FATHER SATURNINO URIOS UNIVERSITY

BACHELOR OF SCIENCE IN NURSING – 3RD YEAR LEVEL

NCM 310 MEDICAL – SURGICAL NURSING
N33 | PRELIMS | MRS. APRIL LOVE OJA, RN-MAN
TRANS #03 | TRANSCRIBED BY:
KATHLEEN MARIE E. CANONIO
SODIUM IMBALANCES
 Sodium is the most plentiful electrolyte in ECF,
with normal serum sodium levels ranging from CLINICAL MANIFESTATIONS: SALT LOSS
135 to 145 mEq/L
Stupor/Coma
Anorexia, nausea vomiting
Lethargy
Tendon reflexes decreased
Limb weakness
Orthostatic hypotension
Seizure, Headaches
Stomach cramps
DECREASED ECF NORMAL OR INCREASED ECF
● Postural Hypotension ● Weight gain
● Decreased BP ● Increased BP
● Decreased Jugular ● Increased CVP
Venous filling
● Increase pulse, thread
FUNCTIONS OF SODIUM ● Cold, clammy skin

● Primary regulator of the volume, osmolality, and DIAGNOSTIC FINDINGS

distribution of ECF. 1. SERUM SODIUM AND OSMOLALITY
● It is also important for maintaining – Decreased in hyponatremia
neuromuscular activity. 2. 24-HOUR URINE SPECIMEN
– Is obtained to evaluate sodium excretion
HOW SODIUM AFFECTS WATER DISTRIBUTION
BETWEEN FLUID COMPARTMENTS MEDICAL MANAGEMENT
Sodium and Water RETENTION DECREASED ECF NORMAL OR EXCESS ECF
➢ RAAS ● Sodium-containing ● Loop Diuretics:
➢ increase ADH fluids (oral, NGI, IV) isotonic diuresis
● To replace both water ● No to Thiazide
and sodium Diuretics
Sodium and Water ELIMINATION ● Isotonic Ringer’s or
➢ Kidneys (increase GFR) Isotonic Saline Solution
➢ decrease ADH NURSING MANAGEMENT
1. Risk for Imbalanced Fluid Volume
HYPONATERMIA 2. Risk of Ineffective Cerebral Tissue Perfusion.
● Hyponatremia is a serum sodium level of less RISK FOR IMBALANCED FLUID VOLUME
than 135 mEql/L. 1. Use an intravenous flow control device to administer
● Results from a loss of sodium from the body, but hypertonic saline (3% and 5% NaCl) solutions;
it may also be caused by water gains that dilute carefully monitor flowrate and response.
ECF. 2. If fluids are restricted, explain the reason for the
restriction, the amount of fluid allowed and how to
calculate fluid intake.
RISK OF INEFFECTIVE CEREBRAL TISSUE
1. Assess for neurological changes, such as lethargy,
altered level of consciousness, confusion, and
convulsion.
2. Assess muscle strength and tone and deep tendon
reflexes.

CAUSES OF HYPONATREMIA: 4D1N

➢ Diuretics
➢ Diarrhea
➢ Dehydration (Impaired Aldosterone and cortisol
production, Excessive Sweating)
➢ Drains (NGT suction)
➢ Neurological Conditions: stroke, cerebral
hemorrhage

1 | NCM 310 MED SURG | CANONIO, K

 FATHER SATURNINO URIOS UNIVERSITY
BACHELOR OF SCIENCE IN NURSING – 3RD YEAR LEVEL
NCM 310 MEDICAL – SURGICAL NURSING
N33 | PRELIMS | MRS. APRIL LOVE OJA, RN-MAN
TRANS #03 | TRANSCRIBED BY:
KATHLEEN MARIE E. CANONIO

HYPERNATREMIA NURSING MANAGEMENT

● Hypernatremia is a serum sodium level greater
than 145 mEq/L.
● It may develop when sodium is gained in excess
of water or when water is lost in excess of
sodium.
● Either fluid volume deficit of fluid volume excess
often accompanies hypernatremia.
RISK FOR INJURY
1. Monitor and maintain fluid replacement to within the
prescribed limits.
2. Monitor serum sodium levels and osmolality; report
rapid changes to the attending doctor.
3. Monitor neurological function, including mental
status, levels of consciousness and other
manifestations such as headache, nausea, vomiting,
elevated blood pressure, and decreased pulse rate.
4. Institute safety precautions as necessary: keep the
bed in its lowest position, side rails up and padded,
and an airway at the bedside.

