Dehydration

Hey guys in this lesson we are talking about dehydration in the pediatric patient.

Dehydration can occur easily and quickly in pediatric patients. Because they have a higher percentage of total body water than adults as well as an increased body surface area they lose fluids more easily through their skin. They also have an increase metabolic rate so their fluids and electrolytes are turning over and being used more quickly.

Common causes for pediatric dehydration are fever, decrease fluid intake, vomiting and diarrhea from something like a stomach bug. Some less common but really important diagnoses to think of with dehydration are burn injuries and new onset diabetes or diabetic ketoacidosis.

Weight loss is probably the most objective sign that the child has lost fluid. 3-6% weight loss indicates mild dehydration where 10% or more indicates severe dehydration.

Other things we need to assess are vital signs, capillary refill time (remember we want this to be less than 2 seconds!), skin turgor, mucus membranes to see if they are moist or dry, fontanelles (for our infants) to see if they are sunken in, and urine output.

The last thing I have listed here is super important! Always remember to check a blood sugar! A child who has new onset diabetes may present with dehydration and weight loss so it’s super important to identify that really quickly.

When we assess a child for dehydration we are probably going to end up putting them in one of three categories. They either have mild dehydration, moderate dehydration, or severe dehydration.
We’ve made a cheatsheet for you that actually has a table that shows you all the different signs of symptoms that go along with these different categories of dehydration.

What I want to do here is highlight symptoms that you would see in a child who is in the severe category of dehydration. Now, as we look at this list of symptoms I want you to keep in mind what it actually means to be dehydrated. When a patient is dehydrated, they have decreased water in the body, which means they will also have less blood volume. When blood volume is decreased you get poor perfusion, and that is where these symptoms come into play. They are all signs that a patient has become so dehydrated that they no longer have enough blood volume to perfuse their body.

So the most concerning symptoms are: extreme lethargy and sleepiness; not responding painful procedures; extreme tachycardia and tachypnea; cool, mottled arms and legs and a very delayed capillary refill. Remember a CRT of <2 seconds is a sign of good perfusion, so if you press on that skin and it takes 3- 4 seconds for the color to come back to it- you should be very worried!

And probably the very last thing to happen in a kid with severe dehydration is their blood pressure will drop. Kids can compensate for a really long time so don’t wait for a drop in BP to give fluids! It is a very late sign of poor perfusion.

Our treatment of a child that is dehydrated is all about giving them fluids either using oral rehydration solution or using IV Fluids. We’ll talk a bit more about the specifics of rehydration in just a minute.

If we are rehydrating a patient we need to monitor their electrolytes really closely. So we need baseline blood work that will allow us to keep an eye on their electrolytes, specifically their sodium and potassium levels.

Kids who are at risk for dehydration need to be on strict I’s & O’s which means that everything that goes in and comes out of their body has to be measured or weighed for accuracy. It’s not enough for mom or dad to say they had a bottle or a juice- we need to know exactly how much. When weighing diapers, remember that 1 gm is equal to 1 ml.

Oral rehydration is the preferred method and usually what we aim for is 5ml’s every 2-5 minutes. It’s important to use an oral rehydration solution because these have electrolytes, like sodium, potassium, chloride in them along with some glucose.

If you only use water the child is at risk for being hypoglycemic and also having really wacky electrolytes- especially sodium and potassium. Too much water will over dilute the sodium in the child’s body making them hyponatremic. Remember, if hyponatremia becomes severe enough you can see neurological changes and even seizures.

Potassium is lost every time a child vomits or has a loose stool so a child with a stomach bug is at high risk for being hypokalemic. So, again the special rehydration solution will hopefully prevent both of these things from happening

Sometimes oral rehydration isn’t an option it is contraindicated and this is usually the case in kids who are too lethargic to drink without aspirating, or kids who breathing too rapidly to drink without aspirating. So Decreased LOC and Increase RR are your two primary contraindications for treating dehydration orally.

And for these patients we are going to use IV fluids to rehydrate. If the child needs a bolus you will give 20 ml/kg of Normal Saline or Lactated Ringers. If they need maintenance fluids the Holliday-Segar formula is used to calculate how much they can have based on their weight. We’ve made a cheatsheet for you that explains this formula and also goes through a few examples for you. The first time you look at it you are going to think, “this is confusing and I don’t understand it” but just work through the examples and be patient with it, the more you practice it the easier it gets, I promise!

Your priority nursing concepts for the pediatric patient with dehydration are fluid and electrolyte balance, perfusion and safety.
Okay so what are your major take away points for this lesson.

So, always remember that kids are at an increased risk for becoming dehydrated.

When you are assessing their hydration status remember there are 3 categories of dehydration mild, moderate and severe.

If you know your red flags you’ll be able to identify which kids are at risk for being severely dehydrated or even in shock.

The goal of treatment is to replace fluids. Oral is best when it can be done safely, just always remember to use special oral rehydration solutions to avoid hyponatremia and hypokalemia. When IV Fluids are used always make sure they are prescribed based on the child’s weight

With the potential for electrolyte disturbances it’s really important to monitor electrolytes and fluid intake and output very very close to avoid complications.

That’s it for our lesson on dehydration in pediatrics. Make sure you check out all the resources attached to this lesson. They are so helpful for putting all the information together and also will help you with your fluid calculations. Now, go out and be your best self today. Happy Nursing!