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Fluid & Electrolytes:
K, Ca, Mg, Phosphorus, Cl
Potassium
• Major electrolyte in intracellular fluid (98% of k in the body is inside the cell. The 2% in the ECF and that 2% is important for neuromuscular function)
• Normal serum K+ is 3.5 to 5.0 mEq/L
• Influences both skeletal and cardiac muscle activity
• Minor variations are significant
• Renal system important in keeping balanced potassium – kidneys adjust the amt of K to be excreted in the urine and as K levels rise, this creates movement of K into the renal tubules with the loss of K in the urine. Renal failure is the #1 cause of Hyperkalemia.
• Body does not conserve potassium. Needs to be adjusted daily. Bananas are the best source
Hypokalemia
• K+ < 3.5 mEq/L
• Cause
– GI suction, vomiting, diarrhea
– TPN or IVF without K+ replacement
– Trauma – K leaves the cells when injured
– Diabetes – uncontrolled
– Low oral intake of K+
– Sweat loss
– Medications – diuretics (could use aldactone for K sparing), laxatives, insulin
Renal Loss of K+
• Diuretics
• Hyperaldosteronism (causes increased retention or Na & H2O then increases excretion of K)
• High dose Na+ PCNs
• Large dose corticosteroids
S/S Hypokalemia
• Fatigue
• Anorexia, N/V, Decrease bowel motility
• Muscle weakness & leg cramps
• Impaired glucose tolerance
• Paresthesias (numbness & tingling)
• Impaired renal concentrating ability
• Diminished deep tendon reflexes
• Flaccid paralysis – late sign
• Increased sensitivity to digitalis
• Dysrhythmias
• Severe hypokelemia – death by cardiac arrest
Hypokalemia commonly accompanies alkalosis
Hypokalemia & Cardiac Changes
• ↓ strength of contraction
• Myocardium irritability
• ST segment depression
• K+ < 2.7 mEq/L may result in PACs, PVC's, Vfib or cardiac arrest
• K+ < 3.5 assoc. with metabolic alkalosis, high pH & high HCO3
• Digoxin toxicity – Hypokalemia potentiates the action of digoxin
Works by inhibiting the myocardial cell Na/K pump thereby increasing the cellular K
Hypokalemia: Lab Results
• K+ deficit < 3.5 mEq/L
• K+ < 3.5mEq/L often assoc. with metabolic alkalosis, high pH, & high HCO3
• K+ < 2.7 may result in dangerous dysrhythmias - Danger signs: arrhythmias, cardiac arrest, dig toxicity, muscle paralysis, resp arrest
• ↑ pH & HCO3
Medical Treatment Hypokalemia
• K+ replacement (PO or IV)
• Increase on a daily basis
– 40-80 mEq/day
• At risk patient
– 50-100 mEq/day
• K+ rich foods
• Treat the underlying cause
Oral K+ Supplements
• Minimize GI irritation
– Dilute liquid & effervescent supplement
– Give tabs & capsules w/ 8 oz. H2O
– Give K+ with food
• Adverse reaction – N/V, diarrhea, GI bleed
Oral Potassium Supplements
• Avoid overdose (hyperkalemia)
• ↓ K+ dose if using K+ salt substitute
• Not used with K+ sparing diuretics
Intravenous K+ Supplement
• Must be diluted
• Do NOT give by direct IVP – causes cardiac arrest!
