n325 electrolytes

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what are electrolytes?

• essential ions found in the body

• positively charged (+, cation)

• negatively charged (-, anion)

cations

• positive charge

• ex)

  • Na+

  • K+

  • Ca+2

  • Mg+2

anions

• negative charge

• ex)

  • chloride:Cl-

  • bicarbonate: HCO3-

  • phosphate: PO4-3

  • sulfate: SO4-2

functions of electrolytes

• nerve conduction

• muscle function

• fluid balance

• acid-base balance

• cellular function

normal Na+ lab values

• 135 - 145 mEq/L

normal Cl- lab values

• 98 - 106 mEq/L

normal K+ lab values

• 3.5 - 5.0 mEq/L

normal Ca+2 lab values

• 9.0 - 10.5 mEq/L

normal Mg+ lab values

• 1.3 - 2.1 mEq/L

normal PO4-3 lab values

• 3 - 4.5 mg/dL

Na+ functions

• normal range: 135 - 145 mEq/L

• influences fluid distribution

• influences blood pressure

• acid-base balance

• muscle contraction

• nerve impulse transmission

• regulated by kidneys

• nutrient transport

Cl- functions

• normal range: 98 - 106 mEq/L

• direct relationship with Na+

• nerve conduction

• acid-base balance

• lost in sweat

• part of stomach acid, pancreatic enzymes

• nutrient transport

dietary intake - Na+

• higher sodium

  • processed foods

  • preserved foods

  • cheese

  • dried meats

  • canned foods (not fruits)

• lower sodium

  • fresh/frozen veggies and fruits

  • dried druits

  • canned fruit

  • rice, pasta

  • unsweetened oatmeal

  • fish, shellfish

  • fat-free/low-fat milk & yogurt

hypernatremia

• serum sodium: >145 mEq/L

• losing water → sodium is now more conc in the blood

• or gaining more sodium than water → hypertonic fluid IV or eating crazy sodium

• water shifting into the bloodstream and out of cells → sodium more concentrated in the blood → cells shrink

patients at risk for hypernatremia

• Na+ retention

  • hyper-aldosteronism → aldosterone incr sodium/water retention

  • cushing’s

  • uncontrolled diabetes mellitus

• Na+ intake

  • lots of dietary Na+

  • corticosteroids → incr sodium/water rentention

  • IV fluids

  • hypertonic tube feedings w/o free H2O

• water loss

  • H2O deprivation

  • increased insensible water loss (fever)

  • diarrhea

  • diabetes insipidus (DI) → peeing out body’s volume

• inadequate water intake

  • elderly

  • infants

  • comatose pts

  • pts with cognitive dysfunction

hypernatremia: assessment findings

• extremely rapid shift/extremely high Na+

  • brain cell shrinkage

  • vascular rupture

  • cerebral bleeding

  • neurological damage

  • death

• increased Na+ = thirst

  • CNS signs → confusion, restless, agitation, seizures, coma, death

• hypovolemic hypernatremia

  • see this w dehydrated ppl → see neurosymptoms and hypovolemia symptoms

  • tachycardia

  • decreased BP

  • dry mucous membranes

• hypervolemic hypernatremia

  • see neuro symptoms + hypervolemia symptoms

  • weight gain

  • peripheral/pulmonary edema

  • increased BP

  • increased JVD

hypernatremia: interventions

• hypovolemic

  • NS or LR until hypovolemia improves

  • provider will calculate H2O deficit

  • if necessary, then admin hypotonic fluid (1/2 NS, D5W, or PO H2O) to replace fluid deficit

  • rehydrate them by giving fluids

• euvolemic

  • provider will calculate H2O deficit

  • adminster hypotonic fluid (1/2 NS, D5W, or H2O) to replace water deficit

  • give hypotonic fluid bc that will balance sodium level faster without adding too much volume

• hypervolemic

  • free water replacement (D5W) + loop diuretics

  • hemodialysis if renal failure

• dietary

  • restrict Na+

• meds

  • diuretics

  • no meds that contain sodium

• monitor

  • physical assessment findings

  • Is & Os

  • daily weights

  • labs: HCT, glucose, electrolytes

• comfort

  • mouth, lip care

  • alcohol-free mouthwash

  • skin care

• education

  • teach abt sodium in foods (<2000 mg/day)

