Fluid and Electrolyte Mnemonics

Electrolyte lab values

Magnesium: 1.5-2.5 mEq/L (1.6-2.6 @CCBC)

Phosphate: 2.5-4.5 mg/dL (2.57-4.5 @CCBC)

Potassium: 3.5-5 mEq/L (3.5-5.3 @CCBC)

Calcium (total): 8.5-10.5 mg/dL (8.2-10.2 @CCBC)

Chloride: 95-105 mEq/L (97-107 @CCBC)

Sodium: 135-145 mEq/L (same @CCBC)

Kidney/Other Blood lab values

BUN 10-20

Creatinine 0.7-1.4

Specific Gravity 1.001-1.029

Hemocrit (Hct) (%RBC): Men 38 – 51%, Women 33 – 45%

So ~30-50%

Affect of other Conditions on Electrolytes

Acidosis (>H+) = Hyperkalemia (>K+)

—More H+ goes into ICF and sends out K+ to ECF in exchange

Alkalosis (

> Insulin = Hypokalemia (

Cushing's (Hypercortisol, Hyperaldosterone): >Na+,

Hypokalemia Causes

Drugs (laxatives, diuretics, corticosteroids)

Inadequate consumption of Potassium (NPO, anorexia)

Too much water intake (dilutes the potassium)

Cushing’s Syndrome (during this condition the adrenal glands produce excessive amounts of cortisol (if cortisol levels are excessive enough, they will start to affect the action of the Na+/K+ pump which will have properties like aldosterone and cause the body to retain sodium/water but waste potassium)…hence hypokalemia

Heavy Fluid Loss (NG suction, vomiting, diarrhea, wound drainage, sweating)

Hypokalemia S/S

Easy way to Remember 7 L's

Lethargy (confusion)

Low, shallow respirations (due to decreased ability to use accessory muscles for breathing)

Lethal cardiac dysrhythmias

Lots of urine

Leg cramps

Limp muscles

Low BP & Heart

Hypokalemia Interventions

Administer oral Supplements for potassium with doctor's order: usually for levels 2.5-3.5...give with food can cause GI upset

IV Potassium for levels less 2.5 (NEVER EVER GIVE POTASSIUM via IV push or by IM or subq routes)

-Give according to the bag instruction don't increase the rate...has to be given slow...patients given more than 10-20 meq/hr should be on a cardiac monitor and monitored for EKG changes

-Cause phlebitis or infiltrations

Don't give LASIX, demadex , or thiazides (waste more Potassium) or Digoxin (cause digoxin toxicity) if Potassium level low...notify md for further orders)

Physician will switch patient to a potassium sparing diuretic Spironolactone (Aldactone), Dyazide, Maxide, Triamterene

Potassium Foods

Remember POTASSIUM to help you remember the foods

Potatoes, pork

Oranges

Tomatoes

Avocados

Strawberries,

Spinach

fIsh

mUshrooms

Musk melons: cantaloupe

Hyperkalemia Causes

Remember the phrase “The Body CARED too much about Potassium”

Cellular Movement of Potassium from Intracellular to extracellular (burns, tissue damages, acidosis)

Adrenal Insufficiency with Addison’s Disease

Renal Failure

Excessive Potassium intake

Drugs (potassium-sparing drugs: spironolactone), Triamterene, ACE inhibitors, NSAIDS)

Acidosis can cause hyperkalemia.

Hyperkalemia S/S

Signs & Symptoms of Hyperkalemia

Remember the word MURDER

Muscle weakness

Urine production little or none (renal failure)

Respiratory failure (due to the decreased ability to use breathing muscles or seizures develop)

Decreased cardiac contractility (weak pulse, low blood pressure)

Early signs of muscle twitches/cramps…late profound weakness, flaccid

Rhythm changes: Tall peaked T waves, flat p waves, Widened QRS and prolonged PR interval

hyperkalemia Interventions

Nursing Interventions for Hyperkalemia

Monitor cardiac, respiratory, neuromuscular, renal, and GI status

Stop IV potassium if running and hold any PO potassium supplements

Initiate potassium restricted diet and remember foods that are high in potassium

Remember the word POTASSIUM for food rich in potassium

Hyponatremia causes

Remember “NO Na+”

Na+ excretion increased with renal problems, NG suction (GI system rich in sodium), vomiting, diuretics, sweating, diarrhea, decreased secretion of aldosterone (diabetes insipidus) (wasting sodium)

