Med-Surge Objective 5 Lecture 2 Electrolytes and Protein Imbalances in Nursing

Solutes

Non-liquid substances present and transported within the fluids (ECF, ICF) in our bodies.

Common solutes

Glucose, Protein (amino acids), Oxygen, Carbon dioxide, Antibodies, blood cells, Clotting factors, chemicals, salt, potassium, waste products (urea and creatinine).

Electrolytes

Minerals that are dissolved in our body fluids and have an electrical charge.

Cations

Electrolytes with a positive charge.

Anions

Electrolytes with a negative charge.

Chloride (Cl-)

An anion that is one of the electrolytes.

Bicarbonate (HCO3-)

An anion that is one of the electrolytes.

Phosphate (P04-)

An anion that is one of the electrolytes.

Sulfate (SO4-)

An anion that is one of the electrolytes.

Sodium (Na+)

A cation that is one of the electrolytes.

Potassium (K+)

A cation that is one of the electrolytes.

Calcium (Ca++)

A cation that is one of the electrolytes.

Magnesium (Mg++)

A cation that is one of the electrolytes.

Hydrogen ions (H+)

A cation that is one of the electrolytes.

Electrolyte functions

Regulate water distribution, nerve impulse transmission, muscle contraction, regulate enzyme reactions (ATP), regulate acid-base balance, blood clotting.

Nerve impulse transmission

The process that allows nerves to send messages.

Muscle contraction

The process influenced by electrolytes that allows muscles to contract and relax.

Blood pressure regulation

The control of blood pressure influenced by electrolytes.

Gland function

The proper functioning of glands influenced by electrolytes.

Practical nurse responsibilities

Knowledge of normal electrolyte concentrations, effects of imbalances, conveying results to PHCP, implementing PHCP orders for electrolyte monitoring.

Common electrolytes

Sodium, Potassium, Calcium, Phosphate, Magnesium.

Electrolyte concentrations

Differ in each of the fluid compartments; ICF has K+ as the most common cation and phosphate as the most common anion, while ECF has Na+ as the most common cation and chloride as the most common anion.

Blood samples

Obtained from the intravascular space and measured for various components.

Serum levels

Many blood work/lab values are serum levels, not whole blood levels.

Measurement of solutes

More solutes in fluid space means more concentrated; less solutes means less concentrated.

Units of measurement

Different units of measurement include mmol/L (Canada) and meq/dL (American).

Sodium (Na+)

Most abundant electrolyte in ECF, serum level 135-145 mmol/L, regulates volume of body fluids.

Hypernatremia

Condition characterized by serum level > 145 mmol/L caused by too much sodium or too little water.

Hyponatremia

Condition characterized by serum level <135 mmol/L caused by too much water or too little Na+.

Symptoms of Hyponatremia

Includes abdominal cramps, confusion, nausea/vomiting, headache, pitting edema, muscle weakness, and seizures.

Treatment of Hyponatremia

Includes diuretics, anti-emetics, dietary sodium consumption, and IV therapy with sodium chloride.

Symptoms of Hypernatremia

Includes intense thirst, dry mucous membranes, oliguria, confusion, agitation, and seizures.

Treatment of Hypernatremia

Encourages oral fluid intake, IV therapy, and avoiding overly rapid correction to prevent cerebral edema.

Nursing interventions for Na imbalances

Includes monitoring changes in level of consciousness, vital signs, intake and output, and serum sodium levels.

Potassium (K+)

Major cation in ICF with a serum level of 3.5-5.0 mmol/L, needed for nerve impulse and muscle fiber transmission.

Kidneys and Potassium

Kidneys eliminate 90% of K+; impaired renal function may lead to toxic levels being retained.

Foods high in sodium

Includes cured meats, pickled foods, canned soups, sausages, processed meats, and salad dressings.

Causes of Hyponatremia

Can be caused by profuse diaphoresis, excessive water ingestion, diuresis, Addison's disease, and certain medications.