  • OTC meds that contain Na+ should be stopped

  • body positioning if FVE

hyponatremia

• serum sodium <135 mEq/L

• losing more sodium than water

• higher concentration of sodium in the cells than in vasculature

• water moves into cells → cells swell → BAD in brain cells

  • cerebral edema → serizures + confusion

patients at risk for hyponatremia

• increased water

  • syndrome of inappropriate ADH secretion (SIADH)

    • increased ADH → body holds onto more water

  • CHF

  • psychogenic polydipsia

• increased Na+ loss

  • renal loss

  • GI loss

  • NG suctioning

  • skin loss

    • wound damage

    • severe burns

• hormonal

  • hypoaldosteronism → body doesn’t retain as much sodium anymore (uncommon)

• decreased dietary Na+ intake

  • rare

extreme hyponatremia

• serum sodium: <120 mEq/L

• patient might be suddenly very confused when they were not before → check their sodium level

• acute cases: brain swelling is big concern

signs of hyponatremic encephalopathy

• lethargy

• headache

• restlessness

• disorientation

• seizures, coma, death

• anorexia

• nausea & vomiting

• muscle cramps

• weakness

• weak/absent DTRs

hyponatremia assessment findings

• neuro

  • cerebral edema → headache

  • confusion

  • headache

• MS

  • decreased muscle tone

  • weakness

  • decreased DTRs

  • fatigue

• CV

  • increased HR

  • increased JVD if hypovolemia

  • postural hypotension

• GI

  • increased motility

  • cramping

  • nausea/vomiting

• respiratory

  • severe muscle weakness can inhibit respiratory functions

• labs

  • na+ , cl - will be decreased

  • increased serum osmolality

  • increased HCT

hyponatremia interventions

• monitor

  • I & O

  • labs

  • daily weights

  • LOC

  • potential for seizures if severe

• fluids

  • hypovolemia: IVF/PO - w Na+ replacement → 0.9% NaCl

  • euvolemia: treat cause, no additional fluids needed

  • hypervolemia: restrict fluids if delusional or too much intake

  • severe/rapid onset w lots of symptoms: 3% NS slowly

    • prevent major risks w correcting sodium too fast

    • brain cells are super sensitive to fluid shifts

• other

  • prevent further decline in serum na+

  • reorient

  • safety interventions

  • educate pt and family

hypertonic NaCl safety

• 3% or 5% NaCl IV

• restrict to CCU/ICU/ED

• never override drug dispensing machine to obtain the med

• use smart pump alerts for proper rate guidelines

• central line recommended

• monitor Na+ q6h

• monitor for possible side effects

  • elevated intracranial pressure (ICP), renal impairment, subarachnoid hemorrhage (SAH), natriuresis, increased urine output (UOP)

• program rate as prescribed

• too-rapid rate can cause osmotic demyelination syndrome

  • permanent brain damage

  • be careful in bringing Na+ level down and up

  • can’t be too quick or too aggressive

  • strip myelin off of nervous cells → irreversible damage to the brain

potassium normal serum level

• 3.5 - 5.0 mEq/L

potassium functions

• correlates frequently with Na+ (opposing), but not direct relationship

• important in cardiac and muscle function

  • too much or too little causes arrythmias

• maintaining electrolyte balance

• nerve function

• muscle function

  • cramping

• heart function

  • arryhthmias

• acid-base balance

• kidney function

• cellular metabolism

• **K+ plays big role in depolarization of muscle

dietary intake - K+

• higher K+

  • dried fruit

  • spinach

  • beef

  • chocolate

  • pork

  • tomatoes

  • potatoes

  • bananas

• lower K+

  • eggs

  • bread

  • cherries

  • apples

  • peaches

  • cauliflower

  • celery

  • green beans

  • peppers

  • peas

hyperkalemia serum levels

• serum potassium: >5 mEq/L

hyperkalemia patients at risk

• decreased excretion → bc renal failure

• decreased aldosterone → bc adrenal insufficiency/addison’s disease

• potassium-sparing diuretic → spironolactone

• K+ shift → excessive exercise, cell injury, catabolism, diabetes mellitus, medications

