Electrolyte

Imbalances
 Sodium
Imbalances
Sodium
most abundant electrolyte in the ECF
Sodium
most abundant electrolyte in the ECF
135 to 145 mEq/L
Sodium
most abundant electrolyte in the ECF
135 to 145 mEq/L
primary determinant of ECF volume
and osmolality
Sodium
controls H2O distribution
Sodium
controls H2O distribution
does not cross the cell wall membrane
easily
Sodium
regulated by
ADH
Sodium
regulated by
ADH
thirst
Sodium
regulated by
ADH
thirst
RAAS
Sodium
a loss or gain of Na is usually
accompanied by a loss or gain of H2O
Sodium
establish the electrochemical state
muscle contraction
transmission of nerve impulses
Sodium Imbalances
syndrome of inappropriate secretion
of antidiuretic hormone (SIADH)
Sodium Imbalances
syndrome of inappropriate secretion
of antidiuretic hormone (SIADH)
arginine vasopressin (AVP)
ADH
↓ Plasma osmolality
↓ blood volume
↓ BP
Sodium Imbalances
syndrome of inappropriate secretion
of antidiuretic hormone (SIADH)
older adults
AIDS
mech vent
selective serotonin reuptake inhibitors
(SSRIs)
Sodium Imbalances
sodium deficit
sodium excess
 Sodium Deficit
hyponatremia
less than 135 mEq/L
acute or chronic
 Sodium Deficit
acute hyponatremia
result of a fluid overload in a surgical
patient
 Sodium Deficit
chronic hyponatremia
outside the hospital setting
 Sodium Deficit
chronic hyponatremia
outside the hospital setting
longer duration
 Sodium Deficit
chronic hyponatremia
outside the hospital setting
longer duration
less serious sequelae
 Sodium Deficit
exercise – associated hyponatremia
↓ in Na levels after prolonged physical
activity
extreme temperatures
 Contributing Factors
loss of sodium
use of diuretics
 Contributing Factors
loss of sodium
use of diuretics
loss of GI fluids
 Contributing Factors
loss of sodium
use of diuretics
loss of GI fluids
renal disease
 Contributing Factors
loss of sodium
use of diuretics
loss of GI fluids
renal disease
adrenal insufficiency
 Contributing Factors
loss of sodium
use of diuretics
loss of GI fluids
renal disease
adrenal insufficiency
hyperglycemia
 Contributing Factors
loss of sodium
use of diuretics
loss of GI fluids
renal disease
adrenal insufficiency
hyperglycemia
heart failure
 Contributing Factors
loss of sodium
gain of water
excessive administration of H20
supplements
 Contributing Factors
loss of sodium
gain of water
excessive administration of H20
supplements
diseases associated with SIADH
low blood Na most common cause
 Contributing Factors
loss of sodium
gain of water
excessive administration of H20
supplements
diseases associated with SIADH
medications associated with H2O
retention
 Contributing Factors
loss of sodium
gain of water
psychogenic polydipsia
 Signs & Symptoms
anorexia
 Signs & Symptoms
anorexia
nausea and vomiting
 Signs & Symptoms
anorexia
nausea and vomiting
headache
 Signs & Symptoms
anorexia
nausea and vomiting
headache
lethargy
 Signs & Symptoms
anorexia
nausea and vomiting
headache
lethargy
dizziness
 Signs & Symptoms
anorexia
nausea and vomiting
headache
lethargy
dizziness
confusion
 Signs & Symptoms
muscle cramps and weakness
 Signs & Symptoms
muscle cramps and weakness
muscular twitching
seizures
 Signs & Symptoms
muscle cramps and weakness
muscular twitching
seizures
papilledema
 Signs & Symptoms
muscle cramps and weakness
muscular twitching
seizures
papilledema
dry skin
 Signs & Symptoms
↑ pulse
 Signs & Symptoms
↑ pulse
↓ BP
 Signs & Symptoms
↑ pulse
↓ BP
weight gain
edema
 Laboratory Findings
