Electrolytes and Fluid Balance

Loop Diuretics

• Before administering loop diuretics, check the patient's electrolyte levels, particularly potassium.

Diuretics

• Osmotic diuretics are distinct from other types.

• Potassium sparing diuretics.

• For overhydration, expect an order for osmotic diuretics.

Arterial Oxygen Level

• Normal arterial oxygen level: 80 {to} 100. Not 95 to 100.

Normal pH

• Normal pH: 7.35 {to} 7.45. 7.5 is incorrect

Hyponatremia

• Hyponatremia (low sodium) typically leads to low blood pressure.

• Losing sodium results in a loss of pressure.

Calcitonin

• Administering calcitonin lowers calcium levels in the body.

• Calcitonin tones down calcium.

Electrolytes

• Normal sodium level: 135 {to} 145 milliequivalents per liter (mEq/L).

• Normal chloride level: 98 {to} 108 mEq/L.

• Normal potassium level: 3.5 {to} 5 mEq/L.

• Normal calcium level: 8.5 {to} 10.5 milligrams per deciliter (mg/dL).

• Normal magnesium level: 1.5 {to} 2.5 mEq/L.

• Normal phosphorus level: 2.5 {to} 4.5 mg/dL.

• Electrolyte values can vary slightly based on laboratory and equipment calibration.

• Potassium may range from 3.7 {to} 5.2.

• Sodium may range from 136 {to} 147.

Electrolyte Relationships

• Sodium and chloride are closely linked; they often move together in the body.

• Calcium and magnesium tend to follow each other; when one level goes up, the other often does too.

• Calcium and phosphorus are complete enemies; administering one can drive the other level down.

• In renal patients with high phosphorus levels, calcium is administered to lower phosphorus.

Sodium

• Normal sodium: 135 {to} 145. Regulated by ADH and aldosterone.

• Low sodium: Cause ADH to be released to hold in water.

• Aldosterone: Raises sodium levels by causing sodium and water retention.

• Sodium's primary purpose: Osmotic balance of fluid, nerve transmission and muscle contraction.

• Low sodium symptoms: Weakness, cramping, seizure activity from nerve and muscle issues.

• Low sodium's most prominent effect: Water moves into interstitial and cells (especially brain cells) leading to cerebral edema.

• Hyponatremia: Causes hypovolemia because water leaves circulation.

• Symptoms of hyponatremia: Hypovolemia, increased heart rate and respiratory rate.

Hyponatremia vs Overhydration

• Actual hyponatremia: Sodium deficit. Requires water restriction and sodium administration.

• Seizure precautions: Padded side rails, suction setup, pillows, quiet environment, dim lights.

Hypernatremia

• Hypernatremia: Too many particles in circulation leading to water leaving cells and interstitial, causing dehydration and hypervolemia.

• Major issue in hypernatremia: Hypervolemia

• Symptoms: Increased heart rate, blood pressure, respiratory rate, agitation, and confusion.

• Treatment: Sodium restriction, fluid restriction, diuretics (possibly loop).

Chloride

• Normal chloride level: 98 {to} 108 mEq/L.

• Chloride: Works with sodium; think of it as sodium.

Potassium

• Normal potassium: 3.5 {to} 5 mEq/L (narrow range).

• Regulated in the kidneys: By exchange for sodium and secretion of aldosterone.

• Primary function: Electricity for body systems.

• Low potassium: Not enough electricity.

• High potassium: Too much electricity.

• GI secretions: High in potassium, so GI disturbances can lower potassium levels.

• Potassium movement into cells: Influenced by insulin, adrenal steroids, and alkalosis (lowers levels).

• Potassium movement out of cells: Tissue damage (burns) or acidosis (raises levels).

• Excretion: Primarily through the kidneys.

• Hypokalemia: Potassium level below 3.5.

• Causes: Potassium-wasting diuretics, excessive laxative use, vomiting, diarrhea, nasogastric suctioning, inadequate intake, starvation, alcoholism.

• Kidneys: The way to rid of potassium.