• other→ salt substitutes, digoxin, beta-blockers

hyperkalemia: asssessment

• GI

  • nausea/vomiting

  • abdominal cramping

  • diarrhea

• cardiac

  • tall, peaked T-waves

  • widening QRS

  • deadly arrhythmias

• mental

  • irritability (not confusion)

  • anxiety

  • fatigue

• neuromuscular

  • paresthesia

  • weakness

  • muscle cramping

hyperkalemia: ECG changes

• tachycardia → bradycardia

• possible cardiac arrest

• tall, tented T waves

hyperkalemia: interventions

• eliminate K+ intake → no salt subtitutes

• increased K+ elimination → loop diuretics, SODIUM POLYSTYRENE SULFONATE

  • promotes GI excretion of potassium in stool

• force K+ out of ECF into ICF

  • insulin + glucose

    • insulin lowers blood sugar by moving sugar into cells

    • glucose goes into cells but K+ does too

    • K+ levels decrease because it moved inside the cells

    • give insulin IV to lower K+ levels → BUT ALSO GIVE GLUCOSE bc we made glucose also move inside the cells → prevent hypoglycemia

• protect the heart

  • 10% calcium gluconate IV

• dialysis if renal failure

• monitor: ECG, labs, bowel sounds, stool, muscle strength

• educate: diuretic use, muscle weakness, avoid K+ rich foods, safety

hypokalemia serum level

• serum K+: <3.5 mEq/L

hypokalemia: patients at risk

• renal

  • hypoaldosteronism

• skin

  • excessive diaphoresis

• GI

  • vomiting, diarrhea, NG suctioning, poor PO intake

• meds

  • K+ wasting meds → furosemide

  • corticosteroids → prednisone… in hyperaldosterone, high levels of steroids in body.. steroid hormones cause elevated blood sugar → increase insulin production. K+ goes into cell as a result along with glucose.

  • conditions/medications that cause elevated cortisol or blood sugar will result in hypokalemia → K+ moving inside cells

  • laxative overuse

  • excessive insulin

hypokalemia assessment

• CV

  • prominent U waves

  • S-T depression

  • prolonged QRS

• MS

  • weakness, parethesia

  • decreased smooth muscle function

• neuro

  • decreased DTRs

  • depression

  • confusion

• GI

  • decreased gastrointestinal motility

  • paralytic ileus

• respiratory

  • shallow respirations

• miscellaneous

  • hyperglycemia

  • fatigue

hypokalemia: ECG changes

• prominent U wave

• S-T depression

• prolonged QRS → causes ventricular arrhythmias → deadly

hypokalemia: interventions

• hydrate to maintain urine output of <0.5 mL/kg/hrHydrate

• supplement oral: replace K+ in diet or supplements

• supplement IV:

  • no more than 10-20 mEq/hr by IV pump

  • GIVE 10 MEQ/HR by IV PIGGYBACK → if give too quick, cause cardiac arrhythmias

  • NEVER GIVE K+ IV PUSH → WILL KILL PT

• monitor: ECG, vitals, respiratory status, BS

• other: treat constipation, hold K+ wasting diuretics, consider changing diuretic class change

• education: S/S hypokalemia, laxative overuse, safety, S/S orthostatic hypotension

Ca+2 normal serum levels

• serum level: 9 - 10.5 mEq/L

calcium functions

• required for clotting

• needed for muscle contractions

• used in enzyme activity

• assists with nerve impulses

• important for strength and durability of bones/teeth

what is Ca+2 absorption influenced by

• active vitamin D (calcitrol/sunlight) required for GI absorption

• PTH → increased serum Ca+2

  • PTH releases Ca+2 and signals kidneys to activate vitamin D → GI tract will absorb more Ca+2

• INCR PTH = INCR CA+2

• INCR calcitonin = DECR Ca+2

• Ca+2 and phosphate have an inverse relationship

• when body detects high Ca+2 → stop producing PTH and instead secrete calcitonin

