ELECTROLYTE IMBALANCES Labs indicate:

↓ serum and urine sodium

↓urine specific gravity and
A.SODIUM IMBALANCES
osmolality
(HYPONATREMIA VS HYPERNATREMIA)
 Sodium: 135 to 145 mEq/L (135 to 145 mmol/L)
 Primary determinant of ECF and osmolality
 A loss or gain of sodium = loss or gain of water
 For muscle contraction and transmission of
nerve impulses
 Eg. SIADH (Syndrome of Inappropriate
Anttidiuretic Hormone)
 Causes body to retain too much water (water >
sodium)
 Adrenal Insufficiency- deficiency of aldosterone

HYPONATREMIA ASSESSMENT AND DIAGNOSTIC FINDINGS

 Serum Na < 135 mEqs/L  History and physical examination
 Acute or Chronic esp.Neurologic examination
 Acute: common result of fluid overload in  Evaluation of signs and symptoms; lab tests
surgical patient  Identifying hyponatremia with increased blood
 Chronic: outside hospital setting; less volume and decreased blood volume
serious neurological sequelae
 Type of Hyponatremia: HYPONATREMIA WITH INCREASED OR
o Exercise-associated hyponatremia- NORMAL BLOOD VOLUME
excess fluid intake before exercise
or prolonged exercise → decrease Causes:
serum sodium  SIADH- impaired water secretion
 Fluid shifts- eg edema, hypotonic IV solutions,
CONTRIBUTING FACTORS hyperglycemia
 Use of diuretics  ↑ fluid intake
 Loss of GI fluids Signs and Symptoms:
 Renal disease (fluid overload) muscle weakness, headache, lethargy, apathy,
 Adrenal insufficiency convulsions, confusion, edema, weight gain, elevated
 Excessive administration of water supplements, BP, muscle cramps, coma, increased mean arterial
D5W, hypotonic tube feedings pressure (MAP)
 SIADH
 Oxytocin (causes water retention) HYPONATREMIA WITH DECREASED BLOOD
 Hyperglycemia VOLUME
 Heart Failure
Causes:
SIGNS/SYMPTOMS & LABORATORY FINDINGS  GI losses: diarrhea, vomiting, laxatives
 Anorexia, nausea and vomiting  Renal loss: diuretic, hypoaldosteronism
 Headache, dizziness and confusion, seizures Signs and Symptoms:
 Lethargy, muscle cramps and weakness tremors, personality changes, anxiety, cold skin,
 Muscular twitching irritability, dizziness, postural hypotension, clammy
 Papilledema ( swollen eyes) skin, dry mucous membrane, seizure, coma, decreased
 Dry skin, poor skin turgor, dry mucosa mean arterial pressure (MAP), decreased central
 Increase pulse venous pressure (CVP), decreased cardiac output
 Decrease BP
 Weight gain and edema
MEDICAL MANAGEMENT  For patients with IV: Assess for signs of
 Treating the underlying condition circulatory overload (eg cough, dyspnea and
 Sodium replacement: usual daily sodium puffy eyelids, excess weight gain in 24 hours)
requirement in adults is approximately 100
mEq, provided there are not excessive losses  For patient with SIADH and on lithium therapy:
o sodium is consumed abundantly in a normal salt and oral fluid intake is encouraged
normal diet
o Lactated Ringer’s Solution or isotonic
saline (0.9% NSS) as prescribed

TAKE NOTE: serum Na+ must not be increased more

than 12 mEqs/L in 24 hrs to avoid neurologic
damage
 Water restriction ( for hyponatremia with
excess fluid)
 Administer small volumes of hypertonic sodium
solution as prescribed

