Evidenced-Based Analysis of a Clinical Competency: Fluid and Electrolyte Balance of the Neonate - Essay Example

?EVIDENCE-BASED ANALYSIS OF A CLINICAL COMPETENCY Evidenced Based Analysis of a Clinical Competency: Fluid and Electrolyte Balance of the Neonate Introduction Clinical competency in the fluid and electrolyte balance of the neonate is an important clinical skill to develop in paediatric care. Aggarwal and colleagues (2001, p. 2) have pointed out that disorders of fluid and electrolyte are prevalent among neonates, and understanding the physiological changes in the neonate’s body water and solute after birth is crucial in securing an efficient shift from the aquatic in-utero environment. Evidence in this research was able to establish that the newborn kidney has a very limited capability of excreting excess water and sodium; therefore, the overload of sodium during the first week can result in necrotizing enterocolitis and patent ductus arteriosus (Aggarwal, et.al., 2001, p. 2). Different trials have shown that remedies like using transparent barriers, caps, and socks on neonates have been effective in reducing water loss (Aggarwal, et.al., 2001, p. 2). In effect, this study has shown the importance of applying effective skills in fluid and electrolyte balance. In order to improve the health outcomes of neonates, the development of skills in fluid and electrolyte balance have to be enhanced and targeted. Clinical competency in fluid and electrolyte balance in the neonate is therefore an important clinical skill; and building knowledge in support of such skill can help ensure improved health outcomes for the neonate. Discussion Background In evaluating fluid and electrolyte balance among neonates, it is important to first consider the physiology of the newborn and how such make-up affects the management of his fluids and electrolytes. A discussion seen in the website Anaesthesia.uk. points out that the extracellular fluid compartment of neonates is expanded and their total body water covers 85% of their body weight; and 75% of the body weight of term babies is water. This is in contrast to the 60% body weight of adults (Anaesthesia.uk, 2007). The website further emphasizes that the expanded extracellular fluid compartment is caused by the higher volume of distribution from commonly prescribed drugs and higher dose requirements in these drugs, regardless of their increased sensitivity (Anaesthesia.uk, 2007). It is also important to understand that the contraction of the extracellular fluid compartment and the weight loss during the first several days following birth is part of the normal bodily processes of the neonate – caused by dieresis, induced by atrial naturetic peptide (ANP) and sometimes by the higher pulmonary blood flow and stretch of the left atrial receptors (Anaesthesia.uk, 2007). When the state of negative water and sodium balance in the neonate’s system stabilizes, the water and sodium elements would increase and match the elements needed by the growing baby. It is therefore important to restrict fluids until the postnatal weight loss has become manifest. Studies have indicated that high fluid intake in the first few days after birth has been associated with negative patient outcomes among premature infants (Anaesthesia.uk, 2007). For these infants, fluid needs often gradually increase from the first day of their life at 60mL/kg/day to 150mL/kg/day at their 1st week of life (Anaesthesia.uk, 2007). The competence in evaluating the changes needed in the neonate’s feeding and fluid management is therefore a crucial competency for the health professionals to acquire. For immature neonates with respiratory distress syndrome, there is usually a delay in the acute contraction of the extracellular compartment. Before surfactants were used, this incident was marked by the natriuresis or diuresis which was seen when the respiratory functions were being improved (Modi, 2004, p. 109). For healthy newborn children who were able to receive surfactants, the diuresis often occurs at a lower degree. For the healthy newborns, only about 10% of the total body water is often decreased in the postnatal week and is manifested as postnatal weight loss. Extracellular fluid loss is seen as cardiopulmonary adaptation, mainly in pulmonary vascular pressure, not in renal maturation (Modi, 2004, p. 109). Since extracellular fluid is mainly sodium and water, the balance of said elements is considered negative in the postnatal phase. The main clinical implication of such observations is on the delay of the sodium administration until the loss of weight is seen. The water intake should then be fashioned to fit the insensible water loss and renal allowance to retain a urine production of 30mL/kg/day and increasing to 60mL/kg/day once the weight loss becomes manifest (Modi, 2004, p. 109). Such considerations are crucial elements in balancing the fluid and electrolytes of neonates. Basically, these neonates, especially the premature and those in the immediate postnatal condition have a different physiological make-up from the normal adults and normal infants (Fowlie, 2009, p. 309). Such differences impact on their type of care and management and consequently, the skills and competency needed to ensure efficient care calls for a thorough review and scrutiny. In a paper by Demetriou, et.al. (2005, p. F509), the authors set out to establish if insensible water