Causes of Hypernatremia

Can be caused by profuse watery diarrhea, excessive salt intake, high fever, and severe burns.

S/S of Hypernatremia

Includes increased blood pressure, rough dry tongue, weight gain, and pulmonary edema.

Prevention of Hypernatremia

Involves monitoring client's diet and fluid consumption.

Hyperkalemia

too much potassium

Hypokalemia

too little potassium

Foods high in potassium

oranges, bananas, melons, tomato's, raisins, deep green and yellow vegetables

Hyperkalemia Serum level

Serum level >5 mmol/L

Causes of Hyperkalemia

Excessive potassium intake - IV fluids, potassium containing drugs, salt substitutes; Certain illnesses that cause a shift of potassium out of cells: acidosis, fever, blood infection (sepsis), crush injury's, tumor lysis syndrome, burns; Failure to eliminate - renal disease, potassium-sparing diuretics

Signs/Symptoms of Hyperkalemia

Muscle weakness particularly with lower extremities, cardiac changes - irregular pulse, cardiac arrest is extremely high, nausea/vomiting, abdominal cramps, diarrhea, numbness and tingling in fingers, face, tongue, irritability, anxiety

Hypokalemia Serum level

Serum level < 3.5 mmol/L

Causes of Hypokalemia

Nutritional deficit: Inadequate intake, alcoholism; Medications side effects: diuretics/corticosteroids; Illness processes: excessive vomiting & diarrhea

Signs/Symptoms of Hypokalemia

fatigue, weakness, nausea and vomiting, soft flabby muscles, weak irregular pulse, cardiac arrhythmias, polyuria, hyperglycemia, leg cramps, muscle weakness, and paresthesias, low blood pressure, death

Nursing Interventions for K+ Imbalances

Implementing orders from PCHP which treat the cause; Monitor for changes in pulse regularity, client reports palpitations, ECG changes will occur with both imbalances; Monitor and report VS, I & O, and serum potassium level, urine sample for testing, ensure adequate urinary output (0.5 ml/kg/hr); Alter nutritional sources of potassium to correct balance until resolved

Increasing oral sources of potassium

Increasing oral sources of potassium (bananas) until resolved

Eliminate oral sources of potassium

Eliminate oral sources of potassium (bananas) until resolved

Administer potassium supplements

Administer potassium supplements: oral or IV

IV solutions potassium limit

IV solutions should not exceed 60 mmol/L preferred

Severe cases potassium treatment

administer kayexelate, insulin infusion, or hemodialysis (Client very unstable- not signed to LPN)

Calcium CA++ Serum level

Serum level 1.15-1.35 mmol/l (Total non-ionized calcium: 2.1- 2.5 mmol/L)

Calcium in the body

Calcium is bound to proteins in the body (albumin), most of calcium (99%) is found in your bones/teeth

Functions of Calcium

Needed for nerve transmission, vitamin B12 absorption, muscle contraction & blood clotting

Regulation of Calcium levels

The level of calcium in the blood is regulated by the parathyroid hormone (PTH). When PTH excreted, calcium levels in body increase. Thyroid releases calcitonin (hormone) to decrease excess calcium.

Vitamin D

Needed for Ca absorption.

Inverse relationship with Phosphorus (PO4-)

Calcium and phosphorus levels affect each other inversely.

Hypercalcemia

Too much calcium in the blood.

Hypocalcemia

Too little calcium in the blood.

Hypercalcemia Serum Level

Serum level > 1.35 mmol/L; total Calcium > 2.5 mmol/L.

Causes of Hypercalcemia

Includes hyperparathyroidism (2/3), cancer (1/3), vitamin D overdose, and thiazide diuretics.

S/S of Hypercalcemia

Deep bone pain, pathological fractures, kidney stone formation, muscle weakness, decreased reflexes, anorexia, N/V, polyuria, dehydration, and mental changes.

Hypocalcemia Serum Level

Serum level is < 1.15 mmol/L (total calcium < 2.1 mmol/L).

