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Electrolyte Imbalance + Normal

Ranges and Disturbances for
Common Electrolytes
CPD 16m Published: 16 May 2018

Electrolyte imbalances can occur due to

hundreds of factors, none of which line up
in neat, tidy queues.
Look at a few of the most common examples:

Patients suffering from congestive heart failure often

end up as rebound hospitalisations due to abnormal
sodium and potassium levels.

A grandmother with diabetes or hypertension may

eventually find herself on the business end of a
calcium or magnesium imbalance.

The toddler with explosive diarrhoea and the elite

Australian athlete, otherwise wildly unalike, both
routinely find themselves on the business end of
electrolyte imbalances.

A proper understanding of these imbalances is

essential for current management and future
prevention.

5:32

Facts and Figures

Electrolyte imbalances occur across many different
diagnostic categories.

In Australia, harsh summer environmental exposure,

with resulting dehydration, is just one example of a
potential root cause1; sadly, more Australians are
killed from the ill-effects of heatwaves than all other
natural hazards, combined.2

This is just potential cause, however. There are

hundreds of other root causes for fluid and
electrolyte imbalances, including:

In children: a leading cause of dehydration and

electrolyte imbalance in children is acute
gastroenteritis, a disorder which can be
effectively treated with oral rehydration.3
In the older adult: one of the primary reasons
older populations are at an elevated risk of
dehydration and electrolyte imbalance is a
diminished thirst response.4
In the athlete: Electrolyte imbalances during
exercise come from multiple sources.
Strangely, the muscles doing work do not lose
water content during exercise; rather, the
muscles dehydrate during the immediate post-
exercise recovery period, presumably in an
effort to restore plasma volume and to stabilise
the cardiovascular system.5,6

What is an Electrolyte
Imbalance?
Put simply, electrolytes are naturally occurring
minerals with an electric charge.

They exist in the human body and they are also

present in food and fluids we ingest every day.

Potassium, magnesium, and sodium are several

commonly known electrolytes, but they are not
alone; calcium and phosphate also play critical roles.
These electrolytes serve crucial functions in the
body such as keeping water in balance, regulating
the body’s base pH levels, and moving nutrients and
waste to and from cells.7

Electrolyte Imbalance
Symptoms
Electrolyte imbalance can be a marker of many
common diseases and illnesses.

Assessing a patient for electrolyte imbalance can

give practitioners an insight into the homeostasis of
the body and can serve as a marker or proxy for the
presence of other illnesses.

Practitioners can use physical examination, ECGs,

serum electrolyte levels and pathologic signs as
methods to assess for electrolyte imbalance.

Certain symptoms can even point to a specific

electrolyte that is out of balance in a patient. For
example, confusion is a common symptom of
hypocalcaemia.8

By using the aforementioned examination

techniques, practitioners can pinpoint which
electrolytes are out of balance and thus craft a more
effective treatment plan for the patient.

There are many different symptoms of electrolyte

imbalance that can present themselves in a patient.

Some Common Electrolyte

Imbalance Symptoms are:8
Dyspnoea
Fever
Systemic deterioration
Confusion
Oedema
Rales
Tachycardia
Atrial fibrillation
Vomiting
Abdominal pain

What Causes an Electrolyte

Imbalance?
Dehydration does not occur at some standardised
setpoint; it is caused by consuming too little fluid for
the present needs of the body.

This can happen by either decreased consumption

or outside factors that cause the body to require
more water than normal.

When the body becomes dehydrated, certain

symptoms can arise such as dry mouth or increased
thirst. However, these are not universal indicators of
dehydration. In fact, they may not be clinically useful
for diagnosing dehydration.9

Whenever the body is overhydrated or

underhydrated – or when the body’s filtration
systems do not operate normally – electrolytes no
longer function as they should.

Abnormal electrolyte levels can occur anytime the

body’s fluid levels fluctuate outside of norms such
as after serious burns, vomiting, diarrhoea, and
excessive sweating.

Infrequently, overhydration can also result in serious

repercussions. Certain medicines and dysfunctions
of the liver and kidneys can also throw the body’s
electrolytes out of normal range.

Electrolyte Imbalance Risk

Factors
While absolutely anyone can develop an electrolyte
disorder, the older population are at an increased
risk.

Some factors that can increase the risk of an

electrolyte imbalance in older populations include:10

Diabetes
Hypertension
Use of diuretics (which promote fluid excretion
by the kidneys)

Within these risk factors there is increased risk to

those who use certain combinations of diuretics and
to those with diabetes. Patients who use both
thiazides and benzodiazepines are associated with
higher rates of hyponatremia, which in turn, is
associated with a higher mortality risk.10

The use of angiotensin-converting enzyme inhibitors

(ACE inhibitors), potassium and calcium
supplements and certain hormones, which are
classified as ‘potassium-sparing’, can also lead to
imbalances.