Overload of fluid with congestive heart failure, hypotonic fluids infusions, renal failure (dilutes sodium)

Na+ intake low through low salt diets or nothing by mouth

Antidiuretic hormone over secreted **SIADH (syndrome of inappropriate antidiuretic hormone secretion…remembers retains water in the body and this dilutes sodium)

Hyponatremia interventions

Nursing Interventions for Hyponatremia

Watch cardiac, respiratory, neuro, renal, and GI status

Hypovolemic Hyponatremia: give IV sodium chloride infusion to restore sodium and fluids (3% Saline hypertonic solution….harsh on the veins…given in ICU usually through central line very slowly…must watch for fluid overload)

Hypervolemic Hyponatremia: Restrict fluid intake and in some cases administer diuretics to excretion the extra water rather than sodium to help concentrate the sodium. If the patient has renal impairment they may need dialysis.

Caused by SIADH or antidiuretic hormone problems: fluid restriction or treated with an antidiuretic hormone antagonists called Declomycin which is part of the tetracycline family (don’t give with food especially dairy or antacids…bind to cations and this affect absorption).

If patient takes Lithium remember to monitor drug levels because lithium excretion will be diminished and this can cause lithium toxicity.

Instruct to increase oral sodium intake and some physicians may prescribe sodium tablets. Food rich in sodium include: bacon, butter canned food, cheese, hot dogs, lunch meat, processed food, table salt

Hyponatremia S/S

Remember “SALT LOSS”

Seizures & Stupor

Abdominal cramping, attitude changes (confusion)

Lethargic

Tendon reflexes diminished, trouble concentrating (confused)

Loss of urine & appetite

Orthostatic hypotension, overactive bowel sounds

Shallow respirations (happens late due to skeletal muscle weakness)

Spasms of muscles

Hypernatremia causes

Remember the phrase “HIGH SALT”

Hypercortisolism (Cushing’s Syndrome), hyperventilation

Increased intake of sodium (oral or IV route)

GI feeding (tube) without adequate water supplements

Hypertonic solutions

Sodium excretion decreased (body keeping too much sodium) and corticosteroids

Aldosterone overproduction (Hyperaldosteronism)

Loss of fluids (dehydrated) infection (fever), sweating, diarrhea, and diabetes insipidus

Thirst impairment

Hypernatremia S/S

Remember: “No FRIED foods for you!” (too much salt)

Fever, flushed skin

Restless, really agitated

Increased fluid retention

Edema, extremely confused

Decreased urine output, dry mouth/skin

Hypernatremia treatment

Nursing Interventions for Hypernatremia

Restrict sodium intake! Know foods high in salt such as bacon, butter, canned food, cheese, hot dogs, lunch meat, processed food, and table salt.

Keep patient safe because they will be confused and agitated.

Doctor may order to give isotonic or hypotonic solutions such as 0.45% NS (which is hypotonic and most commonly used). Give hypotonic fluids slowly because brain tissue is at risk due to the shifting of fluids back into the cell (remember the cell is dehydrated with hypernatremia) and the patient is at risk for cerebral edema. In other words, the cell can lyse if fluids are administered too quickly.

Educate patient and family about sign and symptoms of high sodium level and proper foods to eat.

Hypomagnesemia causes

Remember “Low Mag”

Limited intake Mg+ (starvation)

Other electrolyte issues cause low mag levels (hypOkalemia, hypOcalcemia)

Wasting Magnesium kidneys (loop and thiazide diuretics & cyclosporine…stimulates the kidneys to waste Mag)

Malabsorption issues (Crohn’s, Celiac, proton-pump inhibitors drugs “Prilosec, Nexium, Protonix”…drug family ending in “prazole” Omeprazole, diarrhea/vomiting)

Alcohol (due to poor dietary intake, alcohol stimulates the kidneys to excreted mag, acute pancreatitis)

Glycemic issues (Diabetic Ketoacidosis, insulin administration)

Hypomagnesemia S/S

Remember “Twitching” because the body is experiencing neuromuscular excitability. This is the OPPOSITE in hypermagnesemia where everything system of the body is lethargic.

