Electrolyte Electrolyte ImbalancesImbalances

Part VIPart VI

Peggy D. JohndrowPeggy D. Johndrow

20092009

HypomagnesemiaHypomagnesemia

Causes includeCauses include Prolonged fasting or starvationProlonged fasting or starvation Chronic alcoholismChronic alcoholism Fluid lossFluid loss Prolonged parenteral nutrition without Prolonged parenteral nutrition without

supplementationsupplementation DiureticsDiuretics Osmotic diuretics from high glucose levelsOsmotic diuretics from high glucose levels

Hypomagnesemia Clinical Hypomagnesemia Clinical ManifestationsManifestations

Hyperactive deep tendon reflexesHyperactive deep tendon reflexes TremorsTremors Seizures Seizures Cardiac dysrhythmias Cardiac dysrhythmias ConfusionConfusion

Hypomagnesemia ManagementHypomagnesemia Management

Oral supplementsOral supplements Increase dietary intakeIncrease dietary intake Discontinue medication that promote Mg Discontinue medication that promote Mg

lossloss Mg++ antacids; may cause diarrheaMg++ antacids; may cause diarrhea Give calcium if hypocalcemiaGive calcium if hypocalcemia Severe: give Mg sulfate IV; give slowly, Severe: give Mg sulfate IV; give slowly,

monitor carefully (do not give IM)monitor carefully (do not give IM)

Nursing DiagnosesNursing Diagnoses

Risk for injury r/tRisk for injury r/t Risk for altered cardiac function r/tRisk for altered cardiac function r/t Imbalanced nutrition less than Imbalanced nutrition less than

requirements r/trequirements r/t Knowledge deficitKnowledge deficit

Nursing ActionsNursing Actions Monitor serum levelsMonitor serum levels Administer Oral MgAdminister Oral Mg Nutrition therapy: foods high in Mg (green Nutrition therapy: foods high in Mg (green

vegetables, nuts, peanut butter, chocolate, vegetables, nuts, peanut butter, chocolate, grapefruit, orange juicegrapefruit, orange juice

Monitor closely if give IV MgSO4 if severeMonitor closely if give IV MgSO4 if severe May administer Ca gluconate for tetanyMay administer Ca gluconate for tetany Monitor respiratory status, V/S, HR, ECGMonitor respiratory status, V/S, HR, ECG Teach use of diuretics, laxatives, dietTeach use of diuretics, laxatives, diet

Who does the shift with Clarissa?Who does the shift with Clarissa?

Accompanied by decreases in Na & KAccompanied by decreases in Na & K Chloride shift: Cl- enter cells when exchanged for Chloride shift: Cl- enter cells when exchanged for

another anion (leaving cell usually HCO3)another anion (leaving cell usually HCO3)

Chloride shift: Cl- enter cells when Chloride shift: Cl- enter cells when exchanged for another anion (leaving cell exchanged for another anion (leaving cell usually HCO3)usually HCO3)

ChlorideChloride

Normal levels 98-106 mEq/LNormal levels 98-106 mEq/L Function: maintain plasma acid-base Function: maintain plasma acid-base

balance (chloride shift); maintain plasma balance (chloride shift); maintain plasma electroneutrality; formation of electroneutrality; formation of hydrochloric acidhydrochloric acid

Hypochloremia CauseHypochloremia Cause Usually occur r/t other electrolyte imbalances; Usually occur r/t other electrolyte imbalances;

accompanied by decreases in Na & Kaccompanied by decreases in Na & K Metabolic disorders(alkalosis)Metabolic disorders(alkalosis) GI suction, vomiting, diarrhea GI suction, vomiting, diarrhea Ingestion of alkaline substancesIngestion of alkaline substances Renal: advanced renal disorders, diureticsRenal: advanced renal disorders, diuretics Hormonal influences: SIADH, Addison diseaseHormonal influences: SIADH, Addison disease Hypervolemic HF & cirrhosisHypervolemic HF & cirrhosis Skin/environment: burns, fever, large skin woundsSkin/environment: burns, fever, large skin wounds

ManagementManagement

Correct cause; replace other electrolytes; Correct cause; replace other electrolytes; restore acid-base balancerestore acid-base balance

Replace oral if not too low & able to Replace oral if not too low & able to tolerate; IV if critical/unable to tolerate tolerate; IV if critical/unable to tolerate POPO

Monitor serum/urinary Cl levels; ABGMonitor serum/urinary Cl levels; ABG Monitor I&O; B/PMonitor I&O; B/P Dietary changesDietary changes

What are nursing diagnoses for What are nursing diagnoses for hypochloremia?hypochloremia?

