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* An electrolyte is a substance that upon dissolving in a solution, ionizes, Meaning that some of its molecules split or become electrically charged atoms or ions.
* Each body fluid compartment contains a specific composition (or recipe) of electrolytes. Each compartment has its own recipe within its compartment which must maintain this recipe to function properly. When one electrolyte moves out of a cell another one moves in to maintain homeostasis. The compartments are separated by semi-permeable membranes.
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Sodium Imbalances
- * Norma serum level is 135 145 mEq/L
- Sodium is the most plentiful electrolyte in extracellular fluid
- Responsible for regulating the osmolality, volume, & distribution of extracellular fluids
- Disorders of Na+ and H2O often occur together
- Maintains neuromuscular activity
- Imbalance often associated with fluid volume balance
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Hyponatremia:
- Serum level lower than <135 meq="" l="" br=""> Losses occur:
- through GI tract-vomiting, diarrhea, GI suction
- Kidney disease
- by excessive sweating/loss of skin surface
- use of diuretics
- Adrenal insufficiency w/impaired aldosterone & cortisol production leads to excess Na+ excretion in urine (decreased secretion of aldosterone)
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Manifestations of Hyponatremia:
- Depend on rapidity of onset, severity & cause of imbalance
- Anorexia, ABD cramping, muscle cramps
- Exhaustion, weakness, fatigue
- Headache, depression, personality changes, irritability
- Coma
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Treatment/Care of Hyponatremia:
- 24 hour urine specimen collection
- Isotonic fluids/ Isotonic Ringers/0.9NaCl
- Loop diuretics
- Fluids restriction
- Na+ rich foods
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Nursing Care of Hyponatremia:
- Identify persons at risk
- Teach patients how to recognize s/s
- Importance of drinking fluids containing electrolytes at frequent intervals
- Monitor intake and output
- Wear cool, loose clothing
- Older adults effects of meds/potential fluid imbalances
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Hypernatremia:
- Serum Na more than >145mEq/L
- Causes hyperosmolality of ECF, water moves out of the cell, cellular dehydration
- Most serious cause of cellular dehydration seen in brain
- Patients unable to respond to thirst
- Due to altered mental status
- Physical disability
- Excess water loss may occur with
- Watery diarrhea
- Increased water losses from:
- Fever
- Hyperventilation
- Excessive perspiration
- Massive burns
- Infection
- Caused by ingestion of excess salt
- Hypertonic IV solutions
- Patients w/diabetes insipidus
- Clients who experience near drowning in seawater
- Heatstroke
- Other possible causes: Corticosteroids, Cushing syndrome, Kidney disease, Hyperaldosteronism (conn)
- Manifestations of Hypernatremia:
- Thirst, rough, dry tongue
- Elevated temp, flushed skin
- Restlessness
- CNS changes, brain cells contract and may tear and bleed
- May lead to seizures, coma, and death in severe dehydration
- Heat Exhaustion
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Treatment for Hypernatremia:
- May be H20 or IV replacement
- Gradual decrease of serum sodium by infusion of hypotonic solution
- 0.45% NaCl/D5W IV solution
- Diuretics- increase Na+ excretion
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Nursing Care for Hypernatremia:
- Primary focus is prevention
- Restrict sodium/fluid as prescribed
- Identify risk factors
- Teaching patients/caregivers
- Monitoring lab test results
- Reduce risk of potential for hypernatremia
- Monitor for potassium imbalance also
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Health Promotion for Hypernatremia:
- Offer fluids at regular intervals
- If unable to maintain adequate fluid intake, may need alternate route for fluid intake
- Teach caregivers the importance of providing adequate water intake for client receiving tube feedings
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Nurse diagnosis/interventions for Hypernatremia:
- Monitor/maintain fluid replacement w/in prescribed limits
- Review lab results of Na+
- Monitor neurologic function, include mental status, level of consciousness
- Headache
- n/v
- Hypertension/bradycardia
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Safety measures
- Keep bed in lowest position, side rails up
- Airway at bedside
- Keep familiar items at bedside
- Allow family/significant others to remain w/client as much as possible
- Identify risk factors
- Risk for injury
- Monitor & maintain fluid replacement
- Monitor neurological function
- Institute safety precautions
- Keep familiar items at bedside
- Potassium imbalances
- Normal K, 3.5-5.0 mEq/L
- K+ primary intracellular cation
- Plays a vital role in cell metabolism, cardiac & neuromuscular functions
- Maintained by daily dietary intake
- Potassium Imbalances affect:
- Transmission & conduction of nerve impulses
- Maintenance of normal cardiac rhythms,
- Contraction of skeletal & smooth muscle
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Hypokalemia:
- K+ < 3.5 mEq/L is a deficit
- Potentially life threatening: every body system is affected
- Caused by:
- GI losses: n/v, diarrhea, suctioning
- Renal loss, medications
- Heavy perspiration-diaphoresis
- Burns
- Poor intake: NPO or poor nutrition
- Anorexia nervosa
- Alcoholism
- Excessive use of diuretics or corticosteroids
- Kidney disease impairing reabsorption
- Increased secretion of aldosterone
- Cushing syndrome for example
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Manifestations of Hypokalemia:
- Muscle weakness/leg cramps
- Increased risk for digitalis toxicity
- Anorexia, Abdominal distention, nausea/vomiting
- Dysrhythmias-atrial & ventricular
- ECG changes, depressed ST, inverted T waves
- Figure 1010 The effects of changes in potassium levels on the electrocardiogram (ECG). A, Normal ECG; B, ECG in hypokalemia; C, ECG in hyperkalemia.