• calcitonin tells bones to absorb calcium bc too much in blood and tells kidneys to not secerete vitamin D. also tells gut to not absorb calcium

• CALCIUM CALMS

dietary intake Ca+2

• higher in Ca+2

  • almonds

  • antacids

  • creamed soups

  • molasses

  • sardines

  • turnip greens

  • spinach

• lower in Ca+2

  • fruits

  • beans

  • carrots

  • radishes

hypercalcemia serum concentration

• serum calcium > 10.5 mEq/dL

patients at risk for hypercalcemia

• RHINO

• Renal Insufficiency

  • cannot decrease Ca+2 through kidneys

• Hyperparathyroidism

  • parathyroid hormone is overactive

  • too much PTH = too much Ca+2 absorbtion

• Immobilization

  • reduced mechanical loading on bones → calcium leaks out of bones

• Neoplasms

  • cancer

  • bone metastasis → cancer eats away at bones and bone contents release

• Other endocrineopathies

  • issues w thyroid → impact parathyroid

hypercalcemia assessment

• neuro

  • LOC changes

  • confusion

  • depression

  • lethargy

• GI

  • decreased peristalsis

  • constipation

  • abdominal discomfort

• MS

  • weakness

  • fatigue, lethargy

  • decreased DTRs

  • bone pain

• GU

  • kidney stones

  • polyuria

  • dehydration

• CV

  • decreased HR

  • DVT risk

  • heart block

  • postural hypotension

  • ECG changes → shortened S-T

hypercalcemia interventions

• hydration

  • 3-4 L daily → decreases risk of calcium stones → flush it thru

• promote excretion

  • IV NS → match rate up to UOP

  • loop diuretics

• reduce serum Ca+2

  • calcitonin → inhibits bone breakdown

  • avoid Ca+2 containg meds

  • calcimimetics to regulate PTH

• inhibit bone loss of Ca+2

  • weight-bearing activities

  • bisphosphonates → decrease calcium release from bones by inhibiting osteoclasts

• safety/monitor

  • protect against fractures

  • ambulation

  • fall risk

  • telemetry

  • monitor VS, labs

• other

  • strain urine (stones)

  • Tx constipation, nausea

  • decreased dietary intake of Ca+2

  • dialysis → if kidneys aren’t working at all

  • correct underlying cause

  • no thiazide diuretics

hypocalcemia serum level

• serum Ca+2: <9 mg/dL

• start seeing effects when less than 7 mg/dL

patients at risk for hypocalcemia

• inadequate Ca+2 intake

• inadequate absorption

  • ETOH → ethanol alcohol

  • vitamin D deficiency → not absorbing Ca+2

• Ca+2 excretion

  • diuretics

  • anticonvulsants

  • calcitonin

  • laxatives

• other

  • increased dietary phosphate

  • decreased PTH

  • calcium deposits in bone, tissue

  • blood transfusions

memory trick for patients at risk of hypocalcemia

• DAILY PIC CAD

• diuretics

• alcohol

• inadequate intake/absorption

• laxatives

• yielded photphate increase

• pth decreased

• iv blood transfusions

• calcitonin

• calcium depots in bone/tissue

• anticonvulsants

• vitamin D deficiency

hypocalcemia assessment → mild to moderate

• NEURO SYMPTOMS: CATT (mild to moderate) HILLS (severe)

  • Confusion

  • Anxiety

  • Tremors & palpitations

    • Tingling & numbness in hands, toes, and lips

• CV

  • palpitations

• Miscellaneous

  • muscle cramping

  • fatigue

  • weakness

  • brittle nails, hair loss

hypocalcemia assessment → severe

• NEURO SYMPTOMS: CATT (mild to moderate) HILLS (severe)

  • Hyperreflexia → big DTR reaction reflex

  • Irritability

  • LOC changes → delirium, non-responsiveness

  • Laryngospasm & stridor

    • not enough Ca+2 can cause muscle excitability

    • bad if have spasm in larynx bc can close airway and cause stridor

  • Seizures & tetany

    • overexcitability → missing calm component

  
  