Risk for sensory/perceptual alterations r/tRisk for sensory/perceptual alterations r/t Risk for injury r/tRisk for injury r/t Fatigue r/tFatigue r/t Anxiety r/tAnxiety r/t Risk for fluid volume excess r/tRisk for fluid volume excess r/t

Nursing ActionsNursing Actions

Assess neuromuscular, LOC, V/S, S/SAssess neuromuscular, LOC, V/S, S/S Monitor serum/urinary Cl levels; ABG, serum Monitor serum/urinary Cl levels; ABG, serum

Na/KNa/K Safety measuresSafety measures Monitor respiratory/cardiac statusMonitor respiratory/cardiac status I&OI&O Provide diet (tomato juice, salty broth) or oral Provide diet (tomato juice, salty broth) or oral

supplementssupplements Use NS for flush/irrigationUse NS for flush/irrigation Provide quiet calm atmosphereProvide quiet calm atmosphere

Hyperchloremia CauseHyperchloremia Cause Related to Na, K and bicarb (inverse relationship with Related to Na, K and bicarb (inverse relationship with

bicarb)bicarb) Metabolic disorders (acidosis) Metabolic disorders (acidosis) GI: increased retention or intakeGI: increased retention or intake Hyperkalemia/hypernatremiaHyperkalemia/hypernatremia Severe vomitingSevere vomiting Renal: reduced glomerular filtrationRenal: reduced glomerular filtration Hormonal influences: excess adrenocortical hormone Hormonal influences: excess adrenocortical hormone

production, IV or oral cortisone therapyproduction, IV or oral cortisone therapy Head traumaHead trauma Medications: salicylates (overdose)Medications: salicylates (overdose)

Nursing DiagnosesNursing Diagnoses

Imbalanced nutrition greater than r/tImbalanced nutrition greater than r/t Risk for sensory/ perceptual alterations Risk for sensory/ perceptual alterations

r/tr/t Risk for injury r/tRisk for injury r/t Risk for impaired skin integrity r/tRisk for impaired skin integrity r/t Anxiety r/tAnxiety r/t

Nursing ActionsNursing Actions Assess V/S, S/S Assess V/S, S/S Evaluate neuromuscular statusEvaluate neuromuscular status Monitor serum/urinary Cl levels; ABG, serum Na/KMonitor serum/urinary Cl levels; ABG, serum Na/K Safety measuresSafety measures Monitor respiratory/cardiac statusMonitor respiratory/cardiac status I&OI&O Assess LOC; reorient as neededAssess LOC; reorient as needed Restrict Na & Cl if orderedRestrict Na & Cl if ordered If receiving NaBicarb assess for S/S If receiving NaBicarb assess for S/S

overcompensation (alkalosis)overcompensation (alkalosis)

SummarySummary

Na & K Disorders Signs & SymptomsNa & K Disorders Signs & Symptoms

Electrolyte Electrolyte ExcessExcess DeficitDeficit

Sodium (Na)Sodium (Na) HypernatremiaHypernatremiaThirstThirstCNS deteriorationCNS deteriorationIncreased interstitial fluidIncreased interstitial fluid

HyponatremiaHyponatremiaCNS deteriorationCNS deterioration

Potassium (K)Potassium (K) HyperkalemiaHyperkalemiaVentricular fibrillationVentricular fibrillationECG changesECG changesCNS changesCNS changes

Hypokalemia Hypokalemia BradycardiaBradycardiaECG changes ECG changes CNS changesCNS changes

Ca & Mg Disorders Signs & SymptomsCa & Mg Disorders Signs & SymptomsElectrolyte Electrolyte ExcessExcess DeficitDeficit

Calcium (Ca)Calcium (Ca) HypernatremiaHypernatremiaThirstThirstCNS deteriorationCNS deteriorationIncreased interstitial fluidIncreased interstitial fluid

HypocalcemiaHypocalcemiaTetanyTetanyChvostek’s, Trousseau’s Chvostek’s, Trousseau’s Muscle twitchingMuscle twitchingCNS changesCNS changesEKG changesEKG changes

Magnesium (Mg)Magnesium (Mg) Hypermagnesemia Hypermagnesemia Loss of deep tendon reflexes Loss of deep tendon reflexes (DTRs)(DTRs)Depression of CNSDepression of CNSDepression of neuromuscular Depression of neuromuscular functionfunction

Hypomagnesemia Hypomagnesemia Hyperactive DTRsHyperactive DTRsCNS changesCNS changesEKG changesEKG changes