• Potassium: Not stored and deadly if given straight because it stops the heart.

Hypokalemia Symptoms

• Confusion, lethargy, diminished level of consciousness.

• Hypoactive bowel sounds, constipation.

• Decreased respiratory rate.

• Diminished reflexes.

• Dysrhythmias.

• Treatment: Increase potassium in diet and administer potassium.

• Oral potassium: Can cause GI upset.

• IV potassium: Must be dilute and given in a large vein to avoid caustic effects.

• Monitor: Heart for arrhythmias and treat constipation if present.

Hyperkalemia

• Hyperkalemia: Level above 5.0.

• Causes: Renal failure (most common), rapid IV administration, salt substitutes.

• High because: Potassium left the cell.

• Infections, burns, diabetic ketoacidosis are examples of high potassium.

Hyperkalemia Symptoms

• Irritability, agitation, anger.

• Dysrhythmias, potential cardiac arrest.

• Diarrhea, hyperactive bowel sounds, abdominal cramping.

• Hyperactive reflexes.

• Increased respiratory rate.

• Treatment: Diuretics (loop), drugs to excrete potassium through GI system (Kayexalate, Veltassa, Lokelma) and calcium or sodium zirconium cyclosilicate bind and pull the potassium out.

• Insulin: Administered to move potassium into the cell (give with glucose).

• Monitor: GI system and keep patient calm.

Calcium

• Normal calcium: 8.5 {to} 10.5 mg/dL.

• Functions: Bone formation, nerve impulse transmission, muscle contraction, blood coagulation, vitamin B12 absorption.

• Calcitonin: Tones it down.

• Impacted by: Calcitonin and parathyroid hormone.

Hypocalcemia

• Hypocalcemia: Below 8.5.

• Association: With low magnesium.

• Severe depletion: Causes tetany (tonic spasm), a precursor to seizures.

• Hypocalcemia symptom: Neuromuscular irritability: Irritated nerves and muscles common with alcohol abuse, vitamin D deficiency.

• Neuromuscular irritability and potential for tetany progression to seizure activity. There are signs that indicate neuromuscular irritability and signal a higher risk for seizures soon.

• Schvostek's sign: Twitching of the face when tapping the facial nerve.

• Trousseau's sign: Carpal spasm when inflating a blood pressure cuff.

• Calcium Symptoms: Heart rate and blood pressure to drop. Fractures. Diarrhea.

• Treatment: Calcium chloride, calcium gluconate, calcium carbonate orally or IV; vitamin D; restrict phosphorus.

Hypercalcemia

• Hypercalcemia: Above 10.5.

• Cause for leave from the bone: bone cancer and Paget's disease.

• Sign and symptoms: High Heart rate and blood pressure.

• Kidney stones, constipation due to calcium clumping.

• Treatment: Weight bearing activities, calcitonin, diuretics, increased fluid intake with acid ash fluids (cranberry and prune juice), and restrict calcium.

Magnesium

• Normal magnesium: 1.5 {to} 2.5 mEq/L.

• Necessary for: Neuromuscular activity, activation of insulin and enzyme systems, regulated by calcitonin and parathyroid hormone.

• Hypomagnesemia: Below 1.5.

• Causes: Excess loss from GI tract, diuretics, chronic alcoholism, and lack of intake.

• Symptom: Neuromuscular irritability, increased heart rate and blood pressure, and constipation.

• Treatment: Administer magnesium orally or IV (magnesium sulfate).

Hypermagnesemia

• Hypermagnesemia: Above 2.5.

• Causes: Renal failure, adrenal insufficiency, treatment with magnesium during pregnancy.

• Two conditions during pregnancy are treated with magnesium even though magnesium is not low. Preterm labor which slows down contractions and pregnancy induced hypertension because it lowers blood pressure and prevents seizure activity.

• Symptoms: Low heart rate and blood pressure, hypoactive reflexes, sleepiness and drowsiness.

• Treatment: Loop diuretics, fall precautions, and close monitoring.