat the cause of the issue b. IV calcium – automatically everything went relaxed if  having tetany c. Vitamin D helps with absorption of calcium Calcium Imbalances A. Pediatric Considerations: DiGeorge Syndrome  chronic  hypocalcemia) a. Deletion form chromosome 22 b. Often cleft lip/plate c. Congenital heart defects d. Severe developmental delay e. Hearing loss f. Absent thymus gland i. Immunologic disorders g. Deficient parathyroid gland i. Chronic hypocalcemia  h. Life expectancy is not into adulthood for this Lab Values Review Acid-Base Imbalances A. What are the normal values (for blood) for: a. pH: 7.35-7.45 b. pCO2: 35-45 c. pO2: 80-100 (not going to tell you what is going on but it is good to know – not related to the acid-base balance per say) d. HCO3: 22-26 (bicarb) ROME A. Respiratory Opposite – whatever pH is – if pCO2 is in opposite  direction it’s respiratory B. Metabolic Equal – if bicarb and pH are in same direction =  metabolic  Case Study 1 A. You are caring for a 10-year-old boy with cystic fibrosis. He is  lethargic, confused, and c/o a headache. His blood gas is B. p C. 7D. p E. 5

F. p G.6 H. H I. 2


What is an example of a hypotonic IV solution?



Don't forget about the age old question of How many models of Abnormality are there?

 J. K. LOW L. HIGH M. Low but doesn’t matter N. NORMAL O. Which acid-base imbalance is this? a. Respiratory Acidosis P. What nursing interventions would you anticipate? a. Kid is probably in distress – CPT (chest PT), cough it up  (maybe not), suction him – do that first THEN he needs to  get oxygen à if still not okay – repeat ABG and still no  change – bipap (positive pressure) or if bad enough he  might need to be intubated  b. Start with trying to get mucous out to get him to breathe  easier  Q.  R. Case Study 2 A. Patient is a 4-month-old girl who has had projectile vomiting for 4 days. She presents with S&S of dehydration. Her blood gas is S. p H U. p CO2 T. 7 .60 V. 4 5 W. p O2 X. 8 8 Y. H CO3 Z. 3 2

AA. AB. HIGH AC. Normal AD. Normal AE. HIGHB. Which acid-base imbalance is this? a. Metabolic Alkalosis b. With vomiting you can have respiratory alkalosis or  acidosis but when you loose all that GI acid you can have  alkalosis when you’re just plain dehydrated not vomiting  you can have acidosis C. What nursing interventions would you anticipate? a. Hydrate – this alone should fix it  AF.  AG. Case Study 3 A. Patient is a 3-year-old boy who was found unattended in his  parent’s garage. Next to Dylan was an opened bottle of anti freeze. His initial blood gas is: AH. pH AJ. pC O2 AI. 7 .15 AK. 40 AL. pO2 AM. 102 AN. HCO 3 AO. 12


What nursing interventions would you anticipate?




What will you focus your assessments on?



Don't forget about the age old question of refer to the accompanying figure. in every case, caterpillars that feed on oak flowers look like oak flowers. in every case, caterpillars that were raised on oak leaves looked like twigs. these results support which of the following hypotheses?
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AP.LOW AQ. Normal AR. Normal high AS. LOW B. Which acid-base imbalance is this? a. Metabolic Acidosis  C. What nursing interventions would you anticipate? a. Treat with IV fluids (dilute everything they already  absorbed in their system) – ingested something you give  activated charcoal (thick charcoal milkshake look) – given through NG tube – need decent size NG tube  because it’s thick and need to push water through it too  b. Can drink it – not always the best – can throw it back up on  you – spit it back up, etc. AT.  AU. Case Study 4 A. You are caring for a 5 year old girl on mechanical ventilation. Her  blood gas is: AV.p H AW. 7.5 1AX. pCO 2 AY. 2 9

