Untitled

• Electrolytes are minerals with an electric charge found in body fluids and also known as salts.
• Electrolytes regulate fluid balance and hormone production.
• Electrolytes strengthen skeletal structures.
• Electrolytes act as catalysts in nerve response, muscle contraction, and nutrient metabolism.
• Major electrolytes include sodium, potassium, chloride, magnesium, phosphorus, and calcium.
• Positive electrolytes (cations) include magnesium, potassium, sodium, and calcium.
• Negative electrolytes (anions) include phosphate, sulfate, chloride, and bicarbonate.
• Monitoring laboratory values can help identify electrolyte imbalances.
• Electrolyte concentrations within cells cannot be directly measured with lab tests.
• Recognizing the manifestations of electrolyte imbalance is important.
• Infants, children, older adults, clients with cognitive disorders, and clients with chronic illnesses are at greatest risk of electrolyte imbalance.

Expected Reference Ranges

• Sodium: 136 to 145 mEq/L
• Calcium: 9 to 10.5 mg/dL
• Potassium: 3.5 to 5 mEq/L
• Magnesium: 1.3 to 2.1 mEq/L
• Chloride: 98 to 106 mEq/L
• Phosphorus: 3 to 4.5 mg/dL

Sodium Imbalances

• Sodium (Na+) is the major electrolyte in ECF but is present in most body fluids or secretions.
• Sodium is essential for maintenance of acid-base & fluid balance.
• Sodium is also essential for active and passive transport mechanisms, and nerve and muscle tissue irritability and conduction.

Hyponatremia

• Hyponatremia occurs when blood sodium level is less than 136 mEq/L.
• Hyponatremia results from excess water in the plasma or loss of sodium-rich fluids.
• Hyponatremia delays and slows the depolarization of membranes.
• Water moves from the ECF into the ICF, which causes cells in the brain and nervous system to swell.

Assessment/Data Collection: Risk Factors for Hyponatremia

• Deficient ECF volume
• Excessive GI losses (vomiting, nasogastric suctioning, diarrhea, tap water enemas)
• Renal losses (diuretics, kidney disease, adrenal insufficiency, excessive sweating)
• Skin losses (burns, wound drainage, GI obstruction, peripheral edema, ascites)
• Increased or normal ECF volume (excessive oral water intake, SIADH)
• Edematous states (heart failure, cirrhosis, nephrotic syndrome)
• Excessive IV administration of dextrose 5% in water
• Inadequate sodium intake (NPO status)
• Use of hypotonic irrigating solutions
• Hyperglycemia
• Increased risk in older adults due to chronic illnesses, diuretic medications, and risk for insufficient sodium intake

Expected findings for Hyponatremia

• Physical assessment findings can vary with a normal, decreased, or increased ECF volume.
• There can be hypothermia, tachycardia, rapid thready pulse, hypotension, or orthostatic hypotension
• Neuromusculoskeletal findings include headache, confusion, lethargy, muscle twitching/weakness with possible respiratory compromise, fatigue, decreased deep tendon reflexes (DTRs), seizures, or coma
• GI findings are increased motility, hyperactive bowel sounds, abdominal cramping, anorexia, nausea, or vomiting

Patient-Centered Care for Hyponatremia

• Nursing care involves monitoring I&O and weighing the client daily at the same time of day using the same scale.
• Monitor vital signs and level of consciousness and report irregular findings.
• Encourage the client to change positions slowly.
• Follow any prescribed fluid restrictions.
• Monitor respiratory status if muscle weakness is present.
• Foods and fluids high in sodium should be encouraged (cheese, milk, condiments).
• Fluid overload must be avoided
• Restrict water intake as prescribed, most effective when fluid volume is normal to high.
• For severe hyponatremia, administer hypertonic oral and IV fluids as prescribed.
• Hypertonic IV fluids are solutions with a greater concentration of particles than blood, such as 3% or 5% sodium chloride.

