Balance and Imbalance of Body Fluids

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Balance and Imbalance of Body Fluids

• Nurs 309
• Spring 2006

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Distribution of body fluids

• Total body fluids (TBF)
• Intracellular fluids (ICF)
• Extracellular (ECF)
• Water is the major constituent of body tissues
  ranging from 45 to 75

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Distribution of body fluids

• ICF refers to the fluid within the cells
• ECF
• Intravascular
• Interstitial
• Transcellular

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Water balance in infants

• Infants and small children have greater need for
  water
• Infants have a greater fluid intake relative to
  size
• Water and electrolyte disturbances occur more
  frequently and more rapidly

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Water balance in infants

• The fluid compartment varies from the adults
• The ECF accounts for more than 50 of TBW
• The ECF compartment remains larger than the
  adults until age two

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Water balance in infants

• Fluid loss is divided between insensible, urinary
  and fecal
• 2/3 of the loss is insensible and 1/3 respiratory
  
• Insensible loss is influenced by
• Heat
• Humidity
• Body temperature
• Respiratory rate

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Water balance in infants

• Infants and young children have an increased
  tendency for fevers
• Fevers increase insensible losses by 7mg/kg/24
  hours for every degree rise over 37.2C (99F)
• Increase body surface are related to volume

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Water balance in infants

• There is an increase in insensible loss due to
  increased body surface area
• The metabolic rate is higher in infants resulting
  in increase metabolic waste
• Immature kidneys at birth potentiates dehydration
  or over hydration

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Dehydration

• Dehydration occurs whenever total output exceeds
  intake
• Dehydration can be due to decreased fluid intake
• Dehydration is children is usually due to water
  loss associated with vomiting or diarrhea

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DehydrationIsotonic

• Primary form seen in children
• Water and electrolytes are lost in same
  proportion
• Loss is from the ECF
• Hypovolemic shock is greatest threat
• Severe diarrhea or vomiting

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DehydrationHypotonic

• Electrolyte loss exceeds water loss
• Fluid shifts from ECF to ICF for osmotic
  equilibrium
• This shift increases ECF deficit
• Shock is a frequent result
• Usually due to increased intake of free water

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DehydrationHypertonic

• Water loss exceeds electrolyte loss
• Fluids shift from ICF to ECF
• May occur infants with diarrhea who have been fed
  concentrated formula
• Neurologic disturbances are more common

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Dehydration
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Clinical signs of dehydration

• Tachycardia
• Dry skin and mucus membranes
• Sunken fontanels
• Cool mottled skin
• Loss of elasticity of the skin
• Delayed capillary refill time

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Degrees dehydrationMild

• Fluid volume loss lt50 ml/kg
• Skin color pale
• Skin elasticity decreased
• Mucus membranes dry
• Urinary output decreased
• Blood pressure normal
• Pulse
  normal-increased
• Capillary refill lt 2 sec

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Degrees dehydrationmoderate

• Fluid volume loss 50-90 ml
• Skin color gray
• Skin elasticity poor
• Mucus membranes very dry
• Urinary output oliguria
• Blood pressure normal-low
• Pulse increased
• Capillary refill 2-3 sec

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Degrees dehydrationsevere

• Fluid volume loss gt100 ml
• Skin color
  mottled
• Skin elasticity very
  poor
• Mucus membranes parched
• Urinary output oliguria/azotemia
• Blood pressure lowered
• Pulse
  rapid/thready
• Capillary refill gt3
  sec

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Dehydration management

• Mild cases may be treated at home
• Oral rehydration therapy consists of rapid fluid
  replacement
• Replacement of continued losses
• Provision of maintenance fluids

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Dehydration management

• Parenteral fluid therapy
• Replace deficits
• Replace ongoing losses
• Provide normal physiologic needs
• IV therapy is initiated immediately
• Normal saline or lactated Ringers

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Dehydration management

• First phase
• Bolus of 20 to 30ml/kg repeatedly
• Second phase
• Deficit and maintenance therapy
• Third phase
• Return to normal and begin oral feedings

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Edema

• Abnormal accumulation of interstitial fluid
• Any factor that causes sodium retention will
  cause or augment edema
• Can be due the sodium retaining qualities of
  steroids

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Edema

• Alteration in cell membrane permeability
• A decrease in plasma protein will decrease
  vascular osmotic pull
• Obstruction of venous return

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Edema

• Assessment
• Can occur in any part of the body
• Daily weights are sensitive indicators in
  children
• Abdominal girths are good indicators
• Pitting edema may be present
• Management
• Treatment of the underlying cause
• Recognition is primary role for nurses

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Edema
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Disturbances in acid base balanceRespiratory
acidosis