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MULTISYSTEM EFFECTS of Hypokalemia
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Nursing Care & Interventions:
- Monitor serum K+ Levels
- K+ replacement, PO or IV
- Dietary sources
- Monitor I & O to assess kidney function during k+ administration
- Monitor heart rhythm
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Nursing Responsibilities of Hypokalemia:
- Med Administration
- When administering oral K+
- Dilute liquid K+ in fruit or vegetable juice or cold water
- Chill to increase palatability
- Give w/food to minimize GI effects
- Nursing Responsibilities of Hypokalemia Continued:
- Medication Administration:
- IV forms of Potassium (KCL)
- * Do NOT administer IV push: will kill pt!
- * Never give k+ by IV push, intramuscular injection or subcut injection
- * Do NOT add to IV fluids already hanging
- * Recommended to Dilute to 1mEq/10mL or more
- * Infuse at rate not to exceed 10mEq/hour
- * Do NOT administer undiluted
- * Assess IV site frequently: K+ can cause phelitis
- * Always use an infusion pump
- * Cardiac monitor if administering high/rapid doses
- * May be switched to K+ sparing diuretic
- * Monitor I & O to assess kidney function during k+ administration
- * Monitor heart rhythm
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Nursing Education
- Do not take K+ supplement if taking a K+ sparing diuretic
- Do not chew enteric coated tabs or allow to dissolve in mouth; may affect potency & action of meds
- Take K+ supplement w/meals
- Do not use salt substitutes when taking K+ as salt K+ based
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Hyperkalemia
- K+ greater than 5 mEq/L
- Impaired renal excretion of K+ primary cause
- Untreated renal failure
- Adrenal insufficiency/Addisons disease
- K+ sparing diuretics
- Hyperkalemia
- Rapid IV administration
- Transfusion of aged blood
- Chemotherapy
- Tissue trauma
- Starvation
- Hyperkalemia affects heart, skeletal muscle function and GI tract
- Effect on cardiac function
- Slows heart rate
- Possible heart blocks
- Ventricular dysrhythmias develop
- Cardiac arrest
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Manifestations of Hyperkalemia:
- Early signs include:
- Diarrhea
- Abdominal cramping
- Anxiety
- Irritability
- Muscle twitching & tremors
- Manifestations
- Muscle weakness develops
- Heart rate slows to a bradycardia
- Irregular heart rate
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Nursing Care/Interventions of Hyperkalemia
- Nursing care-to return K+ level to normal by txing underlying cause/avoid additional K+ intake
- Meds- Ca+gluconate-IV-counter effects on cardiac conduction system
- Administer regular insulin/glucose -promotes K+ uptake by cells
- Kayexalate-orally or rectally
- Pts at risk-
- those who use K+ supplements, K+ sparing diuretics
- Teach to read all food & dietary supplements carefully
- Take K+ supplement as ordered
- Maintain adequate fluid intake
- Effects of excess K+ on electrical conduction & contractility heart are priority
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Calcium Imbalances
- Normal Calcium levels- 8.5-10.0mEq/L
- Transmits nerve impulses, blood clotting, bone metabolism, & forms teeth & bones
- Only 20% ingested is absorbed into blood; rest is excreted in feces
- Levels regulated by 3 hormones; PTH, calcitonin, & calcitriol ( metabolite of vitamin D)
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Hypocalcemia
- Calcium-- < 8.5 mEq/L
- Caused by:
- Inadequate dietary intake vitamin D
- Increased excretion, burns, infection, renal failure
- Surgical removal of parathyroid gland
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Risk Factors for hypocalcemia:
- Lactose intolerance
- Alcoholism
- Decreased exposure to sun
- Older adults-less active
- Women at risk after menopause
- Medications can interfere w/calcium absorption or promote calcium excretion
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Pathophysiology for hypocalcemia:
- Due to surgical removal of parathyroid
- Surgical procedures: Radical neck dissection, acute pancreatitis, thyroidectomy
- Manifestations of Hypocalcemia often occur within first 24 hours, but can be delayed
- Extracellular calcium acts to stabilize neuromuscular membranes
- Effect is decreased in hypocalcemia, increasing neuromuscular irritability
- Nervous system becomes more excitable, muscle spams develop
- Heart muscle-dysrhythmias/ventricular tachycardia & cardiac arrest
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Manifestations/Complications for hypocalcemia:
- Tetany-most serious complication
- Increased anxiety
- Deep tendon reflexes become hyperactive
- Numbness & tingling around mouth
- Low calcium levels (hypocalcemia) trigger the release of parathyroid hormone (PTH), increasing calcium ion levels through stimulation of bones, kidneys, and intestines.