Hypernatremia

• Hypernatremia occurs when blood sodium level is greater than 145 mEq/L.
• Hypernatremia is a serious electrolyte imbalance that can cause neurologic, endocrine, and cardiac disturbances.
• Increased sodium causes blood hypertonicity causing water to shift out of cells, resulting in cellular dehydration.

Assessment/Data Collection: Risk Factors for Hypernatremia

• Water deprivation (NPO)
• Heat stroke
• Excessive sodium intake (dietary sodium intake, hypertonic IV fluids, hypertonic tube feedings, bicarbonate intake)
• Excessive sodium retention (kidney failure, Cushing's syndrome, aldosteronism, some medications like glucocorticosteroids)
• Fluid losses (fever, diaphoresis, burns, respiratory infection, diabetes insipidus, hyperglycemia, watery diarrhea)

Expected findings for Hypernatremia

• Hyperthermia, tachycardia, orthostatic hypotension can be seen in vital signs
• Neuromusculoskeletal issues like restlessness, fatigue, disorientation, irritability, muscle twitching/weakness, seizures, decreased level of consciousness, or reduced to absent DTRs
• Thirst, dry and sticky mucous membranes, and dry and swollen tongue that is red in color
• Increased GI motility, hyperactive bowel sounds, abdominal cramping, or nausea
• Other findings: Edema, warm flushed skin, oliguria

Patient-Centered Care for Hypernatremia

• Nursing care involves monitoring level of consciousness, ensure safety
• Provide oral hygiene and other comfort measures to decrease thirst.
• Monitor I&O and alert the provider if urinary output is inadequate.
• Maintain prescribed diet (low sodium, no added salt).
• Encourage oral fluids as prescribed.
• Monitor laboratory results (serum sodium).
• Fluid loss is Based on blood osmolarity Administer hypotonic or isotonic (non-sodium) IV fluids:
  • Hypotonic IV fluids have a lesser salt concentration than blood, including Dextrose 5% in water, Dextrose 10% in water, 0.225% sodium chloride, 0.45% sodium chloride, and Dextrose 5% in 0.45% sodium chloride.
• Encourage water intake and discourage sodium intake.
• Administer diuretics (loop diuretics) if impaired kidney excretion is the cause of hypernatremia.

Potassium Imbalances

• Potassium (K+) is the major cation in ICF.
• Potassium plays a vital role in cell metabolism, nerve impulse transmission, functioing of cardiac, lung, and muscle tissues, also the acid-base balance.
• Potassium and sodium have a reciprocal relationship.

Hypokalemia

• Hypokalemia occurs when blood potassium level is less than 3.5 mEq/L.
• Hypokalemia usually comes from an increased loss of potassium from the body, decreased potassium intake/absorption, or movement of potassium into the cells.

Assessment/Data Collection: Risk Factors for Hypokalemia

• Hyperaldosteronism
• Inadequate dietary intake (rare)
• Prolonged administration of non-electrolyte-containing IV solutions (5% dextrose in water)
• Receiving total parenteral nutrition
• Metabolic alkalosis
• Excessive GI losses (vomiting, nasogastric suctioning, diarrhea, excessive laxative use)
• Renal losses (excessive use of potassium-excreting diuretics like furosemide or corticosteroids)
• Skin losses (diaphoresis, wound losses)

Expected findings for Hypokalemia

• Weak/irregular pulse, hypotension, orthostatic hypotension, respiratory distress
• Ascending bilateral muscle weakness with respiratory collapse and paralysis, muscle cramping, decreased muscle tone and hypoactive reflexes, paresthesias, mental confusion
• Electrocardiogram (ECG): Premature ventricular contractions (PVCs), bradycardia, blocks, ventricular tachycardia, flattening, flattened, or inverted T waves, increased U waves, and ST depression
• Decreased GI motility, hypoactive bowel sounds, abdominal distention, constipation, ileus, nausea, vomiting, anorexia
• Anxiety, which can progress to lethargy

