ELECTROLYTE

IMBALANCES
 SODIUM (Na+)
135 – 145 mEq/L
most prevalent cat ion in ECF
controls osmotic pressure
transmits nerve impulses
aids in maintenance of acid-base
Balance
necessary for glucose to be transported
into cells
maintained via regulation of water
intake and excretion.
 HYPONATREMIA

 sodium deficit resulting from either a

sodium loss or water excess
 serum-sodium level below 135 mEq/L
 Neurologic symptoms usually does not
occur until below 120 mEq/L or unless
there’s rapid drop in serum sodium level.
 Permanent neurologic damage occurs
when plasma sodium level is less than 115
mEq/L.
CAUSES

Sodium deficit resulting from either a

sodium loss or water excess
Excessive diaphoresis,diuretics,vomiting,
diarrhea, GI wound drainage, renal disease,
decreased secretion of aldosterone.
Inadequate sodium intake:
Dilution of Serum Na:
Excessive admin of hypotonic IVF,
excessively dilute enteral feeding, renal
failure, SIADH.
ASSESSMENT

Cardiovascular: Neuromascular: Gastrointestinal:

*Normovolemic: * ⇩ DTR, skeletal * Increased
rapid pulse rate; ms. weakness motility, hyperactive
Normal BP Renal: bowel sounds,
*Hypovolemic: * Decreased urine abdominal
Thready, weak, spec. grav, increase cramping, diarrhea
rapid, pulse; flat UO.
neck veins, Normal
to low CVP
*Hypervervolemic;
Respiratory:
rapid bounding
* Shallow
pulse, BP normal to
Ineffective
elevated. CVP:
respiration related
Normal to elevated
to skeletal ms.
weakness
NURSING CARE PLAN
GOAL: obtain normal sodium level
prevent further sodium loss
prevent injury
INTERVENTIONS:
 Increase oral intake
 Replacement of sodium and fluid losses
 Replacement of other electrolytes
 IV hypertonic saline
 Removal of underlying cause
 Diuretics
 Water restriction.
 Sodium Values of Common Foods
Food Source Amount (mg)
Table salt (1tsp) 2000
Soy sauce (1 tbsp) 1029
Pork, cured (4oz) 850
Cheddar cheese (1oz) 176
Ketchup (1 tbsp) 156
Skim milk (8oz) 126
White bread ( 1 slice) 123
Butter (1tsp) 123
Whole milk (8oz0 120
Chicken, light meat (4oz) 70
Chicken, dark meat (4oz) 70
Beef, lean (4oz) 60
Pork, lean fresh (4oz) 60
 HYPERNATREMIA

 excess sodium in the blood, resulting from

either high sodium intake, water loss, or
low water intake
 *Hypernatremia causes hypertonicity
which may cause shift of water out of the
cells causing cellular dehydration and
increased ECF volume.
CAUSES
 High sodium intake:
 Excessive oral sodium or admin of Na containing
IVF.
 Low water intake; NPO
 Increased water loss; Increased Metabolic Rate,
fever, hyperventilation, infection, excessive
diaphoresis, DI, diarrhea
 Decreased sodium excretion: use of
corticosteroids, cushing syndrome, RF,
hyperaldosteronism
 ASSESSMENT:
CARDIOVASCULAR: NEUROMASCULAR: CNS:
*HR and BP responds *Early; Spontaneous *Altered cerebral fxn is
to vascular volume ms. Twitches; Irreg. the most common
status ms. Contaction manifestation.
Late: Skeletal ms. Normovolemia or
Weakness; ⇩DTR hypovolemia:
RENAL: INTEGUMENTARY: Agitation,
*Inc. Urine spec. grav *Dry skin confusion, seizures
Decreased UO Presence or absence Hypervolemia: Stupor,
of edema lethargy, coma
depending on fluid
volume changes.
NURSING CARE PLAN
INTERVENTIONS:
1.Monitor CV, Resp, NM, cerebral, renal and
integumentary status of patient.
2. Decreased oral intake
3. Diuretics, IV or water replacement
( Sodium correction is corrected slowly over
approximately 2 days to avoid great shift of fluid
into brain cells)
4. promote safety to patient
 POTASSIUM (K+)
3.5 – 5.0 mEq/L
 Has a direct effect on excitability of nerves
and muscles. Along with Ca, Mg, controls
rate and force of contraction of the heart
thus the CO.
 contributes to intracellular osmotic
pressure and influences acid-base balance.
 major cat ion of the cell
 required for storage of nitrogen as muscle
protein.
 HYPOKALEMIA

