Electrolyte Imbalances PDF - Nursing Notes

Electrolytes are minerals (sometimes called salts) that have an electric charge and are present in all body fluids. They regulate fluid balance and hormone production, strengthen skeletal structures, and act as catalysts in nerve response, muscle contraction, and the metabolism of nutrients. Major e...

Electrolytes are minerals (sometimes called salts) that have an electric charge and are present in all body fluids. They regulate fluid balance and hormone production, strengthen skeletal structures, and act as catalysts in nerve response, muscle contraction, and the metabolism of nutrients. Major electrolytes in the body include sodium, potassium, chloride, magnesium, phosphorus, and calcium. Electrolytes are either positive (cations: magnesium, potassium, sodium, calcium) or negative (anions: phosphate, sulfate, chloride, bicarbonate). Monitoring laboratory values can help in identifying any electrolyte imbalances. While laboratory tests can accurately reflect the electrolyte concentrations in plasma, it is not possible to directly measure electrolyte concentrations within cells. It is important to recognize the manifestations of electrolyte imbalance. Clients at greatest risk for electrolyte imbalance are infants, children, older adults, clients who have cognitive disorders, and clients who have chronic illnesses. 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 found in ECF and is present in most body fluids or secretions. Sodium is essential for maintenance of acid-base and fluid balance, active and passive transport mechanisms, and irritability and conduction of nerve and muscle tissue. Hyponatremia Hyponatremia is a blood sodium level less than 136 mEq/L.  Hyponatremia results from an excess of 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 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, gastrointestinal obstruction, peripheral edema, ascites Increased or normal ECF volume: excessive oral water intake, syndrome of inappropriate antidiuretic hormone secretion (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 Older adult clients are at greater risk due to an increased incidence of chronic illnesses, use of diuretic medications, and risk for insufficient sodium intake. Expected findings Physical assessment findings: Vary with a normal, decreased, or increased ECF volume Vital signs: Hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension Neuromusculoskeletal: Headache, confusion, lethargy, muscle twitching, muscle weakness with possible respiratory compromise, fatigue, decreased deep tendon reflexes (DTRs), seizures, coma GI: Increased motility, hyperactive bowel sounds, abdominal cramping, anorexia, nausea, vomiting Patient-Centered Care Nursing Care Monitor I&O and weigh the client daily at same time of day using the same scale. Monitor vital signs and level of consciousness, report irregular findings. Encourage the client to change positions slowly. Follow any prescribed fluid restrictions. Monitor respiratory status if muscle weakness is present. Encourage foods and fluids high in sodium (cheese, milk, condiments). Fluid overload Restrict water intake as prescribed. This treatment is typically effective when fluid volume is normal to high. Severe hyponatremia: Administer hypertonic oral and IV fluids as prescribed. Hypertonic IV fluids are solutions that has a greater concentration of particles as blood, such as 3% or 5% sodium chloride Hypernatremia Hypernatremia is a blood sodium level greater than 145 mEq/L. Hypernatremia is a serious electrolyte imbalance. It can cause significant neurologic, endocrine, and cardiac disturbances. Increased sodium causes hypertonicity of the blood. This causes a shift of water out of the cells, making the cells dehydrated. Assessment/Data Collection Risk Factors 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 (glucocorticosteroids) Fluid losses: fever, diaphoresis, burns, respiratory infection, diabetes insipidus, hyperglycemia, watery diarrhea Expected findings Vital signs: Hyperthermia, tachycardia, orthostatic hypotension Neuromusculoskeletal: Restlessness, fatigue, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased level of consciousness, reduced to absent DTRs GI: Thirst, dry and sticky mucous membranes, dry and swollen tongue that is red in color, increased motility, hyperactive bowel sounds, abdominal cramping, nausea Other findings: Edema, warm flushed skin, oliguria Patient-Centered Care Nursing Care Monitor level of consciousness (may see restlessness or disorientation)and 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: Based on blood osmolarity  Administer hypotonic or isotonic (non-sodium) IV fluids. Hypotonic IV fluids are solutions that has a lesser concentration (dilute) of particles as 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. Excess sodium Encourage water intake and discourage sodium intake. Administer diuretics (loop diuretics) if impaired kidney excretion is the cause of hypernatremia. A nurse is planning care for a client who has hypernatremia. What actions should the nurse include in the plan of care? Potassium imbalances Potassium (K+) is the major cation in ICF. Potassium plays a vital role in cell metabolism; transmission of nerve impulses; functioning of cardiac, lung, and muscle tissues; and acid-base balance. Potassium has reciprocal action with sodium. Hypokalemia Hypokalemia is a blood potassium level less than 3.5 mEq/L. Hypokalemia is the result of an increased loss of potassium from the body, decreased intake and absorption of potassium, or movement of potassium into the cells. Assessment/data collection Risk Factors 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 (furosemide, corticosteroids) Skin losses: Diaphoresis, wound losses Expected findings Vital signs: Weak, irregular pulse, hypotension, orthostatic hypotension, respiratory distress Neuromusculoskeletal: 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 GI: Decreased motility, hypoactive bowel sounds, abdominal distention, constipation, ileus, nausea, vomiting, anorexia Other clinical findings: Anxiety, which can progress to lethargy Patient-Centered Care Nursing Care Treat the underlying cause. Replace potassium. Provide dietary education and encourage foods high in potassium (avocados, dried fruit, cantaloupe, bananas, potatoes, spinach). Provide oral potassium supplementation. IV potassium administration might be required; it should always be diluted and administered slowly by intermittent infusion (5 to 10 mEq/hr). Never IV bolus (high risk of cardiac arrest). Monitor for and maintain an adequate urine output. Monitor for shallow, ineffective respirations and diminished breath sounds. Monitor cardiac rhythm and intervene promptly as needed. Monitor clients receiving digoxin. Hypokalemia increases the risk for digoxin toxicity. Monitor level of consciousness and ensure safety. Monitor bowel sounds and abdominal distention and intervene as needed. Hyperkalemia Hyperkalemia is a blood potassium level greater than 5.0 mEq/L.  