Exam 2 Corbett Ch 5 and 7 Electrolytes

• Na | Cl
•  K  | BiCarb

• Sodium
• Chloride
• Bicarbonate

• Potassium
• Magnesium
• Phosphate

• (Positive ions)
• Sodium
• Potassium

• (Negative ions)
• Chloride
• Bicarbonate

136-145 mEq/L

3.5-5.1 mEq/L

98-107 mEq/L

21-30 mEg/L

• Most abundant electrolyte in ECF
• Controls and regulates water balance
• Primary regulator of ECF volume
• Need 2 grams of Na per day

• dehydration - most frequent
• overuse of IV saline solutions
• exchange transfusion with stored blood
• impaired renal function
• unconscious - not drinking or unable to verbalize thirst
• tumor of adrenal gland
• (each 3 mEq/L above normal = 1 Liter depleted)

• subjective - complains of thirst - may be intense
• restlessness, agitation to lethargy
• dry mucous membranes
• dry, flushed skin
• nausea and vomiting
• urine output low (< 30 mL/hr)
• diagnostics - an increase in specific gravity of urine (> 1.020) except for diabetes insipidus

• salt free fluids
• sodium restriction
• diuretics and water
• monitor client for vital signs, level of consciousness, intake and output, labs, and weight.
• also monitor oral hygiene, client safety, and teach client proper sodium and fluid intake
• administer IV solutions with caution - hypotonic sodium solutions such as 0.45% and 0.33% normal saline

• excessive water - "dilutional" hyponatremia
• loss of sodium by vomiting, diarrhea, GI suctioning, or sweating
• use of diuretics, diabetic acidosis, Addison's disease, renal disease; all cause increased loss of sodium via urine
• irrigating N/G tubes with water
• use of D5W or hypotonic IV fluids such as 0.45%, 0.33% Normal Saline

• postural hypotension (assess BP, HR)
• rapid thready weak pulse
• cold, clammy skin
• abdominal cramps and nausea
• muscle weakness, cramps, tremors
• lethargy, headache, decrease in level of consciousness, confusion
• diagnostic labs - decreased urine specific gravity (< 1.010)
• decrease in HCT

• identify and treat cause
• restrict fluids
• encourage high sodium foods
• administer hypertonic sodium chloride very slowly (such as D5% 0.45% NS, D5% NS, D5% LR)
• monitor client's vital signs, level of consciousness, intake and output, weight, labs, and safety
• teach client about healthy sodium and water intake

• Deficient fluid volume
• Excessive fluid volume related to excess sodium
• Deficient knowledge related to need for sodium restriction

• Excess fluid volume related to water intoxication
• Imbalanced nutrition related to sodium depletion
• Deficient knowledge related to specific need for replenishing sodium

• vital for normal neuromuscular and cardiac function
• excreted daily by kidneys
• source is a balanced diet
• need 40-80 mEq/day

• renal failure
• too rapid IV infusion of potassium replacement
• initial reaction to massive tissue damage (trauma, burns)
• associated with metabolic acidosis
• drugs such as:
• ACE inhibitors
• aldactone (K sparing diuretic)
• ARBs
• NSAIDs
• hormonal contraceptives

• Neuromuscular - parenthesias, muscle weakness, paralysis; leg muscle to respiratory muscles
• GI hyperactivity
• Cardiac - heart rate, irregular pulse, hypotension
• Diagnostics - K > 5, ECG changes (tented T wave, flat P wave, wide QRS)

• tented T wave, flat P wave, wide QRS

• Restrict potassium
• Monitor vital signs, ECG, intake and output, digoxin levels, labs, client safety
• Medications:
• Lasix
• Sodium Polystyrene Sulfonate (Kayexalate)
• Dextrose and regular insulin given IV
• Calcium Gluconate
• Dialysis

• Lasix: Inhibits NaCl reabsorption in the thick ascending loop of Henle (used when K is elevated but not critical)
• Sodium Polystyrene Sulfonate (Kayexalate): potassium is exchanged with Na or Ca ions and excreted in feces.  Given orally or rectally (retention enema)
• Dextrose and regular insulin given IV: as glucose goes into cell, K goes with it.  Must be given together as IV push.  For when K+ is very high - rapid acting
• Calcium Gluconate: blocks the affect of K on heart.  Doesn't change the K levels but reduces the excitability of cardiomyocytes.  Used in life threatening situations
• Dialysis: cleans the blood, artificial kidney process.

