electrolytes and electrolyte imbalances

* 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.

• * 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

• • 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)

• • Depend on rapidity of onset, severity & cause of imbalance
• • Anorexia, ABD cramping, muscle cramps
• • Exhaustion, weakness, fatigue
• • Headache, depression, personality changes, irritability
• • Coma

• • 24 hour urine specimen collection
• • Isotonic fluids/ Isotonic Ringer’s/0.9NaCl
• • Loop diuretics
• • Fluids restriction
• • Na+ rich foods

• • 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

• • 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

• • 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

• • 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

• • 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

• • 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

• • 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

• – Transmission & conduction of nerve impulses
• – Maintenance of normal cardiac rhythms,
• – Contraction of skeletal & smooth muscle

• • 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

• • 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 10–10 The effects of changes in potassium levels on the electrocardiogram (ECG). A, Normal ECG; B, ECG in hypokalemia; C, ECG in hyperkalemia.

• • Monitor serum K+ Levels
• • K+ replacement, PO or IV
• • Dietary sources
• • Monitor I & O to assess kidney function during k+ administration
• • Monitor heart rhythm

• 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

• • 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

• • K+ greater than 5 mEq/L
• • Impaired renal excretion of K+ primary cause
• • Untreated renal failure
• • Adrenal insufficiency/Addison’s 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

• • Early signs include:
• – Diarrhea
• – Abdominal cramping
• – Anxiety
• – Irritability
• – Muscle twitching & tremors
• – Manifestations
• • Muscle weakness develops
• • Heart rate slows to a bradycardia
• • Irregular heart rate

• • 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
• Pt’s 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

• • 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)

• • Calcium-- < 8.5 mEq/L
• • Caused by:
• – Inadequate dietary intake vitamin D
• – Increased excretion, burns, infection, renal failure
• – Surgical removal of parathyroid gland

• • 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

• • 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

• • 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.

• Positive Trousseau’s sign.

• • Airway obstruction
• • Respiratory arrest
• • Ventricular dysrhythmias
• • Cardiac arrest
• • Heart failure
• • Convulsions

• • Oral or IV Calcium
• – Oral-Caltrate, Tums, OsCal
• – IV-Calcium Chloride
• • Dietary sources of calcium
• – Dairy products
• – Canned salmon
• – Spinach, broccoli
• – Tofu

• • 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

• • 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

• • Treat the underlying cause
• • Reduce serum Calcium level
• • Renal function
• • Inability to maintain an adequate fluid intake

• • IV fluids with diuretics
• • IV fluids-isotonic saline
• • Biophosphonates
• • Low Calcium diet

• • Risk for injury
• • Digitalis toxicity
• • Promote fluid intake
• • Caution w/potential fx’s
• 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

• • 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

• • Low Ca+ &/or low K+
• • Hyperactive reflexes
• • Seizures
• • Tremors
• • Confusion
• • Mood changes

• • 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

• Magnesium greater than 2.6 mg/dL

• – Chronic Renal Failure
• – Antacid use
• – Over the counter laxative use
• – Other meds that contain Magnesium

• • Decreased blood pressure
• • Flushing
• • Warmth, sweating
• • Decreased deep tendon reflexes
• • Flaccid paralysis
• • CNS depression

• • Prevention
• • All medications or compounds containing magnesium are withheld
• • Patients w/renal failure, hemodialysis or peritoneal dialysis used to remove excess magnesium
• • TABLE 10–8 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

• Treatment:
• • Aimed at prevention, treating the underlying cause, & replacing phosphate
• • Diet
• • IV phosphate when levels drop below 1mg/dL

• • Serum greater than 4.5 mg/dL
• • Acute or chronic renal failure
• • Excess vitamin D
• • Chemotherapy

• • 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