• Inadequate pulmonary ventilation causing a rise
  in plasma CO2
• Increase levels of hydrogen and carbonic acid and
  subsequent rise in pH
• Correction of primary problem and normalizing CO2
• Oxygen and mechanical ventilation may be needed

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Respiratory acidosis

• Depression of respiratory center
• Head injury, depressant drugs, CNS infection
• Lung disease
• Pulmonary disease, pneumonia, pulmonary edema
• Chest wall function
• Chest wall trauma, skeletal disease or deformity

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Respiratory alkalosis

• Increased rate and depth of pulmonary ventilation
• CO2 is blown off causing a decrease in pH
• Causes are associated with extreme emotions,
  congestive heart failure
• Ventilated patients
• Treatment is rebreathing

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Metabolic acidosis

• Lowered plasma concentrations of HCO3 with
  subsequent decrease in pH
• Immediate pulmonary compensation
• Kussmaul respirations
• Associated with diabetic ketoacidosis, starvation
• Treatment directed at correcting HCO3 deficit

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Metabolic alkalosis

• Elevation of plasma pH with reduction of H
  concentration
• Associated with hydrochloric acid loss
• Treatment is aimed at alleviation of acid losses

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Nursing responsibilities Assessment

• Electrolyte imbalance can occur rapidly in
  children
• Diarrhea and vomiting
• Fever and sweating
• Cardiac anomalies
• Renal disease
• Medications
• Trauma surgery burns

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Assessment and history

• General observation
• Toxic appearing
• Loss of appetite
• Irritable
• History
• Estimation of all output
• Estimation of all intake

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Clinical observations

• Tachycardia
• Dry mucus membranes
• Lack of tears
• sunken fontanel
• Loss of skin elasticity
• Prolonged capillary refill time
• Weight change

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Intake and output in children

• Careful weighing of diapers and pads
• 1gm 1 ml
• Urine, stool, vomitus
• Insensible loss due to radiant warmers or bili
  lights
• At home note number of voids
• Number of diapers

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The child who is NPO

• Signs
• On the door
• At the bedside
• On the child
• Monitor
• Sinks
• Fountains
• Toilets
• Appropriate nursing care

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Venous access devices in pediatrics

• Peripherally inserted central catheters (PICCS)
• One week to three months
• Silastic catheter threaded into SVC
• Parenteral infusions
• Blood draws
• Infection rate lt 2

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Peripherally inserted central catheters (PICCS)
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Peripherally inserted central catheters (PICCS)
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Long term venous access devices

• Long term venous access devices (VADS) include
  tunneled and implanted ports
• Single of multiple lumens
• Tunneled from the subclavian to superior vena
  cava or right atrium
• Strict aseptic technique is used whenever the
  device is entered

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Long term venous access devices
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Port-a-cath
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Long term venous access devices

• Central line sepsis is a major complication
• Line access should be minimized
• Dressing changes are sterile and follow hospital
  protocols
• Family teaching
• Line access
• Trouble shooting line breaks and/or occlusions

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Total parenteral nutrition (TPN)

• Hyperalimentation provides total nutrition
• Chronic bowel obstruction
• Sepsis
• Short bowel
• Prematurity
• Concentrated glucose, proteins, vitamins and
  minerals
• Intralipids are IV fats
• Peripheral IV infusion is contraindicated

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Total parenteral nutrition (TPN)
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Gastrointestinal disorders Diarrhea

• Estimated 1.3 Billion cases of childhood diarrhea
  each year
• 24 of childhood deaths attributed to diarrhea
• Diarrhea is present when there is an increase in
  stool frequency and water content
• Diarrhea varies in severity and duration

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Acute diarrhea

• Sudden increase in the frequency and consistency
  of the stools
• Usually caused by an infectious agent
• Usually self limiting (lt14 days)
• Usually no specific treatment needed if there is
  no dehydration

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Acute diarrhea

• Most cases are spread by the fecal oral route
• Overcrowding, lack of clean water, poor hygiene
  contribute to the spread of diarrhea
• The increase incidence in infants is an age
  related susceptibility

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Rotavirus

• The most common pathogen in the U.S. is Rotavirus
• Rotavirus is a major killer worldwide
• In the U.S. it is responsible for 60,000 hospital
  admissions per year and 20 deaths per year

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Rotavirus

• Epidemics late fall through early spring
• Fecal oral person to person
• Family spread is common
• The virus is very environmental hardy

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Rotavirusclinical features

• Begins with fever an vomiting followed by
  diarrhea
• Typically there is 1o to 20 bowel movements per
  day
• Diarrhea usually lasts between 3 to 8 days
• Vomiting is limited to the first 24 hours and
  occurs 80 to 90 of the time

