Electrolytes Imbalance PDF

Electrolytes Imbalance - Maintain blood proper pH - Molecules or minerals that help carry electrical signals throughout the body - Nerve impulse: when you get the body to move, it happens because electrolyte b/cnerve transmission is all about Na and K - Ca: help keep muscles c...

Electrolytes Imbalance - Maintain blood proper pH - Molecules or minerals that help carry electrical signals throughout the body - Nerve impulse: when you get the body to move, it happens because electrolyte b/cnerve transmission is all about Na and K - Ca: help keep muscles contraction, adequate Ca in sarcoplasmic reticulum to cause muscle contraction Expected Reference Ranges Sodium 135 to 145 mEq/L ○ Same as blood pH ○ Help fluid balance Calcium: 8.5 to 10.5 mg/dL ○ 3B: Bone, Blood clotting, heat Beating Potassium: 3.5 to 5.0 mEq/L ○ Banana: bunches 3-5 ○ Help heart pump: stable rhythm ○ Most critical electrolytes ○ Very narrow range ○ Fluid balance Magnesium: 1.3 to 2.1 mEq/L ○ Mellows the muscles ○ Make you sleep Tired Chloride: 95 to 105 mEq/L ○ Maintain hydration status ○ See this in respiratory & metabolic acidosis and alkalosis ○ Help with blood pH  Phosphorus: 3.0 to 4.5 mg/dL ○ Inverse relationship with calcium ○ ↑ phosphorus = ↓ calcium ○ ↑ calcium= ↓ phosphorus Electrolyte Imbalances Only normal, high or low Hyper: high Hypo: low Sodium Hypernatremia Hyponatremia Potassium Hyperkalemia Hypokalemia Calcium Hypercalcemia Hypocalcemia Magnesium Hypermagnesemia Hypomagnesaemia Chloride Hyperchloridemia  Hypochloridemia Phosphorous Hyperphosphatemia Hypophosphatemia Sodium Imbalances General Sodium (Na+ ) is the major electrolyte (cation) found in ECF and maintains ECF osmolarity. ○ += cation Sodium within ICF is low (14 mEq/L). The difference in ICF and ECF sodium levels is very important in maintaining skeletal muscle contraction, cardiac contraction, and nerve impulse transmission. ○ Na+ in ICF maintains the osmolarity of ECF ○ ↑ Na= ↑ fluid ○ Na in ICF is lower than in ECF ○ The difference where Na is at helps with passive diffusion, osmosis ○ Imbalance high in ECF and low in ICF helps with muscle contraction, cardiac contraction and nerve impulses ○ Water flows in the direction of Na concentration ( if there’s more Na in intravascular space, a lot of fluid) if you see salt, you have a lot of fluid ○ Water flows in the direction of sodium concentration. The ECF sodium level influences fluid retention, excretion, and movement of fluid from one body space to another. The kidneys regulate sodium levels with the assistance of aldosterone, antidiuretic hormone (ADH), and natriuretic peptide. ○ Aldosterone: salt retaining hormone; releases a lot of aldosterone: release a lot of hormone to retain salt in the body which also retains more fluids in the body. When the body not producing a lot of aldosterone, not able to have salt retention and my body is going to lose fluids. Comes from adrenal cortex in adrenal gland ○ Antidiuretic hormones (ADH): anti-peeing, not peeing fluid→ fluid stay in vascular space or body. ↑ ADH= not peeing. ↑ ADH: retain fluid ↓ ADH: pee a lot. ○ What type of diabetes do you have when ADH is low? Diabetes insipidus (all about water) Diabetes mellitus (all about sugar) ○ Diabetes inisipidus: ↓ ADH→ peeing all the fluid → thirsty a lot Endocrine disturbance. How do we fix? Give synthetic ADH (known as vasopressin) ○ Natriuretic peptide: when the heart ventricles is really stretch, it releases BNP. Congested heart failure: BNP is elevated. We want to have BNP less than 100 which means there’s not heart failure. Because of stretch of ventricle, BNP is going to try to process fluid out of the body b/c it is overloading the heart. Hypernatremia – General Information Increased sodium causes hypertonicity of the blood. This causes a shift of water out of the cells, resulting in dehydrated cells. ○ 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 (how electrical signal file from AV node to SA node to bundle of His and fiber; how electricity of nerve impulse is going. Na& K big role) Notes: ○ Na: can change the osmolarity of blood, and cause movement of water. If we have a lot of salt in vascular space, we are going to pull a lot of water from cell to go to vascular space (grape cells turn into raisins) ○ Hypernatremia: cells are dehydrated Hypernatremia – Risk Factors Actual Sodium Excess (actual high sodium in the body) Kidney failure Cushing’s syndrome Aldosteronism (too much high aldosterone) Some medications (such as glucocorticosteroids) (steroids: works in adrenal cortex, increase aldosterone which cause retain salt) Excessive intake of oral sodium (eating chips) Relative sodium excess due to decreased fluid volume ( high Na b/c of fluid loss) Water deprivation (NPO) Hypertonic enteral feedings without adequate water supplement (important to follow 3 water flushes; not following 3 water flush in tube feed can potentially cause electrolytes imbalance b/c not getting enough water) (tube feeding sugar that can affect hydration status and electrolytes status) Diabetes insipidus (losing fluid: hemoconcentration: salt level is high b/c loss a lot of plasma because of peeing) Heatstroke Hyperventilation Watery stools Burns Excessive sweating Hypernatremia – Expected Findings Thirst VITAL SIGNS: Hyperthermia, tachycardia, orthostatic hypotension NEUROMUSCULOSKELETAL: Restlessness; irritability; muscle twitching to the point of muscle weakness, including respiratory compromise; decreased or absent DTRs; seizures; coma GASTROINTESTINAL: Thirst, dry mucous membranes, nausea, vomiting, anorexia, occasional diarrhea Hypernatremia S&S – FRIED SALT Hypernatremia – Laboratory Tests Blood sodium: Increased to greater than 145 mEq/L Blood osmolarity: Increased to greater than 300 mOsm/L (typical 270-300) Urine specific gravity and osmolarity: Increased (urine very concentrated) Hypernatremia – Nursing Care General Nursing Care Monitor level of consciousness and ensure safety. (can cause coma and seizure) Monitor vital signs and heart rhythm. Auscultate lung sounds. (why? Might get fluid in lungs, might hear crackles, give lasix) Provide oral hygiene and other comfort measures to decrease thirst. ( if mucous membrane is dry, pathogen go to body) Monitor I&O, and alert the provider of inadequate urinary output (30mL per hour as adequate urine output) Fluid Loss Based on blood osmolarity and hemodynamic stability ○ (replace based on osmolarity) ○ Different disease processes use different fluids Dextrose 5% in 0.45% sodium chloride is a hypertonic solution prior to infusion. However, once infused, the glucose rapidly metabolizes, and it becomes a hypotonic solution. 0.3% sodium chloride can be prescribed as a hypotonic solution, which provides a more gradual reduction in blood sodium levels and reduces the risk of cerebral edema. This is the preferred IV solution if the client also has severe hyperglycemia. (salt is cause brain swelling and help reduce pressure) Dextrose 5% in water and 0.9% sodium chloride are isotonic solutions. Excess Sodium Encourage water intake and discourage sodium intake. Administer diuretics (loop diuretics) for clients who have poor kidney excretion. Hypernatremia – Interprofessional Care Nutritional services can be consulted for low-sodium food choices and to restrict fluid intake Talk to a dietitian: low salt diet Depending on the severity, you might restrict fluid intake b/c Na level is really high, even if they try to hemodilute the concentration of Na in the body, sometimes it can cause fluid retention Blood sodium 160: not push fluid but 150 push fluid (work with doctor and team) If Na is so high, even if you give fluids, it is going to give you what you want to happen b/c fluid overload 26:09 Hypernatremia – Client Education Weigh daily. Notify the provider of a 1- to 2-lb gain in 24 hr, or 3-lb (1.4 kg) gain in 1 week. Consume a low-sodium diet, read food labels for sodium content, and keep a record of daily sodium intake. (limit Gatorade b/c it has salt) Adhere to fluid intake as prescribed.  Over-the-counter medications that contain sodium bicarbonate can increase sodium levels. (the Na+ in Sodium bicarbonate gets processes will increase Na) Hypernatremia – Complications Severe Hypernatremia Seizures, convulsions, and death can result from severe hypernatremia if not treated immediately. NURSING ACTIONS ○ Maintain open airway and monitor vital signs. ○ Implement seizure precautions, and take appropriate action if seizures occur. Siderail Suction Have medication (benzodiazepine, valium) ○ Monitor level of consciousness Hyponatremia Hyponatremia is a net gain of water or loss of sodium-rich fluids that results in sodium levels less than 135 mEq/L. Hyponatremia delays and slows the depolarization of membranes. (nerve impulse) Water moves from the ECF into the ICF, causing cells to swell (cellular edema). ○ Grape cells become plump and plump until they pop. Urine sodium levels help to differentiate between non-kidney fluid loss (vomiting, diarrhea, and sweating) and kidney salt wasting, which can occur with diuretic use. ○ When people have vomiting, diarrhea, sweating, it does not show in the kidney or urine: non-kidney fluid (not gonna see high slat in urine) ○ Kidney salt wasting: high concentration of Na in the urine, kidneys are improbably getting rid of salt (cause of hyponatremia) Hyponatremia generally is caused by fluid imbalance, which results in