loss differed between infants exposed or not exposed antenatally to corticosteroids; it also set out to establish the possible tools in the early postnatal diureses associated with antenatal steroid exposure. In the process of research, the authors were able to establish that infants who were exposed to antenatal steroids differed slightly from the infants under controlled settings; they both had lower insensible water loss and higher urine output on the first day, and a lesser number developed hyponatremia (Demetriou, et.al., 2005, p. F509). In effect, the study concluded that infants who were given antenatal conrticosteroids had lower IWL (insensible water loss). All in all, the authors established that better skin maturation, and better perfusion, not decreased respiratory status, leads to early diuresis among infants exposed to antenatal steroids (Demetriou, et.al., 2005, p. S509). A discussion by Manglik, (n.d) pointed out important elements of neonatal management. For the most part, neonates, like other human beings need nutrition, fluids, electrolytes, and environmental/temperature control. While some babies may need additional respiratory and infection management measures, they all need fluid, electrolyte, nutrition, as well as environmental management measures (Manglik, n.d). For babies in the NICU, some, but not all of them, may need IV fluids, both in quantity or composition. In any case, if the wrong fluids are given, their kidneys would not be well-equipped to handle fluid infusion. In some cases, serious morbidity and mortality may result from fluid and electrolyte imbalance (Manglik, n.d). Newborn babies have excess total body water, mainly in their extra-cellular space; and this ECF needs to be removed. While adults have 60% water, term babies have 75% water, and preterm neonates have even more water (Manglik, n.d). These newborn babies are also unable to concentrate or dilute urine as well as adults; they are therefore at risk for being dehydrated or having fluid overload (Wise, 2000, p. 27). As these newborn babies eventually mature, their renal function also starts to mature. The management of fluid and electrolytes among newborn babies is therefore the health professional’s responsibility, taking into consideration the aspects and characteristics inherent in the newborn. Manglik (n.d) further points out that it is important to allow initial loss of ECT during the first week; and ECT loss is different from weight loss. In the process, the intravascular volume and tonicity has to be maintained. The water and electrolyte balance, as well as requirements for body growth, must be maintained (Wise, 2000, p. 26). Moreover, an individualized approach for fluid and electrolyte maintenance must also be applied, noting patient’s individual characteristics and assessment to guide management and interventions (Wise, 2000, p. 27). In the management of newborn’s fluid and electrolytes, during the first 3 days, sodium, potassium, and chloride are normally not required; but after three days and for the rest of the first week, the newborn would need 1-2 mEq/kg/day. After the first week, and during the newborn’s growth, his needs are about 2-3 or up to 4 mEq/kg/day. Analysis of management of fluid and electrolyte balance Various studies have conceptualized different approaches in the management of fluid and electrolyte imbalance among newborn babies. Some of their studies have revealed that plastic wraps, dressings, and bags help reduce heat loss and thereby, help maintain fluid and electrolyte balance. Baumgart, and other researchers (1984, p. 1022) were able to reveal that the use of single barrier layers of Saran draped loosely over the baby can reduce water loss in the first few days following the baby’s birth. Baumgart advocated the use of Saran most especially for infants of extremely low birth weight (1984, p. 1022). However, issues with bacterial colonization of infection have been raised while this Saran wrap was used. Other practitioners have then suggested the use of semi-occlusive barriers like Tegaderm in order to reduce tape trauma (Knauth, et.al., 1989, p. 945). Still, other practitioners have suggested the use of polyutherane plastic barriers which are treated with antimicrobial suppressants in order to reduce infections in the wound dressings (Knauth, et.al., 1989, p. 945). Porat and colleagues were keen in noting their remedy of covering the infant completely in polyutherane as a means of reducing fluid and electrolyte loss (1993, p. 231). The use of polyutherane in the infants resulted in marked reduction in hypernatremia, excessive fluid volume intake, weight loss, bronchopulmonary dysplasia and mortality (Porat, 1993, p. 231). Better skin integrity was also noted during the use of polyethylene. Vohra and colleagues (1999) had occasion to evaluate the use of polyethylene and in the process of their research, they were able to establish that using polyethylene during resuscitation at delivery helped to maintain the infant’s temperature, thereby leading to improved chances for survival. In a paper by Chawla (2008, p. 2), the authors studied fluid and electrolyte management in term and preterm neonates. They also noted the newborn kidney’s limited capacity in excreting excess water and sodium. The authors then recommended simple measures of reducing fluid and electrolyte loss through the use of transparent plastic