 Deficit is related to dehydration, starvation,

vomiting, diarrhea, diuretics.
 Symptoms may not occur until below 2.5
mEq/L
 Potentially life threatening because every
body system is affected.
CAUSES

 Reduction in total body potassium

 -Excessive use of diuretics, corticosteroids, ⇧secretion
of aldosterone, vomiting, diarrhea, wound drainage,
burn, NGT suctioning, excessive diaphoresis renal
disease.
 Inadequate K intake
 STRESS
 Shift of potassium from ECF to ICF
 Alkalosis, Hyperinsulinism
 Dilution of of serum potassium
 Water intoxication, IV therapy with potassium poor
solution
ASSESSMENT
CARDIOVASCULAR: NEUROMASCULAR: GI:
*Thready, weak, *Anxiety, lethargy, Decreased motility,
irregular pulse, confusion, coma, hypoactive or
Orthostatic skeletal ms. absent bowel
hypotension, ECG Weakness, eventual sounds.
Changes; ST flaccid paralysis. NV, constipation,
depression, shallow Loss of tactile abdominal
flat or inv. T wave discrimination, distention, paralytic
and prominent U hyporeflexa ileus.
wave
RESPIRATORY: RENAL:
*Shallow ineffective ⇩ Urine spec grav
respiration 2 to ⇧UO
profound weakness
of skeletal ms,
diminished breath
sounds.
Prominent U waves after T waves in hypokalemia
NURSING CARE PLAN
INTERVENTIONS:

 Monitor CV, NM, Resp, GI,Renal status and

place in cardiac monitor.
 Monitor Electrolyte Values
 increase potassium in diet
 liquid PO potassium medications
> dilute in juice to aid taste
> give only if kidneys functioning
 prevent infiltration, pain, tissue damage
 prevent potassium loss
- irrigate NGTs with saline, not water
PRECAUTIONS for IVF administered
potassium

•Potassium is never given by IV push, IM

or SQ route.
•In adding K in a IV solution, rotate,
invert the bag. It should be properly
labeled.
•Max infusion rate 5-10 mEq/hr.
•Should be placed on cardiac monitor
•Check IV site.
•Assess renal function before
administration of potassium correction.
Potassium Values of Common Foods
Food source Amount (mg)
Avocado (1 medium) 1097
Raisins (1/2 c) 700
Pork, fresh (4oz) 525
Cantaloupe (1c pieces) 494
Beef (40z) 480
Banana (1 medium) 451
Potato, white (1 medium) 407
Skim milk (8oz) 406
Tuna fish (4oz) 375
Whole milk (8oz) 370
Tomato (1 medium) 366
Carrot (1 large) 341
Cauliflower (1c pieces) 295
Beef liver (3 1/2oz) 281
 HYPERKALEMIA
CAUSES:
 Excessive K intake
 Overingestion of K containing foods or medications
such as KCl or salt substitutes, rapid infusion of K
containing IV solutions
 Decreased K excretion
 K sparing diuretics, RF, Adrenal insufficiency such as
Addison’s dse.
 Movement from ICF to ECF
 Tissue damage, acidosis, hypercatabolism.
ASSESSMENT
CARDIOVASCULAR:
*Slow, irregular HR, ⇩BP, ECG
changes: Tall peaked T waves,
widened QRS conplexes,
prolonged PR interval
RESPIRATORY:
*Profound weakness of skeletal
ms leading to respiratory failure.
NEUROMASCULAR:
*Early: Ms. Cramps, paresthesias
Late: Profound ms. Weakness,
ascending flaccid paralysis in the
arms and legs( trunk, head and
Resp ms. When K level reaches
lethal level.
GI:
Increased motility, hyperactive
bowel sounds. Diarrhea
NEUROLOGIC:
apathy, lethargy, fatigue,
weakness
irritability, mental confusion
Peaked T waves in hyperkalemia
Widened QRS complexes in a patient whose
serum potassium level was 7.8 mEq/L.
ECG of a patient with pretreatment potassium level of 7.8 mEq/L and
widened QRS complexes after receiving 1 ampule of calcium chloride.
Notice narrowing of QRS complexes and reduction of T waves.
NURSING CARE PLAN
INTERVENTIONS

•Monitor CV, Respi, NM, Renal, and GI status.