• Max. dose is 60 mEq at a time
• Must use IV pump
• Monitor renal output
• CHS policy – pt on heart monitor
• Monitor IV site for extravasation
Nursing Interventions: Hypokalemia
• Identify pt at risk – esp. if on Digoxin
• Monitor ECG & BP
• Monitor serum K+
• Pt education – diuretics & laxatives
• Administer K+ supplements PO or IV
• ↑ dietary K+
• Monitor urine output
Hyperkalemia
• Serum K+ > 5.5 mEq/L
• Causes
– Renal failure is the #1 cause
– Release of K+ from damaged cells – ex: chemo kills cells and causes the release
– Acidosis
– Addison’s Disease
– K+ sparing diuretics
– High K+ intake
– Medications
– If you’re giving blood, the longer the blood sits there the higher the K gets
S/S Hyperkalemia
• Main effects cardiac function
• Muscle weakness and paralysis
• Ventricular conduction is slowed
• Paresthesias & irritability
– Respiratory and speech muscles
• Flaccid muscular paralysis
– Legs→trunk→arms (including respiratory)
• GI hyperactivity
– N/V, colic, & diarrhea
As the K level increases, symptoms changes from irritability to weakness
Hyperkalemia & Cardiac Changes
• Slows heart rate
• ECG changes
– Tall, peaked T wave, short QT interval
– Longer PR interval, widening QRS complex
– Risk for Heart Block, A-fib, or, V-fib
• Severe ↑ K+
– Decreased heart contraction strength
– Dilated & flaccid heart (when K is greater than 7)
ECG & Potassium Hyperkalemia: Lab Data
• Serum potassium > 5.5 mEq/L
• ECG abnormalities
• Arterial blood gases – low pH indicating acidosis
Metabolic acidosis is usually accompanied by hyperkalemia
Hyperkalemia Medical Treatment
• K+ restricted diet
• Stop K containing medications
• Monitor for “Digitalis toxicity”
• Cation-exchange resins
– Kayexalate – PO or PR – substitutes Na for K and gets it out of the system
– 1Gm of resin removes 1 mEq K+
• Dialysis - If conservative methods not suffice
Emergency Medical Treatment: Hyperkalemia
• Ca Gluconate – IV
– Does NOT ↓ K+
– Antagonizes K+ action on heart
– Always has to be on ECG
• Hypertonic Glucose & Insulin
– Insulin - facilitates K+ movement into cells
– Glucose - ↑ insulin release from pancreas
• NaHCO3
– K+ shifts into cells
Nursing Interventions: Hyperkalemia
• Be aware of pt at risk
• Monitor for:
– Generalized weakness & dysrhythmias
– Irritability & GI symptoms
– Nausea & intestinal colic
– ECG or lab abnormalities
• Prevention of hyperkalemia
• Educate pt: medication & diet
• Do NOT draw blood above K+ infusion site
Calcium
• Serum Ca++ level 8.6 – 10.2 mg/dl (total)
• 99% stored in bones (bones & teeth)
• Found in three forms:
- bound: to proteins (less than 50%)
- ionized: found in serum (50% of calcium and is most important)
- complexed: combined with nonprotein anions: phosphate, citrate, and carbonate
Ionized Calcium
• Activate body chemical rxn
• Muscle contractions and relaxation
• Promote transmission of nerve impulse
• Cardiac contractility & automaticity
• Formation of prothrombin
Calcium and Phosphorus have a reciprocal relationship
Ca low=Phos high
Ca high=Phos low
Calcium Regulators
• Parathyroid Hormone (PTH) pulls
– Releases Ca from the bone
– Increases Ca absorption from GI
Increases Ca absorption from renal tubules
• Calcitonin – secreted by thyroid (keeps)
– Antagonist of PTH
– Secretion stimulated by high serum Ca++
– Inhibits Ca reabsorption from bone
• Phosphate
– Reciprocal relationship with Ca
– ↑Ca = ↓ Phos
• Vitamin D
– Necessary for absorption & utilization of Ca
Hypocalcemia
• Serum Ca++ < 8.5 mg/dl
• Causes include:
- hypoparathyroidism & surgical hypoparathyroidism
- malabsorption syndrome
- vitamin D deficiency
- prolonged admin. of Ca free IVF
- acute pancreatitis
Causes
- Excessive admin. of citrated blood
- Alkalosis
- Hyperphosphatemia
- Hypomagnesemia
- Thyroid cancer
- Low serum albumin
- Cimetidine (Tagamet)
- Alcohol Abuse
- Medications
S/Sx
• Tetany (# 1 sign)
• Vary with severity, duration & rate of development
• Numbness & tingling
• Spasms of muscles of extremities & face
• Pain
• Hyperactive deep tendon reflexes
• Abdominal muscle spasms
• Respiratory effects
• Altered mood & memory
• Convulsion/Seizures
• Laryngeal spasm
• + Trousseau’s
• + Chvostek’s
+ Trousseau’s Sign
• Carpopedal spasm of hand when
o Blood supply ↓
o Pressure on nerve
• Occurs several minutes after BP cuff inflated > systolic BP
+ Chvostek’s Sign
• Spasm of muscles innervated by facial nerve
• Tap facial nerve anterior to ear lobe below zygomatic process
Cardiac Effects
• Prolonged QT interval
• Prolonged ST segment
• ↓ cardiac contractility
• ↓sensitivity to Digoxin
Lab Data
• Serum calcium levels < 8.5 mg/dl
• Albumin/protein levels can give incorrect levels of Ca
• Ionized (serum) levels of Ca should be obtained for accurate results
• PTH levels rise in response to hypocalcemia
• Magnesium and phosphorus levels should also be obtained
Low Magnesium=Low Calcium
High Phosphorus=Low Calcium
High pH=Low Calcium
Hypocalcemia Medical Treatment
• Acute symptomatic ↓ Ca is emergency.