  • CV

    • impaired clotting

    • hypotension

    • ECG changes

      • vtach, vfib

      • prolonged QT interval

      • *treat EKG changes with calcium gluconate..give calcium to lower threshold for cardiac arrhythmias

hypocalcemia assessment: mild to severe

• chvostek’s sign

  • muscular contraction/twitching on the face

• trousseau’s sign

  • arm curls in when BP cuff placed on

hypocalcemia: interventions

• administer

  • Ca+2 supplements

    • PO: 1-1.5 hours after meals

    • IV: calcium gluconate

  • meds

    • vitamin D w/dietary Ca+2

    • phosphate binders: lower phosphate levels, increase Ca+2 due to inverse relationship

    • pain management

• monitor

  • breathing

  • bone fx

  • chvostek and trousseau signs

  • labs

  • ECG

• other

  • safety: seizure precautions, fall precuations, reorient if changes in LOC, lift/draw sheet

• educate

  • decreased risk of osteoporosis: Ca+2, vitamin D, exercise (esp if weight bearing)

phosphate normal serum levels

• serum phosphate: 3 - 4.5 mg/dL

phosphate functions

• bone and teeth formation

• essential to tissue oxygenation (RBCs)

• cellular metabolism (ATP)

• DNA and RNA synthesis

• acid-base balance

• Ca+2 regulation → inverse relationship

• cell membrane structure

• **influenced by PTH due to inverse relationship with Ca+2

• phosphate is regulated by the kidneys → excreted by kidneys

phosphate dietary intake

• most of the phosphate in our body comes from our diet

• higher in phosphate

  • dairy products

  • meat and poultry

  • fish

  • lentils

  • split peas

  • chickpeas

  • almonds

  • sunflower seeds

  • whole wheat bread

  • brown rice

  • bran cereals

  • carbonated beverages (containing phosphoric acid)

• lower in phosphate

  • fruits

  • vegetables

  • grains

  • starches

  • white bread

  • white rice

  • eggs

  • pasta

hyperphosphatemia serum level

• serum level: > 4.5 mg/dL

hyperphosphatemia: patients at risk

• increased intake

  • vitamin D intoxication

  • phosphate laxatives or enemas

• production or release (cell damage)

  • hemolysis

  • rhabdomyolysis

  • tumor lysis syndrome

  • sickle cell, hemolytic anemia

  • hemolysis

• reduced loss

  • renal insufficiency

  • hypoparathyroidism → less Ca+2 → more phosphate

  • thyrotoxicosis

hyperphosphatemia assessment

• typically patients experience effects of hypocalcemia → bc inverse relationship w phosphate

• neuro

  • tetany

  • faster nerve transmission

• GI

  • abdominal cramping

  • diarrhea

  • nausea

• CV

  • increased HR (prolonged QT interval)

• other

  • decreased serum Ca+2

  • calcium deposits in skin, soft tissues, corneas, kidneys (longer-term consequence)

hyperphosphatemia interventions

• prevention

• identify and treat the cause (usually renal)

• restrict phosphate-containing foods (stop diary)

• IV fluids (to dilute) + diuretics to increase renal excretion

  • isotonic fluids → don’t wanna change serum osmolality → hydrate body and get rid of excess electrolytes

• adminster phosphate-binding agents (sevelemer, Phos-Lo) → give with meals

  • bind to phosphate → less phosphate in the blood

• hemodialysis may be necessary → if kidney’s aren’t functioning

hypophosphatemia serum level

• serum phosphate < 3 mg/dL

hypophosphatemia: patients at risk

• dietary

  • malnutrition

    • malabsorption of vitamin D

    • parenteral nutrition

    • chronic ETOH related to decreased dietary intake, diuresis

• GI

  • vomiting

  • anorexia

  • chronic diarrhea

  • gastric suction

• hormones

  • hyper-parathyroidism

    • more Ca+2 → loss phosphate

• other

  • phosphate-binding antacids

  • diuretics

  • respiratory alkalosis

hypophosphatemia: assessment

• symptoms usually only present when severe

• symptoms are related to impaired cellular energy and O2 delivery

• neuro

  • CNS dysfunction

  • confusion

  • coma

• GU

  • renal wasting of Mg, Ca, and HCO3-

• CV

  • arryhthmias

  • decreased stroke volume

• MS

  • muscle fatigue → includes respiratory muscles

  • weakness

  • osteomalacia (softening of bones)