sodium loss. Compensatory mechanisms include the kidney excretion of sodium-free water (non- kidney: have low sodium in urine; kidney: kidney is wasting extra salt: urine high in salt and have hyponatremia in blood) Hyponatremia – Risk Factors Actual sodium deficits Excessive sweating Diuretics Wound drainage (especially gastrointestinal) Nasogastric tube suction of isotonic gastric contents Decreased secretion of aldosterone (not having salt retaining salt) Hyperlipidemia Kidney disease Inadequate sodium intake (nothing by mouth [NPO] status) Hyperglycemia Low-sodium diet Cerebral salt wasting syndrome Relative sodium deficits due to dilution (add fluid; overhydration) Hypotonic fluid excess (forced oral intake, psychogenic polydipsia, irrigation with hypotonic solutions) Freshwater submersion accident Kidney failure (nephrotic syndrome) Heart failure (giving diuretics, losing fluid) Syndrome of inappropriate ADH secretion Anticonvulsant medications, SSRIs, or desmopressin (desmopressin cause relative Na loss) Older adult clients at a greater risk due to increased incidence of chronic illnesses, use of diuretic medications, and risk for insufficient sodium intake Hyponatremia Signs and Symptoms – SALT LOSS Hyponatremia – Expected Findings Clinical indicators depend on whether the ECF volume is normal (euvolemic), decreased (hypovolemic), or increased (hypervolemic). (fluid shifts) If the client is hypervolemic with hyponatremia, the pulse quality is usually bounding. The client’s blood pressure can be within or above the expected reference range. VITAL SIGNS (WITH HYPOVOLEMIA): Hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension, diminished peripheral pulses NEUROMUSCULOSKELETAL: Headache, confusion, lethargy, muscle weakness to the point of possible respiratory compromise, fatigue, decreased deep-tendon reflexes (DTRs), seizures, lightheadedness, dizziness GASTROINTESTINAL: Increased motility, hyperactive bowel sounds, abdominal cramping, nausea ○ Hyponatremic: loss of salt: dehydrated: weak pulse ○ Hyponatremic: too much fluid: bounding pulse b/c too much fluid ○ Dehydration status and hypervolemia status affect electrolytes ○ Seizure precaution Hyponatremia – Laboratory Tests Blood sodium: Decreased, less than 135 mEq/L Blood osmolarity: Decreased (except in azotemia with toxin accumulation) Urine sodium: Less than 20 mEq/L (in sodium loss); greater than 20 mEq/L (in SIADH) (salt waster kidney: high sodium) Urine specific gravity: Decreased (1.002 to 1.004 in sodium loss; greater than 1.012 in SIADH) Hyponatremia – Nursing Care If the client can tolerate PO fluids, sodium can be easily replaced by intake of foods and fluids. Encourage foods and fluids high in sodium (beef broth, tomato juice). Administer IV fluids (lactated Ringer’s, 0.9% isotonic saline). Replacement of sodium should not exceed 12 mEq/L in a 24-hr period because rapid rise in sodium level risks development of neurologic damage due to demyelination. ○ overcorrect sodium can cause demyelination of myelin sheath → myelin is destroyed, the conduction is delayed ○ severe thing that can happen when overcorrecting Na and have destruction of myelin sheath → lock in syndrome: lock body unable to move ○ When replace sodium, do not do it TOO fast; but if you don’t replace it, there’s severe consequences For fluid overload, restrict water intake as prescribed. ○ Hyponatremia, psychogenic polydipsia: drink all fluid and not keeping adequate salt, going to have hyponatremia (b/c too much fluid); it is not a salt issue it’s fluid issue) Monitor I&O and daily weight. Monitor vital signs and level of consciousness. Report abnormal findings to the provider. Hyponatremia – Interprofessional Care Nephrology can be consulted for electrolyte and fluid replacement. Respiratory services can be consulted for oxygen management. ○ When giving extra fluid can cause pulmonary edema, so need oxygen (ventilation support) Nutritional services can be consulted for high-sodium food choices and restricting fluid intake Hyponatremia – Client Education Weigh daily and notify the provider of a 1- to 2-lb gain in 24 hr, or 3-lb (1.4 kg) gain in 1 week. (TEST QUESTION) Consume a high-sodium diet, including reading food labels to check sodium content and keeping a daily record of sodium intake. Hyponatremia – Complications – Severe Hyponatremia Complications (coma, seizures, respiratory arrest) can result from acute hyponatremia if not treated immediately. NURSING ACTIONS The goal is to elevate the blood sodium level enough to decrease neurologic manifestations associated with hyponatremia (lethargy, confusion, seizures). Maintain an open airway and monitor vital signs. Implement seizure precautions, and take appropriate action if seizures occur. Monitor level of consciousness. Administer hypertonic oral and IV fluids as prescribed. Administer 3% sodium chloride slowly and monitor sodium levels frequently. When using hypertonic solutions, the blood sodium level should not be greater than 125 mEq/L. Administer medications as prescribed (such as conivaptan or tolvaptan, which promote excretion of excess fluid). Potassium Functions Priority electrolytes both highs and lows can kill you Pumps the heart Potassium Imbalances General Information Potassium (K+) is the major cation in ICF. 98% of the body’s potassium is within the cells. 