•Use Cardiac Monitor.
•Identify and treat cause of imbalance.
• Cat ion exchange resins (Use of Kayexalate)
•Give foods low in K+.
•Avoid drugs or IVFs containing K+
•Use of IV calcium gluconate, IV glucose with
Insulin, Serum bicarbonate.
•If kidney failure present, may need to prepare for
dialysis
•If with BT use fresh blood.
 CALCIUM (Ca2+)
4.5 – 5.5 mEq/L
 Needed for process:
 bone formation
 coagulation of blood (conversion of thrombin to
prothrombin)
 excitation of cardiac and skeletal muscle

 conduction of neuro muscular impulses.

 regulation of endocrine and exocrine glands

 Controlled by parathyroid hormone

 Reciprocal relationship between calcium and
phosphorus
 HYPOCALCEMIA

CAUSES

 Inhibition of Ca absorption from GIT

 Inadequate intake of Ca, Lactose intolerance,
malabsorption syndrome, inadequate intake of vit. D.
ESRD.
 Increased renal excretion
 RF, polyuric phase, diarrhea, wound drainage esp. GI
 Conditions that decrease ionized fraction of Ca
 Hyperproteinemia, hyperphosphatemia, immobility,
removal of parathyroid gland
ASSESSMENT
Cardiovascular: Neuromascular: Gastrointestinal:
⇩HR, Hypotension Irritable skeletal ms: * Increased motility,
Diminished twitches, cramps, hyperactive
peripheral pulses tetany, seizures bowel sounds,
ECG changes; Painful ms spasms in abdominal
Prolong ST interval, calf or foot cramping,
prolonged QT Paresthesias diarrhea
interval followede by Respiratory:
numbness that Not directly
affects lips, nose, affectedmay
ears cause respiratory
(+) Trosseau’s and arrest
Chvostek’s signs
Hyperactive DTR’s
Anxiety, Irritability
NURSING CARE PLAN
INTERVENTIONS
GOALS monitor patient status
prevent tetany
increase calcium intake
• Monitor patients CV, NM, respi, CNS status; place in
cardiac monitor.
•Administer Calcium supplements.
•Calcium gluconate IV, 2.5-5.0 ml 10% solution;
repeated q10min to maximum dose of 30ml. Administer
slowly to avoid infiltration. Warm injection sol’n to body
temperature.
•Monitor Calcium level
caution: drug interaction with carbonate, phosphate,
digitalis
 Administer meds that may increase Ca absorption; Al
hydroxide decrease phosphorous level which may cause
increase Ca level; Vit. D enhances absorption if Ca from
the GIT.
 Provide quite environment.
 Siezure precaution
 Move client carefully
 Instruct patient to consume foods high in Ca.
 Calcium Values of Common Foods

Food Source Amount (mg)

Yogurt, low-fat (1c) 415

Skim milk (8oz) 302
Whole milk (8oz) 288
Cheddar cheese 204
Tofu (3oz) 100
Broccoli, raw (1/2 c) 75
Green beans (1c) 62
Carrot (1 large) 37
 HYPERCALCEMIA
CAUSES

 Increased Ca absorption
 Excessive oral intake of Ca and Vit. D
 Decreased Ca excretion
 RF, Thiazide diuretics
 Increased bone resorption of Ca
 Hyperparathyroidism, Malignancy, Immobility,
use of glucosteroids
ASSESSMENT

Cardiovascular: Neuromascular: Gastrointestinal

⇧Increased heart Profound ms. :
rate in early Weakness, Decreased
phase, then Diminished or motility,
bradycardia⇨ absent DTR’s hypoactive bowel
CARDIAC ARREST Disorientation, sounds, abdominal
Increased lethargy, coma distention, NV,
bounding pulses Renal: anorexia,
ECG changes: ⇧UO, formation of constipation
Shortened ST renal calculi Respiratory:
segment, widened Ineffective resp.
T wave movement
NURSING CARE PLAN
GOALS
Monitor patient’s status
Prevent Injury
Reduce Ca Intake