Patient-Centered Care for Hypokalemia

• Nurse should treat the underlying cause and replace potassium.
• Provide dietary education and encourage foods high in potassium such as avocados, dried fruit, cantaloupe, bananas, potatoes, spinach.
• Also provide oral potassium supplementation.
• IV potassium administration must be diluted and administered slowly by intermittent infusion (5 to 10 mEq/hr), never IV bolus due to increased risk of cardiac arrest.
• Monitor for and maintain an adequate urine output.
• Monitor for shallow, ineffective respirations and diminished breath sounds.
• Intervene promptly if cardiac rhythm needs it.
• Increased risk for digoxin toxicity if digoxin is present.
• Monitor level of consciousness and ensure safety.
• Monitor bowel sounds and abdominal distention, intervene as needed.

Hyperkalemia

• Hyperkalemia occurs when blood potassium level is greater than 5.0 mEq/L.
• Hyperkalemia results from increased potassium intake, movement of potassium out of cells, or inadequate renal excretion.
• Hyperkalemia is uncommon in clients with adequate kidney function.
• Hyperkalemia is potentially life-threatening due to the dysrhythmias and cardiac arrest.

Assessment/Data Collection: Risk Factors for Hyperkalemia

• Increased total body potassium (IV potassium administration, salt substitutes, blood transfusion)
• ECF shift; Insufficient insulin, acidosis (diabetic ketoacidosis), tissue catabolism (sepsis, burns, trauma, surgery, fever, or myocardial infarction)
• Hypertonic states (uncontrolled diabetes mellitus)
• Decreased excretion of potassium (kidney failure, severe dehydration, potassium-sparing diuretics, ACE inhibitors, adrenal insufficiency)
• Older adult clients at greater risk due to decreased kidney function, medical conditions, salt substitutes, angiotensin-converting enzyme inhibitors, or potassium-sparing diuretics

Expected Findings for Hyperkalemia

• Slow, irregular pulse, hypotension for vital signs
• Neuromusculoskeletal findings include irritability, confusion, weakness with ascending flaccid paralysis, paresthesia, lack of reflexes
• GI effects would be increased motility, diarrhea, abdominal cramps, and hyperactive bowel sounds
• Diagnostic Procedures: ECG shows peaked T waves, widened PR and QRS; dysrhythmias and asystole are possible.

Patient-Centered Care for Hyperkalemia

• Implement continuous ECG monitoring to monitor cardiac rhythm, and intervene promptly as needed
• Decrease potassium intake by stopping infusion of IV potassium, withholding oral potassium, provide a potassium-restricted diet.
• Monitor serum potassium levels, perform dialysis if extremely high.
• Administer IV fluids with dextrose and regular insulin as prescribed to promote the movement of potassium from the ECF to the ICF.
• Follow agency protocol and ensure patent IV access.
• Administer sodium polystyrene sulfonate as prescribed.

Medications for Hyperkalmia

• Loop diuretics increase potassium excretion from renal system if kidney function is adequate.
• Sodium polystyrene sulfonate can be given orally or as an enema, and increases potassium excretion from the gastrointestinal system.
• Other medications can include calcium gluconate, albuterol, and patiromer.

Calcium Imbalances

• Calcium is found in the body's cells, bones, and teeth.
• Calcium balance is essential for proper functioning of the cardiovascular, neuromuscular, and endocrine systems, as well as blood clotting and bone and teeth formation.

Hypocalcemia

• Hypocalcemia is a total blood calcium level less than 9 mg/dL.

