Electrolytes Electrolyte Imbalances

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Polly
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258114
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Electrolytes Electrolyte Imbalances
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2014-01-23 18:35:14
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Electrolytes Electrolyte Imbalances
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Med Surg 2014
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Electrolytes Electrolyte Imbalances
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  1. * 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.
  2. 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
  3. Hyponatremia:
    • • Serum level lower than <135 mEq/L
    • – 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)
  4. 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
  5. Treatment/Care of Hyponatremia:
    • • 24 hour urine specimen collection
    • • Isotonic fluids/ Isotonic Ringer’s/0.9NaCl
    • • Loop diuretics
    • • Fluids restriction
    • • Na+ rich foods
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. • 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
  13. Potassium Imbalances affect:
    • – Transmission & conduction of nerve impulses
    • – Maintenance of normal cardiac rhythms,
    • – Contraction of skeletal & smooth muscle
  14. 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
  15. 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 10–10 The effects of changes in potassium levels on the electrocardiogram (ECG). A, Normal ECG; B, ECG in hypokalemia; C, ECG in hyperkalemia.
  16. MULTISYSTEM EFFECTS of Hypokalemia
  17. 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
  18. 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
  19. 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
  20. Hyperkalemia
    • • 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
  21. 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
  22. 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
    • 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
  23. 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)
  24. Hypocalcemia
    • • Calcium-- < 8.5 mEq/L
    • • Caused by:
    • – Inadequate dietary intake vitamin D
    • – Increased excretion, burns, infection, renal failure
    • – Surgical removal of parathyroid gland
  25. 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
  26. 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
  27. 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.
  28. • Positive Chvostek’s sign.
    • Positive Trousseau’s sign.
  29. Complications for hypocalcemia:
    • • Airway obstruction
    • • Respiratory arrest
    • • Ventricular dysrhythmias
    • • Cardiac arrest
    • • Heart failure
    • • Convulsions
  30. 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
  31. 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
  32. 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
  33. Treatment for hypercalcemia:
    • • Treat the underlying cause
    • • Reduce serum Calcium level
    • • Renal function
    • • Inability to maintain an adequate fluid intake
  34. Nursing Diagnosis & Interventions for hypercalcemia:
    • • IV fluids with diuretics
    • • IV fluids-isotonic saline
    • • Biophosphonates
    • • Low Calcium diet
  35. Nursing Care/Interventions for hypercalcemia:
    • • 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
  36. 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
  37. Manifestations of hypomagnesemia
    • • Low Ca+ &/or low K+
    • • Hyperactive reflexes
    • • Seizures
    • • Tremors
    • • Confusion
    • • Mood changes
  38. 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
  39. Hypermagnesemia
    • Magnesium greater than 2.6 mg/dL
  40. Caused by:
    • – Chronic Renal Failure
    • – Antacid use
    • – Over the counter laxative use
    • – Other meds that contain Magnesium
  41. Manifestations of hypermagnesemia
    • • Decreased blood pressure
    • • Flushing
    • • Warmth, sweating
    • • Decreased deep tendon reflexes
    • • Flaccid paralysis
    • • CNS depression
  42. 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 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
  43. Hypophosphatemia:
    • Treatment:
    • • Aimed at prevention, treating the underlying cause, & replacing phosphate
    • • Diet
    • • IV phosphate when levels drop below 1mg/dL
  44. Hyperphosphatemia
    • • Serum greater than 4.5 mg/dL
    • • Acute or chronic renal failure
    • • Excess vitamin D
    • • Chemotherapy
  45. 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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