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Positive Chvosteks sign.
Positive Trousseaus sign.
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Complications for hypocalcemia:
- Airway obstruction
- Respiratory arrest
- Ventricular dysrhythmias
- Cardiac arrest
- Heart failure
- Convulsions
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Treatment for hypocalcemia:
- Oral or IV Calcium
- Oral-Caltrate, Tums, OsCal
- IV-Calcium Chloride
- Dietary sources of calcium
- Dairy products
- Canned salmon
- Spinach, broccoli
- Tofu
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Nursing Care for hypocalcemia:
- Teach all clients the importance of maintaining adequate calcium intake through diet and supplements as needed
- Weight bearing exercises, aerobics, and weight training exercise regime
- Bone density exam in women/men who are at risk for osteoporosis
- Hypercalcemia
- Serum Ca-- >10.0 mEq/L
- Caused by:
- Hyperparathyroidism
- Metastatic Cancer
- Drug usage
- Immobilization of client
- Chronic renal failure
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Manifestations for hypercalcemia:
- CNS changes
- Neuromuscular activity-muscle weakness & fatigue
- Cardiovascular effects
- GI-n/v, anorexia, constipation
- Increased thirst & urine output
- Peptic ulcer disease
- Flank pain/kidney stones
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Treatment for hypercalcemia:
- Treat the underlying cause
- Reduce serum Calcium level
- Renal function
- Inability to maintain an adequate fluid intake
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Nursing Diagnosis & Interventions for hypercalcemia:
- IV fluids with diuretics
- IV fluids-isotonic saline
- Biophosphonates
- Low Calcium diet
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Nursing Care/Interventions for hypercalcemia:
- Risk for injury
- Digitalis toxicity
- Promote fluid intake
- Caution w/potential fxs
- Magnesium Imbalances
- Normal Magnesium- 1.6 2.6 mg/dL
- Critical for intracellular processes
- Include-enzyme rxns & synthesis of proteins/nucleic acids
- Essential for neuromuscular & cardiovascular function
- Usually occur along w/low serum potassium & calcium levels
- Primary cause of hypomagnesium:
- Chronic Alcoholism
- Chronic GI losses
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Hypomagnesemia
- Magnesium less than 1.6 mg/dL
- Caused by:
- Inadequate intake: Diet low in Mg, Long term IV therapy without Mg in solution
- Inadequate absorption: Malabsorption syndrome ,Bowel Resection
- Increased loss: Increased excretion, NG suction, diuretics, alcoholism
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Manifestations of hypomagnesemia
- Low Ca+ &/or low K+
- Hyperactive reflexes
- Seizures
- Tremors
- Confusion
- Mood changes
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Treatment of Hypomagnesemia:
- Magnesium sulfate given Deep IM injection or IV (Preferred)
- Need normal renal function
- Watch labs to avoid overcorrection
- Monitor for depressed deep tendon reflexes (indicate too much Mg)
- Monitor cardiac rhythm
- PO causes diarrhea, is contraindicated
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Hypermagnesemia
Magnesium greater than 2.6 mg/dL
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Caused by:
- Chronic Renal Failure
- Antacid use
- Over the counter laxative use
- Other meds that contain Magnesium
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Manifestations of hypermagnesemia
- Decreased blood pressure
- Flushing
- Warmth, sweating
- Decreased deep tendon reflexes
- Flaccid paralysis
- CNS depression
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Treatment of hypermagnesemia:
- Prevention
- All medications or compounds containing magnesium are withheld
- Patients w/renal failure, hemodialysis or peritoneal dialysis used to remove excess magnesium
- TABLE 108 Manifestations of Magnesium Disorders
- Phosphate Imbalance
- 2.5 to 4.5 mg/dL
- Levels vary with age, gender, & diet
- Ingested in diet, absorbed in jejunum, and primarily excreted by kidneys
- Inverse relationship exists between phosphate and calcium
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Hypophosphatemia:
- Treatment:
- Aimed at prevention, treating the underlying cause, & replacing phosphate
- Diet
- IV phosphate when levels drop below 1mg/dL
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Hyperphosphatemia
- Serum greater than 4.5 mg/dL
- Acute or chronic renal failure
- Excess vitamin D
- Chemotherapy
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Treatment of hyperphosphatemia:
- Administer meds orally in divided doses during day to bind phosphate
- Medications-phosphorus binding agents
- Calcium acetate
- Aluminum hydroxide
- Renal dialysis
- Decrease diet in phosphate
- Monitor electrolytes
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