Fluid and Electrolytes: Part 3

hypermagnesemia and hyperalcemia

-they act like sedatives (always with these 2 think muscles first!)

Magnesium

-excreted primarily by the kidneys but can also be lost via the GI tract

-If kidneys are messed up, you wont be able to get rid of the magnesium

-Hypermagnesemia

-causes

-renal failure-if the kidneys are not working, they cannot get rid of the magnesium so it will build
up in the blood

-anytime you have a pt with hypermagnesemia they probably already have a kidney problem

- S&S

-flushing and warmth. Magnesium causes us to vasodilate (that is why it is given to the PIH
(pregnancy induced hypertension) pt whose BP is really high and when you give magnesium, it
will cause the pt to vasodilate, making their BP drop. The Magnesium will also prevent seizures
for PIH pts b/c it works like a sedative)

-if im sedated, deep tendon reflexes will decrease

-muscle tone will be weak and flaccid

-could have arrhythmia

-Level of consciousness will decrease

-pulse will decrease

-RR will decrease

-safety issues b/c these pts are sedated

-treatments

-might need ventilator depending on RR. If RR goes below 12 where they become toxic on
magnesium, they will need a ventilator

-might need dialysis b/c the kidneys are probably not working-and it is the kidneys that may
have caused the hypermagnesemia to begin with

-every time you have a problem with magnesium, you need to keep calcium glutamate
available. Calcium glutamate is the antedote for magnesium toxicity

-calcium glutamate reverses respiratory depression and potential arrhythmias that may
be caused by magnesium toxicity
Calcium

Hypercalcemia

-causes

-hyperparathyroidism-too much PTH

-when serum calcium is too low, the PTH kicks in and pulls the calcium from the bone
and puts it in the blood, therefore the serum calcium level will go up

-thiazides

-make us retain calcium

-immobilization affects the bones, thus affecting calcium

-if we are immobile, calcium will not stay in our bones, it will leave the bone and go into
the blood (we have to bear weight to keep the calcium in the bone)

-S&S

-brittle bones

-develop kidney stones b/c their serum calcium is high and a majority of stones is made up of
calcium

-it acts as a sedative and thus get some of the similar S&S of hypermagnesemia

-muscle tone will be weak and flaccid

-Deep tendon reflexes decrease

-increase risk for arrhythmias

-decreased level of consciousness

-decreased pulse

-decreased RR

-treatments

-get the pt moving and bear weight, making the calcium leave their blood and return to their
bones

-give fluids to prevent kidney stone formation

-phospho Soda and Fleets Enema which both have phosphorous. Calcium has an inverse
relationship with phosphorous

-if im a pt and I have hypercalcemia, it means the calcium levels are high and the
phosphorus levels are low. When you give these 2 products, you are building up the
phosphorous levels which will cause calcium levels to go down

-steroids decrease serum calcium

-add more phosphorous to the diet to decrease the serum calcium-anything with protein**
 -initiate safety precautions b/c these pts are sedated

-must have vitamin D to use calcium-from sunlight to be activated

-calcitonin will decrease serum calcium. When you give calcitonin, you are treating osteoporosis
b/c it is driving the calcium back into the bones

Hypomagnesemia and hypocalcemia

-not enough sedatives

Hypmagnesemia

-causes

-diarrhea: we have a lot of magnesium in our intestines, thus if we have diarrhea, we are also losing a lot
of magnesium

-alcoholic-most frequent pts with hypomagnesemia

-alcohol suppresses release of ADH and a decrease in ADH means pt will diuress

-alcohol is also a hypertonic solution which will also make you diuress

-we get major magnesium in our body from the food that we eat. Do alcoholics like to eat?-no
they like to drink and when they drink a lot of alcohol, they diuress instead of retaining, thus
losing the alcohol

-S&S

-remember not sedated

-rigid and tight muscle tone

-could have seizures

-could have stridor and laryngo spasms b/c the airways is made of smooth muscle

-+ chvostek’s (check by tapping the cheek and it starts to twitch due to hyperirritability-C for cheek)

-+ Trousseas’s: pumping up BP cuff and their hand starts to tremor

-can have arrhythmia

-Deep tendon reflexes will increase

-mind changes-they can be psychotic, depressed, can be anything

-swallowing problems b/c their esophagus is a smooth muscle

-concern of aspiration

-treatment

-magnesium
 -but before giving IV Mag, need to check their kidney function

-ex: say we are giving a pt IV mag. We are checking the urine output as supposed to and their
urine output 10pm was 180mL. an hr later, their urine output dropped to 140mL. are you
worried about that?

-always worried on the test questions!!!

-we don’t always worry about urine output till its really low, as we learned till it gets to
30mL. and it seems like going from 180-140 is not a big difference. But we need to be a
safe nurse so assume the worst!!!

-if urine output dropped from 180-140, we are worried about retaining magnesium-as
magnesium acts as a sedative

1) call the primary HCP-sometimes this is the only answer you can choose but if
there is something you can do to help the problem now-then do that first before
calling the doc!