Other conditions that can increase the risk of an

electrolyte disorder include:

Significant burns
Significant trauma (such as broken bones)
Congestive heart failure
Abuse of alcohol (especially long-term abuse)
Kidney disorders
Diarrhoea or vomiting
Heat exhaustion
Eating disorders (such as anorexia or bulimia)
Thyroid, parathyroid and adrenal gland
disorders (such as Addison’s disease)

Diagnosing an Electrolyte
Imbalance
There are several types of tests that can be used to
diagnose electrolyte imbalance.

Each type of test has its own pros and cons for
detecting various types of imbalances. Here are just
a few of the ways practitioners test for electrolyte
dysfunction:7

The Anion Gap Blood Test is a blood test that

analyses the levels of acid in the blood. This
can indicate an electrolyte imbalance, as one
of the functions of electrolytes is balancing the
pH of the blood.
Carbon Dioxide Blood Tests are used to
measure CO2 levels in the blood. CO2 in the
blood is often in the form of an electrolyte
called bicarbonate.
Chloride Tests measure the levels of chloride,
another electrolyte, in the blood.
Sodium Blood Tests analyse sodium levels in
the blood, another common portion of an
electrolyte blood panel.

Electrolyte Imbalance
Treatment

Individuals who experience serious symptoms,

tachycardia, mental confusion, sunken eyes,
reduced elasticity of the skin and/or a loss of
consciousness need immediate medical attention.

Individuals who dehydrate through exercise or

activity can typically look to the electrolyte
restoration possibilities of sports drinks. An excellent
guide to the use of such sports drinks was put out
by Australia’s AIS Sports Supplement Framework, an
initiative of AIS Sports Nutrition.6

Between these two extremes is a vast middle ground

with some patients requiring rapid – though not
emergency – medical assistance, and some patients
self-correcting without ever knowing anything more
than that they ‘felt a bit off’.

Normal Ranges and

Disturbances of Common
Electrolytes
Although there are many trace elements that keep
the body healthy, several important electrolytes can
severely affect patients when they are either too
high (hyper…) or too low (hypo…).

Understanding what each electrolyte does, what

happens when there isn’t enough of one or too
much of another, is essential knowledge for nurses
and can help guide electrolyte therapy.

Sodium

Sodium, or Na, is one of the most important

electrolytes in the body and is responsible for a
number of important functions, mostly related to
fluid and water regulation. The normal accepted
range for sodium is 134 to 145 mEq/L.

Hyponatraemia is considered to be a serum sodium

below 134 mEq/L. A common cause of
hyponatraemia is water retention due to cardiac or
renal or hepatic failure.

Other causes of hyponatraemia include some

medicines, psychogenic polydipsia (excessive water
intake) and syndrome of inappropriate ADH
(antidiuretic hormone) secretion, and chronic or
severe vomiting and diarrhoea.

Common symptoms of hyponatraemia include

confusion, agitation, nausea and vomiting, muscle
weakness, spasms or cramps.

Hypernatraemia is defined as a serum sodium

greater than 145 mEq/L.

Causes of hypernatraemia can be thought of simply

as anything that leads to excessive water loss or salt
gain. For example, water depletion or dehydration
may be caused by vomiting or diarrhoea.

Excessive ingestion of sodium is rare, but the

administration of infusions containing sodium such
as sodium chloride or sodium bicarbonate may lead
to hypernatraemia.

Clinical features of hypernatraemia may include

fever, irritability, drowsiness, irritability, lethargy and
confusion.

Potassium

Potassium, or K, is responsible for the functioning of

excitable tissues such as skeletal and cardiac
muscle and nerves. The normal range for
potassium is 3.5 to 5.0 mmol/L.

Hypokalaemia is defined as a serum potassium less

than 3.5 mmol/L. A low serum potassium may be
caused by decreased oral intake, increased renal or
gastrointestinal loss of potassium, or a shift of
potassium within the body’s fluid compartments
(from outside the cell where it should be, to inside
the cell).

Common clinical features of hypokalaemia range

from muscle weakness and ileus (lack of peristalsis),
to serious cardiac arrhythmias such as ventricular
tachycardias.

Hyperkalaemia, a serum potassium greater than 5.0

mmol/L, may be caused by excessive intake, tissue
damage from burns or trauma, medicines such as
potassium sparing diuretics, and most commonly,
due to renal failure.