QUESTIONS:
1. A patient with a sodium level of 178 is ordered to be
started on 0.45% Saline. What is the most
IMPORTANT nursing intervention for this patient?
TWO REGULATORY MECHANISM THAT PROTECT THE A. Maintain patent IV
BODY FROM HYPERNATREMIA B. Give rapidly to ensure fluids levels are shifted
1. Excess sodium in ECF stimulates the release of properly
ADH so more water is retained by the kidneys. C. Clarify doctor's order because 0.45% saline is
2. The thirst mechanism is stimulated to increase contraindicated in hypernatremia
the intake of water. D. Give slowly and watch for signs and
symptoms of cerebral edema
CAUSE OF HYPERNATREMIA: 7DS
➢ Diuresis 2. You have completed diet teaching with a patient who
➢ Diarrhea has hypernatremia. Which statement by the patient
➢ Diabetes Insipidus causes concern?
➢ Dehydration A. "I will buy fresh vegetables and fruits."
➢ Disease of Kidney B. "I will avoid eating canned foods.
➢ Doctors and nurses (Iatrogenic) C. "I'm glad I can still eat sandwiches with
➢ Drowning bologna."
CLINICAL MANIFESTATIONS: FRIED D. "I will avoid cooking with butter.
➢ Fever, Flushed Skin
➢ Restless, Really Agitated and Thirsty 3. A patient with Cushing's Syndrome has been
➢ Increased Fluid Retention experiencing an infection and has a fever of 102'F.
➢ Edema, Extremely confused On assessment, you find the patient to be confused,
➢ Decreased Urine Output, Dry mouth and skin restless, has dry mucous membranes and flushed
skin. Which finding below correlates with the
DIAGNOSTIC FINDINGS presentation of this patient?
 SERUM SODIUM LEVELS A. Sodium level of 144
- are greater than 145 mEq/L in B. Sodium level of 115
hypernatremia. C. Sodium level of 170
 SERUM OSMOLALITY D. Sodium level of 135
– is greater than 295 mOsm/kg in
hypernatremia.
 WATER DEPRIVATION TEST
– may be conducted to identify diabetes
insipidus.
MEDICAL MANAGEMENT
➢ Oral or intravenous water replacement
➢ Hypotonic intravenous fluids such as0.45 NaCI
solution or 5% dextrose in water
➢ Diuretics may also be given to increase sodium
excretion

2 | NCM 310 MED SURG | CANONIO, K

 FATHER SATURNINO URIOS UNIVERSITY
BACHELOR OF SCIENCE IN NURSING – 3RD YEAR LEVEL
NCM 310 MEDICAL – SURGICAL NURSING
N33 | PRELIMS | MRS. APRIL LOVE OJA, RN-MAN
TRANS #03 | TRANSCRIBED BY:
KATHLEEN MARIE E. CANONIO
POTASSIUM IMBALANCES
 The primary intracellular cation, plays a vital role
in cell metabolism and cardiac and DRUGS CAUSING HYPOKALEMIA: BAD FIT
neuromuscular function.
Beta-2 Agonists (Epinephrine, Albuterol, Salmeterol)
 Normal Value: 3.5-5 mEq/L Amphotericin B
Digoxin
Furosemide
Insulin
Thiazides
HYPOKALEMIA: LOW AND SLOW
HEART MUSCULAR GI
● Arrhythmias ● Decreased ● Decreased
● ECG Changes Deep Tendon motility
flattened/inverted Reflexes ● Constipation
T waves, ● Muscle ● Abdominal
development of U cramps Distention
waves, depressed ● Flaccid ● Paralytic ileus
ST segment paralysis
FUNCTIONS OF POTASSIUM
DIAGNOSTIC FINDINGS
● Involved in cardiac and neuromuscular function
 SERUM POTASSIUM (K+)
● Regulates intracellular osmolality and promoting
- Mild: 3.0 to 3.5 mEq/L, Moderate: h 2.5 to 3.0
cell growth
mEq/L
● Required by glycogen to be deposited in muscle
- Severe: less than 2.5 mEq/L
and liver cells
 ARTERIAL BLOOD GASES (ABGS)
● Plays a role in acid base balance
- is measured to determine acid-base status.
An increased pH (alkalosis) often is
EXTERNAL BALANCE
associated with hypokalemia.
Kidneys: eliminate  RENAL FUNCTION STUDIES
potassium well - such as serum urea and creatinine, may be
EXCRETION