AZ. pO2 BA. 168 BB. HCO 3 BC. 22

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BD. HIGH BE. LOW BF.High BG. NORMALB. Which acid-base imbalance is this? a. Respiratory Alkalosis C. What nursing interventions would you anticipate? a. Patient is over ventilated – probably on a rate that is too  high – you blow off CO2 with every breathe à adjust the  rate on the ventilator à PO2 is also high: can change FIo2  on ventilator, etc.  D. Compensated – partially compensated reflects – body trying to  fix it à respiratory being over ventilated a. Bicarb regulated by kidneys – b. When something is going on with the lungs the kidneys are like we’re alkalotic but we can do something about this – that’s when you would see the bicarb be abnormal trying  to fix something  BH.  BI. What Acid-Base Imbalance Do You Suspect (without knowing the  blood gas)? A. AN infant with severe respiratory distress: a. Respiratory acidosis B. An anxious teenage who is hyperventilating: a. Respiratory alkalosis C. A child with DKA: a. Metabolic acidosis D. A patient with infant botulism: a. Respiratory acidosis E. An infant with severe dehydration: a. Metabolic – can be acidosis or alkalosis (vomiting see alk.) BJ. BK. Alterations in Endocrine and Metabolic Function BL.  BM. Diabetes Insipidus (DI)  BN. Disorder of Posterior Pituitary Gland A. Central (Neurogenic) a. ADH Deficiency b. Have a deficiency in ADH, for some reason – usually from a neurological source  B. Nephrogenic  a. Familial (takes place in the kidneys and is much less  common and harder to treat C. Both: cause decrease in ADH production or sensitivity (anti diuretic hormone) D. Has nothing to do with blood sugar AT ALL E. Causes: a. Usually some sort of insult to the central nervous system i. Can be injury, TBI, surgery, a tumor, infection like  meningitis or encephalitis – CNS infectionsii. Disorder of the pituitary F. Signs and Symptoms a. Cardinal signs: i. Polydipsia 1. Drink a lot – excessive thirst ii. Polyuria 1. Pee a lot – excessive urination 2. Excessive urine output, dumping urine 3. Adults 30 ml/hour – wouldn’t expect that on an  infant – measure it by kg (normal 1-2 ml/mg/hr) 3kg infant = 3-9 ml/hr 4. With DI you’ll see large dilute urine outputs –  foley might look like water 5. Specific gravity done on a UA – measures how  concentrated or dilute the urine is that is all  the specific gravity tells you. Normally the  specific gravity is about 1.010 called 1010, the  lower the number the more dilute it is, lower  than 1.01 is dilute SIADH has the opposite – higher specific gravity 6. Peeing out all this water you’ll get dehydrated,  so worry about electrolyte imbalances as well 7. Electrolyte changes you could see a change in  mental status, seizures (hypernatremia) G. Treatment a. Fluid replacement; they will be easily dehydrated b. We are hypernatremia, thiazide diuretic will help take  excess sodium off but we are already peeing and  dehydrated diuresing – but if we do pros and cons – we can replace fluid and it’s hard to get rid of sodium c. Also want slow down the urine and some meds do that,  DDVAP – desmopressin – it slows down the urine output so  the patient isn’t diuresing as much – has cardiac side  effects d. Main goals: i. Get rid of sodium, volume resuscitate, slow down the urine output which will stop so much water being  excreted  H. What teaching would you review with parents of a child with DI? a. Can have familial side to it – if it is from some type of insult that needs to be treated before it really gets better b. If you have parents tell them to look for polyuria and  polydipsia, are they in diapers?  i. May have parents measure urine for awhile c. If you correct the cause it can come back so teaching  parents is importantd. S/S of dehydration and also how to prevent so teach  parents how important it is for them to take in enough  volume – if it was severe look for s/s of hypernatremia BO.  BP.Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) A. Excessive excretion of ADH a. Complete opposite of DI B. Causes a. Neurologic for this as well b. Some sort of central nervous system insult just like DI c. Can see it with a couple pulmonary disorders like CF d. Treat the cause! C. Signs and symptoms a. Everything with DI is completely the opposite: i. Little urine output – very very concentrated urine,  tea colored urine – specific gravity is elevated because your body is holding onto everything, it’s  holding onto volume and not getting rid of anything  you get hyponatremia everything is really diluted ii. Decreased urine output, increased specific gravity,  potentially hyponatremia, you are volume overloaded so may see pulmonary and peripheral edema, so  respiratory distress increased, weight they everyday  it lets you know if we are taking stuff off or not iii. So much extra volume that will cause tachycardia –  heart is trying to pump so much, may not see BP  changes it may go up D. Treatment a. This kid is volume overloaded b. Get stuff of so we will do diuretics – get rid of fluid/volume i. Volume overload so we will restrict fluid – see most in kids post spinal fusion a back surgery ii. Fluid restrict them but don’t want them dehydrated  so we give some fluids they are hyponatremic so we  will give them hypertonic 3% c. A specific drug blocks ADH action  E. What is the child as risk for? a. Pulmonary edema, tachycardia classified as congestive  heart failure – not being able to move along the volume  you have b. Hyponatremia – biggest risk c. Since we have risk of seizures with DI and SIADH you will  implement seizure precautions: pad the side rails, want  chairs low to floor incase they seize BQ. BR. DI or SIADH?A. Post operative spine surgery patient weighs 50kg has 100ml of  urine for 12 hour shift a. SIADH –they have little urine output B. Leukemia patient with hypertension and SOB a. SIADH – they are signs of fluid overload C. Head injury patient weight 25 kg and has 1000 ml of dilute urine  over 12 hours a. DI D. Patient in ER is dehydrated, has recent history of bedwetting and BMP show Na of 160 a. DI – sodium is high and they are having bedwetting  because they have so much volume E. PICU patient on ventilator with seizure sand elevated specific  gravity of urine a. SIADH – seizures don’t tell you anything cause it could be  either – but elevated specific gravity = SIADH F. Infant with increased amount of wet saturated diapers, lethargy a. DI BS. BT.Thyroid Disorders BU. Hypo and Hyper BV. In children you’ll see a lot of hypothyroidism in the  congenital so you’ll see it early on – want to catch and fix early –  easy fix need to figure it out quick BW. BX. Hypothyroidism A. Congenital (thyroid dysgenesis) or acquired (thyroiditis) B. Girls > boys C. Features a. Umbilical hernia, skin is mottled, tongue is large and  protruding b. Normally have difficulty feeding, irritability, vitals will be  decreased, bradycardia, hypotension, hypo everything*  everything is slowing down c. Book says you’ll see a goiter – an enlarged thyroid but  rarely/hard to see BY.D. Treatment a. Levothyroxine (synthroid) synthetic thyroid hormone can  get in a solution (a suspension) and give it to them orally –  treatment is really easy E. Maintenance a. Need to test thyroid function by doing a thyroid panel b. T3 and T4 are LOW c. TSH (thyroid stimulating hormone) HIGH because it’s trying to stimulate the thyroid to produce more hormones d. Still need to check their thyroid function when giving  synthroid regularly to make sure they’re therapeutic e. Difficult in kids because they are constantly growing so  need different doses – challenging  F. What are the major consequences of untreated hypothyroidism  in children? a. It is so important because if it goes untreated for a long  time they will have severe intellectual disabilities,  developmental delays and things like they; it is an easy fix  needs to be identified early on  BZ. CA. Hyperthyroidism A. Most often due to Grave’s disease B. More common in adolescent girls C. Clinical manifestations a. Can have a goiter, protruding eyes (exophthalmos), weight  loss, increased metabolism which increases your HR  tachycardia and possibly HTN could have diaphoresis  (especially in a thyroid storm) – makes them really irritable, neurologically awake but kind of confused. You sweat so  much you get head intolerance  D. Treatment a. Thyroidectomy (surgery), usually do a partial one this can  sometimes cause hypothyroidism b. Can give PTU (propylthioruracil) medication that inhibits T3 and T4 and methimazole c. Radiation – radioactive iodine which you ingest, inactivates the thyroid so it’s not so hyperactiveCB. CC. CD. Pancreatic Disorders  CE. Diabetes Mellitus  CF.Immune Mediated Type 1 A. What are the classic signs a. 3 P’s b. Polyuria – excessive urine c. Polydipsia – excessive thirst d. Polyphagia – excessive hunger i. So they will be eating more but don’t gain weight –  that’s the difference with type 1 and type 2 B. This is the diabetes that has to do with your blood sugar – the  picture describes insulin production of the pancreas, part of the  pancreas that is responsible for production and distribution of the pancreas isn’t working correctly – it doesn’t secrete enough so  your blood sugar goes up  CG. CH.  