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Rotaviruscontrolling transmission

• The most important measure is good handwashing
• Handwashing alone removes only 75 of virus
• Agents containing alcohol are most effective
• Wash hands and then apply alcohol containing hand
  rub
• Wipe down surfaces and then apply alcohol
  disinfectant

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Acute diarrhea

• Virus
• Norwalk
• Bacteria
• Salmonella ,Shigella, E-Coli
• Parasites
• Giardia
• Other causes
• Laxatives, foods containing Sorbitol or fructose,
  antibiotics

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Acute diarrheaevaluation

• History of current medications, possible
  ingestions, and family history
• Questions regarding onset of diarrhea
• Character of the stools
• Watery explosive
• Large foul smelling greasy
• Onset in relation to introduction of foods

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Acute diarrhealab evaluation

• Neutrophils or red blood cells
• Bacterial infection
• Eosinophils
• Parasitic infection
• C-difficile
• If treated with antibiotics
• Other labs
• CBC, electrolytes, BUN, creatinine, urine
  specific gravity

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Acute diarrheamanagement

• Assessment of fluid and electrolyte balance
• Rehydration
• Maintenance of fluid therapy
• Reintroduction of adequate diet

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Acute diarrheamanagement

• Oral rehydration therapy (ORT)
• Pedialyte, Rehydralyte, Infalyte
• Reduce vomiting, diarrheal losses and shorten the
  duration of the illness

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Acute diarrheamanagement

• After initial rehydration ORT can be used as part
  of maintenance program
• Formula, breast feeding, regular diet
• ORT replacement 11 10mg/kg or ½ to 1 cup per
  diarrheal stool
• Continued feeding or early reintroduction
  beneficial

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Assessment

• Urinary output
• Poor turgor
• Fontanel
• Mucus membranes
• Tears
• Prolonged CRT
• Elevated heart rate

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Plan

• The child will maintain hydration
• The child will maintain appropriate nutrition
• The child will not spread infection
• The family will receive support and education
  especially for home care

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Implementation

• Hygiene, handwashing, diaper disposal, changing
  table hygiene
• Caregiver taught to monitor child for signs of
  dehydration.. number of wet diapers, or voids,
  fluid intake patterns
• Continuation of oral intake with ORT for improved
  nutrition and fluid status
• BRAT diet no longer recommended

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Implementation

• When the child is hospitalized, strict IO
• Attention to hygiene, handwashing, crib, changing
  table
• Appropriate skin care and protection, (zinc oxide
  or 1-2-3 cream)

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Evaluation

• Monitor fluid losses, strict I0
• Monitor food intake
• Observe for evidence of complications e.g. fluid
  and electrolyte disturbances
• Observe and interview family for effectiveness
  of teaching and outcome care of patient

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Vomiting

• Forceful ejection of the gastric contents from
  the mouth
• Nausea and retching
• Regurgitation is more passive
• Common in childhood and self limiting

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Vomitingetiology

• Green bilious
• Bowel obstruction
• Curdled
• Delayed emptying
• Fever and diarrhea
• infection
• Localized pain
• Appendicitis
• Change in level of consciousness
• CNS involvement

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Vomitingevaluation

• History
• When does it occur
• How much
• How often
• Associated with diarrhea or pain
• Is it forceful
• Dizziness, blurred vision or headache

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Vomitingevaluation

• Hydration status
• Abdominal pain
• Lab work
• Urine analysis
• CBC
• Electrolytes
• Abdominal imaging
• Imaging of the head

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Vomitingmanagement

• Assessment
• Appearance, amount, frequency and behaviors
• Maintenance of hydration paramount
• Anti emetics to break the cycle
• Continued fluid support with progression to
  regular diet

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Hypertrophic pyloric stenosis
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Hypertrophic pyloric stenosispathophysiology
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Hypertrophic pyloric stenosisclinical
manifestations

• Progressive non bilious projectile vomiting
• Usual age of onset is 3 weeks
• Initially the infant is hungry and irritable
• With progression the infant become dehydrated
  with weight loss
• Ultimately failure to thrive

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Hypertrophic pyloric stenosisdiagnostic
evaluation

• The diagnosis is based on history of projectile
  vomiting
• Olive like mass palpated in upper abdomen
• The diagnosis is confirmed with ultra sound
• Elevated BUN and creatinine
• Low sodium and potassium

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Hypertrophic pyloric stenosis
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Hypertrophic pyloric stenosisnursing
considerations

• Pre operative
• Rehydration and restoration of electrolyte
  balance
• NPO with NG decompression
• IOs with attention to overall status
• NG function and patency
• Parental support, education and reassurance

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Hypertrophic pyloric stenosisnursing
considerations