PHARMACOLOGIC THERAPY HYPERNATREMIA

 AVP receptor antagonists: IV conivaptan
hydrochloride (Vaprisol)  Serum Sodium level >145 mEq/L (145 mmol/L)
o Limited to hospitalized patients  Gain of sodium in excess water or loss of water
(moderate to severe) in excess of sodium
o C/I: SEIZURES, delirium or coma
(warrants use of hypertonic saline)- Causes:
produce lesions that result to myelin  Water loss: px loses more water than Na+
destruction →↑serum Na+
 Lithium (Lithobid)- for SIADH; antagonizes  concentration and ↑ concentrations PULLS fluid
osmotic effect of ADH OUT of the cell
 Tolvaptan (Samsca): for significant o Diabetes insipidus , watery diarrhea,
hypervolemic and euvolemic hyponatremia  Excess sodium: hypertonic saline solution
(D5LR, D5NSS),
NURSING MANAGEMENT o Cushing’s syndrome
 Monitor intake and output, as well as body
weight
 Be alert for GI manifestations such as vomiting ,
anorexia
 Monitor for neurological changes such as
lethargy, confusion
 Monitor for lab values: serum sodium, urine
sodium and specific gravity
 Encourage foods and fluids with high sodium CLINICAL MANIFESTATIONS
(canned or processed foods, iced tea,  Increased plasma sodium concentration
lemonade or fruit drinks) for patient with  Cellular dehydration (water moves out of the
abnormal losses of sodium when in general cell) and more concentrated ECF
diet.  Primary characteristic: Thirst
o Ex: broth made with one beef cube
contains approximately 900 mg of CONTRIBUTING FACTORS
sodium; 8 oz of tomato juice contains  Fluid deprivation
approximately 700 mg of sodium  Hypertonic tube feeding w/o adequate water
 Restrict fluid intake as ordered ( if primary supplements
problem is water retention)  Diabetes insipidus
 Heatstroke
  Watery diarrhea  Ensure adequate water intake for patients with
 Burns Diabetes Insipidus
 Diaphoresis  Monitor for patient’s response to parenteral
 Excess corticosteroid fluids
 Excess sodium chloride administration Note: Too-rapid reduction in the serum sodium →causes
 Saltwater near-drowning victims movement of fluid into brain cells and dangerous
cerebral edema.
SIGNS AND SYMPTOMS
 Thirst B.POTASSIUM IMBALANCES
 Elevated body temp  Normal range:
 Swollen dry tongue 3.5 to 5 mEq/L (3.5 to 5 mmol/L)
 Lethargy, restlessness  Influences both skeletal and cardiac muscle
 Twitching, hyperreflexia activity
 Hyperreflexia  Commonly associated with various diseases,
 Increased BP and pulse injuries, medications (ACE inhibitors) and acid-
base imbalances
LABORATORY FINDINGS  Regulated by kidneys to maintain balance: 80%
 ↑serum Na K+ excreted by kidneys, 20% by bowel and
 ↑urine specific gravity sweat
 and osmolality  When pH is low, the excess H+ ion in the blood
 ↓urine sodium move into the cells. To maintain electric
 ↓ CVP equilibrium potassium moves out of the cell in
response.

HYPOKALEMIA (POTASSIUM DEFICIT)

Causes:
MEDICAL MANAGEMENT
 gradual lowering of the serum sodium level by
the infusion of a hypotonic electrolyte solution
(e.g., 0.3% sodium chloride) or an isotonic
nonsaline solution (e.g., dextrose 5% in water
[D5W])
 Diuretics
 serum sodium level is reduced at a rate no Signs/ symptoms:
faster than 0.5 to 1 mEq/L/h
 Desmopressin acetate (synthetic ADH) for
diabetes insipidus
 Monitor fluid losses and gains
 Obtain medication history
 Monitor for clinical signs and symptoms
 Provide oral fluids at regular intervals- for
patients unable to perceive thirst
 Consult with primary provider to plan an Laboratory findings:
alternative route of intake(unconscious patient
or intake remains inadequate); enteral or
parenteral route
 serum potassium level below 3.5 mEq/L (3.5
mmol/L)
 Inadequate intake of Potassium
 Increased urine production: aldosterone
stimulation (hyperaldosteronism)
 Movement of Potassium into the cells:
anabolism, alkalosis, treatment of DKA with
insulin, refeeding syndrome, treatment of
acidosis
 Increased GI losses, bulimia
 Excess perspiration
 Medications: antibiotics, diuretics, laxatives
 Fatigue, anorexia, nausea and vomiting,
 Muscle weakness, leg cramps
 Polyuria
 Decreased bowel motiliy (Reduced neural
conduction in ENS)
 Weak pulse
 Ventricular dysrhythmia
 ECG changes: flat T waves or inverted T waves
or both
 o Prominent U wave  Monitoring fluid intake and output is necessary
o ST depression, prolonged PR interval  Oral route is ideal ( mild to moderate): absorbs
 ↑urine Potassium K+ well.