– Requires prompt adm. of IV Calcium
• 10% Ca-Gluconate
– For severe symptoms
• Ca-Chloride
– Never give IM – faster than Ca-Gluconate
• Oral Ca or Vitamin D
Nursing Interventions Hypocalcemia
• Identify pt at risk
• Seizure precautions if severe ↓Ca
• Monitor airway
• Monitor ECG
• Educate pt: Ca loss & risks & Ca rich foods (green leafy veggies, canned salmon, sardines, fresh oysters, dairy products)
Hypercalcemia
• Calcium > 10.5 mg/dl
• If severe – dangerous with ↑ mortality
• Causes include:
– Hyperparathyroidism – most common cause
– malignant neoplastic disease and chemotherapies – second most common
– prolonged immobilization
– large doses Vit. D & Vit. A
S/S
• Decreased neuromuscular excitability:Muscle weakness and incoordination
• ↓ GI motility: anorexia, N/V, constipation – leads to dehydration
• Altered memory, confusion, slurred speech, lethargy, acute psychotic behavior, & coma
• Depressed deep tendon reflexes
• Bone pain & abdominal pain
• Hypercalcemic crisis: severe polyuria & polydipsia, intractable nausea, abdominal cramps, lethargy, coma and cardiac arrest
• Can cause kidney stones
Cardiac Changes – focus on cardiac changes inn Na & K – not so much these
• Calcium: inotropic effect on heart & reduces heart rate (decreases the contractility)
• Shorten ST segment & QT interval
• Prolonged PR interval
• Potentiate digoxin toxicity
Lab Data
• Serum calcium > 10.2 mg/dl
• ECG-dysrythmias
• PTH- increased
• X-ray-reveal osteoporosis
• Urine
Medical Treatment
• Treat underlying cause
• Dilute serum Ca++ with NS – encourages dieresis to get Ca out
• Lasix/furosemide
• IV phosphate
• Calcitonin
• Glucocorticoids – inhibit the intestinal absorption of Ca
• Hemodialysis or CAPD
Nursing Interventions
• Monitor for pt risk
• ↑activity & fluids if possible
• ↓ Ca++ intake
• Safety measures for confusion
• Monitor ECG, I&O, breath sounds
• Monitor for Digoxin toxicity
• Prevent Ca++ renal stones
Magnesium
• Normal 1.3 – 2.3 mEq/L
• Mg is important for neuromuscular function
• Activator for enzymes
• Carbohydrate & protein metabolism
• Vasodilation in peripheral arteries
• Found in bone and tissue
• Eliminated by kidneys
Magnesium is the 2nd most abundant cation in the intracellular compartment, next to K
Hypomagnesemia
• Mg < 1.3 mEq/L
• 1/3 Mg is bound to protein, 2/3 remains as free cation
• Causes include:
• GI loss
-Alcoholism: decrease dietary intake, impairs renal conservation, intestinal malabsorption, intermittent diarrhea and vomiting
The kidney is the primary route of magnesium excretion
Chronic alcoholism is the most common cause – because of poor dietary intake
Causes
• Intestinal malabsorption syndromes
• Diarrhea
• Diuretics
• Prolonged admin. Mg free IVF/TPN
• NG Suction
• Renal or liver disease
• Diabetic ketoacidosis
• Lower GI tract has the highest magnesium concentration
S/Sx
• Usually occur Mg < 1.0 mEq/L
• Most are neuromuscular: hyperexcitability with muscle weakness, tremors & athetoid movements (slow, involuntary movement)
• Tetany
• + Trouseau’s and Chvostek’s
• Seizures
• Laryngeal stridor
• Signs of low hypocalcemia r/t low PTH
• Alterations in mood: apathy, depression, agitation, dizziness, insomnia, audio or visual hallucinations, psychoses
• Digoxin Toxicity
Cardiac Changes
• Predisposes to dysrhythmias
– PVC or V-fib
• ↑risk for digoxin toxicity
• ECG:
– Prolonged PR & QT intervals
– Widening QRS complex
– depressed ST segment
– Flattened T waves
– Prominent U waves
Lab Data
• Mg < 1.3 mEq/L
• Potassium
• Calcium
• ECG
• Urine Mg. level
Medical Treatment
• Diet
– Can be used alone for mild _ Mg
– Green vegetables, meat, seafood, nuts, seeds, legumes, whole grains,peanut butter, cocoa
– Spinach is the best source
• Mg replacement
– Assess renal function – route of Mg elimination
– PO Slow-Mag
• Diarrhea possible side effect
– IV or IM