serum and urine sodium ↓
 Laboratory Findings
serum and urine sodium ↓
urine specific gravity and osmolality ↓
 Pathophysiology
hyponatremia is due to imbalance of
H2O rather than Na
 Pathophysiology
hyponatremia is due to imbalance of
H2O rather than Na
urine Na values
 Pathophysiology
hyponatremia is due to imbalance of
H2O rather than Na
urine Na values
↓ urine Na
vomiting, diarrhea, sweating
 Pathophysiology
hyponatremia is due to imbalance of
H2O rather than Na
urine Na values
↓ urine Na
↑ urine Na
renal salt wasting
 Pathophysiology
dilutional hyponatremia
ECF volume is ↑ without any edema
 Pathophysiology
adrenal insufficiency
↓ aldosterone
 Pathophysiology
adrenal insufficiency
anticonvulsants
Levetiracetam (Keppra)
Valproic Acid (Depakene)
Phenobarbital
Lorazepam (Ativan)
Phenytoin (Dilantin)
 Pathophysiology
SIADH
 Pathophysiology
SIADH
↑ ADH
 Pathophysiology
SIADH
↑ ADH
H2O retention
dilutional hyponatremia
 Pathophysiology
SIADH
↑ ADH
H2O retention
dilutional hyponatremia
↓ Na urine excretion
 Pathophysiology
SIADH
sustained secretion of ADH
 Pathophysiology
SIADH
sustained secretion of ADH
aberrant ADH production
 Pathophysiology
SIADH
central nervous system
 Clinical Manifestations
poor skin turgor
dry mucosa
decreased saliva production
 Clinical Manifestations
poor skin turgor
dry mucosa
decreased saliva production
abdominal cramping occur
 Clinical Manifestations
neurologic changes
altered mental status
status epilepticus
coma
Clinical Manifestations
 Clinical Manifestations
higher mortality rate with cerebral
edema
 Clinical Manifestations
acute ↓ in Na
brain herniation
 Clinical Manifestations
acute ↓ in Na
brain herniation
compression of midbrain structures
 Clinical Manifestations
acute ↓ in Na
chronic ↓ in Na
 Clinical Manifestations
severity of symptoms ↑ with the
degree and speed
 Clinical Manifestations
severity of symptoms ↑ with the
degree and speed
Na ↓ to less than 115 mEq/L
signs of ↑ intracranial pressure
lethargy, confusion, seizures, death
Assessment & Diagnostic Findings
targeted assessment
hx & physical assessment
Assessment & Diagnostic Findings
targeted assessment
hx & physical assessment
neuro exam
Assessment & Diagnostic Findings
targeted assessment
hx & physical assessment
neuro exam
s/sx
Assessment & Diagnostic Findings
targeted assessment
hx & physical assessment
neuro exam
s/sx
lab findings
Assessment & Diagnostic Findings
targeted assessment
hx & physical assessment
neuro exam
s/sx
lab findings
current IV fluids
Assessment & Diagnostic Findings
targeted assessment
hx & physical assessment
neuro exam
s/sx
lab findings
current IV fluids
medications
Assessment & Diagnostic Findings
serum Na level is < 135 mEq/L
SIADH, ↓ 100 mEq/L
serum osmolality ↓
Assessment & Diagnostic Findings
due to Na loss
urinary Na content is < 20 mEq/L
Assessment & Diagnostic Findings
due to Na loss
urinary Na content is < 20 mEq/L
USG is 1.002 to 1.004
Assessment & Diagnostic Findings
due to Na loss
due to SIADH
urinary Na content is > 20 mEq/L
Assessment & Diagnostic Findings
due to Na loss
due to SIADH
urinary Na content is > 20 mEq/L
USG is > 1.012
Assessment & Diagnostic Findings
due to Na loss
due to SIADH
urinary Na content is > 20 mEq/L
USG is > 1.012
no peripheral edema
Assessment & Diagnostic Findings
due to Na loss
due to SIADH
urinary Na content is > 20 mEq/L
USG is > 1.012
no peripheral edema
pitting edema
 Medical
Management
 Na Replacement
Oral
NGT
Parenteral
 Na Replacement
diet
