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Electrolytes

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Substances that, when in solution, seperate (or dissociate) into electrically charged particles called ions

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Na+

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Sodium 135-155 mEq/L. a.Most abundant electrolyte in exctracellular fluid. b.Involved in maintaining water balance, transmitting nerve impulses & contracting muscles c.It is the primary determinant of extracellular fluid osmolality

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Chloride

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98-108 mEq/L Located outside of cells. Helps maintain osmotic pressure (water-pulling pressure). Gastric mucosal cells need chloride to produce hydrochloric acid, which breaks down food into absorbable components.

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Ca+

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Calcium. 8.9 - 10.1 mg/dL Located outside of cell. The major cation involved in the structure and function of bones and teeth. Needed to: stabilize the cell membrane and reduce its permeability to sodium, transmit nerve impulses, contract muscles, coagulate blood, and form bone and teeth.

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K+

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Potassium. 3.5-5 mEq/L . Most ICF cation Regulates neuromuscular exictability and muscle contraction It is regulated primarily by the kidney. Decreased urine output equals decreased potassium excretion. There is an exchange mechanism with the sodium ion. When sodium is retained, potassium is excreted

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Magnesium

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1.5-2.5 mEq/L Acts as a catalyst for enzyme reactions. Regulates neuromuscular contractions, promotes normal functioning of the nervous and cardiovascular systems, aids in protein synthesis and sodium & potassium ion transportation.

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Diffusion

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The movement of substances from an area of high concentration to an area of low concentration

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Filtration

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The movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressure

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Osmosis

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The movement of fluid from an area of low solute concentration to an area of high solute concentration until the solutions are of equal concentrations

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Regulators that Maintain Normal Fluid Balance

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Food and fluid intake Kidneys Skin Lungs GI tract

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Serum osmolality

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Reflects the concentration of sodium in blood

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Urine osmolality

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Reflects the concentration of urea, creatinine and uric acid in urine.

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Urine Specific Gravity

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Normal value is 1.010-1.025 Measures the kidneys' ability to excrete or conserve water. Varies inversely with urine volume. The larger the volume of urine, the lower the specific gravity. The smaller the volume of urine, the higher the specific gravity. Is compared to the weight of distilled water, which has a specific gravity of 1.000

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BUN Increases with

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Dehydration Decreased renal function GI bleeding Increased protein intake Fever Sepsis

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BUN Decreases with

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End stage liver disease A low protein diet Starvation Any condition that results in expanded fluid volume

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Creatinine

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Normal value is 0.7-1.5mg/dl An end product of muscle metabolism Better indicator of renal function than the BUN because it does not vary with protein intake and metabolic state. Level increases when renal function decreases

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Hematocrit

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Normal value 44-52% in males& 39-47% in females Measures the % of RBCs in the whole blood Level increases with Dehydration Polycythemia ( blood disorder in which your bone marrow makes too many red blood cells.)decreases with,Anemia,Overhydration

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BUN

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Measures urea Normal value is 10-20mg/dl

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Hypovolemia

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Fluid Volume Deficit 1. ECF fluid is decreased 2. Water and electrolytes are lost in the same proportion. 3. Serum electrolyte concentration remains unchanged 4. Should NOT be confused with dehydration in which water only is lost and serum sodium levels increase

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Hypovolemia, Causes of

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Vomiting Diarrhea GI suctioning Sweating Decreased fluid intake Hemorrhage Third space fluid shifts

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Hypovolemia, Clinical Manifestations of

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Weight loss Decreased sin turgor Oliguria Postural hypotension Tachycardia Increased temperature Cool, clammy skin Anorexia Muscle weakness and cramps

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Hypovolemia, Assessment and Diagnostic Findings

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Elevated BUN in relation to the serum creatinine (a ratio greater than 20:1) Increased hematocrit Increased specific gravity Increased urine osmolality nMay have imbalances of sodium or potassium

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Hypovolemia, Medical Management

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Encourage p.o fluids IV therapy -

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Isotonic solutions

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•Used to treat hypotension because they expand the volume of plasma •Examples are: Lactated Ringers •0.9% Sodium Chloride

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Hypotonic Solutions

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•Used to treat clients who have normal blood pressure (normotensive) •Provide both electrolytes and water •Examples are 0.45% Sodium Chloride

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Hypovolemia, Nursing Management

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Maintain patent airway Administer oxygen as ordered Perform frequent assessment of: Mental status, vital signs, Weight, breath sounds Sin color & turgor, mucous membranes, Urine output, lab results Maintain IV access with a large bore catheter. Administer fluids, blood and medications as ordered by M.D. Monitor client's response to treatment