– MOM helps for constipation
– Because the kidneys are the main route of excretion, u have to watch the BUN, creatinine
Admin. Of Mg Sulfate IV
• Monitor rate closely
– Too rapid: risk cardiac arrest
– Dose: based on severity
– Rate not to exceed 150 mg/min or 67 mEq over 8 hours (severe)
• Contraindicated in heart block
Before u start the med, check DTR FIRST
• Monitor urinary output
– 100 ml q 4 hr
• Assess patellar reflexes
• Monitor respiratory status
– Risk respiratory arrest
Nursing Interventions
• Identify & monitor pt at risk
• Asses of digoxin toxicity
• Seizure precautions
• Monitor airway
• Safety for confusion / psychosis
• Pt education: diuretics & laxative use
• Pt education: diet
Hypermagnesemia
• Mg > 2.5 mEq/L
• Causes
– Hemolyzed blood samples – can get a false high level
– Renal failure – most common cause
– Addison’s Disease
– Excessive use antacids and laxatives
– Untreated ketoacidosis
– Excessive infusion
– Hypothermia
– Lithium toxicity
S/S
• Acute elevations: peripheral and CNS depression
• Mild increases:
-low blood pressure
-N/V
-facial flushing
-sensations warmth
• Higher increases:
-lethargy
-dysarthria – difficulty articulating; damage to a central or peripheral motor nerve
-drowsiness
-loss of deep tendon reflexes
-muscle weakness and paralysis
-depressed respirations
-coma
Cardiac Changes
• Sinus Bradycardia
• Prolonged PR, & QT intervals
• Tall T waves
• Widened QRS
• Heart Block
• Cardiac arrest in diastole
Lab Data
• Mg > 2.5 mEq/L
• ECG
• K+ increased
• Ca- increased
• Creatinine clearance decreases to less than 3.0 ml/min.
Medical Treatment
• Prevention is key
• Avoid administration of Mg in renal failure
• Hemodialysis
• Emergency treatment if respiratory or cardiac problems develop
– Ventilator support
– Calcium Gluconate
• Direct antagonist to Magnesium
• 5 – 10 mEq may reverse cardiac or respiratory problems
• Lasix
• NaCL or LR
Nursing Interventions
• Monitor pt at risk
• Monitor vital signs
– Low BP
– Shallow resp. with apnea
• Assess patellar reflexes
– Absent reflexes implies Mg > 7.0
• Monitor LOC
– Drowsy, lethargy, coma
• Monitor pt at risk
• Monitor vital signs
– Low BP
– Shallow resp. with apnea
• Assess patellar reflexes
– Absent reflexes implies Mg > 7.0
• Monitor LOC
– Drowsy, lethargy, coma
Phosphorus
• Normal 2.5-4.5 mg/dl (adult)
• Essential for fxn of muscle & RBCs
• Essential to nervous system
• Essential to metabolism of:
– Carbohydrate
– Protein
– Fats
• Aids in the formation of ATP and 2,3 diphosphoglycerate
• Maintenance in acid-base balance
• 85% is located in bones and teeth
• 14% located in soft tissue
• 1% in ECF
• Critical to nerve and muscle function
Important for WBC Phagocytosis & platelet function
Hypophosphatemia
• Phosphorus < 2.5 mg/dl
• Causes
–Severe protein –
• calorie malnutrition
• Anorexia
• Alcoholism
• Overfeeding with simple carbohydrates
• Elderly debilated & unable to eat
• Hepatic encelopathy
• Prolonged intense hyperventilation
– Alcohol withdrawal
– Diabetic ketoacidosis
– Major thermal burns
Total phosphorus in the body is related to dietary intake, hormonal regulation, kidney excretion, and transcellular shifts
S/S
• Most signs & symptoms 2nd to deficiency
– Impaired cellular energy resources (ATP)
– Impaired oxygen delivery to tissues (2,3Diph) DPG
• Neurological
– Irritability, Apprehension, weakness,
– Numbness, confusion
– Seizure, fatigue, parasthesia, coma
• Hyperglycemia
– 2nd to predisposed insulin resistance
• Muscle damage
– 2nd to _ ATP level in muscle tissue
– Muscle weakness & pain
– Acute rhabdomyolysis
• Disintegration of striated muscle
– Impaired ventilation
o 2nd to weakened respiratory muscles
Lab Data
• Phos < 2.5 mg/dl
• Glucose/insulin administration causes a decrease in phosphorus
• PTH
• Alkaline phosphatase
• X-ray
Medical Treatment
• Prevention
• TPN & TF should have adequate Phos.