Trouesseau’s (positive due to hypocalcemia)

Weak respirations

Irritability

Torsades de pointes (abnormal heart rhythm that leads to sudden cardiac death…seen in alcoholism) Tetany (seizures)

Cardiac changes (moderate loss: Tall T-waves and depressed ST segments*** severe loss: prolonged PR & QT interval (prolong of QT interval increases patient’s risk for Torsades de pointes) with widening QRS complex, flattened t-waves, Chvostek’s sign (positive which goes along with hypocalcemia)

Hypertension, hyperreflexia

Involuntary movements

Nausea

GI issues (decreased bowel sounds and mobility)

Hypomagnesemia intervention

Monitor cardiac, GI, respiratory, neuro status. Place on a cardiac monitor (watching for any EKG changes prolonging of PR interval and widening QRS complex)

May administer potassium supplements due to hypokalemia (hard to get magnesium level up if potassium level is down)

Administering calcium supplements (oral calcium supplements w/ Vitamin-D or 10% Calcium Gluconate)

Administer Magnesium Sulfate IV route. Monitor Mg+ level closely because patient can become magnesium toxic (***Watch for depressed or loss of deep tendon reflexes)

Place patient in seizure precautions

Oral forms of Magnesium may cause diarrhea which can increase magnesium loss so watch out for this

Watch other electrolyte levels like calcium and potassium

Encourage foods rich in Magnesium:

Magnesium foods

“Always Get Plenty Of Foods Containing Large Numbers of Magnesium”

Avocado

Green leafy vegetables

Peanut Butter, potatoes, pork

Oatmeal

Fish (canned white tuna/mackerel)

Cauliflower, chocolate (dark)

Legumes

Nuts

Oranges

Milk

Hypermagnesemia causes

Remember “MAG”

Hypermagnesemia is less common than hypomagnesemia. It typically happens when you are trying to correct hypomagnesemia with magnesium sulfate IV infusion. However, other causes can include:

Magnesium containing antacids and laxatives***(Mylanta, Maalox)

Addison’s disease (adrenal insufficiency)

Glomerular filtration insufficiency (<30mL/min) renal failure. This is because the kidneys are keeping too much magnesium.

Hypermagnesemia S/S

Remember: Every system of the body is “Lethargic” (opposite of hypomagnesemia where the body systems are experiencing hyper-excitability)

Note: You will typically only see symptoms in severe cases of hypermagnesemia (mild cases patient will be asymptomatic)

Lethargy (profound)

EKG changes with prolonged PR & QT interval and widened QRS complex

Tendon reflexes absent/grossly diminished

Hypotension

Arrhythmias (bradycardia, heart blocks)

Respiratory arrest

GI issues (nausea, vomiting)

Impaired breathing (due to skeletal weakness)

Cardiac arrest

Hypermagnesemia interventions

Monitor cardiac, respiratory, neuro system, renal status. Put patient on cardiac monitor (watch for EKG changes)

Ensure safety due to lethargic/drowsiness

Prevention:

Avoid giving Magnesium containing antacids/laxative to patients with renal failure

Assess for hypermagnesemia during IV infusions of magnesium sulfate for hypomagnesemia (sign and symptom would be diminished/absent deep tendon reflexes)

Withhold foods high in magnesium

Administer diuretics that waste magnesium (if patient is not in renal failure) such as Loop and Thiazide diuretics

Patient in renal failure patient prep for dialysis

IV calcium may be order to reverse side effects of Magnesium (watch IV for infiltration...prefer central line)

Hypocalcemia causes

Remember “Low Calcium”

Low parathyroid hormone due. This is due to the destruction or removal parathyroid gland (any surgeries of the neck ex: thyroidectomy you want to check the calcium level) Professors love to ask this on an exam.

Oral intake inadequate (alcoholism, bulimia etc.)

Wound drainage (especially GI System because this is where calcium is absorbed)

Celiac’s & Crohn’s Disease cause malabsorption of calcium in the GI track

Acute Pancreatitis

Low Vitamin D levels (allows for calcium to be reabsorbed)

Chronic kidney issues (excessive excretion of calcium by the kidneys)

Increased phosphorus levels in the blood (phosphorus and calcium do the opposite of each other)

Using medications such as magnesium supplements, laxatives, loop diuretics, calcium binder drugs

Mobility issues

Hypocalcemia S/S

Remember “CRAMPS”

Confusion

Reflexes hyperactive

Arrhythmias (prolonged QT interval and ST interval) Note: definitely remember prolonged QT interval…another major test question

Muscle spasms in calves or feet, tetany, seizures

Positive Trousseau’s! You will see this before Chvostek’s sign or before tetany. This sign may be positive before other manifestations of hypocalcemia such as hyperactive reflexes.