FOODS RICH IN POTASSIUM

• Apricots and apricot juice
• Avocados
• Cantaloupe and honeydew melon
• Fat-free or low-fat (1 percent) milk
• Fat-free yogurt
• Grapefruit and grapefruit juice (talk to your
healthcare provider if you’re taking a cholesterol-
lowering drug)
• Greens
• Halibut
• Lima beans
• Molasses
• Mushrooms
• Oranges and orange juice
• Peas
• Potatoes
• Prunes and prune juice
• Raisins and dates
• Spinach
• Tomatoes, tomato juice and
• tomato sauce
• Tuna

 Potassium is given if there is ADEQUATE URINE

MEDICAL MANAGEMENT
 increase intake in the daily diet or by oral
potassium supplements
 Cautious IV replacement therapy for severe
hypokalemia (serum level of 2 mEqs/L)
 Dietary intake of potassium in the average adult
is 50 to 100 mEq/day
 Food high in K+: fruits (banana and avocado),
vegetables, legumes, whole grains
 Potassium acetate or Potassium phosphate may
be prescribed
NURSING MANAGEMENT
 Monitor early presence of s/s in patients at risk:
fatigue, anorexia paresthesia
o e.g patients receiving digitalis or digoxin
 Encourage to take in foods high in potassium
like bananas, melon, citrus fruits, fresh
and frozen vegetables (avoid canned
vegetables), lean meats, milk, and whole grains
OUTPUT.
 NEVER give Potassium by IV push or
Intramuscularly
 Administration of IV potassium is done with
extreme caution using an infusion pump.
 Caution must be used when selecting a
premixed solution of IV fluid containing KCl, as
the concentrations range from 10 to 40
mEq/100 mL
 Monitor BUN, creatinine levels and urine output
HYPERKALEMIA (POTASSIUM EXCESS)
 serum potassium level greater than 5 mEq/L [5
mmol/L])
 more dangerous because cardiac arrest is
 more frequently associated with high serum
potassium levels
 Causes:
 decrease renal excretion of K+
 Excess IV potassium administration
 Insulin deficiency, acidosis (low pH, high K+)
Contributing factors
 Oliguric kidney injury
 Use of Potassium- conserving diuretics
 Addison’s disease / hypoaldosteronism
  Stored bank blood transfusions (serum
potassium concentration of stored blood
increases due to red blood cell deterioration)
 ACE inhibitors, NSAIDS and cyclosporine
 burns
Signs and Symptoms:
 respiratory distress, diarrhea, irritability,
anxiety, muscle weakness, paresthesia,
abdominal cramping, anuria, ECG changes,
hyperreflexia
LABORATORY FINDINGS:
 ECG: tall tented T waves, prolonged PR interval
and QRS duration, absent P waves and ST
depression
NURSING MANAGEMENT
C. CALCIUM IMBALANCES
MEDICAL MANAGEMENT
 Obtain ECG tracing
 Repeat serum potassium levels without IV
infusing potassium solution
 Restriction of dietary potassium and potassium
containing medication to correct balance
 Sodium polystyrene sulfonate (Kayexelate): oral
or as an enema
 IV Calcium Gluconate (for severe hyperkalemia):
antagonizes action
 of hyperkalemia on the heart but does not ↓
serum K+ concentration
 IV Sodium bicarbonate: treat metabolic
acidosis→ shift K+ into cells
 IV administration of regular insulin and a
hypertonic dextrose solution
 Loop diuretics, such as furosemide, increase
excretion of water by inhibiting sodium,
potassium, and chloride reabsorption in the
ascending loop of Henle and distal renal tubule
 Beta-2 agonists, such as albuterol (Proventil,
Ventolin), are highly effective in decreasing
potassium
 Peritoneal dialysis and hemodialysis- for long
term
 Close monitoring for signs of hyperkalemia to
patients withkidney disease; muscle weakness
and dysrhythmias.
 Encourage px to adhere to the prescribed
potassium restriction
 Avoid potassium-rich foods such as vegetables,
legumes, whole- grain breads, lean meat, milk,
eggs, coffee, tea, and cocoa
 Foods with minimal K+ content are butter,
margarine, cranberry juice or sauce, ginger ale,
gumdrops or jellybeans, hard candy, root beer,
sugar, and honey
 Caution patients to use salt substitutes
sparingly, or other supplementary forms of K+