• Phosphorus – PO
– Aluminum Phosphate (Phosphojel)
• Phosphorus < 1.0 mg/dl (severe)
– K-Phosphate or Na-Phosphate
• 0.2 mMol /kg/hr is max. rate
• Risk of hypocalcemia & tetany
Giving a high phosphate=risk for low calcium due to inverse relationship
Nursing Interventions
• Identify & monitor pt at risk
• Gradual introduction of TPN & TF
– Avoid rapid shift of phosphorus
• Prevent infection
• Monitor serum phosphate levels
• Administer meds safely
• Teach about diet
Hyperphosphatemia
• Phosphorus > 4.5 mg/dl
• Causes
– Renal failure = most common cause due to the kidney’s inability to excrete phosphorus
o ↓Excretion of phosphorus
– Chemotherapy for neoplastic disease – due to significant cell destruction
– ↑Phosphorus intake
– Profound muscle necrosis
– Hypoparathyroidism
S/S
• Similar to S/S of hypocalcemia
• Tetany
– Mild to moderate: Tingling then numbness – fingertips & around mouth
– Severe: Spreads proximally to limbs & face ↑ severity
• Muscle spasm & pain
• Progressive renal impairment
Lab Data
• Phos > 4.5 mg/dl
• Calcium will be low
• X-ray
• PTH • Bun and creatinine
Medical Treatment
• Treat underlying disorder
• If 2nd to tumor cell lysis
– Allopurinol – prevent urate nephropathy
• If 2nd to renal failure
– Phosphate binding gels – take it out of the circulatory system by binding to it
– ↓ phosphate diet
– Dialysis
• Acute hyperphosphatemia
– NS – IVF
o Promotes renal excretion
– Hypertonic dextrose & regular insulin
o Drive phosphorus into cells
– Hemodialysis or Peritoneal dialysis
– Surgery
Nursing Interventions
• Identify & monitor pt at risk
• Monitor lab results
• Pt education: Avoid meds with Phos.
– Laxatives & enemas
• Change in urine output
Nursing Interventions
• Pt education: Avoid ↑Phos. Foods
– Dried fruit & vegetables
– sardines
– Hard cheeses,
– Whole grain cereal
– Nuts
Chloride
• Normal: 97 – 107 mEq/L
• Major anion in ECF along with Na
• Chloride in ISF & lymph > in IVF
• Assists in maintaining serum osmolality & osmotic pressure
• Component in gastric fluid , pancreatic fluid, & in sweat
• Inverse relationship to bicarbonate
↑Cl = ↓HCO3
Hypochloremia
• Cl < 96 mEq/L
• Causes
– Prolonged vomiting
– Prolonged NG suctioning
– Prolonged diarrhea
– GI drainage
– Salt restricted diet
– Diuretics
S/S
• ↑ Bicarbonate level
• ↓ Na level
• Hyperexcitability of muscles
– Tetany, twitching, weakness
• Hyperactive deep tendon reflexes
• Cardiac dysrhythmia
• Water excess
Lab Data
• Cl < 96 mEq/L
• Sodium
• Potassium
• Arterial Blood Gases: metabolic alkalosis
• Urine chloride level
Medical Treatment
• Correct the cause
• IV therapy: NS or ½NS
• Ammonium chloride
– Dose calculated on chloride deficit
– 100mEq / 500ml NS – give slowly
– Treat metabolic alkalosis
– Foods high in chloride
Nursing Interventions
• Monitor I&O
• Monitor bicarbonate & sodium level
• Assess LOC, muscle strength & movement
Avoid bottled water
• Pt education: food ↑ in chloride
– Tomato juice = best source of chloride
– canned vegetables
– broth, fruit, processed meat
Hyperchloremia
• Cl > 107 mEq/L
• Causes:
– Loss of bicarbonate
o Kidney
o GI tract
S/S - rarely produces s/sx on its on major symptoms are usually due to metabolic acidosis
• S/S same as those of metabolic acidosis, hypervolemia and hypernatremia.
• ↑Na level
• Fluid retention
• Tachypnea
• Weakness
• Lethargy
• ↓Cognitive ability
• HTN
• If Untreated
– ↓Cardiac output
– Dysrhythmias
– Coma
Medical Treatment
• IV fluid – Lactated Ringer’s - slowly
• Diuretics
• Restrict –
– Sodium
– Chloride
– Fluids other than LR until Cl level ↓
Lab Data
• Cl > 108 mEq/L
• Sodium >145
• pH ................
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