Assessment/Data collection: Risk Factors for Hypocalcemia

• Increased calcium output: Chronic diarrhea, Laxative misuse, Steatorrhea as with pancreatitis (binding of calcium to undigested fat)
• Inadequate calcium intake or absorption: Malabsorption syndromes like Crohn's disease, Vitamin D deficiency (alcohol use disorder, chronic kidney disease)
• Calcium shift from ECF into bone or to an inactive form: Rapid infusion of citrated blood transfusion, Post-thyroidectomy, Hypoparathyroidism, Hypoalbuminemia, Alkalosis, Pancreatitis, and Hyperphosphatemia

Expected findings for Hypocalcemia

• Muscle twitches/tetany can cause Numbness and tingling (fingers and around mouth), Frequent painful muscle spasms at rest that can progress to tetany, Hyperactive DTRs, Positive Chvostek's sign (tapping on the facial nerve triggering facial twitching), Positive Trousseau's sign (hand/finger spasms with sustained BP cuff inflation), and Laryngospasms
• Cardiovascular: Weak, thready pulse, tachycardia or bradycardia.
• Cardiac dysrhythmias: prolonged QT interval and ST segments
• GI: Hyperactive bowel sounds, diarrhea, abdominal cramping
• Central Nervous System: Seizures due to overstimulation of the CNS

Patient-Centered Care for Hypocalcemia

• Nursing care includes administering oral or IV calcium supplements and vitamin D supplements; seizure and fall precautions; emergency equipment on standby; encourage foods high in calcium, including dairy products and dark green vegetables.

Hypercalcemia

• Hypercalcemia has a blood calcium level greater than 10.5 mg/dL.
• The reasons this comes about are thiazide diuretic, or long-term glucocorticoid use, Paget's disease, hyperthyroidism and hyperparathyroidism, and bone cancer.

Expected Findings for Hypercalcemia

• Decreased reflexes
• Bone pain
• Cardiovascular: Dysrhythmias (shortened QT and ST intervals), Increased risk for blood clot
• GI: Anorexia, nausea, vomiting, constipation
• Central nervous system: Weakness, lethargy, Confusion, decreased level of consciousness, and Personality change
• GU: Hypercalciuria

Patient-Centered Care for Hypercalcemia

• Treat by restricting calcium and increasing fluid intake.

Magnesium Imbalances

• Most magnesium exist in the bones. Magnesium in smaller amounts is found within the body cells but a very small amount is found in ECF.

Hypomagnesemia

• Occurs if blood magnesium is less than 1.3 mEq/L.

Assessment/Data Collection: Risk Factors for Hypomagnesemia

• Increased magnesium output: GI losses like diarrhea or nasogastric suction + Thiazide or loop diuretics. Often associated with hypocalcemia
• Shift Into Inactive Form: Rapid infusion of citrated blood
• Inadequate magnesium intake or absorption: Malnutrition, Alcohol use disorder, and Laxative misuse

Expected Findings for Hypomagnesemia

Increased nerve impulse transmission (hyperactive DTRs, paresthesia, muscle tetany), positive Chvostek's and Trousseau's signs, tetany, seizures, insomnia

Patient-Centered Care for Hypomagnesemia

• Stop magnesium-depleting medications
• Mild manifestations can be treated with magnesium orally given as IV if severe like diarrhea can be worsened by oral magnesium.
• Recommend intake of foods such as whole grains and dark green vegetables.

Hypermagnesemia

• When blood magnesium level is greater than 2.1 mEq/L
• Cases include kidney or adrenal impairment, increased intake of medications containing magnesium (laxatives, antacids).

Expected Findings for Hypermagnesemia

• Diminished deep tendon reflexes (DTRs)
• Muscle paralysis
• Shallow respirations, decreased respiratory rate can affect a patient.
• They may experience Bradycardia, hypotension, Cardiac arrest, and Dysrhythmias, ECG changes (prolonged PR interval)
• They may also experience Lethargy, Prolonged PR interval, widened QRS
• Perform frequent focused assessments (vital signs, level of consciousness, reflexes).

Patient-Centered Care for Hypermagnesemia

• Administer loop diuretics and magnesium free IV fluids if kidney function is adequate
• Administer calcium gluconate for severe cardiac changes.