CI. Case Study A. Amy is a 5-year-old girl who presented to the emergency  department with a one week history of polydipsia, polyuria, and  feeling generally “sick”. Her parents state that today she become more lethargic, vomited twice, and was breathing heavy. Upon  assessment, you not Amy is obtunded and has Kussmaul  respirations. Her VS: HR 130, RR 28, BP 76/40 a. What diagnostic information would you like to obtain?i. BP is really low for a 5 year-old, that is appropriate  for an infant not 5, Kussmaul respirations (rapid,  deep breathing why her RR is 28 – too high) ii. ABG will show metabolic acidosis iii. Glucose: when you do bedside and it’s high – take it  again, if you get another high one you get a blood  one which will show a serum glucose B&B – want to  confirm it with a lab iv. Want to know electrolytes because glucose and  potassium have a relationship so we constantly  check glucose and K+ b. What do you suspect is happening i. Her sugar was 600 – she had DKA c. What treatment do you anticipate? i. She needs insulin – her pancreas isn’t working  properly – not producing enough insulin ii. In this case – give it IV – when it is high you need to  bring it down slowly because it can cause cerebral  edema – don’t wan it to go too high to too low really  quickly 1. This is why we give dextrose as we give insulin iii. Potassium is effected so you’ll do frequent  electrolytes iv. You will check the blood sugar at least every hour – if you see any change in symptoms you’ll do it more  frequently 1. Once you start the IV insulin you’ll do it in a  half hour then at least every hour d. What continuing nursing assessment will you perform? i. Will focus on neuro (they intubated this patient  because they were worried about her respiratory  status) she was unresponsive, you have metabolic  acidosis so the lungs to try fix the acidosis and you  get Kussmaul respirations  ii. Neuro and respiratory** iii. Closely monitoring blood sugars and changing out  fluids with every stick we do iv. Want to look at urine output, it should slow down as  we treat things CJ.  CK. Diabetic Ketoacidosis A. 30% of new onset Type 1 in children presents as DKA a. Because the hunger, peeing and drinking can be  overlooked b. Calcium can be lower in the beginning and then it can go  higher as you treat itB. Consists of a. Glucose > 200 b. Acidosis c. Glycosuria d. Ketonuria – spilling of ketones in urine and glucose ^ C. Risks a. Cerebral edema D. Goal a. To keep blood sugar normal  E. DKA in the emergency Department a. We talking about how we treat DKA but how do we treat  Type 1 in kids? i. Insulin: injectable SQ, or a pump (SQ) and that gives  a small amount continuously ii. Compliance can be an issue, when kids go to a  birthday party, don’t monitor, adolescence iii. We look at CARBS and do insulin based on the cards  iv. Pumps need to be rotated  CL.  CM. Diabetes Mellitus Type 2 A. Associated with insulin resistance and obesity a. Type 2 in children is rare – normally in adolescents that  have had poor eating habits for a very long time b. From eating a lot of the sugary stuff on a chronic basis you  pancreas is oversecreting insulin to compensate then your  body becomes resistant towards it c. Onset isn’t quick like it is with type 1 it takes time – you  may have the 3 P’s – maybe  B. Hyperinsulinemia  insulin resistance C. Insidious onset a. Obesity  i. High waist circumferences b. Fatigue c. Hypertension d. May have mild 3 P’s e. Androgen mediated symptoms i. Excessive hair, get this from an increase of  testosterone D. Treatment a. Nutrition i. Diet is number one and easiest if you have someone  who will follow it; loose weight, don’t eat high  sugar/high carb food, be more active b. Activity c. Oral meds i. You take to help bring blood sugar down ii. Metformin – Glucophage iii. Oral meds in the beginning just to get their sugars  more stable and to not be so resistant but then life  style change is the BIG thing, diet and exercise d. Compliance is always an issue with type 1 and type 2 CN.  CO. Diabetes Mellitus A. What are some issues unique to the pediatric population with  diabetes? a. Compliance – you have 2 patients family and actual  patients, does B. What type of teaching would you anticipate for a child with DM  Type 1? Type 2? a. Does an adolescent actually understand the risks of  hyperglycemia? No – treatment isn’t fun have needles  CP. CQ. CR. CS. CT. CU. CV.
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