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 a reciprocal action with sodium. (inverse relationship or opposite action w/ Na; they do an opposite thing at each process) Minor variations in the level of potassium in the body is a significant finding. (one-off is a big thing) Hyperkalemia – General Information Hyperkalemia is the result of an increased intake of potassium, movement of potassium out of the cells, or inadequate kidney excretion resulting in a blood potassium level greater than 5.0 mEq/L. Increased risk of cardiac arrest Rare in clients who have normal kidney function ○ urine, pee K so if you are in dialysis, don’t pee, chronic kidney disease pt, you don’t get rid of K, it stays in the blood, high 3.5-5.0 range.) Hyperkalemia – Risk Factors Actual potassium excess (too much K) Older adult clients due to decreases in renin and aldosterone, and increased use of salt substitutes, ACE inhibitors, and potassium-sparing diuretics Overconsumption of high-potassium foods or salt substitutes (salt substitutes are potassium chloride: low salt diet and eat potassium chloride → ↑ K Excessive or rapid potassium replacement (oral or IV) RBC transfusions Adrenal insufficiency ACE inhibitors or potassium-sparing diuretics Kidney failure Relative potassium excess (too much K b/c low fluid) Extracellular shift caused from decreased insulin production Acidosis (diabetic ketoacidosis) Tissue damage (sepsis, trauma, surgery, fever, myocardial infarction) Hyperuricemia Hyperkalemia – Expected Findings Vital signs: Slow irregular pulse, hypotension Neuromusculoskeletal: Restlessness, irritability, weakness to the point of ascending flaccid paralysis, paresthesia ECG: Premature ventricular contractions, ventricular fibrillation, peaked T waves, widened QRS Gastrointestinal: Increased motility, diarrhea, hyperactive bowel sounds Other manifestations: Oliguria (pee less than 400) Hyperkalemia – Laboratory Tests and Diagnostic Procedures Blood potassium: Increased to greater than 5.0 mEq/L Hemoglobin and hematocrit ○ Increased with dehydration (↑K, ↑hbg ↑hct: pt is dehydrated: not a K problem it is fluid problem) state of hemoconcentration and need to add fluids ○ Decreased with kidney failure (↑ K, ↓ hgb & hct: kidney issue, not a fluid issue→ Kidney affect fluid, so not add fluid and manage kidney better: maybe give lasix, get off K sparing diuretics) BUN and creatinine: Increased with kidney failure (creatinine is clearance of toxic substance from kidneys; BUN: state of dehydration ↑ BUN level) Arterial blood gases: Metabolic acidosis (pH less than 7.35) with kidney failure (if you have sepsis and are on Lasix, K not going to increase b/c lasix dealing w/ K before it gets too high) Electrocardiogram: Peaked T waves, widened PR and QRS, absent/flat P waves, ST depression, possible dysrhythmias (heart block, ventricular fibrillation, asystole) Hyperkalemia – Nursing Care Priority nursing care is to prevent falls, assessing for cardiac complications, and health teaching. (fall precaution b/c dizziness) Monitor cardiac rhythm and intervene promptly as needed. (telemetry) Monitor I&O. Assess for muscle weakness. Observe for GI manifestations, such as nausea and intestinal colic. For clients who have elevated potassium levels, report and stop IV infusion of potassium, maintain IV access, stop all potassium supplements, and promote a potassium-restricted diet. Monitor for manifestations of hypokalemia while receiving medications to reduce the potassium level. Monitor blood potassium levels. (when you fix high, you can overcorrect it to be low, we don’t want to over correct) (down in normal range) Severe hyperkalemia can require administration of calcium gluconate. Chronic or severe hyperkalemia can require dialysis. Promote movement of potassium from ECF to ICF. ○ Administer IV fluids with dextrose and regular insulin. ○ Administer sodium bicarbonate to reverse acidosis ○ Calcium gluconate(helps protect heart from arrhythmia, shield from K. ↑ K, make sure not go in arrhythmia; to stabilize the heart) Hyperkalemia – Prevention Avoid administering “aged” blood in clients who have impaired kidney function because the deterioration of red blood cells releases potassium into the stored blood. ○ Don’t want to administer old blood, it is only good for a few months; don’t giving old blood to pt w/ kidney disease, give fresh blood b/c reduce the chance of having higher K level  Encourage the client to avoid foods high in potassium (citrus fruits, legumes, whole-grain foods, lean meat, milk, eggs, cocoa, some cola beverages). Encourage the client to read food labels for potassium content. Fruits and juices low in potassium include raw apples, cranberries, grapes, canned peaches, and cranberry and grape juice. Vegetables low in potassium include lettuce, cabbage, cucumbers, green peppers, sweet onions, green peas, and green beans. It is possible to reduce the content of most vegetables by leaching them (slice, peel, soak overnight, drain water, and boil). Refined grains have less potassium than whole grains and cereals. Beverages low in potassium include brewed tea and coffee, ginger ale, and root beer. Other food items with low potassium content include applesauce, angel food cake, butter, margarine, hard candy, sugar, and honey. Clients who have impaired kidney function and are taking potassium-conserving diuretics should not receive potassium replacement or salt substitutes.(if they have kidney disease and taking K-conserving diuretics, should not receive K replacement or substitute, they don’t need extra K) Hyperkalemia – Medications Loop diuretics (furosemide) Administer if kidney function is adequate. Loop diuretics increase the depletion of potassium from the renal system. When you are peeing, you are not only peeing fluid but also K. Too get rid of K, give Lasix and furosemide NURSING ACTIONS: ○ Monitor intake and output. Cation exchange resins Sodium polystyrene sulfonate works as a laxative and excretes excess potassium from the body. Kayexalate: take by mouth, bind to potassium and excrete it. NURSING ACTIONS: ○ If potassium levels are extremely high, dialysis can be required. CLIENT EDUCATION ○ Adhere to a potassium-restricted diet. ○ Hold oral potassium supplements until advised by the provider. Beta-2 agonists (albuterol) Back-to-back meds: help push K to the cells NURSING ACTIONS: ○ Monitor for tachycardia and chest pain. LoKelma (expensive) Used for chronic hyperkalemia IV push insulin (regular) and 25 gm dextrose: give sugar first (lower blood sugar and push K back to cell) when giving pt in insulin IV route, concern hypoglycemia, and hypokalemia (move sugar and K in cell) Hyperkalemia – Interprofessional Care Nephrology can be consulted if dialysis is needed and for electrolyte and fluid management. Nutritional services can be consulted for food choices containing potassium-restricted foods. Cardiology can be consulted for dysrhythmias. Hyperkalemia – Client Education Remember which potassium-restricted foods to consume. Prevent an increase in potassium by reading food labels and avoiding salt substitutes containing potassium Hyperkalemia – Complications Cardiac arrest NURSING ACTIONS ○ Treat dysrhythmias. 1st: give calcium gluconate to stabilize the heart. 2nd: Lokalma, Kayexalate; albuterol; insulin: start shifting K Dysrhthmia: Vtach w/o pulse or V-fib: defib; asystole: CPR ○ Perform continuous cardiac monitor Hypokalemia – General Information Hypokalemia is the result of an increased loss of potassium from the body or movement of potassium into the cells, resulting in a blood potassium less than 3.5 mEq/L. Hypokalemia – Risk Factors Actual potassium deficits Overuse of diuretics, digitalis, corticosteroids Increased secretion of aldosterone (when intake salt, you lose K) Cushing’s syndrome Loss via GI tract: vomiting, diarrhea, prolonged nasogastric suctioning, and excessive use of laxatives or tap water enema administered repeatedly because tap water is hypotonic, and gastrointestinal losses are isotonic NPO status  Kidney disease, which impairs the reabsorption of potassium (blocks reabsorption of K; some types of kidney disease don’t allow secretion and waste a lot of K which why diuretics work because retain K b/c kidney does not do that) Relative potassium deficit Alkalosis Hyperinsulinism (secrete extra insulin or gave too much insulin) ○ Insulin can drive low blood sugar and hypokalemia; too much insulin causes hypokalemia; from cancer or give too much insulin) Hyperalimentation Total parental nutrition (not give enough potassium) Water intoxication (dilution) Older adult clients due to increased use of diuretics and laxatives (reduce K) Hypokalemia – Expected Findings VITAL SIGNS: Decreased blood pressure, thready weak pulse, orthostatic hypotension NEUROLOGIC: Altered mental