Hyperkalemia is the result of an increased intake of potassium, movement of potassium out of the cells, or inadequate renal excretion. Hyperkalemia uncommon in clients who have adequate kidney function. Hyperkalemia is potentially life-threatening due to the risk of cardiac dysrhythmias and cardiac arrest. Assessment/Data Collection Risk Factors 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, myocardial infarction) Hypertonic states: Uncontrolled diabetes mellitus Decreased excretion of potassium: Kidney failure, severe dehydration, potassium-sparing diuretics, ACE inhibitors, adrenal insufficiency Age: Older adult clients at greater risk due to decreased kidney function and medical conditions resulting in the use of salt substitutes, angiotensin-converting enzyme inhibitors, and potassium-sparing diuretics Expected findings Vital signs: Slow, irregular pulse; hypotension Neuromusculoskeletal: Irritability, confusion, weakness with ascending flaccid paralysis, paresthesia, lack of reflexes GI: Increased motility, diarrhea, abdominal cramps, hyperactive bowel sounds Diagnostic Procedures ECG will show peaked T waves, widened PR and QRS. Dysrhythmias and asystole are possible. Patient-Centered Care Nursing Care  Implement continuous ECG monitoring to monitor cardiac rhythm, and intervene promptly as needed Decrease potassium intake. Stop infusion of IV potassium. Withhold oral potassium. Provide a potassium-restricted diet. Monitor serum potassium levels If potassium levels are extremely high, dialysis might be required. Prepare the client for dialysis if prescribed. 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. Ensure patent IV access. Administer sodium polystyrene sulfonate as prescribed. Medications To increase potassium excretion Administer loop diuretics (furosemide) if kidney function is adequate. Loop diuretics increase the excretion of potassium from the renal system. Sodium polystyrene sulfonate is given orally or as an enema. Sodium polystyrene sulfonate increases the excretion of potassium from the gastrointestinal system.  Other medications can include calcium gluconate, albuterol, and patiromer. A nurse is planning caring for a client who has a potassium level of 5.2 mEq/L. What actions should the nurse plan to take? 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 Increased calcium output Chronic diarrhea Laxative misuse Steatorrhea as with pancreatitis (binding of calcium to undigested fat) Inadequate calcium intake or absorption Malabsorption syndromes (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 Hyperphosphatemia Expected findings Muscle twitches/tetany 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 blood pressure cuff inflation) 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 Nursing Care Administer oral or IV calcium supplements and vitamin D supplements. Initiate seizure and fall precautions. Keep emergency equipment on standby. Encourage foods high in calcium, including dairy products and dark green vegetables. Hypercalcemia Hypercalcemia is a total blood calcium level greater than 10.5 mg/dL. Hypercalcemia is not as common as hypocalcemia. Causes include thiazide diuretic or long-term glucocorticoid use, Paget’s disease, hyperthyroidism and hyperparathyroidism, and bone cancer. Expected findings Neuromuscular 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 Personality change GU: Hypercalciuria Patient-Centered Care Nursing Care Treatment includes restricting calcium and increasing fluid intake. Monitor the client for pathological fractures. A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance. Match the electrolyte imbalance to the associated risk factor. Hypernatremia Hyponatremia Hypocalcemia Hypercalcemia Diabetes insipidus Hypoparathyroidism Hyperparathyroidism Excessive water intake Magnesium imbalances Most of the body’s magnesium is found in the bones. Magnesium in smaller amounts is found within the body cells. A very small amount is found in ECF. Hypomagnesemia Hypomagnesemia is a blood magnesium level less than 1.3 mEq/L. Assessment/Data collection Risk Factors Increased magnesium output GI losses (diarrhea, 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 Laxative misuse Expected findings Neuromuscular: Increased nerve impulse transmission (hyperactive DTRs, paresthesia, muscle tetany), positive Chvostek’s and Trousseau’s signs, tetany, seizures, insomnia GI: Hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus Cardiovascular: Dysrhythmias, tachycardia, hypertension, ECG waveform changes or PVCs Patient-Centered Care Nursing Care Discontinue magnesium-losing medications. Magnesium replacement can be required orally (if the client is experiencing mild manifestations) or IV (if manifestations are severe). Oral magnesium can cause diarrhea and increase magnesium depletion.  Encourage foods high in magnesium, including whole grains and dark green vegetables. Hypermagnesemia Hypermagnesemia is a blood magnesium level greater than 2.1 mEq/L. Causes include kidney or adrenal impairment and increased intake of medications containing magnesium (laxatives, antacids). Expected findings Neuromuscular Diminished DTRs Muscle paralysis Shallow respirations, decreased respiratory rate Cardiovascular Bradycardia, hypotension Cardiac arrest Dysrhythmias, ECG changes (prolonged PR interval) Central nervous system: Lethargy Diagnostic Procedures ECG: Prolonged PR interval, widened QRS Patient-Centered Care Nursing Care Perform frequent focused assessments (vital signs, level of consciousness, reflexes). Notify the provider of changes or absent reflexes. Administer loop diuretics and magnesium free IV fluids if kidney function is adequate. Administer calcium gluconate for severe cardiac changes.