or K+ conserving diuretics.
 NORMAL TOTAL SERUM CALCIUM:
8.6 to 10.2 mg/dL (2.2 to 2.6 mmol/L)
 Calcium is found in the ECF but less than 1% of
total body Calcium is there.
 Major component of bones and teeth; 99% of
body’s Calcium is located in
 skeletal system
 Plays a major role in TRANSMITTING NERVE
IMPULSES, helps regulate MUSCLE
CONTRACTION AND RELAXATION including
Cardiac muscle
 Plays a role in BLOOD COAGULATION
  Calcium is absorbed from foods in the presence
of normal gastric acidity and
 vitamin D
 Controlled by PTH and calcitonin
HYPOCALCEMIA (CALCIUM DEFICIT)
• SERUM CALCIUM LEVEL
8.6mg/dl (2.15 mmol/L)
CAUSES:
 Hypoparathyroidism- common
 Thyroid and Parathyroid surgery
 Massive transfusion of citrated blood
 Pancreatitis
 decreased intake: decreased absorption
(diarrhea, gastric surgery)inadequate Vitamin D
consumption, magnesium deficiency
 diuretics
 Hyperphospatemia
 Osteoporosis
CLINICAL MANIFESTATIONS
• Tetany: most characteristic of hypocalcemia
and hypomagnesemia; involuntary contraction
of muscles, spasms or tremors
• Chvostek sign- twitching of facial
muscles in response to tapping over
the area of facial nerve
• Trousseau sign- carpopedal spasm
induced by inflating a bp cuff
SIGNS AND SYMPTOMS
• Seizures/convulsions
• Mental changes: depression, impaired memory
• Dyspnea and laryngospasm
• Tingling fingers
• hyperactive bowel sounds, dry and brittle hair
and nails, and abnormal clotting- if
severe
• ECG TRACING: prolonged QT intervals due to
prolongation of ST segment
• Torsades de pointes- type of ventricular
tachycardia may occur; due to long QT
interval
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Evaluate serum Calcium levels and Serum
albumin levels (some Calcium in blood is bound
to protein) and pH
• Magnesium: low Mg may cause low Ca
• Parathyroid hormone: Decreased levels indicate
hypoparathyroidism which is related to low
calcium
• Phosphorus: elevated Phosphorus may cause
low Ca
MEDICAL MANAGEMENT
• Calcium replacements: IV Calcium gluconate
(best option) and Calcium chloride (More
irritating to IV site)- IV site must be observed for
evidence of infiltration
Nutritional Therapy
• Vitamin D supplement
• Regular sun exposure (7am-9am) atleast 10-30
minutes
• Calcium supplements must be given in divided
doses of no higher than 500 mg to promote
calcium absorption
• Calcium-containing foods include milk products,
cheese, soy ; green, leafy vegetables
(spinach); salmon; canned sardines; and fresh
oysters,
NURSING MANAGEMENT
• SEIZURE Precaution if severe
• Monitor status of airway- laryngeal stridor
• Educate px about foods rich in Calcium
• Calcium supplements
• Advise px to limit intake of alcohol and caffeine
in high doses; limit smoking
• Avoid overuse of laxatives and antacids that
contain phosphorus → decrease Calcium
absorption
HYPERCALCEMIA (CALCIUM EXCESS)
• Serum Calcium > 10.2mg/dL (2.6 mmol/L)
CAUSES:
 Malignancies and hyperparathyroidism
 Immobility ( multiple fractures and spinal injury)
 Thiazide diuretics- potentiate action of PTH
 Vitamin A and D intoxication
 Hypophosphatemia, hyperthyroidism
 Digoxin toxicity
ASSESSMENT AND FINDINGS
SIGNS AND SYMPTOMS
 Muscle weakness, nausea, vomiting abdominal
cramps, constipation, bone pain, polyuria and
polydipsia, dehydration, Flank pain, calcium
stones, bradycardia
 Hypercalcemic crisis: acute rise in serum Ca+
level to 17mg/dl or
 more – severe thirst and polyuria
 ECG findings: shortening QT interval and ST
segment, prolonged PR interval. more severe:
ventricular dysrhythmia.
 XRAY: Bone cavitation, urinary calculi
MEDICAL MANAGEMENT
• Treating the underlying cause is very important
(e.g. hyperparathyroidism, chemotherapy for
malignancy)
Pharmacologic Therapy
• Administration of fluids to dilute serum calcium
such as 0.9% Sodium Chloride Solution →
increases urinary Ca+ secretion
• IV phosphate- also drops serum Calcium
• Furosemide- together with saline solution→