 Monitor CV, Respi, Renal and GI status; place patient in cardiac

monitor
 DC IV infusions of sol’ns containing Ca and oral meds containing Ca
and Vit D
 DC of thiazide diuretics
 Administer that inhibit calcium resorption from bone, such as
calcitonin, phosphorous.
 Prepare for dialysis.
 Monitor for flank pain.
 Strain urine for urinary stones.
 Move client carefully to prevent fractures.
 MAGNESIUM (Mg2+)
1.5 – 2.5 mEq/L
 Used as index to determine metabolic activity
and renal function.
 Concentrated in the bone, cartilage and within
cell itself.
 Required for use of ATP.
 Necessary for Carbohydrate metabolism, protein
synthesis, nucleic acid synthesis, contraction of
muscular tissue.
 Regulates neuromuscular activity and clotting
mechanism.
 HYPOMAGNESEMIA

CAUSES
 deficit is related to;
 impaired absorption in the GI tract
 excess loss through kidneys

 prolonged periods of poor nutritional intake

 Intracellular movement
 Hyperglycemia
 Insulin administration

 Sepsis
ASSESSMENT

Cardiovascular: Neuromuscular: CNS:

ECG changes: Tall T Twitches, Irritability
waves, depressed paresthesias, (+) Confusion
ST segment Trousseau and Respiratory:
Tachycardia Chvostek’s sign Shallow respiration
Hypertension Hyperreflexia
Tetany
siezures
INTERVENTIONS

 Interventions aim is to restore normal

calcium level.
 Admin MgSO4
 Initiate seizure precautions.
 Monitor DTR, RR
 HYPERMAGNESEMIA

 excess is related to:

 renal insufficiency
 overdose during replacement therapy

 severe dehydration

 repeated enemas with Mg2+ sulfate (epsom

salts)
ASSESSMENT
Cardiovascular: Neuromuscular: CNS:
Bradycardia, dysrythmias Diminished DTR’s Drowsiness and
Hypotension Skeletal ms. lethargy which
ECG changes: Prolonged PR Weakness progress to coma
interval, widened QRS Respiratory:
complexes Respiratory
insufficiency when
skeletal ms are
involved.
INTERVENTIONS

 Monitor CV, Respi, NM, CNS status; place

in cardiac monitor.
 Diuretics
 IV admin of Calcium Chloride or Calcium
gluconate to reverse effect of Mg on
cardiac ms.
 Avoid use laxatives and antacids
containing Mg.
 PHOSPHOROUS
2.7- 4.5 mg/dl
 Needed for generation of bone tissue.
 Functions in metabolism of glucose and lipids.
 Important in bone formation, energy storage and
release, urinary acid base buffering.
 Absorbed from food and excreted by kidneys.
 High concentrations are stored in bone and
skeletal muscle.
 Has an inverse relationship with CALCIUM.
HYPOPHOSPHATEMIA
CAUSES
 Insufficient oral intake
 Increased excretion
 Hyperparathyroidism
 Malignancy

 Use of aluminum hydroxide or magnesium based

antacids
 Intracellular shifts
 Hyperglycemia

 Respiratory alkalosis
ASSESSMENT
Cardiovascular: CNS: Hematological:
Decreased Irritability, Decreased platelet
contractility and Confusion, Seizure aggregation and
CO. Neuromuscular: increased
Slowed peripheral Weakness, bleeding.
pulses. decreased DTR’s, Immunosuppressi
decreased bone on
density, Respiratory:
rhabdomyolysis Shallow
respiration
INTERVENTIONS

 Monitor CV, Respi, NM, p and hematological

status
 DC meds that contribute to hypophosphatemia.
 Prepare to administer phosphorous IV when
level falls below 1 and when client exhibits
critical clinical manifestations.
 Administer IV phosphorous slowly.
 Increase oral intake of foods high in
phosphorous.
 HYPERPHOSPHATEMIA

CAUSES
 Decreased renal excretion
 Tumor Lysis Syndrome
 Increase oral intake
 Hypoparathyroidism
INTERVENTIONS
 Interventions entail management of Ca.
 Administer phosphate binding medications
that increase excretion by binding
phosphorous from food in the GIT.
 Instruct patient to avoid phosphate
containing meds.
 Phosphate binding meds are taken with
meals or immediately after meals.
THANK YOU

SOURCES:comprehensivereviewnclexrn/annsilvestri/saunders/4th Ed
Manual of Critical Care/ Applying Nursing Diagnosis to Adult Illness/Swearingen and Keen/ 2nd Ed
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