Electrolyte Imbalance

Sodium Imbalance

• Sodium is a major electrolyte found in the extracellular fluid (ECF).
• It is essential for acid-base balance, fluid balance, active and passive transport mechanisms, and nerve-muscle tissue conduction.
• The normal range for Sodium is 135-145 mEq/L.
• Increased sodium levels often correspond to decreased potassium levels.

Hypernatremia

• Hypernatremia is indicated by a sodium level above 145 mEq/L.
• Signs and symptoms can be remembered with the mnemonic "fried salt".
• F Flushed skin
• R Restless, anxious, confused, irritable
• I Increased BP and fluid retention
• E Edema (pitting)
• D Decreased urine output
• S Skin flushed & dry
• A Agitation
• L Low-grade fever
• T Thirst (dry mucous membranes)

Hypernatremia Risk Factors

• Excess administration of IV fluids with sodium
• Hypertonic IV fluids
• Fluid loss
• Fever
• Watery diarrhea
• Diabetes insipidus
• Excessive sweating
• Infection
• Decreased sodium excretion
• Kidney problems

Hypernatremia Interventions

• Administer IV infusions for fluid loss.
• Give diuretics that promote sodium loss if the cause is inadequate renal excretion of sodium
• Restrict sodium and fluid intake as prescribed.

Hyponatremia

• Hyponatremia is indicated by a sodium level below 135 mEq/L.
• Signs and symptoms can be remembered with the mnemonic "salt loss".
• S Stupor/coma
• A Anorexia (nausea/vomiting)
• L Lethargy (weakness/fatigue)
• T Tachycardia (thready pulse)
• L Limp muscles (muscle weakness)
• O Orthostatic hypotension
• S Seizures/headache
• S Stomach cramping (hyperactive bowels)

Hyponatremia Risk Factors

• Increased sodium excretion
  • Diaphoresis (e.g., high fever)
  • Drains (NGT suction)
  • Diuretics (thiazide and loop diuretics)
• SIADH (syndrome of inappropriate antidiuretic hormone secretion)
• Adrenal insufficiency (adrenal crisis)
• Fasting, NPO, low-salt diet
• Kidney disease
• Heart failure

Hyponatremia Interventions

• Administer IV sodium chloride infusions only if due to hypovolemia (low blood volume).
• Administer Diuretics if due to hypervolemia
• Monitor daily weights; where sodium goes, water flows
• Ensure patient safety; orthostatic hypotension increases fall risk
• Airway protection (NPO) for lethargic, confused clients; increased risk for aspiration.
• Limit water intake in hypervolemic hyponatremia (high fluid & low salt).
• Educate about foods high in sodium, such as canned food, packaged/processed meats, etc.

Potassium Imbalance

• Potassium plays a vital role in cell metabolism and nerve impulse transmission.
• It is a key component in cardiac, lung, and muscle tissue function, as well as acid-base balance.
• The normal range is 3.5-5 mEq/L.
• Hyperkalemia and hypokalemia refer to high and low potassium levels, respectively.

Hyperkalemia

• Hyperkalemia exists where potassium levels are above 5 mEq/L.
• Signs and symptoms can be remembered with the mnemonic MURDER:
  • M Muscle cramps & weakness
  • U Urine abnormalities
  • R Respiratory distress
  • D Decreased cardiac contractility (+HR, +BP)
  • E ECG changes (Tall peak T wave, Flat P waves, Widened QRs complexes, prolonged pr intervals)
  • R Reflexes (increased DTR – deep tendon reflexes)

Hyperkalemia Risk Factors

• Medications
  • Potassium-sparing diuretics (Spironolactone)
  • ACE inhibitors
  • NSAIDs
• Excessive potassium intake (e.g., rapid infusion or potassium-containing IV solutions)
• Kidney disease or dialysis
• Decreased potassium excretion
• Adrenal Insufficiency (Addison’s disease)
• Tissue damage
• Acidosis

Hyperkalemia Interventions

• Monitor EKG
• Discontinue IV and PO potassium.
• Put the patient on a potassium-restricted diet.
• Administer Potassium-excreting diuretics
• Prepare the client for dialysis.
• Prepare for administration of IV calcium gluconate & IV sodium bicarb
• Avoid salt substitutes or other potassium-containing substances.

Hypokalemia

• Hypokalemia exists where potassium levels are below 3.5 mEq/L.
• Symptoms include:
  • generalized weakness
  • Thready, weak, irregular pulse
  • Orthostatic hypotension
  • Shallow respirations
  • Anxiety, lethargy, confusion, coma
  • Paresthesias
  • Hyporeflexia (* DTR)
  • Hypoactive bowel sounds (constipation)
  • Nausea, vomiting, and abdominal distention
  • ECG changes (ST depression, shallow or inverted T waves, prominent U waves)

Hypokalemia Risk Factors

• Inadequate potassium intake
• Fasting, NPO
• Movement of potassium from the extracellular fluid to the intracellular fluid
• Alkalosis
• Dilution of serum potassium
• Water intoxication
• IV therapy with potassium-deficient solutions

Hypokalemia Interventions

• Administer oral potassium supplements.
• Administer Liquid potassium chloride
• Administer Potassium-sparing diuretics
• Potassium should NEVER be administered by IV push, IM, or subQ routes.
• IV potassium should always be diluted and administered using an infusion device.