increases Ca+ excretion
• Calcitonin- useful for patients with heart and
kidney disease; reduces bone resorption ; given
IM
• Bisphosphonates e.g Pamidronate disodium
(Aredia) and Ibandronate sodium (Boniva)-
inhibits osteoclast activity; often used for
malignant disease
• Plicamycin: cytotoxic antibiotics that decreases
bone resorption. Used with neoplastic
disorders
• Corticosteroids: competes with Vitamin D for
absorption in small intestine→ decreases
calcium absorption
NURSING MANAGEMENT
• Monitor for patients at risk of hypercalcemia:
s/s
• Increase patient mobility
• Ambulate as possible (for hospitalized patients)
• Encourage fluids; fluids containing sodium
assists with Calcium excretion (2.8 to 3.8 L of
fluid daily) unless contraindicated
• Adequate fiber in diet : for constipation
• Cardiac rate and rhythm are monitored for any
abnormalities
D. PHOSPHORUS IMBALANCES
 Normal serum phosphorus (HPO4) level:
2.5 to 4.5 mg/dl (0.8 to 1.45mmol/L)
 Phosphorus is the main anion of the cell
 Stored with Calcium in bones and teeth
 Regulated by Parathyroid hormone: phosphate
reabsorption in the kidney
 and allows shift of phosphate from bone to
plasma
FUNCTION OF PHOSPHORUS:
• Nerve and muscle function and red blood cells
• Acid/base balance
• Component of ATP
• CHO, CHON, and fat metabolism
• Part of structure of bones and teeth
HYPOPHOSPHATEMIA
 Value < 2.5mg/dl (0.8 mmol/L)
 Abnormally low content of phosphorus in lean
tissues
CAUSES:
 Inadequate intake: TPN with inadequate
phosphorus
 Refeeding after starvation, alcohol withdrawal,
respiratory and metabolic alkalosis, burns,
diarrhea
 Medications: phosphate binding
antacids(aluminum,calcium,magnesium),diureti
cs, laxative abuse
 Low magnesium levels and low Potassium levels
 Hyperparathyroidism
ASSESSMENT AND DIAGNOSTIC FINDINGS
SIGNS AND SYMPTOMS
 Paresthesia, muscle weakness, bone pain,
seizures, tissue hypoxia.
 Confusion, respiratory failure, nystagmus
 ( repetitive uncontrolled movement of
 the eyes)
 Insulin resistance and hyperglycemia- causes
slight decrease in serum phosphorus levels
LABORATORY FINDINGS:
 Increased PTH levels
 Low serum magnesium levels
 Increased Alkaline Phosphatase – due to
increased osteoblastic activity Xray: changes in
bone density; osteomalacia(softening of bones)
or rickets
MEDICAL MANAGEMENT
 Treating the underlying cause
 IV preparation of phosphorus: sodium or
potassium phosphate
 (IV site should be monitored: may cause tissue
sloughing and necrosis due to infiltration
 Avoid phosphate binders such as aluminum,
magnesium and calcium
 antacids
NURSING MANAGEMENT
 Gradually introduce parenteral solutions (for
malnourished patients)- to avoid rapid shifts of
phosphorus into the cells.
 Encourage patient to take in foods rich in
Phosphorus such as milk and milk products,
organ meats, fish, poultry and whole grains
HYPERPHOSPHOTEMIA
 Serum Phosphorus levels
o >4.5mg/dl (1.45 mmol/L)
CAUSES:
 hypoparathyroidism, acute or chronic renal
failure
 Excessive Vitamin D intake and phosphorus
supplements, excessive use of laxatives and
enemas (absorbs phosphorus)
 respiratory acidosis and metabolic acidosis,
diabetic ketoacidosis, infection
 Neoplastic disease (leukemia, lymphoma),
increased tissue catabolism (trauma, crush
injury), tumor lysis syndrome, chemotherapy,
rhabdomyolysis (breakdown of striated muscle)
SIGNS AND SYMPTOMS
 Tetany (low calcium; high phosphorus): inverse
relationship
 Signs and symptoms of hypocalcemia
  Muscle weakness (pulls Calcium out of your  AVOID phosphate containing laxatives and
bones),Tachycardia, nausea and vomiting enemas (absorbs phosphates; also causes
 Soft tissue calcifications in lungs, heart, kidneys hypocalcemia)
and cornea  Monitor for changes in urine output
LAB FINDINGS:
 BUN, Creatinine: to assess renal status
 PTH levels are low: hypoparathyroidism
 XRAY: Skeletal changes with abnormal
development
 Low serum Calcium levels