ordered to evaluate for potential causes or

INGESTION

Aldosterone: Increase
effects of hypokalemia.
potassium (K+) =
Food  ECG RECORDINGS
Increase elimination
- are obtained to evaluate the effects of
GI Tract: diarrhea, hypokalemia on the cardiac conduction
through a drainage system.
ileostomy

INTERNAL BALANCE
ICF -> ECF ECF -> ICF
Exercise Insulin
Hyperosmolality Epinephrine
Cell lysis Alkalosis
Acidosis

HYPOKALEMIA
● Is an abnormally low serum potassium less than
3.5 mEq/L
● Results from excess potassium loss
CAUSES OF HYPOKALEMIA: BADLOAD
Barter Conn’s syndrome (hyperaldosteronism)
Alkalosis
Drugs
Laxative abuse, Losses via vomiting & gastric suction
Overdose of Insulin
Acute Glucose Load (Dm- Osmotic Diuresis)
Diarrhea, Drainage

3 | NCM 310 MED SURG | CANONIO, K

 FATHER SATURNINO URIOS UNIVERSITY
BACHELOR OF SCIENCE IN NURSING – 3RD YEAR LEVEL
NCM 310 MEDICAL – SURGICAL NURSING
N33 | PRELIMS | MRS. APRIL LOVE OJA, RN-MAN
TRANS #03 | TRANSCRIBED BY:
KATHLEEN MARIE E. CANONIO
PHARMACOLOGIC MANAGEMENT CLINICAL MANIFESTATIONS: TIGHT AND CONTRACTED
Oral Route Intravenous HEART GI NEUROMUSCULAR
● ST elevation and
● Paralysis
Peaked T Waves ● Diarrhea
● Increased Deep
● Severe VFIB or ● Hyperactive
Tendon Reflex
Cardiac Standstill Bowel Sounds
(DTR)
● Hypotension,
Bradycardia

Clinical Tip:
• Do NOT administered as IV push
• Do not administer undiluted
NURSING MANAGEMENT
1. Decreased Cardiac Output
2. Activity Intolerance
3. Risk of Imbalanced Fluids
DECREASED CARDIAC OUTPUT
1. Monitor serum potassium levels, particularly in the
person at risk of hypokalemia).
2. Monitor vital signs, including orthostatic vitals and DIAGNOSTIC FINDINGS
peripheral pulses.  SERUM ELECTROLYTE
3. Monitor the person taking digitalis for toxicity. - serum potassium level greater than 50
Monitor response to antiarrhythmic drugs. mEa/L
ACTIVITY INTOLERANCE  ABGS
1. Monitor skeletal muscle strength and tone, which are - are measured to determine if acidosis is
affected by moderate hypokalemia. present
2. Monitor respiratory rate, depth and effort; heart rate  ECG
and rhythm, and blood pressure at rest and following - to evaluate the effects of hyperkalemia on
activity. cardiac conduction and rhythm

RISK FOR IMBALANCED FLUID VOLUME MEDICAL MANAGEMENT: C BIG K DIE

1. Maintain accurate intake and output records. (If you see a big k, the patient could die)
Gastrointestinal fluid losses can lead to significant CALCIUM GLUCONATE
potassium losses. - Given intravenously to counter the effects of
2. Monitor bowel sounds and abdominal distension. hyperkalemia on the cardiac conduction system