Calcium Imbalance

• Calcium is found in the body's cells, bones, and teeth and is needed for proper functioning of cardiovascular, neuromuscular, and endocrine systems, as well as blood clotting & teeth formation.
• The normal range is 9.0 - 11.0 mg/dl

Hypercalcemia

• Hypercalcemia is when the body's calcium level is above 11.0 mg/dL
• Signs and symptoms include:
  • Bone pain
  • Arrhythmias
  • Cardiac arrest (bounding pulses)
  • Kidney stones
  • Muscle weakness + (DTR)
  • Excessive urination

Hypercalcemia Risk Factors

• Increased calcium absorption
• Decreased calcium excretion
• Kidney disease
• Thiazide diuretics
• Increased bone resorption of calcium
• Hyperparathyroidism / Hyperthyroidism
• Malignancy (bone destruction from metastatic tumors)
• Hemoconcentration

Hypercalcemia Interventions

• Discontinue IV or PO calcium.
• Discontinue Thiazide diuretics
• Administer phosphorus, calcitonin, bisphosphonates, & prostaglandin synthesis inhibitors (NSAIDs)
• Avoid foods high in calcium

Hypocalcemia

• Hypocalcemia is when the body's calcium level is below 9.0 mg/dL

• Symptoms include:

  • Convulsions
  • Arrhythmias
  • Tetany
  • Spasms & stridor
  • GO NUMB Numbness in fingers, face, limbs

• In hypcalcemia patients may present POSITIVE CHVOSTEKS & TROUSSEAUS SIGN

Hypocalcemia Risk Factors

• Inhibition of calcium absorption from the GI tract
• Increased calcium excretion
• Kidney disease, diuretic phase
• Diarrhea & steatorrhea
• Wound drainage
• Conditions that decrease the ionized fraction of calcium
• Vitamin D deficiency

Hypocalcemia Interventions

• Administer calcium PO or IV; warm before and administer slowly when administering intravenously
• Administer aluminum hydroxide & Vitamin D
• Initiate seizure precautions.
• Administer 10% calcium (acute calcium deficit)
• Consume foods high in calcium

Magnesium Imbalance

• Magnesium and calcium levels mirror one another in the body
• Most magnesium is found in the bones, while calcium is stored in a variety of tissues
• Magnesium regulates BP, blood sugar, muscle contraction & nerve function
• The normal range is 1.5 - 2.5 mg/dL

Hypermagnesemia

• Hypermagnesemia is when magnesium level is above 2.5 mg/dL
• Symptoms of LOW (d) everything, AKA SEDATED:
  • Decreased energy (drowsiness / coma)
  • Decreased (bradycardia)
  • Decreased BP (hypotension)
  • Decreased HR (bradypnea)
  • & Respirations (shallow)
  • & Bowel sounds
  • & DTRs (deep tendon reflex)

Hypermagnesemia Risk Factors

• Increased magnesium intake, such as
  • magnesium-containing antacids (TUMS)
  • laxatives
• Excessive administration of magnesium IV
• Renal insufficiency

Hypermagnesemia Interventions

• Administer diuretics.
• Administer IV calcium chloride or calcium gluconate
• Restrict dietary intake of Mg-containing foods; avoid the use of magnesium-containing laxatives and antacids.
• Hemodialysis to filter magnesium from the blood.

Hypomagnesemia

• Hypomagnesemia is when magnesium levels fall below 1.5 mg/dL
• Symptoms of HIGH (T) everything, AKA NOT SEDATED:
  • Increased HR (tachycardia)
  • Increased BP (hypertension)
  • Increased deep tendon reflex (hyperreflexia)
  • Shallow respirations
  • Twitches, paresthesias
  • Tetany & seizures
  • Irritability & confusion

Hypermagnesemia

• Patients with hypomagnesemia present POSITIVE CHVOSTEKS & TROUSSEAUS SIGN

Hypomagnesemia Risk Factors

• Insufficient magnesium intake
• Malnutrition/vomiting/diarrhea
• Malabsorption syndrome (Celiac & Crohn's disease)
• Increased magnesium excretion
  • Diuretics or chronic alcoholism
• Intracellular movement of magnesium
• Hyperglycemia & Insulin administration
• Sepsis

Hypomagnesemia Interventions

• Administer magnesium sulfate IV or PO
• Take Seizure precautions
• Instruct the client to increase magnesium-containing foods

IV Solutions Explained

• IV solutions are categorized based on their tonicity, which affects how water moves between cells and the solution.
• The three types of solutions listed below.

Isotonic Solutions

• Isotonic solutions have the same concentration of solutes as blood, and they're known as "same- same"
• Water does not significantly shift in and out of cells; cells stay the same size.
• Used for:
  • dehydration
  • blood loss
  • maintaining normal blood pressure.
• Examples: Normal Saline (0.9% NaCl) and Lactated Ringer's

Hypotonic Solutions

• Hypotonic solutions have a lower concentration of solutes than blood and known as "too little salt, more water"
• Water moves into the cells, causing them to swell.
• Used for:
  • conditions where cells are dehydrated (e.g., in diabetic ketoacidosis)
  • diluting extra-salty body fluids
  • correcting high sodium levels
• Example: 0.45% NaCl (half-normal saline)

Hypertonic Solutions

• Hypertonic solutions have a higher concentration of solutes than blood and known as "too much salt, less water"
• Water moves out of the cells, causing them to shrink.
• Used for:
  • brain swelling
  • low sodium levels
  • critical situations in the ICU requiring quick fluid shifts
  • quickly raising low salt levels
• Example: 3% NaCl

Test your knowledge of electrolyte imbalances, their signs and symptoms, risk factors, and appropriate nursing interventions. This quiz covers sodium, potassium, calcium imbalances, including hypernatremia, hyponatremia, hypercalcemia, and hypocalcemia.