  • rhabdomyolysis

• other

  • increased serum Ca+2

  • decreased tissue oxygenation

hypophosphatemia: interventions

• identify underlying cause

• phosphate supplementation

  • moderate - severe deficiency (<1 ng/dL) can be fatal

  • identify at-risk patients

  • oral or IV phosphate (no faster than 10 mEq/hr)

    • don’t give IV too quick → usually over 4 hours

  • monitor labs, vitals, ECG

magnesium normal serum level

• serum magnesium: 1.3 - 2.1 mEq/dL

functions of magnesium

• important cofactor in hundreds of enzyme systems

  • protein synthesis

  • blood glucose control

  • blood pressure regulation

• strengthens bones and teeth

• helps with transport of Ca+ and K+ across cell membrane

  • nerve impulses

  • muscle contractions

  • cardiac rhythm

magnesium: dietary intake

• higher in Mg+2

  • dark chocolate

  • avocados

  • nuts

  • seeds

  • legumes

  • tofu

  • whole grains

  • fatty fish

  • bananas

  • leafy greens

• lower in Mg+2

  • dairy products

  • spices/herbs

  • baby foods

  • fats/oils

  • poultry products

  • soups, sauces, gravies

  • sausages/luncheon meats

hypercalcemia serum level

• serum magnesium: > 2.1 mEq/dL

hypermagnesia: patients at risk

• excessive magnesium intake

  • laxatives/cathartics, antacids

  • IV magnesium (Tx of eclampsia) → used to treat seizures

• metabolic disorders (shifts from ICF to ECF, impaired excretion)

  • kidney dysfunction

  • adrenal insufficiency

  • hypothyroidism

  • metastatic bone disease

  • tumor lysis syndrome

hypermagnesemia: assessment

• magnesium is calming and depressing → worried abt their resp. system

• CNS

  • headache

  • dizziness

  • drowsiness

  • confusion

  • respiratory depression

• GI

  • nausea/vomiting

  • constipation

  • ileus

• MSK

  • weakness

  • loss of DTRs

  • paralysis

• GU

  • urinary retention

• CV

  • vasodilation

  • facial flushing

  • hypotension

  • bradycardia

  • AV block

  • asystole

hypermagnesemia: interventions

• hold Mg+2-containing products/food

• calcium chloride/calcium gluconate IV for acute cardiac symptoms

  • gonna help protect and calm the heart

  • helps lower threshold for arrhythmias

• move it out of the body

  • IV hydration + diuretics

• monitor

  • VS

  • LOC

  • DTRs

hypomagnesemia serum level

• serum magnesium <1.3 mEq/dL

hypomagnesemia: patients at risk

• dietary

  • decreased diet intake

  • prolonged fasting/stavation

  • chronic ETOH → not absorbing magnesium

  • malabsorption syndromes → sometimes w gastric bypasses

• GI fluid loss

  • vomiting

  • diarrhea

  • NG suctioning

• other

  • pancreatitis

  • poorly controlled DM

  • PPI therapy → heartburn treatment

  • diuretics or other causes of excessive loss from urinary tract

hypomagnesemia: assessment

• neuro

  • tremors

  • tetany

  • hyperreflexia

  • paresthesia

  • seizures

  • postitive babinski reflex

  • personality changes with agitation, depression, confusion, hallucinations

• CV

  • ECG changes

    • arrythmias

    • TORSADES DE POINTES (deadly)

      • tornado in the heart

      • nonperfusable rhythm → shocking and decompressions don’t help

hypomagnesemia: interventions

• replacement

  • mild

    • dietary changes: whole grains, nuts, legumes, magnesium salts, etc

  • severe

    • MgSO4 IM or slow IVPB → 1 mg/hr

• monitor

  • LOC

  • Mg+ levels during replacement

  • VS

  • swallow/gag reflex

    • contents can go in lungs instead of stomach → aspiration pneumonia

    • common problem for elderly adults

    • can result in pneumonia and respiratory distress

  • DTRs

  • seizure precautions