status, anxiety, and lethargy that progresses to acute confusion and coma ECG: Flattened T wave, prominent U waves, ST depression, prolonged PR interval GASTROINTESTINAL: Hypoactive bowel sounds, nausea, vomiting, constipation, abdominal distention. Paralytic ileus can develop. MUSCULAR: Weakness. Deep-tendon reflexes can be reduced. RESPIRATORY: Shallow breathing (might need intubation) Hypokalemia – Laboratory Tests and Diagnostic Procedures Blood potassium: Decreased to less than 3.5 mEq/L (3.4 hypokalemia but T wave not obvious) Electrocardiogram (ECG): Inverted/flat T waves, ST depression. An elevated U wave is a finding specific to hypokalemia. Other dysrhythmias possible. Hypokalemia Nursing Care Administer prescribed potassium replacement. Never give potassium via IM or subcutaneous route, which can cause necrosis of the tissues. (tissue die) ○ Give IV piggy bag or oral ○ Best way: GI tract: long lasting ○ IV piggy bag: allow you get high K but going to pee ○ NPO: IV piggy bag and oral K ○ Channel has a primary line, if you have a piggy bag on primary, piggy first then primary, and not happening both. ○ Y site: 2 channel: primary line and K primary line happening at the same time Monitor and maintain adequate urine output. Observe 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. (digoxin toxicity: will see blue, green, yellow halo effect DE VINCI PAINTING) (Medication to give for digoxin toxicity is digibind) (TEST QUESTION) Monitor level of consciousness and maintain client safety. Monitor bowel sounds and abdominal distention and intervene as needed. Monitor oxygen saturation levels, which should remain greater than 95%. Assess hand grasp for muscle weakness. Assess DTRs. Implement fall precautions due to muscle weakness Hypokalemia – Potassium Replacement Oral replacement of potassium ○ Encourage foods high in potassium: avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas, juices, melon, lean meats, milk, whole grains, and citrus fruits. Salt substitutes are high in potassium and can facilitate increased oral potassium intake. ○ Provide oral potassium medications IV potassium supplementation ○ Never administer by IV bolus (high risk of cardiac arrest). ○ The maximum recommended rate is 10 mEq/hr with a concentration of no more than 1 mEq of potassium per 10 mL of solution. (med surg non central line: give 10ml per hr; ICU central line 20 ml/hr) ○ Assess for phlebitis (tissue irritant). Hypokalemia –Interprofessional Care Nephrology can be consulted for electrolyte and fluid management. Respiratory services can be consulted for oxygen management. Nutritional services can be consulted for food choices and potassium-rich foods. Cardiology can be consulted for dysrhythmias. Hypokalemia – Client Education Understand which potassium-rich foods to consume. Prevent a decrease in potassium by avoiding excessive use of diuretics and laxatives Hypokalemia – Complications Respiratory failure NURSING ACTIONS ○ Maintain an open airway and monitor vital signs. ○ Monitor level of consciousness. ○ Monitor for hypoxemia and hypercapnia. ○ Assist with intubation and mechanical ventilation if indicated. Cardiac arrest NURSING ACTIONS ○ Perform continuous cardiac monitoring. ○ Treat dysrhythmias promptly Hypokalemia – S&S – A SIC WALT Potassium Rich Food Remember POTASSIUM to help you remember the foods  Potatoes, pork Oranges Tomatoes Avocados Strawberries, Spinach fish mushrooms Musk melons: cantaloupe Also included are: (carrots, raisins, bananas) Calcium – Ca2+ 3 Functions ○ The B’s Bones Blood (Clotting factors) Beats Inverse Relationship with Phosphate ○ ↑ Ca =↓ Phosphate ○ ↓Ca = ↑ phosphate Hypercalcemia S/S Kidney stones, moans, and groans Constipation Bone Pain Serve Muscle weakness Lethargy Hypercalcemia Causes Hyperparathyroidism ( High PTH = High Calcium) ○ Parathyroid gland: when secreting PTH, retain Ca from bone and put it in bloodstream Cancer Immobility Calcium supplements (Tums) Hypocalcemia – General Information Hypocalcemia is a total blood calcium less than 8.0 mg/dL. Hypocalcemia – Risk Factors Actual calcium deficit Inadequate intake of calcium, including lactose intolerance, malabsorption issues (not having Ca indeed) Diarrhea or steatorrhea Inadequate vitamin D intake (Vit D will increase calcium reabsorption ) End-stage kidney disease Wound drainage Relative calcium deficit Conditions: alkalosis, acute pancreatitis, hyperproteinemia, hyperphosphatemia (↑phosphate ↓Ca), immobility Treatments: calcium chelators, citrate, mithramycin, sodium cellulose phosphate, penicillamine, pamidronate Immobility Parathyroid removal or damage (no Ca in blood) Hypocalcemia Causes Hypoparathyroidism (Low PTH = Low Calcium) Renal Failure – Chronic