Clinical signs of hyperkalaemia include muscle

weakness, hypotension, bradycardia and loss of
cardiac output, and ECG changes may include
peaked T waves and flattened P waves.

Magnesium

Magnesium, or Mg, is another element that has a

strong effect on muscle contractions. The normal
plasma range for magnesium is 0.70 to 0.95
mmol/L.

Hypomagnesaemia, or a decreased plasma

magnesium level, may be caused by decreased
intake or increased loss of magnesium. Clinical signs
include confusion, irritability, delirium, muscle
tremors and tachyarrhythmias.

Hypermagnesaemia is when the level of magnesium

in the blood is above the normal range. Fortunately,
this is uncommon. Symptoms include poor reflexes,
low blood pressure, respiratory depression, and
cardiac arrest. This is usually caused by the
excessive administration of magnesium and lithium
therapy, often in the presence of renal failure.

Calcium

Calcium, or Ca, is an important element in the body

as it helps to control nerve impulses, muscle
contractions and has a role in clotting. The serum
calcium range should be between 2.20 to 2.55
mmol/L when normal.

Hypocalcaemia, the presence of low serum calcium

levels in the blood, is relatively rare because the
bones always act as a reservoir for this electrolyte.
However, parathyroid disease, vitamin D deficiency,
septic shock and acute pancreatitis can cause this
problem. Some symptoms include tetany
(involuntary muscle contraction), mental changes
and decreased cardiac output.

Hypercalcaemia, elevated levels of calcium in the

blood, again arises from parathyroid problems and
vitamin D issues. Signs of this form of electrolyte
imbalance include nausea, vomiting, polyuria,
muscular weakness and mental disturbance.

Phosphate

Phosphate, or P, is an electrolyte used in several

functions throughout the body. Although a
phosphate imbalance isn’t as well known as some of
the other imbalances, it can still cause problems
with your patient’s condition. The normal range of
phosphate in the plasma is generally between 0.8
to 1.3 mmol/L. The signs and symptoms of either
abnormal reading are usually subtle.

For hypophosphataemia, when levels of phosphate

in the blood are below the normal range, the
symptoms generally include muscle weakness, heart
failure, seizure, and coma. It may be caused by
vitamin D deficiency, hyperparathyroidism, or
alcoholism. Hypophosphataemia may also be
present, in addition to other electrolyte
disturbances, in re-feeding syndrome, which is
associated with the commencement of total parental
nutrition (TPN).

Hyperphosphataemia, when levels of phosphate in

the blood are above the normal range, can be
caused by kidney disease, parathyroid issues, and
metabolic or respiratory acidosis. Symptoms are
usually not present, and they are related to
hypocalcaemia. Renal patients can experience
hardened calcium deposits when this condition goes
untreated.

Electrolyte Imbalance
Complications
Improper management of electrolyte imbalances can
worsen the baseline condition.

For example, overly aggressive treatment of hypo-

and hyperkalemia can cause cardiac arrhythmias.11

Some additional complications that can be caused

by electrolyte imbalance include:11

Arreflexic weakness due to hypermagnesemia,

hyperkalemia, and hypophosphatemia
Epileptic encephalopathies from
hypomagnesemia, dysnatremias and
hypocalcemia
Visual loss due to intracranial hypertension
caused by respiratory acidosis
Quadriplegia due to hypermagnesemia
Central pontine myelinolisis due to
mistreatment of hyponatremia

Conclusion
Many electrolyte imbalances self-correct without
any ill-effects. A simple drink of water can correct
others.

However, electrolyte imbalances can be much more

than just a nuisance – they can cause severe
complications when left untreated. It is important for
practitioners to correctly test for and diagnose
electrolyte imbalances in order to treat them in an
appropriate and timely fashion.

References

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Argyropoulos, CP, Malhotra, D, Raj, DS, Agaba, EI,
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5760509/

Health Direct Australia 2016, Hot weather risks and staying

cool, Australian Government Department of Health, viewed
15 May 2018, https://www.healthdirect.gov.au/hot-
weather-risks-and-staying-cool

Santillanes, G & Rose, E 2018, ‘Evaluation and

Management of Dehydration in Children’, Emergency
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December, viewed 15 May 2018,
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AID Sports Nutrition 2017, Sports drinks (carbohydrate-

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Medline Plus 2018, Fluid and electrolyte balance, US

National Library of Medicine, viewed 15 May 2018,
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Balci, AK, Koksal, O, Kose, A, Armagan, E, Ozdemir, F, Inal,

T & Oner, N 2013, ‘General characteristics of patients with
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