barriers, coconut oil application, as well as the use of caps and socks (Chawla, 2008, p. 2). The use of emollients in the management of fluid and electrolyte balance was also considered by various practitioners. Rutter and Hull (1981, p. 669) measured water loss from preterm babies after application of a paraffin mixture in 3 preterm babies naked in incubators. They were able to establish that water loss fell by 40% to 60% after application. This reduction however, did not significantly change fluid balance in the first few days of life (Rutter and Hull, 1981, p. 669). In a 1996 study, Nopper and colleagues sought to review the use of this method by using preservative-free topical ointment therapy on 60 infants. In the course of their study, they were able to establish that using such emollient can reduce water loss for 6 hours following application; it also decreased the severity of dermatitis and bacteria colonization of axillary skin (Nopper, et.al., 1996, p. 660). The study also revealed that the use of the emollient was able to reduce the severity of dermatitis and decreased the bacterial colonization of axillary skin. All in all, this study brought support for the use of emollients in the first few weeks after birth (Nopper, et.al., 1996, p. 660). However, in a report by Campbell and Baker (2000, p. 1041) they noted that an increase in the incidence of systemic candidiasis following application of topical petrolatum among infants with extremely low birth weight. They then recommended additional evaluation studies in order to assess the infectious risks for low birth weight infants receiving emollients (Campbell and Baker, 2000, p. 1041). Due to this issue, the use of emollients have been reduced and reevaluated. Baumgart and colleagues set forth a series of studies from 2006 to 2009 in order to determine the best applicable management for fluid and electrolyte imbalance among neonates and low birth weight infants (2009, pp. 1-9). In the process of their research, they were able to establish that the volume of mineral contents in the fluids administered to the infants must be adjusted about 2-3 times in a day during the first week for low birth weight infants (2006, p. 85). The authors also emphasized the importance of anticipating under and over-hydration among low birth weight babies during the progression of the hydration therapy. Baumgart, et.al., (2006, p. 85) also recommended the importance of checking serum electrolytes every 8 hours for the first 2 days of the child’s life, with adjustments in electrolyte-free solutions every 6 to 8 hours. This is part of the anticipation process which helps prevent the increase of serum sodium when the infant is already low in water volume (Gupta, et.al., 2002, p. 387). In monitoring the preterm infant’s fluids and electrolytes, most often than not, the third day of the infant’s life would reveal lower keratin deposition with the infant’s skin and ECF compartment becoming dry (Sridhar, et.al., 2006, p. 104). The serum sodium then levels off or is reduced. The ability to recognize this point of the baby’s fluid and electrolyte balance is crucial because the health professionals should then reduce the infant’s water volume immediately in order to promote “a hemodynamically significant PDA [patent ductus arteriosus]” (Baumgart, et.al., 2006, p. 86). The authors also recommend that when oliguria is seen during the treatment of PDA and hyponatremia must also be managed through the increase in fluid administration or through the use of furosemide to dilate the PDA. Fluids must also be restricted while the infant’s PDA is being managed. When the PDA is then managed, full fluid and electrolyte management remedies can be fully implemented to the patient. Current approach My approach in the management of fluid and electrolyte balance for the neonate included the following approaches: the use of plastic barriers and IV therapy. Patient evaluation following the use of plastic barriers revealed that the infant had lower heat and fluid loss as compared to the infants who were not given plastic barriers (Kaushal, et.al., 2005, p. 111). Monitoring of the infant’s fluid and electrolytes also revealed changes in the infant’s serum sodium and potassium levels, as well as in the levels of his hydration. The IV therapy was also based on the results of the monitoring process wherein records dictated the increase or reduction of IV fluid therapy. Various studies have been set forth on the effective use of IV therapy in the fluid and electrolyte balance of neonates. In one study by Duck (1997, p. 121), the authors set forth that IV therapy has been effective in neonatal care and is often preferred during the minutes following delivery in instances when resuscitation is involved. For infants with multiple needs, parenteral support has proven to be effective and has provided effective nutrition and respiratory support for them (Duck, 1997, p. 121). IV access or open vein lines have also facilitated the delivery of drugs and other essential nutrients into their system. Valentine and Puthoff (2007, p. 183) were keen in pointing out that newborn infants receiving IV fluid therapy also requires physiologically appropriate remedies in quantity and quality administered based on a timely strategy. It is important to support tissue integrity and growth in the newborn and this requires critical timing for nutrition assessment. Various