Electrolyte management: hypermagnesemia

Definition: promotion of magnesium balance and prevention of complications resulting from serum magnesium levels higher than desired

activities

Obtain speciment for laboratory analysis of magnesium level as appropriate Monitor trends in magnesium levels as available Monitor for electrolyte imbalances associated with hypermagnesium Asses dietary and pharmaceutical intake of magnesium Monitor for causes of increased magnesium level )e.g magnesium infusions, parenteral

nutrition, magnesium rich dialysate solutions, antacids, laxatives, frequent magnesium sulfate enemas, lithium therapy, and renal insufficiency or failure)

Monitor for causes of impaired magnesium excretion (e.g renal insufficiency, advance age) Monitor urinary output in patients of magnesium therapy Monitor for cardiovascular manifestations of hypermagnesemia (e.g hypotensions, flushing,

bradycardia, heart blocks, widened QRS, prolonged QT, and preaked T waves) Monitor for CNS manifestations of hypermagnesemia (e.g drowsiness, lethargy, confusion, and

coma) Monitor for neuromuscular manifestastons of hypermagnesemia (e.g weak –to-absent deep

tendons reflexes, muscle paralysis, and respiratory depression) Administer prescribed calcium chloride or calcium gluconate IV to antagonize neuromuscular

effects of hypermagnesemia as appropriate Increase fluid intake to promote dilution of serum magnesium levels and urine output, as

indicated Maintain bed rest and limit activities, as appropriate Position patients to facilitate ventilation, as indicated Prepare patient for dialysis (e.g assist with catheter placement for dialysis) as indicated Instruct patient and/family on measures instituted to treat the hypermagnesemia

Electrolyte management : hypernatremia

Definition : promotion of sodium balance and prevention of complications resulting from serum sodium levels higher than desiredactivities

Monitor trends in serum levels of sodium in at-risk populations (e.g unconscious patients, very old or very young patients, cognitively impaired patients, patients receiving hypertonic intravenous infusions)

Monitor sodium levels closely in the patients experiencing conditions with escalating effects on sodium levels (e.g diabetes insipidus, ADH deficiency, heatstroke, neardrowning in sea water, dialysis)

Monitor for neurological or musculoskeletal manifestations of hyponatremia (e.g restlessness, irritability, weakness, disorientation, delisions, hallucinations, increased muscle tone or rigidity, tremors and hyperreflexia, seizures, coma, {late signs})

Monitor for cardiovascular manifestations of hyponatremia (e.g orthostatic hypotension, flushed skin, peripheral and pulmonary edema, mild elevations in body temperature, tachycardia, flat neck pains)

Monitor for GI manifestations hyponatremia (e.g dry swollen tongue and sticky mucous membranes)

Obtain appropriate lab specimen for analysis of altered sodium levels (e.g serum and urine sodium, serum and urine chloride, urine osmolality, and urine specific gravity)

Monitor for electrolyte imbalances associated with hypernatremia (e.g hyperchloremia and hyperglycemia), as appropriate

Monitor for indications of dehydration (e.g decreased sweating, decreased urine, decreased skin turgor, and dry mucous membranes)

Monitor for insensible fluid loss (e.g diaphoresis and respiratory infection) Monitor intake and output Weight daily and monitor trends Maintain patent IV access Offer fluids at regular intervals for debilitated patients Administer adequate water intake for patients receiving enteral feeding therapy Collaborate for alternate routes of intake when oral intake is inadequate Administer isotonic (0,9%) saline, hypotonic (0,45% or 0,3%)saline, hypotonic (5%)

dextrose, or diuretic based on fluid status and urine osmolality Administer prescribed antidiuretic agents (e.g desmopressin {DDAVP} or vasopressin

{pitressin} in the presence of diabetes insipidus Avoid administration/intake of high-sodium medications (e.g sodium polystyrene

sulfonate {kayexalate}, sodium bicarbonate, hypertonic saline Maintain sodium restrictions, including monitoring medications with high-sodium

content Administer prescribed diuretics in conjunction with hypertonic fluids for

hyponatremiaassociated with hypervolemia Monitor for side effects resulting from rapid or over-corrections of hypernatremia (e.g

cerebral edema and seizures)

Monitor renal function (e.g BUN and Cr levels), if appropriate Monitor hemodynamic status, including CVP, MAP, PAP, and PCWP, if available Provide frequent oral hygiene Provide comfort measures to decrease thirst Promote skin integrity (e.g monitor areas at risk for breakdown, promote frequent

weight shifts, prevent shearing, and promote adequate nutritions), as appropriate Instruct patient on appropriate use of salt substitutes, as appropriate Instruct the patient/family about foods and over-the-counter medications that are high

in sodium ( e.g canned foods and selected antacids) Institute seizure precautions, if indicated, in severe cases f hypernatremia Instruct the patient and/or family on measures instituted to treat the hypernatremia Instruct the family or significant other on signs and symptom of hypovolemia (if

hypernatremia is related to abnormal fluid intake or output)

Electrolyte management : hyperphosphatemia

Definition : promotion of phosphate balance and prevention of complications resulting from serum phosphate levels higher than desired

Activities

Monitor trends in serum level of phosphorus (e.g inorganic phosphorus) in at risk-populations (e.g patients receiving chemotherapy, patient with high phosphate intake, patient with vitamin D intake

Monitor phosphate levels closely in the patient experiencing conditions with escalating effects on phosphate levels (e.g acute and chronic renal failure, hypoparathyroidism, diabetic ketoacidosis, respiratory acidosis, profound muscle necrosis, rhabdomyolysis)

Obtain speciments for laboratory analysis of phosphate and associated electrolyte levels (e.g ABG, urine, and serum levels)