 Na Replacement
diet
lactated Ringer’s solution
isotonic saline
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
altered cognition and decreased alertness
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
altered cognition and decreased alertness
ataxia
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
altered cognition and decreased alertness
ataxia
paraparesis
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
altered cognition and decreased alertness
ataxia
paraparesis
dysarthria
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
horizontal gaze paralysis
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
horizontal gaze paralysis
pseudobulbar palsy
 Na Replacement
Serum Na must not be ↑ by more than
12 mEq/L in 24 hours
to avoid osmotic demyelination
serum Na concentration exceeds 140 mEq/L
horizontal gaze paralysis
pseudobulbar palsy
coma
 Na Replacement
SIADH
hypertonic saline
 Na Replacement
SIADH
hypertonic saline
excess Na excreted in concentrated urine
 Na Replacement
SIADH
hypertonic saline
excess Na excreted in concentrated urine
diuretic furosemide
 Na Replacement
SIADH
hypertonic saline
excess Na excreted in concentrated urine
diuretic furosemide
lithium
 Water Restriction
restrict fluid
 Water Restriction
restrict fluid
hypertonic Na solution
 Water Restriction
restrict fluid
hypertonic Na solution
alleviate cerebral edema
 Water Restriction
restrict fluid
hypertonic Na solution
alleviate cerebral edema
incorrect use is extremely dangerous
 Water Restriction
restrict fluid
hypertonic Na solution
alleviate cerebral edema
incorrect use is extremely dangerous
3% NaCL
Quality & Safety Nursing Alert

highly hypertonic Na solutions (2% to

23% NaCl) should be given slowly and
the patient monitored closely, because
only small volumes are needed to
elevate the serum Na concentration
from a dangerously low level
 Pharmacologic Therapy
AVP receptor antagonists
stimulates free water excretion
 Pharmacologic Therapy
AVP receptor antagonists
IV conivaptan (Vaprisol)
 Pharmacologic Therapy
AVP receptor antagonists
IV conivaptan (Vaprisol)
CI in patients neurologic problems
 Pharmacologic Therapy
AVP receptor antagonists
IV conivaptan (Vaprisol)
oral tolvaptan (Samsca)
 Nursing
Management
 History
get a thorough hx
performance athletes use salt tablets
 History
get a thorough hx
consider the age of patient
 History
get a thorough hx
consider the age of patient
OTC meds
 History
get a thorough hx
consider the age of patient
OTC meds
loss of access to food or fluids
 Detecting and Controlling
Hyponatremia
I&O
body weight
 Detecting and Controlling
Hyponatremia
I&O
body weight
lab values
 Detecting and Controlling
Hyponatremia
I&O
body weight
lab values
neurologic changes
 Detecting and Controlling
Hyponatremia
Nutrition
encourage foods and fluids high in Na
content
 Detecting and Controlling
Hyponatremia
Nutrition
encourage foods and fluids high in Na
content
beef cube, 900 mg of Na
8 oz of tomato juice, 700 mg of Na
 Detecting and Controlling
Hyponatremia
Nutrition
encourage foods and fluids high in Na
content
beef cube, 900 mg of Na
8 oz of tomato juice, 700 mg of Na
be familiar of Na content in IV fluids
 Detecting and Controlling
Hyponatremia
restrict fluid than administer Na
 Detecting and Controlling
Hyponatremia
restrict fluid than administer Na
elevate the serum Na level
alleviate neurologic sx
 Detecting and Controlling
Hyponatremia
restrict fluid than administer Na