Causes of Hypocalcemia

Includes low oral intake, loop diuretics, and parathyroid disorders.

S/S of Hypocalcemia

Fatigue, EKG changes, cardiac arrhythmias, numbness/tingling, laryngeal spasms, muscle cramps/tetany, seizures, depression, anxiety, and confusion.

Nursing Interventions for Calcium Imbalances

Implement orders from PCHP, modify calcium intake, monitor changes in muscle, nerve sensation, bleeding, and mental status.

Hypercalcemia Nursing Interventions

Reduce nutritional intake of Ca and increase fluid intake.

Hypocalcemia Nursing Interventions

Increase nutritional intake of Ca and implement safety precautions.

Phosphate (PO4-)

Serum level 1.0-1.5 mmol/L; primary anion in ICF.

Hyperphosphatemia

Too much phosphate in the blood; serum level > 1.5 mmol/L.

Causes of Hyperphosphatemia

Includes excessive ingestion of phosphorus foods, phosphate-containing laxatives, and diseases like DKA.

S/S of Hyperphosphatemia

Muscle problems, tetany, rhabdomyolysis, and possible skin crystals causing itching.

Hypophosphatemia

Too little phosphate in the blood; serum level < 1.0 mmol/L.

Causes of Hypophosphatemia

Includes malnourishment, aluminum-containing antacids, and illnesses like burns and DKA.

S/S of Hypophosphatemia

Weak bones leading to pain and fractures, fatigue, and anorexia.

Hyperphosphatemia

Decrease oral sources of phosphorus or administer prescribed supplement to decrease absorption.

Hypophosphatemia

Increasing oral sources of phosphorus (drinking low-fat or skim milk) if mild, or prescribed supplement (may cause diarrhea).

Nursing interventions for PO4 imbalances

Implementing orders from PCHP which treat the cause, modifying oral sources of phosphate until resolved absorption, and monitoring for changes in muscle tone, notifying PHCP of changes, VS, I & O, and serum phosphate levels.

Magnesium (Mg+)

Helps to maintain normal nerve and muscle function, supports a healthy immune system, keeps the heart beat steady, helps bones remain strong, helps to regulate blood glucose levels, and aids in the production of energy and protein.

Serum magnesium level

0.65-1.05 mmol/L.

Hypermagnesemia

Serum levels > 1.05 mmol/L; causes include clients with kidney failure given magnesium salts or taking drugs that contain magnesium.

Symptoms of Hypermagnesemia

Lethargy, drowsiness, N/V, deep tendon reflexes are lost, somnolence, respiratory and cardiac arrest.

Hypomagnesemia

Serum levels < 0.65 mmol/L; causes include high levels of certain hormones, diabetes, malabsorption, impaired GI absorption caused by diarrhea, vomiting, nasogastric suction, and decreased intake due to malnutrition or chronic alcohol use.

Symptoms of Hypomagnesemia

N/V, sleepiness, weakness, personality changes, muscle spasms, cardiac arrhythmias, tremors, and loss of appetite. If severe, hypomagnesemia can cause seizures, especially in children.

Foods high in magnesium

Green vegetables, nuts, bananas, peanut butter, and chocolate.

Magnesium excretion

Excreted by kidneys.

Majority of magnesium in the body

Uncharged and bound to proteins or stored in bone; very little magnesium circulates in the blood.

Concentration camps example

Irregular heart rhythm and even death due to acute (sudden) drops.

Client education for phosphorus

Education on food high in phosphorus.

Muscle tone monitoring

Monitor for changes in muscle tone and notify PHCP of changes.

Serum phosphate levels monitoring

Monitor serum phosphate levels as part of nursing interventions.

Vitamin D role

Helps in the absorption of phosphorus.

Kidney failure and magnesium

Clients with kidney failure may have increased magnesium levels due to magnesium salts or drugs.

Symptoms of magnesium deficiency

Muscle spasms, tremors, and cardiac arrhythmias.

Severe hypomagnesemia consequences

Can cause seizures, especially in children.