Disorder Hypervolemia

Causes Iatrogenic: IV Fluids CRF (CKD) CHF Excessive corticosteroid therapy SIADH

Symptoms Acute weight gain Peripheral edema Shortness of breath/rales confusion, lethargy, weakness Distended neck veins bounding pulse Elevated BP Slow-emptying peripheral veins Effusions into third spaces Acute weight loss Decreased skin turgor, Dry mucous membranes agitation, restlessness, weakness Weak thready pulse Orthostatic hypotension Slow-filling peripheral veins confusion, lethargy stupor, coma Extreme thirst Muscle weakness Dry, sticky mucous membranes

Treatment Fluid restriction Dietary Na+ restriction Diuretic therapy

Hypovolemia

Impaired thirst mechanism Inability to swallow fluids diuretic therapy Diabetes insipidus Fluid losses from GI tract Excessive sweating Diabetes insipidus Renal concentrating disorders diarrhea Profuse diaphoresis without fluid replacement forgetfulness dysphagia Adrenal hyperfunction

Treatment goal is to prevent damage to kidneys via hydration oral or parenteral

Hypernatremi a

Teach elderly patients to drink fluids regularly Offer fluid frequently to patients at risk Monitor replacement of water loss Diuretics Monitor specific gravity of urine

Hyponatremia SIADH Psychogenic polydipsia thiazide or loop diuretics Sodium-losing renal disease Adrenal insufficiency Hyperkalemia Iatrogenic Administration of aged blood salt substitutes ARF/CKD Adrenal insufficiency Spironolactone (Aldactone) Tissue injury (burns, major surgery, or crush injury) Acidosis Insulin deficiency

confusion, lethargy convulsions, coma Muscle weakness Nausea and abdominal cramps Postural hypotension Mental confusion GI hyperactivity Cardiotoxicity EKG changes (K+ > 6 mEq/L: Peaked T waves and prolonged PR interval, wide QRS complex Cardiac arrhythmias bradycardia and heart block Cardiac arrest Muscle weakness/paralysis, flaccid muscles Decreased bowel motility Polyuria EKG changes (serum K+ < 3 mEq/L): ST segment depression, T wave flattening, prominent U waves Cardiac arrhythmias B PACs or PVCs Respiratory failure K+ <1.5 mEq/L

Use normal saline instead of distilled water for irrigations fluid restriction hypertonic IV solutions carefully Evaluate renal function before administering K+ intravenously Teach patients about foods/fluids which are high in K+ NaHCO3 diuretics Kayexalate Decrease dietary sources of K+

Hypokalemia

Anorexia Vomiting, gastric suction Diarrhea, laxative abuse, recent ileostomy Furosemide, Bumetanide and HCTZ Hyperaldosteronism Alkalosis Hypersecretion of insulin

Teach patients which foods have high K+ content Teach patients about their diuretics K+ supplements Never administer potassium solutions by IV push; doing so will very likely cause cardiac arrest

Hypercalcemi a

Hyperparathyroidism Metastatic carcinoma Multiple myeloma Thyrotoxicosis Prolonged immobilization Vitamin D toxicity

Nausea and vomiting Constipation Muscle weakness/flaccidity Depressed deep tendon reflexes Confusion, lethargy, CNS depression Polyuria Pathological fractures Renal calculi EKG changes: Shortened QT interval Cardiac arrest Muscle cramps Confusion, irritability, anxiety Tetany Paresthesias of fingers and circumoral region Positive Chvosteks sign Positive Trousseaus sign Hyperactive deep tendon reflexes Convulsions EKG changes: Prolonged QT interval Cardiac arrest

Increase patient mobility loop diuretics Ensure adequate hydration to decrease possibility of renal calculi Handle patient gently when transferring or repositioning to prevent pathological fractures

Hypocalcemia

Vitamin D deficiency Diet Acute pancreatitis Overuse of antacids Malabsorption Syndromes Hypoparathyroidism Overuse of phosphatecontaining laxatives and enemas CKD

Teach patients dietary sources of calcium and vitamin D Administer oral Ca++ supplements Keep 10 ml of 10% IV calcium gluconate available for emergency use after thyroid surgery. Administer slowly, not exceeding 2 ml/min.

Hypermagnesemi a

Overuse of antacids containing Mg++ (Maalox, Gelusil, Riopan) Overuse of laxatives containing Mg++ (Milk of Magnesia) ESRD Adrenal insufficiency

Hypoactive deep tendon reflexes Drowsiness, lethargy Nausea and vomiting Respiratory depression (serum Mg++ > 15 mEq/L) Cardiac arrhythmias (bradycardia, heart block) Cardiac arrest (serum Mg++ > 25 mEq/L)

Teach patients careful management of Mg+ + containing antacids and laxatives Teach patients with renal problems to avoid preparations containing Mg++ Keep 10% calcium gluconate, a magnesium antagonist, available for emergency use

Hypomagnesemia

Chronic diarrhea Chronic malnutrition Malabsorption syndrome Steatorrhea Small bowel resection Chronic alcoholism

Hyperactive deep tendon reflexes Coarse tremors Tetany Positive Chvostek's and Trousseaus Intense confusion Cardiac arrhythmias (PVC, SVT) Convulsions Coma Increased phosphate with calcium precipitates readily causing calcified deposits in joints, arteries, skin, kidneys, and corneas. Neuromuscular irritability Tetany Mild to moderate could be asymptomatic Muscle weakness Pain Dysrhythmias, cardiomyopathy Severe: CNS depression, confusion

Provide diet counseling for patients at risk Administer IM or IV MgSO4 (20 gms/2ml) Evaluate renal function before administering Mg++ replacement Adequate hydration to enhance renal excretion of phosphate Phoslo

Hyperphosphatemia ARF/CKD Chemotheraphy Excessive ingestion of milk or phosphate-containing laxatives large intakes of vitamin D Hypophosphatemia Malnourishment, malabsorption syndrome Alcohol withdrawal Use of phosphate binding antacids Parenteral nutrition with inadequate phosphate replacement

Oral supplementation IV sodium phosphate or potassium phosphate