HYPERKALEMIA B2-AGONIST SUCH AS SALBUTAMOL

- Temporarily push potassium into the cells
● Abnormally high serum potassium level greater
than 5 mEg/L BICARBONATE
- May be given to treat acidosis
● Result from inadequate excretion of potassium,
excessively high intake of potassium, or a shift INSULIN + 50G OF GLUCOSE
of potassium from the ICS to the ECS. - Promote potassium uptake by the cells shitting
potassium out of ECF
CAUSES OF HYPERKALEMIA: MACHINE
KAYEXALATE (SODIUM POLYSTYRENE SULFONATE)
Medications: ACE Inhibitors, NSAIDs, potassium sparing
- Resin that binds potassium in the Gl tract, may
diuretics
Acidosis, metabolic and respiratory be administered orally or rectally
Cellar destruction (burns or traumatic injury) DIURETICS, DIALYSIS
Hypoaldosteronism (Addison's), Hemolysis - Given to promote potassium excretion
Intake (excessive)
Nephrons (renal failure)
Excretion Impaired

4 | NCM 310 MED SURG | CANONIO, K

 FATHER SATURNINO URIOS UNIVERSITY
BACHELOR OF SCIENCE IN NURSING – 3RD YEAR LEVEL
NCM 310 MEDICAL – SURGICAL NURSING
N33 | PRELIMS | MRS. APRIL LOVE OJA, RN-MAN
TRANS #03 | TRANSCRIBED BY:
KATHLEEN MARIE E. CANONIO
NURSING MANAGEMENT
3. A patient with nasogastric suctioning is experiencing
1. Risk of Decreased Cardiac Output
diarrhea. The patient is ordered a morning dose of
2. Risk of Activity of Intolerance
Lasix 20mg IV. Patient's potassium level is 30. What
3. Risk of Imbalanced Fluid Volume
is your next nursing intervention?
A. Hold the dose of Lasix and notify the doctor
RISK OF DECREASED CARDIAC OUTPUT
for further orders
1. Closely monitor the response to intravenous calcium
B. Administered the Lasix and notify the doctor
gluconate, particularly in people toking digitalis
for further orders.
2. Monitor the ECG pattern for development of peaked,
C. Turn off the nasogastric suctioning and
narrow T waves, prolongation of the PR interval,
administer ed a laxative
depression of the ST segment, widened QRS interval
D. No intervention is needed the potassium
and loss of the P wave
level is within normal range
3. Notify the physician of changes. Progressive ECG
changes from a peaked T wave to loss of the P wave
and widening of the QRS complex indicate an
increasing risk of arrhythmias and cardiac arrest.

RISK FOR ACTIVITY INTOLERANCE

1. Monitor skeletal muscle strength and tone
Increasing weakness, muscle paralysis or
progression of affected muscles to affect the upper
extremities or trunk can indicate increasing serum
potassium levels
2. Monitor respiratory rate and depth. Regularly assess
lung sounds
3. Assist with self-care activities as needed Increasing
muscle weakness can lead to fatigue and affect the
ability to meet self-care needs

RISK FOR IMBALANCE FLUID VOLUME

1. Closely monitor serum potassium, serum urea and
creatinine
2. Maintain accurate intake and output records. Report
an imbalance of 24-hour totals and/or urine output
less than 30 mL/hour.
3. Monitor the person receiving sodium bicarbonate for
fluid volume excess

QUESTIONS:
1. A patient has a potassium level of 90. Which nursing
intervention is priority?
A. Prepare the patient for dialysis and place the
patient on a cardiac monitor
B. Administer Spironolactone
C. Place patient on a potassium restrictive diet
D Administer a laxative
2. Tall peaked T-waves, flat P-waves, prolonged PR
intervals and widened QRS complexes can present in
which of the following conditions?
A Hypokalemia
B. Hyperkalemia
C. Hypokalemia
D. Hyperkalemia

5 | NCM 310 MED SURG | CANONIO, K