MEDICAL MANAGEMENT
 Treatment of underlying disorder
 Vitamin D preparation: calcitriol, which is E. MAGNESIUM IMBALANCES
available in both oral (Rocaltrol) and parenteral  normal serum magnesium level is
(Calcijex, paricalcitol [Zemplar]) formscan help o 1.3 to 2.3 mg/dL (0.62 to 0.95 mmol/L)
reduce PTH levels.  Magnesium (Mg++) is an abundant intracellular
 Phosphate binders: Sevelamer (Renvela) ;binds cation
to Phosphorus in the GI tract to decrease  Activator for many intracellular enzyme systems
absorption; prevents hypocalcemia  Carbohydrate and protein metabolism
 Calcium binding Antacids: calcium carbonate or  Important in neuromuscular function; sedative
calcium citrate effect at neuromuscular junction
o binds phosphorus and decreases  is controlled by Vitamin D; regulated by kidneys
absorption Excretion is affected by 3 things:
 Loop diuretics (Lasix)  ↑ PTH → ↓ Mg Excretion
 Dialysis - severe  ↓ Sodium and Calcium excretion → ↓ Mg
Excretion
NURSING MANAGEMENT  ↓ blood volume → ↓ Mg Excretion
 Monitor patients at risk for hyperphosphatemia
 Low phosphorus diet as prescribed (refined oils:
sunflower oil, palm oil), fruits, vegetables,
eggwhite: good low phosphorus source of
CHON, soymilk; no meat (more phosphorus is
easily absorbed)
 AVOID phosphorus-rich foods, such as hard
cheeses, cream, nuts, meats, whole- grain
cereals, dried fruits, dried vegetables, sardines,
sweetbreads, and foods made with milk
HYPOMAGNESEMIA
• <to normal serum Mg of
• 1.3 mg/dl/0.62 mmol/L
• Associated with HYPOKALEMIA and
HYPOCALCEMIA
CAUSES:
• Decreased intake: decreased GI absorption-
malabsorption
• Increased magnesium excretion: diuretics
• Excess GI loss (vomiting, diarrhea, nasogastric MANAGEMENT
suction, fistula) • Diet: green leafy vegetables, nuts, seeds,
• alcoholism, cirrhosis, hyperthyroidism, legumes, whole grains, seafood, peanut butter,
hypothyroidism, pancreatitis, preeclampsia, and cocoa
hemodialysis, hypercalcemia, hypothermia, • IV or IM Magnesium Sulfate: must be given via
burns, sepsis, wound debridement Infusion pump
• Vital signs must be assessed frequently : cardiac
rate, hypotension and respiratory distress
• Monitor urine output
• Seizure precaution