• diuretics (loop, thiazides) non K sparing
• decreased oral intake (need 40-80 mEq/day)
• inadequate intake when NPO, vomiting, or receiving potassium-free IV feedings
• large doses of corticosteroids
• aftermath of tissue destruction or high stress
• associated with metabolic alkalosis
• prolonged diarrhea, intestinal disease with vomiting and gastric suction

• A SIC WALT:
• Alkalosis
• Shallow respirations
• Irritability
• Confusion, drowsiness
• Weakness, fatigue
• Arrhythmias - Tachycardia, Irregular Rhythm, and/or Bradycardia
• Lethargy
• Thready pulse
• ↓ Intestinal motility, nausea, vomiting, ileus

• Neuromuscular weakness: leg weakness, cramps, paresthesias, fatigue, lethargy, apathy, respiratory weakness
• Decreased GI motility, decreased bowel sounds
• Cardiac problems: weak irregular pulse, palpitations, orthostatic hypotension
• Diagnostics: potassium level less than 3.5, 2.5 is severe, an increase in glucose levels, lower magnesium, increase Digoxin level and ECG changes such as flat T wave and positive U wave - critical situation

• Flat T wave
• positive U wave

• Hypokalemia

• Replace potassium with high potassium foods, oral supplements, IV replacement (max 10 mEq/hr, replace Mg first)
• Monitor vital signs, HR and rhythm, labs, digoxin level, intake and output
• Patient education - list dietary sources of potassium: dried fruits, potatoes, bananas, oranges, leafy greens, meat
• Never direct injection of potassium - fatal
• Avoid layering

• ACE inhibitors
• ARBs
• Hormonal contraceptives
• Potassium sparing diuretics
• NSAIDs (ibuprofen)

• Risk for injury related to effect of hyperkalemia on heart and other muscles
• Deficient knowledge related to sources of potassium
• Risk for injury related to subsequent development of hypokalemia

• Altered cardiac output related to development of arrhythmias
• Risk for injury related to development of muscle weakness
• Risk for injury related to use of IV potassium
• Deficient knowledge related to oral potassium supplements
• Deficient knowledge related to dietary sources of potassium

• Travels with sodium to maintain serum osmolality
• Works with sodium to for CSF
• Secreted by gastric mucosa (HCl) for digestion

• an increase in sodium levels
• a decrease in bicarbonate

• metabolic acidosis
• increased intake with increased water loss
• drugs such as Kayexalate

• Signs and symptoms of metabolic acidosis - tachypnea, Kussmaul respirations, lethargy, weakness
• Signs and symptoms of hypernatremia - fluid retention, edema, hypertension, dyspnea

• Correct the cause
• Restrict sodium and chloride
• Increase water
• IV bicarbonate
• rarely use diuretics
• monitor vital signs, level of consciousness, intake and output, respiratory rate, cardiac rhythm, labs, safety

• reduced intake due to salt restricted diets, salt poor formula
• excessive loss due to - vomiting, gastric suction, diarrhea, draining fistulas, cystic fibrosis
• drugs, increased bicarbonate level, steroids, laxatives and diuretics

• Neuromuscular - Tetany, hyperactive relexes, seizures
• Cardiac arrhythmias
• Diagnostics - sodium less than 135 mEq/L, serum pH > 7.45 (as chloride decreases, bicarbonate increases)

• Correct the cause - hypochloremia is caused by an underlying problem
• Chloride replacement - salty broth, KCl if sodium level is ok, restrict water
• Monitor vital signs, level of consciousness, intake and output, labs, cardiac rhythm, safety

If increase in chloride level is related to increase in sodium level then use hypernatremia nursing diagnoses.

Imbalanced nutrition related to chloride losses

Important component for the equation that keeps the acid-base status of the body in balance

9.0-10.5 mg/dL

• Necessary for bone and teeth structure
• Maintaining cell membrane structure
• Muscle contraction
• Required for blood to clot
• Intake: 1 g/day for adults
• Sources: dairy, calcium supplements and Vitamin D

• false rise caused by dehydration
• hyperparathyroidism (phosphate decreased)
• malignant tumors (bone cancer)
• immobilization
• thiazide diuretics
• Vitamin D intoxication (phosphate increased)
• excessive vitamin A
• low phosphate

• Bone pain
• Neuromuscular weakness
• Decreased motility - anorexia, nausea, vomiting, constipation
• Renal - polyurea and stones
• Diagnostics - ECG changes, x-ray - pathological fractures

• Increase calcium excretion - hydration (0.9% NS, 200-300 mL/hour, loop diuretics, renal dialysis
• Monitor vital signs, level of consciousness, ECG, intake and output, labs
• Safety
• Strain urine
• Ambulate
• Patient education

• false decrease caused by low albumin levels (hypoalbuminemia)
• hypoparathyroidism (phosphate increased)
• chronic renal disease (phosphate increased)
• pancreatitis
• massive blood transfusions
• severe malnutrition (phosphate decreased)
• low magnesium
• high phosphorus
• vitamin D deficiency