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Hypervolemia

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Fluid Volume Excess Extracellular fluid is increased due to the abnormal retention of water and sodium in the same proportions in which they normally exist in extracellular fluid

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Hypervolemia, Clients at risk include those with:

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-Impaired renal function -Impaired cardiac function -Cirrhosis -An increased consumption of salt

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Hypervolemia, Clinical Manifestations of

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Edema Distended neck veins (DNV) Dyspnea Rales Tachycardia Elevated blood pressure nWeight gain

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Hypervolemia, Assessment and Diagnostic Findings

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Lab values: -Decreased BUN and hematocrit due to plasma dilution -Normal serum sodium -CXR (chest x-ray) may show pulmonary congestion

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Hypervolemia, Medical Management of

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Directed at the cause Restrict sodium and fluid Pharmacologic therapy to prevent CHF and pulmonary edema -Loop Diuretics -Thiazide Diuretics -K+ sparing Diuretics -Hemodialysis -Nutritional therapy

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Hypervolemia, Nursing Management of

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Assess vs and hemodynamic status Monitor respiratory status Maintain strict I&O Monitor breath sounds, weight & edema Maintain IV access, Elevate HOB Administer oxygen as ordered Provide mouth and skin care

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Hyponatremia

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Sodium deficit Occurs when there is a less than normal concentration of sodium in the blood, either from sodium loss or water excess The sodium level is less than 135 mEq/L

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Hyponetremia, Causes of

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-kidney disease -GI losses -Adrenal insufficiency -Increased sweating -Use of diuretics -Decreased sodium intake

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Hyponetremia, Signs & Symptoms

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Weak rapid pulse (tachycardia) Hyptension. Mental status changes -Lethargy -confusion, Seizures, Stroke, Coma, Death Muscle problems -Cramps, twitching, weakness, Dry skin

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Hyponetremia, Assessment and Diagnostic Findings

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1.Labs indicate: -decreased serum and urine sodium -Decreased urine specific gravity 2.The following are normal values: -serum Na: 135-145 -Urine Na: 75-220mEq/day -Urine specific gravity: 1.016-1.022

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Hyponetremia, Medical Management

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Sodium Replacement -P.O -IV lactated ringers or 0.9 sodium chloride •Administer carefully •Avoid correcting the hyponatremia too quickly as this can cause cerebral edema Water Restriction -800ml/24 hours

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Hyponetremia, Nursing Management

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Identify patients at risk Use prevention and early intervention Monitor I&O Weigh the client daily Monitor for signs and symptoms Monitor lab results Encourage a diet high in sodium when appropriate: broth, tomato juice

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Hypernatremia

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Sodium Excess Sodium level is greater than 145mEq/L Occurs when there is a greater than normal concentration of sodium in the extracellular fluid from extreme water loss or sodium excess

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Hypernatremia, Causes of

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Ingestion of salt Water deprivation Dehydration IV administration of hypertonic saline solution or hypertonic tube feedings Watery diarrhea Excessive aldosterone secretion Diabetes Insipidous

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Hypernatremia, Signs &Symptoms

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Excessive thirst, Elevated temperature Dry, sticky mucous membranes Mental status changes: -Lethargy -Restlessness -irritability Seizures-Hypotension-Tachycardia Nausea, vomiting and anorexia noliguria

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Hypernatremia, Assessment and Diagnostic Findings

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Labs: -Increased serum sodium -Decreased urine sodium -Increased urine specific gravity and osmolality

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Hypernatremia, Medical Mangement

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Administer hypotonic IV solutions to gradually lower the serum sodium level eg: 0.3% sodium chloride or D5W Diuretics may be given to lower the sodium level A rapid reduction in the serum sodium level may cause cerebral edema

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Hypernatremia, Nursing management

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Maintain I&O Obtain daily weights Monitor vital signs carefully Monitor for mental status changes

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Hypokalemia

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Potassium level is less than 3.5 mEq/L Potassium is not stored in the body, so daily intake is required 80-90% is excreted by the kidneys

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Causes of Hypokalemia

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Inadequate intake, Too much output Severe GI losses from Vomiting, Diarrhea , NG suction Laxative abuse, Starvation, Anorexia nervosa % bulimia, Alcoholism, Hypercalcemia, Hyperglycemia, DKA, Drugs such as: diuretics, antibiotics, corticosteriods and insulin

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Clinical Manifestations Hypokalemia