Kidney Disease (CKD) Hypocalcemia – Expected Findings Tetany is the most common manifestation seen in clients in a hypocalcemic state. It is caused by neural excitability-spontaneous discharges from both the sensory and motor fibers (peripheral nerves). (tap cheek and go to spams and put bp and clamping hand) Paresthesia of the fingers and lips (early manifestation) Muscle twitches as hypocalcemia progresses Seizure due to irritability of the central nervous system Frequent, painful muscle spasms at rest in the foot or calf (Charley horses) 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) History of thyroid surgery or irradiation of the upper chest or neck, which places a client at risk for developing hypocalcemia CARDIOVASCULAR: Prolonged QT interval as a result of a prolonged ST segment. Risk of torsades de pointes. Decreased myocardial contractility (decreased heart rate and hypotension when hypocalcemia is severe). GASTROINTESTINAL: Hyperactive bowel sounds, diarrhea, and abdominal cramps Hypocalcemia S&S Trousseau Signs Tetany – Muscle spams all over Chvostek sign Diarrhea Weak B ○ Bones (weak bones) ○ Blood Clotting – Increased Bleeding ○ Beats – Cardiac Dysrhythmias Hypocalcemia – Laboratory Tests & Diagnostic Procedures Calcium level less than 9.0 mg/dL Decreased blood albumin levels can make the total blood calcium level falsely low. The ionized calcium level should give the true calcium level when the client appears to have hypocalcemia with hypoalbuminemia. Electrocardiogram changes: Prolonged QT and ST interval Hypocalcemia – Nursing Care Administer oral or IV calcium supplements. Vitamin D supplements enhance the absorption of calcium. Implement seizure and fall precautions.  Avoid overstimulation. Keep the client’s room quiet, limit visitors, and use soft lighting in the room. Have emergency equipment on standby. Encourage foods high in calcium, including dairy products, canned salmon, sardines, fresh oysters, and dark leafy green vegetables. A client exhibiting life-threatening manifestations of hypocalcemia will require rapid treatment with calcium gluconate or calcium chloride (not used as often due to risk of tissue damage if infiltrated). IV administration should be diluted in dextrose 5% and water and given as a bolus infusion (using an infusion pump). If administered too quickly, cardiac arrest could occur. Hypocalcemia – Interprofessional Care Endocrinology can be consulted for electrolyte and fluid management. Respiratory services can be consulted for oxygen management. Nutritional services can be consulted for food choices high in calcium. Cardiology can be consulted for dysrhythmias. Hypocalcemia – Client Education Consume foods high in calcium (yogurt, milk). Increase calcium in your diet by reading food labels. Magnesium Functions Mellows the Muscles Hypermagnesemia Causes Renal Failure Alcoholism Malnourishment Hypermagnesemia S&S Heart – High Mellow ○ Heart Block ○ Hypotension ○ Bradycardia Deep Tendon Reflexes – High Mellow ○ Hyporeflexia (Decrease Reflexes) Lungs and GI – High Mellow ○ Depressed respirations ○ Hypoactive Bowel Sounds Hypermagnesemia Treatment Calcium gluconate (stabilizes heart muscle and prevent arrhythmia) IV Fluids Diuretics Dialysis Intubation and Mechanical Ventilation  Temporary pacemaker Hypomagnesaemia – General Information Hypomagnesemia is a blood magnesium level less than 1.3 mg/dL. Hypomagnesaemia – Risk Factors Celiac disease or Crohn’s disease Malnutrition (insufficient magnesium intake) Ethanol ingestion (magnesium excretion) Diarrhea, steatorrhea, or chronic laxative use Citrate from blood products (sodium citrate prevent from clotting, when blood have sodium citrate, it bind to magnesium cause low magnesium and calcium) Steatorrhea Myocardial infarction or heart failure Concurrent hypokalemia and hypocalcemia (low in one, low in all) Medication therapy (aminoglycoside antibiotics, cisplatin, cyclosporine,amphotericin B) Hypomagnesemia – S&S Heart = Low Mellow – Excited ○ Torsade's De Pointes (Arrhythmia) ○ Ventricular Fibrillation Deep Tendon Reflexes = Low Mellow – Excited ○ Hyperreflexia – increased deep tendon reflexes GI = Low Mellow – Excited ○ Diarrhea ○ Hyperactive bowel sounds Hypomagnesaemia – Expected Findings Cardiovascular: Risk for increased blood pressure and dysrhythmias or ECG changes (presence of PVCs, flat/inverted T waves, ST depression, prolonged PR, widened QRS) Neuromuscular: Increased nerve impulse transmission (hyperactive DTRs, paresthesias, muscle tetany, seizures), positive Chvostek’s and Trousseau’s signs Gastrointestinal: Hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus Other: Possible depressed mood, apathy, or agitation Hypomagnesaemia – Nursing Care Correct concurrent imbalance of other electrolytes to prevent worsening of either condition. Encourage foods high in magnesium (dark green vegetables, nuts, whole grains, seafood, peanut butter, cocoa). If there is mild hypomagnesemia, dietary changes can be used to correct it. Discontinue magnesium-depleting medications (loop diuretics, osmotic diuretics, medications that contain phosphorus). (if phosphorus is affected, calcium going low, magnesium going low) Administer oral magnesium sulfate for mild hypomagnesemia. Oral magnesium can cause diarrhea and increase magnesium depletion  IV magnesium sulfate is prescribed if hypomagnesemia is severe. Administer via an infusion pump not to exceed 150 mg/min, or 67 mEq over an 8-hr period. Monitor DTRs hourly during administration. Monitor clients taking digitalis closely if magnesium is low because it predisposes the client to digitalis toxicity. Have calcium gluconate readily available to reverse hypermagnesemia. (calcium gluconate to reverse hypomagnesia: to stabilize the heart tissue) Hypomagnesaemia – Interprofessional Care Endocrinology can be consulted for electrolyte and fluid management. Respiratory services can be consulted for oxygen management. Nutritional services can be consulted for food choices high in magnesium. Cardiology can be consulted for dysrhythmias. Hypomagnesaemia – Client Education Intake foods that are high in magnesium. Increase magnesium in diet by reading food labels. Chloride Functions Like Sodium (but opposite) Maintains ○ Blood Pressure ○ Blood Volume ○ PH balance Hyperchloridemia Nearly the same as high-sodium Swollen Dry tongue Nausea and vomiting Metabolic alkalosis – vomiting acid Risk Factors Dehydration, Excessive IV fluids, Kidney Dysfunction, Metabolic Acidosis, Medications Expected Findings S&S Dehydration, Rapid Deep resp, high blood pressure, cognitive changes Laboratory Tests High CL Nursing Care Fluid Management, Monitor Cl levels, admin meds like bicarbonate and diuretics Interprofessional Care Nephrologist, Dietitian, Pharmacist Client Education Hydration management, monitoring for S&S, avoiding excessive salt/chloride in the diet (table salt is sodium chloride: hyperchloremia or hypernatremia will increase chloride and sodium) Hypochloremia Nearly the same as low-sodium Fatigue and Muscle Cramps Fever (Only Difference) Risk Factors Vomiting, Prolong GI suction, Chronic Resp Conditions, Metabolic Alkalosis, Use of Diuretics, Cystic Fibrosis Expected Findings S&S of dehydration or Overhydration Laboratory Tests Low CL- Nursing Care Correct underlying cause, admin IV fluids, Monitor Cl levels, encourage oral intake, monitor for complications Interprofessional Care Diet, Respiratory Tract, Client Education Diet (eating more salt) , medication management, prevention of future episodes Hyperphosphatemia Risk Factors CKD, Hypoparathyroidism, Excessive Intake, Tumor Lysis Syndrome, Rhabdomyolysis Expected Findings Hypocalcemia S&S, Calcification (mineral deposit in tissue), Arrhythmias ○ Calcification: calcium lesion in skin and skin dies Laboratory Tests High Phos Nursing Care Admin Phos binders like (PhosLo) and Sevelamer (with meal), Monitor Ca Levels Interprofessional Care Nephrologist, dietitian, pharmacist Client Education Phos dietary restriction, medication adherence, symptom monitoring (what to monitor and what to report) Coca-cola: a lot of phosphorus Hypophosphatemia Risk Factors ○ Chronic Alcoholism, Refeeding Syndrome, Chronic N/V/D, DKA, Burns and Trauma Expected Findings ○ Muscle weakness, tremors, paralysis, hypoventilation, apnea, Confusion, irritability, SZ, Reduced oxygen transport – hypoxia Laboratory Tests Nursing Care – Monitor RR, Admin Phos, Increase Phos in Diet Interprofessional Care – Dietitian, Pharmacist, Respiratory Therapist Client Education – Diet teaching, medication adherence, prevention of complication QUESTION A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings?  A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80 mL/hr D. Antibiotic therapy Tap water enema: hypertonic so able to suck sodium and potassium to water. A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Paresthesia A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hyperkalemia A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing’s syndrome D. Thyroidectomy Acidotic state: higher in potassium unless in Lasix A nurse is assessing a client for Chvostek’s sign. Which of the following techniques should the nurse use to perform this test? A. Apply a blood pressure cuff to the client’s arm. B. Place the stethoscope bell over the client’s carotid artery. C. Tap lightly on the client’s cheek. D. Ask the client to lower their chin to their chest.