• Neuromuscular - paresthesias - circumoral, twitching, tremors, muscle cramps, Chvostek's face, Troussau's arm/hand
• Structural changes
• Cardiac arrhythmias
• Anorexia

• Administer calcium gluconate
• Vitamin D supplements
• Increase dietary intake
• Reduce phosphate
• Monitor vital signs, respiratory stridor, ECG, labs, Chvostek's and Trousseau's
• Client safety and education

• Imbalanced fluid requirements related to risk for injury from formation of kidney stones
• Risk for injury related to slowing of reflexes
• Risk for altered cardiac output
• Risk for injury and impaired mobility related to development of pathologic fractures
• Deficient knowledge related to therapy for hypercalcemia
• Imbalanced nutrition - related to possible dietary restrictions
• Impaired skin integrity

• Risk for injury related to the development of tetany
• Risk for injury related to replacement of calcium
• Deficient knowledge related to use of oral calcium supplements
• Imbalanced nutrition - requirement for calcium
• Deficient knowledge related to phosphate binders

3.0-4.5 mg/dL

• Required to activate B vitamins
• Carbohydrate metabolism
• Works with calcium to maintain bone structure and teeth
• Nerve and muscle function

• increased intake
• cell descruction
• decreased excretion due to:
• -hypoparathyroidism (and hypocalcemia)
• -renal failure (and hypocalcemia)
• increased growth hormone
• vitamin D intoxication (and hypercalcemia)
• phosphate intoxication from sodium phosphate enemas

• Same signs as hypocalcemia: anorexic, dysphagia, and circumoral numbness
• Calcification of the eyes
• Diagnostics - lower calcium, skeletal changes shown in x-ray

• Decrease intake
• Increase excretion - fluids, diuretics, dialysis
• Monitor vital signs, Chvostek's & Trousseau's, safety and education

• respiratory hyperventilation
• hyperparathyroidsm (and hypercalcemia)
• diuresis (increased urine production)
• malabsorption, or malnutrition (and hypocalcemia)
• carbohydrate loading or refeeding syndrome (Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved, severely malnourished or metabolically stressed due to severe illness)
• antacid abuse

• Neuromuscular - weakness, confusion, signs and symptoms of hypercalcemia
• Bruising, bleeding, loss of bone density
• Diagnostics - low magnesium and high calcium, osteomalacia from x-ray

• Increase intake with food such as meat, fish, dairy, egg yolks, beans, nuts, or oral supplements
• Monitor vital signs, respiratory rate/rhythm, level of consciousness, intake and output, labs, safety and education

• Imbalanced nutrition - requirement for calcium and phosphorus
• Deficient knowledge related to use of phosphate binders

• Risk for injury related to neuromuscular deficits
• Risk for injury related to replacement therapies
• Imbalanced nutrition - related to decreased phosphorus

1.8-3.0 mEq/L

• 2nd most abundant intracellular cation
• Important for cell metabolism
• Influences cardiac contractility
• Maintains electrical activity in nerves and muscles
• Influences calcium levels

• excessive intake and/or decreased excretion
• renal failure
• IV administration of MgSO4

• Neuromuscular - flushing, warmth, weakness, decreased reflexes
• Cardiac - lower blood pressure
• Diagnostics - ECG changes

• Increased elimination - fluids in loop diuretics
• Block effects - calcium gluconate (serious cases)
• Monitor vital signs, level of consciousness, reflexes, intake and output, labs, ECG

• poor intake and absorption
• increased loss
• pregnancy
• chronic malnutrition (e.g., alcoholism)
• diarrhea or draining GI fistulas
• diuretics
• diabetes
• hypercalcemia or other complex metabolic disorders
• refeeding syndrome (Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved, severely malnourished or metabolically stressed due to severe illness)
• Serum levels may not reflect actual stores

• Neuromuscular - change in level of consciousness, hyperactive reflexes
• Cardiac irritability
• Diagnostics - may see decreased calcium or potassium, ECG changes, increased digoxin levels

• Replace Mg - Oral or IV MgSO₄ 
• Monitor vital signs, level of consciousness, dysphagia, reflexes, intake and output
• Monitor client for safety and educate about high Mg foods such as leafy greens, whole grains, beans

• Risk for injury related to altered neuromuscular functioning
• Deficient knowledge related to hidden sources of magnesium

• Imbalanced nutrition - less than body requirements
• Risk for injury related to alteration in cardiac output
• Altered comfort related to neuromuscular irritability
• Risk for injury related to magnesium replacements

salt, salty foods, processed and canned foods

salty foods, lettuce, celery, olives

dried fruits, potatoes, oranges, bananas, leafy greens, meats, cantaloupe

leafy greens, whole grains, beans

dairy products, leafy greens, shellfish

meats, fish, dairy, egg yolks, beans, nuts