elevate the serum Na level
increase to no greater than 125 mEq/L
 Detecting and Controlling
Hyponatremia
Lithium therapy
observe for lithium toxicity
diarrhea
lack of coordination
tremors
trouble walking
altered LOC
 Detecting and Controlling
Hyponatremia
Lithium therapy
observe for lithium toxicity
instruct patient not to use diuretics
 Detecting and Controlling
Hyponatremia
Lithium therapy
observe for lithium toxicity
instruct patient not to use diuretics
normal salt and fluid intake
 Detecting and Controlling
Hyponatremia
avoid excess water supplements
 Detecting and Controlling
Hyponatremia
avoid excess water supplements
monitor I&O
USG
serum Na levels
Quality & Safety Nursing Alert

assesses for signs of circulatory

overload (cough, dyspnea, puffy
eyelids, dependent edema, weight gain
in 24 hours)
auscultate lungs for crackles
 Sodium Excess
hypernatremia
higher than 145 mEq/L
 Sodium Excess
hypernatremia
higher than 145 mEq/L
gain of sodium in excess of water
 Sodium Excess
hypernatremia
higher than 145 mEq/L
gain of sodium in excess of water
loss of water in excess of sodium
 Sodium Excess
hypernatremia
higher than 145 mEq/L
gain of sodium in excess of water
loss of water in excess of sodium
normovolemia
 Sodium Excess
hypernatremia
higher than 145 mEq/L
gain of sodium in excess of water
loss of water in excess of sodium
normovolemia
extra and intracellular FVD
 Sodium Excess
Na excess via oral route
 Pathophysiology
fluid deprivation in unconscious
patients
 Pathophysiology
fluid deprivation in unconscious
patients
very old
very young
cognitively impaired patients
 Pathophysiology
hypertonic enteral feedings
 Pathophysiology
hypertonic enteral feedings
watery diarrhea
 Pathophysiology
hypertonic enteral feedings
watery diarrhea
↑ insensible water loss
 Pathophysiology
diabetes insipidus
doesn’t experience thirst
fluid restriction
 Pathophysiology
hypertonic saline
 Pathophysiology
hypertonic saline
excessive use of NaHCO3
 Pathophysiology
exertional dysnatremia
 Pathophysiology
exertional dysnatremia
on-site blood sodium testing and
treatment
 Pathophysiology
exertional dysnatremia
on-site blood sodium testing and
treatment
0.9% NaCl
 Pathophysiology
exertional dysnatremia
on-site blood sodium testing and
treatment
0.9% NaCl
3% NaCl
 Pathophysiology
exertional dysnatremia
on-site blood sodium testing and
treatment
0.9% NaCl
3% NaCl
oral hypertonic solution
 Pathophysiology
confusion and disorientation
 Clinical Manifestations
↑ plasma osmolality caused by an ↑
concentration of Na in the blood
Clinical Manifestations
 Clinical Manifestations
mental status and behavioral changes
in older patients
 Clinical Manifestations
mental status and behavioral changes
in older patients
mild ↑ of body temperature
 Clinical Manifestations
mental status and behavioral changes
in older patients
mild ↑ of body temperature
impaired thirst mechanism
 Contributing Factors
fluid deprivation
 Contributing Factors
fluid deprivation
hypertonic tube feedings
 Contributing Factors
fluid deprivation
hypertonic tube feedings
diabetes insipidus
 Contributing Factors
fluid deprivation
hypertonic tube feedings
diabetes insipidus
hyperventilation
 Contributing Factors
fluid deprivation
hypertonic tube feedings
diabetes insipidus
hyperventilation
watery diarrhea
 Contributing Factors
fluid deprivation
hypertonic tube feedings
diabetes insipidus
hyperventilation
watery diarrhea
burns
 Contributing Factors
fluid deprivation