(KNOW How to elicit a positive Trousseau’s. You do this by using a blood pressure cuff and place it around the upper arm and inflate it to a pressure greater than the systolic blood pressure and hold it in place for 3 minutes. If it is positive the hand of the arm where the blood pressure is being taken will start to contract involuntarily (see the teaching tutorial on a demonstration).

Signs of Chvostek’s (nerve hyperexcitability of the facial nerves. To elicit this response you would tap at the angle of the jaw via the masseter muscle and the facial muscles on the same side of the face will contract momentarily (the lips or nose will twitch).

hypocalcemia Interventions

Safety (prevent falls because patient is at risk for bone fractures, seizures precautions, and watch for laryngeal spasms)

Administer IV calcium as ordered (ex: 10% calcium gluconate)….give slowly as ordered (be on cardiac monitor and watch for cardiac dysrhythmias). Assess for infiltration or phlebitis because it can cause tissue sloughing (best to give via a central line). Also, watch if patient is on Digoxin cause this can cause Digoxin toxicity.

Administer oral calcium with Vitamin D supplements (given after meals or at bedtime with a full glass of water)

If phosphorus level is high (remember phosphorus and calcium do the opposite) the doctor may order aluminum hydroxide antacids (Tums) to decrease phosphorus level which in turn would increase calcium levels.

Encourage intake of foods high in calcium:

Young Sally’s calcium serum continues to randomly mess-up.

Yogurt

Sardines

Cheese

Spinach

Collard greens

Tofu

Rhubarb

Milk

Hypercalcemia causes

Remember “High Cal”

Hyperparathyroidism (high parathyroid hormone causes too much calcium to be released into the blood)

Increased intake of calcium (excessive use of oral calcium or Vitamin D supplements)

Glucocorticoids usage (suppresses calcium absorption which leaves more calcium in the blood)

Hyperthyroidism

Calcium excretion decreased with Thiazide* diuretics & renal failure, cancer of the bones

Adrenal insufficiency (Addison’s Disease)

Lithium usage (affects the parathyroid and causes phosphate to decrease and calcium to increase)

Hypercalcemia S/S

“The body is too WEAK”

Weakness of muscles (profound)

EKG changes shortened QT interval (most common) and prolonged PR interval

Absent reflexes, absent minded (disorientated), abdominal distention from constipation

Kidney Stone formation

Hypercalcemia interventions

Mild cases of Hypercalcemia

Keep patient hydrated (decrease chance of renal stone formation)

Keep patient safe from falls or injury

Monitor cardiac, GI, renal, neuro status

Assess for complaints of flank or abdominal pain & strain urine to look for stone formation

Decrease calcium rich foods and intake of calcium-preserving drugs like thiazides, supplements, Vitamin D

To help you remember foods high in calcium remember the phrase:

“Young Sally’s calcium serum continues to randomly mess-up”

Yogurt

Sardines

Cheese

Spinach

Collard greens

Tofu

Rhubarb

Milk

Moderate cases of Hypercalcemia

Administer calcium reabsorption inhibitors: Calcitonin, Bisphosphonates, prostaglandin synthesis inhibitors (ASA, NSAIDS)

Severe cases of Hypercalcemia

Prepare patient for dialysis

Chloride

Chloride does what Sodium does and has an inverse relationship with bicarbonate (HCO3)

Hypochloremia: linked with hyponatremia, metabolic alkalosis

Hyperchloremia: linked to decrease bicarbonat

Phosphate

Calcium and Phosphate have antagonist relationship.

Hypophosphatemia: hypotension, low cardiac output, less oxygen delivered, decreased magnesium levels, increased calcium levels

Hyperphosphatemia:

S&S: CHEMOCardiac irregularities Hyperreflexia Eating poorly Muscle weakness Oliguria

All EKG Changes

Hypokalemia

ST depression

Shallow, flat, or inverted T wave

Prominent U wave

Hyperkalemia

Tall peaked T waves

Flat P waves

Widened QRS complexes

Prolonged PR interval

Hypocalcemia

Prolonged ST segment

Prolonged QT interval

Hypercalcemia

Shortened ST segment

Widened T wave

Heart block

Hypomagnesemia

Tall T waves

Depressed ST segment

Hypermagnesemia

Prolonged PR interval

Widened QRS complexes