complications seen in the parenteral nutrition can however cause various issues like infection, hepatic dysfunction and cholestasis (Valentine and Puthoff, 2007, p. 183). These issues have called on health professionals to provide early parenteral feedings, including drug therapy to improve liver function. Parenteral therapy during the first few weeks or even days following birth is however based on the monitoring done on the infant – for some patient, there may be a need to restrict fluid intake especially for low birth weight infants (Outi, et.al., 1992, p. 207). In a study covering about one hundred low birth weight infants, fluid administration was monitored during the first week until their fourth week following birth. Most of these patients were diagnosed with bronchopulmonary dysplasia (Tammela and Koivisto, 1992, p. 207). After a thorough research process, the authors were able to establish that reducing fluid therapy during for low-term infants can reduce mortality and morbidity because infants with poor respiratory management also have poor tolerance for fluids, especially during the first few weeks of life (Outi, et.al., 1992, p. 207). The administration of fluids to the newborn depends on different variables – variables, which have to be considered by the nurse before any decision on the care of the patient can be considered. Bell and Acarregui (2008, p. 2) were also keen in pointing out that water intake must be restricted in the first few days of life. They recommend that restricting water intake is the more appropriate choice for premature infants in order to ensure that the physiological needs of the infant are met without there being significant dehydration (Bell and Acarregui, 2008, p. 2). Among nurses caring for premature newborn infants, it is important for them to know when to restrict and when to administer fluids to the infant. With proper consultation with the paediatrician and through adequate monitoring of the infant’s fluid and electrolyte levels, it is possible to ensure improved patient outcomes. Conclusion In the proper care of the neonate, both the premature and the term infants, there are various studies which consider different interventions and management for fluid and electrolyte balance. In considering the physiology of the infant, there are varying qualities which have to be integrated in the assessment process in order to ensure that the appropriate interventions are carried out. Several studies have revealed the value of utilizing plastic barriers in order to prevent fluid and heat loss. These studies have reviewed the application of this intervention and endorsed the use of this intervention after applying precautions on infection control. Emollients have also been suggested as remedies, however, their connection with candidiasis have negated their overall and current applicability. Instead, hydration and IV therapy have been suggested in order to ensure fluid and electrolyte balance among newborns. However, this remedy has not been wholly recommended for preterm and extremely low birth weight infants because it can interfere with the efficient delivery of appropriate resources to the infant. For the most part however, the nurses have to establish and harness hydration therapy for the newborn – to know when to restrict it and to know when to administer it. This is a process which requires monitoring of the child’s fluid and electrolyte levels. This is also a process which requires the application of proper assessment skills in order to ensure appropriate remedies and interventions. All in all, evidence strongly supports the application of two remedies which were appropriately applied on the infant. One remedy is the use of plastic barriers and the second is hydration therapy which has to be adjusted based on the child’s fluid and electrolyte levels. Works Cited Aggarwal, R., Deorari, A., and Vinod, P. (2001) Fluid and electrolyte management in term and preterm neonates, World Health Organization, viewed 04 February 2011 from http://www.newbornwhocc.org/pdf/fluid_electrolytes_bablance.pdf Baumgart, S. (1984) Reduction of oxygen consumption, insensible water loss and radiant heat demand with use of a plastic blanket for low birth weight infants under radiant warmers, Paediatrics, volume 74, pp. 1022–1028. Baumgart, S. (2006) Water and electrolyte balance in low birth weight infants, in: Current Pediatric Therapy (18th Edition), F.D. Burg, J.R. Inglefinger, R.A. Polin and A.A. Gershon, eds, Philadelphia, PA, pp. 85–88. Baumgart, S. (2009) What’s new from this millennium in fluids and electrolyte management for VLBW and ELBW premature, Journal of Neonatal-Perinatal Medicine, volume 2, pp. 1–9 Bell, E. & Acarregui, M. (2008) Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants, Cochrane Database of Systematic Reviews, issue 1, pp. 1-19 Campbell, J., Zaccaria, E., & Baker, C. (2000) Systemic candidiasis in extremely low birth weight infants receiving topical petrolatum ointment for skin care: a case-control study, Pediatrics, volume 105, number 5, pp. 1041-5. Chawla, D., Agarwal, R., Deorari, A., & Paul, V. (2008) Fluid and electrolyte management in term and preterm neonates, World Health Organization, viewed 06 February 2011 from http://www.newbornwhocc.org/pdf/fluid_electrolytes_bablance_150308.pdf Demetriou, G., Kavvadia, V., Marcou, M., & Greenough, A. 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