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Leg cramps - most common symptom Weakness, fatigue,Nausea, vomiting, anorexia, Decreased bowel motility, constipation, Muscle weaness, Hypotension Mental status changes-confusion, lethargy Hyporeflexia, Irregular pulse Ventricular arrythmias and cardiac arrest

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Assessment and Diagnostic Findings of Hypokalemia

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Lab results: Potassium less than 3.5 mEq/L EKG Changes Flattened T waves ST depression Prolonged PR interval Characteristic U waves Irregular pulse due to ventricular arrythmias

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Medical Management of Hypokalemia

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Increased dietary potassium. bananas, apricots, oranges, raisins, melons, vegetables, legumes, whole grains, milk and meat. IV replacement therapy Potassium chloride is usually ordered The max admin rate is 10-20 mEq/hr. KCL is administered with a infusion pump!!! It is usually diluted as 10-20 mEq in 100 cc of D5W to run over one hour. Use an adequate IV line. Potassium will irritate the vein and cause a burning sensation. May be given as 20-40mEq in one liter of D5/0.45 saline for maintenance replacement. The client must have adequate urine output before administration.

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Nursing Management-Hypokalemia

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Monitor lab results-report abnormalities to the doctor Monitor for symptoms Maintain I&O Monitor vital signs Assess heart rate, rhythm and EKG

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Hyperkalemia

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There is an excess amount of potassium in the extracellular fluid Potassium level is greater than 5 mEq/L

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Causes of Hyperkalemia

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Renal failure Cellular damage Trauma burns Administration of large amounts of potassium Diabetes Acidosis Addison's Disease

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Clinical Manifestations of Hyperkalemia

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Muscle weakness, cramps, Irritability, Slurred speech Anxiety, Confusion, Nausea, vomiting and diarrhea Ventricular arrhythmias, Cardiac arrest, Death

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Assessment & Diagnostic Findings-Hyperkalemia

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Lab results - postassium level is more than 5.0 mEq/L EKG Changes: Ventricular dysrhythmias Elevated T waves ST depression Prolonged PR interval and QRS duration Absent P waves

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Medical Management of Hyperkalemia

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Monitor EKG's, Restrict potassium rich foods IV Calcium Gluconate, IV sodium bicarbonate IV Regular insulin and hypertonic dextrose solution Kayexelate - a cation exchange resin Can be administered p.o, NGT, GT or by retention enema Action: potassium is exchanged for sodium in the intestinal tract. Potassium is then excreted in the stool May cause diarrhea

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Nursing Management of Hyperkalemia

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Monitor changes in vital signs, EKG's, lab results Assess signs and symptoms

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Calcium

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8.6 - 10.5 mg/dl Needed for cell membrane integrity & structure, adequate cardiac impulse conduction, blood coagulation, bone growth and integrity, muscle relaxation Regulated through the actions of the parathyroid and thyroid glands 99% calcium found in bones and teeth

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Positive Trousseau's Sign

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Elicited by inflating a blood pressure cuff on the upper arm to about 20mm Hg above systolic pressure. Within 2-5 min, carpopedal spasm will occur as ischemia of the ulnar nerve develops

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Positive Chvostek's Sign

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When you tap the facial nerve 2cm in front of the earlobe and just below the zygomatic arch, the muscles supplied by the facial nerve begin to twitch.

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Assessment and Diagnostic Findings of Hypocalcemia

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less than 8.5. My cause: Osteoporosis, Primary hypoparathyroidism Pancreatitis, Renal failure Inadequate Vitamin D consumption

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Medical Management of Hypocalcemia

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Calcium supplement IV administration of Calcium in D5W via slow infusion Calcium gluconate, Calcium chloride Calcium gluceptate Vitamin D therapy to increase calcium absorption from the GI tract

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Nursing Management Hypocalcemia

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Increased dietary calcium to 1000-1500mg/day. Foods high in calcium are milk, green leafy vegetables, canned salmon, sardines and fresh oysters. Encourage exercise Teach the patient about medications such as Fosamax, Actonel, Evista and calcitonin which reduce the rate of bone loss

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Hypercalcemia

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level is greater than 10.5 Causes: Malignancies Hyperparathyroidism Immobility after severe or multiple fractures or spinal cord injury

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Clinical Manifestations of Hypercalcemia

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Depression and lethargy Nausea, vomiting and anorexia Constipation Abdominal pain Bone pain

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Medical Management of Hypercalcemia

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Decreased calcium intake Increased fiber Monitor for sings of digitalis toxicity if the client is receiving digoxin