Monitor for serum imbanlances associated with hyperphosphatemia Monitor for manifestations of hyperphosphatemia (e.g tingling sensations in fingertips and

around mouth, anorexia, nausea, vomiting, muscle weakness, hypereflexia, tetany, tachycardia) Monitor for symptoms of soft tissue, joint and artery calcifications (e.g decreased urine output,

impaired vision, palpitations) Administer prescribed phosphate-binding and diuretic medications with food to decrease

absorption for dietary phosphate Provide comfort measures for the GI effects of hyperphosphstemia Prevent constipation resulting from phosphate-binding medications Avoid laxatives and enemas that contain phosphate Administer prescribed calcium and vitamin D supplements to reduce phosphate levels Avoid phosphate-rich foods (e.g dairy products, whole-grain cereal, nuts, dried fruits or

vegetables, and organ meats) Prepare patients for dialysis (e.g assist with chateter placement for dialysis), as appropriate Institute seizure precautions Instruct the patient and/or family on measures instituted to treat the hyperphosphatemia Instruct patient and/or family on sign and symptoms of impending hypocalcemia (e.g changes in

urine output)

ELECTROLYTE management : hypocalcemia

Definition : promotion of calcium balanceand prevention of complications resulting from serum calcium levels lower than desired

Activities Monitor trends in serum level of calcium (e.g ionized calcium) in at-risk populations (e.g

primary of surgically induced hypoparathyroidism, radical neck dissection {particularly first 24 to 48 hours postoperatively} any thyroid or parathyroid surgery, patient receiving massive transfusions of citrated blood, cardiopulmonary bypass)

Monitor calcium levels closely in the patient experiencing condition with depleting effect on calcium levels (e.g osteoporosis, pancreatitis, renal failure, inadequate vitamin D consumtion, hemodilution, chronic diarrhea, small bowel disease, medullary thyroid cancer, low serum albumin, alcohol abuse, renal tubular disfunction, severe burns or infections, prolonged bedrest)

Estimate the concentration of the ionized fraction of calcium when total calcium levels only are reported (e.g use serum albumin and appropriate formulas)

Observe for clinical manifestations of hypocalcemia (e.g tetany {classic sign}; tingling in tips of fingers, feet, or mouth; spasms of muscles in face or extremities; trousseau`s sign; chvostek`s sign; altered deep tendon reflexes; seizures{late sign})

Monitor for psychosocial manifestations of hypocalcemia (e.g personality disturbances, impaired memory, confusion, anxiety, irritability, depression, delirium, hallucinations, and psychosis)

Monitor for cardiovascular manifestation of hypocalcemia (e.g decreased contractility, decreased cardiac output, hypotension, lengthened ST segment, and prolonged QT interval, torsades de pointes)

Monitor for GI manifestation of hypocalcemia (e.g nausea, vomiting, constipation, and abdominal pain from muscle spasm)

Monitor for integument manifestation of hypocalcemia (e.g scaling, eczema, alopecia, and hyperpigmentation)

Monitor for electrolyte imbalances associated with hypocalcemia (e.g hyperphosphatemia, hypomagnesemia, and alkalosis)

Monitor patient receiving medications that contribute to continued calcium loss (e.g loop diuretics, aluminium-containing antacids, aminoglycosides, caffeine, cisplatin, corticosteroids, mithramycin, phosphates, isoniazid,)

Monitor fluid status, including intake and output Monitor renal function (e.g BUN and Cr levels) Maintain IV access Administer appropriate prescribed calcium salt (e.g calcium carbonate, calcium chloride,

and calcium gluconate) using only calcium diluted in D5W, administered slowly with a volumetric infusion pump, as indicated

Maintain bedrest for patients receiving parenteral calcium replacement therapy to control side effect of postural hypotension

Monitor blood pressure in patients receiving parenteral calcium replacement therapy

Monitor infusions of calcium chloride closely for adverse effects of (higher incidence of tissue sloughing with IV infiltration; not usually initial medication of choice in treatment plans)

Monitor for side effects of IV administration of ionized calcium (e.g calcium chloride), such as increased effects of digitalis, digital toxicity, bradycardia, postural hypotension, cardiac arrest, thrombophlebitis, soft tissue damage with extravasation, clotting, and thrombus formation, as appropriate

Avoid administration of medications decreasing serum ionized calcium (e.g bicarbonate and citrated blood) as appropriate

Avoid administration of calcium salts with phosphates or bicarbonate to prevent precipitation

Monitor for acute laryngeal spasm and letany resulting from hyperventilation of pressure on efferent nerves (e.g by crossing legs)

Initiate safety precautions in patients with petentiaaly harmful psychosocial manifestations (e,g confusion)

Encourage increased oral intake of calcium (e.g at least 1000 to 1500 mg/day from dairy products, canned salmon, sardines, fresh oyster, nuts, broccoli, spinach, and supplement), as appropriate

Provide adequate intake of vitamin D ( e.g vitamin supplement and organ meats) to facilitate GI absorbtion of calcium, as appropriate

Provide pain relief/ comfort measures Monitor for over correction and hypercalcemia Instruct the patient and/or family on measures instituted to treath hypocalcemia

Electrolyte management : hypokaled, miaDefinition : promotion of potassium balance and prevention of complications resulting from serum potassium levels lower than desired

Obtain speciments for laboratory analyze of potassium levels and associated electrolyte imbalances (e.g ABG, urine, and serum levels), as appropriate

Monitor fer early presence of hypokalemia to prevent life threatening sequelae in at-risk patients (e.g fatigue, anorexia, muscle weakness, decrased bowel motility, paresthesias, dysrithmias)

Monitor lab values associated with hypokalemia (e.g elevated glucose, metabolic alkalosis, reduced urine osmolality, urine potassium, hypochloremia, hypocalcemia), as appropriate