• Post operative
• IV management, frequent vital signs, pain
  management
• Reassurance of the family
• Gradual progression of feeds an tolerated
• Post operative wound observation and care

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The Child with Renal Dysfunction

• Creatinine
• Is a produced at a constant rate
• Any that is filtered by the glomerulus is lost
• Production is to excretion
• As the GFR declines the serum creatinine
  increases proportionately
• Creatinine is a good indicator of GFR
• Normal values 0.6 to 1.2 mg/dl

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The Child with Renal Dysfunctionlab values

• BUN (Blood urea nitrogen)
• Reflects glomerular filtration
• BUN levels rise as glomerular filtration drops
• Normal values are 10 to 20 mg/dl
• Specific gravity
• The ability of the kidney to concentrate urine
• Normal value are 1.001- 1.035

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Urinary tract infection(UTI)

• Significant number of bacteria in the urinary
  tract
• Peak incidence between ages 2 and 6 yrs
• Females 10 to 30 times greater risk than boys

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Urinary tract infectionEtiology

• E-Coli accounts for 80 of all UTIs
• Structural anatomy of females attributed to
  higher incidence
• Urinary stasis
• Incomplete bladder emptying
• Obstruction due to constipation

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Urinary tract infectionEtiology

• Indwelling catheters
• Tight clothing
• Poor hygiene
• Infestations
• Sexual intercourse

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Urinary tract infectionclinical manifestations

• Frequency
• Urgency
• Dysuria
• Foul smelling urine
• Daytime enuresis
• Fever

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Diagnostic evaluation

• Urine appears cloudy, thick with visible strands
  of mucus or pus
• The diagnosis is confirmed by culture
• Collection methods
• Bag urine
• Clean catch
• Suprapubic cath
• Straight cath

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Diagnostic evaluation

• Urine dip sticks are useful screens while culture
  is pending
• The presence of nitrates is highly predictive of
  infection
• The absence of nitrates and leukocyte esterase
  have a negative predictive value

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UTImanagement

• Antibiotic therapy is the mainstay of treatment
  for UTI
• Therapy is guided by the culture and sensitivity
• Penicillin, sulfonamides, cephalosporin's,
  nitrofurantoin
• VCUG is recommended after the first UTI

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Nursing considerations

• Obtaining all specimens
• Preparation of family and child for all
  procedures
• Educate the family regarding antibiotic therapy
• Timing of administration
• Possible side effects
• Give all that is prescribed

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Nursing considerationsprevention

• Adequate fluid intake (100ml/kg or 50ml/lb/day)
• Proper perineal hygiene
• Avoid tight clothing, diapers cotton underwear
• Promote urination to children too busy playing
• Increase fiber and water to avoid constipation

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Vesicouretral Reflux(VUR)

• Retrograde flow of urine up the ureters
• Reflux potentiates bladder and kidney infection
• Primary reflux is associated with congenital
  anomaly
• Secondary is acquired
• Primary form is highly familial

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Vesicouretral Reflux(VUR)
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Vesicouretral Reflux(VUR)
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Vesicouretral Reflux(VUR)

• Grade one Grade two

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Vesicouretral Reflux(VUR)

• Grade three Grade four

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Vesicouretral Reflux(VUR)

• Grade five

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Vesicouretral Refluxmanagement

• Grades one and two have an 80 chance of
  spontaneous remission
• Grades four and five require surgical
  reimplantation of the ureters
• Grade three is managed similarly to grade one and
  two unless there are complications

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Hemolytic uremic syndrome(HUS)

• HUS triad
• Renal failure
• Hemolytic anemia
• Thrombocytopenia
• Occurs in children 6 months to 3 years
• Usually follows a GI or URI

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HUSpathophysiology

• Damage to the lining of the arterioles of the
  glomerulus
• Platelet aggregation at the damage site causes
  obstruction
• RBC damaged in narrowed vessels
• Removal of RBCs in spleen

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HUSmanifestations

• The hemolytic process persists for several days
  to two weeks
• Anorexia, irritable and lethargic
• Marked pallor with bruising and purpura
• Severe cases will be anuric
• All cases will have azotemia

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HUSevaluation

• HUS triad is sufficient for diagnosis
• Azotemia
• Elevated creatinine and BUN w/ hematuria
• Low serum hemoglobin and hematocrit
• Elevated reticulocyte levels

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HUSmanagement

• Normalization of electrolytes and acid base
  balance
• Early hemodialysis
• Blood transfusions
• Adequate nutrition enteral or parenteral

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HUSnursing considerations

• Monitoring fluid and electrolyte therapy
• Frequent vital signs
• IO
• Hemodialysis
• Blood transfusion
• Monitoring level of consciousness
• Family support