HYPERMAGNESEMIA
• > 3.0 mg/dl (1.25 mmol/L)
Causes:
• Kidney injury: common cause (kidneys
normally excrete magnesium)
SIGNS AND SYMPTOMS
• Diabetic ketoacidosis
• paresthesia, insomnia, loss of appetite, mood
• Use of Mg antacids (Maalox, Riopan, Mylanta)
changes, confusion, fatigue, weakness,
or laxatives (Milk of Magnesium)
hallucinations
• Opioids and anticholinergics
LABORATORY FINDINGS:
Lab findings: ECG: AV block, prolonged PR interval, tall T
• ECG: may see changes related to magnesium,
waves and
potassium or calcium deficiencies. flat or
widened QRS and high serum Mg levels
inverted T waves; depressed ST
segment.Prolonged PR interval and widened
MANAGEMENT
QRS
• Treat underlying cause: if magnesium is high
• Serum Albumin: if albumin is decreased it may
due to medication,
cause decreased magnesium level
• d/c the medication (antacids or laxatives that
• Serum Calcium and Potassium: decreased ( Mg
have magnesium: Maalox, Mylanta, Mag
helps to transport Ca and K in and out of the
Citrate, Milk of Magnesia, Mag-Sulfate)
cells)
• Loop diuretics and NSS/PLR IV solution will help
• Serum Ionized Mg: decreased – tends to reflect
intracellular magnesium increase magnesium excretion, as long as
• Serum Magnesium: decreased (can be normal patient has adequate renal function.
despite low intracellular magnesium) • IV Ca gluconate: counteract neuromuscular
• Serum Potassium: decreased – hypokalemia effects of Mg if
• Hypermagnesemia is severe.
may be resistant to replacement if the cause is
• Dialysis with a low magnesium dialysate (pt
a problem with the sodium-potassium pump –
with severe renal impairment)
magnesium may need to be repleted first
NURSING MANAGEMENT
• Low Urine Magnesium
• STRICT intake and output
• Place patient under cardiac monitoring
• Watch for hypotension, bradycardia and
respiratory depression (shallow respiration)
 • Assess neuromuscular function: decreased deep  Instruct to avoid drinking free water without
tendon reflex and change in LOC electrolytes (excretes large amounts of
chloride)
F. CHLORIDE IMBALANCES
 Normal range: 97-107 mEqs/L (97-107 mmol/L) HYPERCHLOREMIA
 Found more in interstitial and lymph fluid  >108 mEqs/L
compartments than in blood; also contained in SIGNS AND SYMPYOMS:
gastric, pancreatic juices, sweat, bile and saliva Associated with:
 Largest electrolyte composition of the ECF and  Hypernatremia; dehydration
assist in determining osmotic pressure  Corticosteroids, resp. alkalosis, metabolic
 Produced in the stomach; combines with HCL acidosis
 Dependent with sodium  Head injury (causes water retention)
SIGNS/SYMPTOMS:
-tachypnea, lethargy, weakness , decrease cardiac
output, lethargy, dyspnea
LABORATORY FINDINGS:
 Increased CL, increase K+ and Na+, low pH, low
HCO3, increase urinary chloride level

MANAGEMENT
 Hypotonic solutions may be given
 PLR solution may be prescribed: corrects
acidosis
 IV sodium bicarbonate: excretes excess
HYPOCHLOREMIA chloride ions
 <96 mEq/L  Diuretics
CAUSES: Parallel to hyponatremia  Vital signs, I & O, blood gas values
 Diarrhea and prolonged vomiting  Maintain adequate hydration
 Excessive sweating
 Loop, osmotic diuretics
 Addison’s disease
SIGNS/SYMPTOMS
- agitation, irritability, muscle cramps
- Dysrhythmias, seizures and coma
- s/s of hyponatremia ang hypokalemia,
metabolic acidosis

LABORATORY FINDINGS:
 Decrease serum chloride, decrease serum
sodium, increase pH, increase serum
bicarbonate, increase total CO2 content,
 Decrease urine Chloride level and decrease
potassium

MANAGEMENT
 0.9% NSS or 0.45% NaCl IV for replacement
 Discontinue diuretics
 Ammonium chloride- treats met. Alkalosis
 Diet rich in high chloride content: tomato
juice, bananas, dates, cheese, eggs, milk,
salty broth , canned veggies and processed
meats