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Magnesium

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1.5-2.5mg/dL 2nd most important cation of the ICF Essential for enzyme activities, neurochemical activities and muscular excitability Excreted through renal mechanism

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Hypomagnesemia

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Causes: Alcohol withdrawal - most common cause Prolonged inadequate dietary intake of magnesium Loss from the GI tract by NG suction, diarrhea, or fistulas Problems with the distal small bowel

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Clinical Manifestations of Hypomagnesemia

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Hyperexcitability Muscle weakness Tremors Seizures Mood alterations - apathy, depression Cardiac arrhythmias such as PVCs, SVT, and ventricular fibrillation

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Medical Management of Hypomagnesemia

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IV administration of magnesium Sulfate - 1 gm in 100ml over one hour Encourage client to eat foods irch in magnesium, such as green leafy vegetables, nuts, legumes, whole grains, and seafood.

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Hypermagnesemia

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Clinical Manifestations: Lethargy, drowsiness, coma Decreased deep tendon reflexes Muscle weakness Paralysis Depressed respirations Hypotension AV block Cardiac arrest

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Causes of Hypermagnesemia

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Renal failure is most common cause Untreated DKA Adrenocortical insufficiency Addison's disease Hypthermia Excessive use of antacids or laxatives

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Medical Management of Hypermagnesemia

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IV Calcium Gluconate: antagonizes the neuromuscular effects of magnesium

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Nursing Management of Hypermagnesemia

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Monitor level of consciousness Assess patellar reflexes Monitor vital signs Fluid intake

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Phosphorus

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2.5 - 2.5 mg/L Helps maintain bones and teeth along with calcium Regulated by kidneys, parathyroid hormones and Vitamin D Calcium and phosphorus are inversely related. If one rises, the other one falls

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Hypophosphatemia

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serum level below 2.5mg/dl Clinical Manifestations: Irritability, Apprehension, Fatigue, Weakness Numbness, Confusion, Seizure, coma

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Causes of Hypophosphatemia

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Lab results: serum level below 2.5mg/dl Causes: Malnutrition Anorexia Alcoholism Parenteral nutrition DKA Thermal burns

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Medical Management of Hypophosphatemia

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Administer Fleets Phospho Soda Administer IV phosphorus if: The GI tract is not functioning The serum level is dangerously low - below 1mg/dl

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Nursing Management of Hypophosphatemia

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Identify clients at risk Monitor Signs and Symptoms Encourage dietary intake of foods such as milk, poultry and whole grains

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Hyperphosphatemia

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Clinical Manifestations: tetany ( involuntary contraction of muscles) Serum level > 4.5mg/dl Causes: Renal failure Chemotherapy DKA

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Medical Management of Hyperphosphatemia

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Treat underlying disorder Avoid laxatives and enemas Low phosphorus diet: avoid hard cheese and cream Nursing Management: Monitor at risk clients

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Chloride

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96 - 106mEq/L Primary ECF anion Fluctuations in chloride levels usually parallel sodium Maintained by dietary intake and renal excretion and reabsorption Regulated through the kidneys Gastric mucosa cells need chloride to produce HCL acid

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Hypochloremia

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<96 mEq/L Causes: Salt restricted diets GI drainage Severe vomiting and diarrhea

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Medical Management of Hypochloremia

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IV Therapy Foods high in chloride Review the use of diuretics Nursing Management I & O Monitor level of consciousness Assess muscle strength

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Hyperchloremia

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serum level > 106 mEq/L Clinical Manifestations: Tachypnea, Weakness, lethargy Causes: loss of bicarbonate ions via the kidney or the GI tract

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Nursing management of Hyperchloremia

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Monitor I&O Monitor vital signs Monitor arterial blood gases

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Isotonic Fluids

answer

D5W Normal Saline Lactated Ringer's NS and LR are true isotonic solutions. D5W is isotonic, however, once it is infused into the blood stream, the dextrose (glucose) is quickly metabolized and used up. So the D5W becomes hypotonic when it is in the body.

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Hypotonic Fluids

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0.45 Normal Saline aka ½ NS

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Hypertonic Fluids

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D5/NS D5/LR D5/0.45 NS

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Systemic Complications

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Fluid overload Air embolism Septicemia and other infections

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Local Complications

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Infiltration Phlebitis Thrombophlebitis Clotting and obstruction

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Hypercalcemia & kidney stones

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When a patient has too much calcium in the blood, he becomes prone to kidney stones. Many kidney stones are made up of calcium,some are uric acid. If someone has high calcium levels, strain the urine

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