hypertonic tube feedings
diabetes insipidus
hyperventilation
watery diarrhea
burns
diaphoresis
 Contributing Factors
corticosteroid
 Contributing Factors
corticosteroid
NaHCO3
 Contributing Factors
corticosteroid
NaHCO3
NaCl administration
 Contributing Factors
salt water near-drowning victims
 Signs & Symptoms
vital signs
↑ body temperature
 Signs & Symptoms
vital signs
↑ body temperature
↑ pulse
 Signs & Symptoms
vital signs
↑ body temperature
↑ pulse
↑ BP
 Signs & Symptoms
gastro-intestinal
thirst
 Signs & Symptoms
gastro-intestinal
thirst
swollen dry tongue
sticky mucous membranes
 Signs & Symptoms
gastro-intestinal
thirst
swollen dry tongue
sticky mucous membranes
nausea
vomiting
anorexia
 Signs & Symptoms
respiratory
pulmonary edema
 Signs & Symptoms
neuromuscular
hyperreflexia, twitching
 Signs & Symptoms
neuromuscular
hyperreflexia, twitching
simple partial or tonic-clonic seizures
 Signs & Symptoms
neuromuscular
hyperreflexia, twitching
simple partial or tonic-clonic seizures
restlessness, irritability
 Signs & Symptoms
neuromuscular
hyperreflexia, twitching
simple partial or tonic-clonic seizures
restlessness, irritability
hallucinations
lethargy
 Laboratory Findings
↑ serum sodium
 Laboratory Findings
↑ serum sodium
↓ urine sodium
 Laboratory Findings
↑ serum sodium
↓ urine sodium
↑ urine specific gravity and osmolality
 Laboratory Findings
↑ serum sodium
↓ urine sodium
↑ urine specific gravity and osmolality
↓ CVP
 Medical
Management
 Intravenous Therapy
hypotonic solution
0.3% NaCl
 Intravenous Therapy
hypotonic solution
isotonic nonsaline
D5W
 Intravenous Therapy
hypotonic solution
isotonic nonsaline
 Intravenous Therapy
hypotonic solution
isotonic nonsaline
 Intravenous Therapy
hypotonic solution
hyperglycemia with hypernatremia
 Intravenous Therapy
hypotonic solution
rapid reduction may cause cerebral
edema
 Intravenous Therapy
diuretics
 Na Reduction
serum Na level is reduced at a rate no
faster than 0.5 to 1 mEq/L/h
 Na Reduction
serum Na level is reduced at a rate no
faster than 0.5 to 1 mEq/L/h
desmopressin acetate
 Nursing
Management
 Nursing Interventions
fluid losses and gains
 Nursing Interventions
fluid losses and gains
medication hx
 Nursing Interventions
fluid losses and gains
medication hx
changes in behavior
 Nursing Interventions
fluid losses and gains
medication hx
changes in behavior
relate current s/sx to other clinical
manifestations
 Preventing Hypernatremia
provide fluids at regular intervals
 Preventing Hypernatremia
provide fluids at regular intervals
plan an alternative route for intake
 Preventing Hypernatremia
provide fluids at regular intervals
plan an alternative route for intake
sufficient water with enteral feedings
 Preventing Hypernatremia
provide fluids at regular intervals
plan an alternative route for intake
sufficient water with enteral feedings
be careful and be selective in taking
herbal meds
 Preventing Hypernatremia
diabetes insipidus
adequate water intake
 Preventing Hypernatremia
diabetes insipidus
adequate water intake
provide access to water
 Preventing Hypernatremia
diabetes insipidus
adequate water intake
provide access to water
parenteral fluid therapy
 Correcting Hypernatremia
review serial serum Na levels
 Correcting Hypernatremia
review serial serum Na levels
observe for changes in neurologic
signs
 Correcting Hypernatremia
too-rapid reduction in the serum Na
level will render the plasma
temporarily hypo-osmotic to the fluid
in the brain tissue