2) decrease the infusion-message you are sending, im going to kill her-slowly

3) stop the infusion-if there is a chance they are retaining mag-better turn it off
and get someone else

4) reassess in 15 min-message you are sending-im going to just kill her

-they want you to deal with the situation now! You know your pt is getting mag sulfate
IV and their urine output has dropped and you know you must STOP the respiratory
infusion b/c their RR could become suppressed

-place the pt on seizure precautions b/c there is a chance they may have a seizure and if
their mag is low, we want them to eat foods high in mag

-foods high in magnesium: spinach, mustard greens, summer squash, broccoli, halibut,
turnip greens, pumpkin seeds, peppermint, cucumber, green beans, celery, kale,
sunflower seeds, sesame seeds and flax seeds

-what are we supposed to do if pt complains of flushing and sweating we start them on IV mag:
stop it!!! These are normal S&S when giving normal IV mag but could they be a sign of worse
things to come? Yes! That is why we assume the worse

Management and delegation question:

There are 2 nursing assessment down the hall and they are both about to ambulate a pt.
the first NA is about to ambulate someone with a history of grand mal seizures and the
other NA is about to ambulate someone who is 8 hrs post heart cath. In which situation
should the nurse intervene?

-what is the number one thing we have to worry about with a post heart cath-
hemorrhage** some of these pts can go home after the first 8 hours but they still run the
risk of hemorrhage and bleeding to death. Thus we are worried

-people with a history of grand mal seizure they can walk. If they start having a seizure,
what are we supposed to do-break the fall, take them to the floor, protect their head, turn
them to the side so they don’t aspirate, and record notes to call doc

-we will assist the pt with the heart cath***

Hypocalcemia:

-causes

-hypoparathyroidism

-radical neck dissection

-thyroidectomy

-with all 3 of these, its not enough PTH. If we do not have enough PTH, the serum calcium will go
down

-S&S

-remember not sedated

-rigid and tight muscle tone

-could have seizures

-could have stridor and laryngo spasms b/c the airways is made of smooth muscle

-+ chvostek’s (check by tapping the cheek and it starts to twitch due to hyperirritability-C for cheek)

-+ Trousseas’s: pumping up BP cuff and their hand starts to tremor

-can have arrhythmia

-Deep tendon reflexes will increase

-mind changes-they can be psychotic, depressed, can be anything

-swallowing problems b/c their esophagus is a smooth muscle

-concern of aspiration

-treatment

-vitamin D to help utilize the Ca

-phosphate binders drugs which cause the serum phosphorous go down and causes serum calcium to go
up:

-Sevelamer hydrochloride (Renagel)

-calcium acetate (PhosLo)

-Osco

-IV calcium

-before giving IV calcium, make sure they are on a heart monitor

 -give it slowly b/c if you give it too fast, it can cause a heart arrhythmia (the IV calcium will slow
the person down b/c it acts as a sedative, it decreases the HR and widen the QRS complex

Ex: you are giving IV calcium. You have pt on a heart monitor. Their PQRST is looking good so you are
giving them a lil more IV calcium. It slows them down a little bit and widens the QRS complex. You just
threw this person into asystole, death. We do not want this to happen!!!

Sodium (Na)

-Na level in blood is completely depend on how much water you have in your body

-Na follows water but there are times that they do not follow each other; SIADH and DI, and hypernatremia and
hyponatremia

-Hypernatremia

-exact same thing as dehydration; too much Na and not enough water

-causes:

-hyperventilation: every time you exhale, you loose water aka insensible fluid loss

-heat stroke

-Diabetes insipidus

-S&S

-dry mouth

-swollen tongue (with severe hypernatremia)

-neuro changes (Na think neuro changes)

-our brain does not like it when our Na is messed up whether with hypo or hyper Na

-treatments

-restrict Na

-dilute the pt with IV fluids making their Na go down

-daily weights

-I&O: if pt has a Na problem, they also have a fluid problem

-continue to monitor their labs

-feeding tube clients, they continue to be dehydrated. In Ensure feedings, it has everything for
the pts to survive on, except the water
-say we have pt on tube feeding. With these pts we have to watch their serum Na everyday.
Normal serum Na is 135-145. 2 days ago, pts serum Na was 135, yesterday was 137. Today its 139.
The numbers are WNL but everyday they are going up. To prevent dehydration, we ask the PCP if
we can give them more water through their tube feedings. Don’t wait till its out of range to do
something. Do something ahead of time

-hyponatremia

-is too diluted-too much water and not enough Na

-causes:

-drinking too much water for fluid replacement for when the client has been vomiting or
sweating: this only replaces the water and dilutes the blood

-these pts lose fluids and electrolytes

-maybe need to drink Gatorade to replace the fluids and electrolytes

-psychogenic polydipsia-client loves to drink water!!!

-pts getting D5W-sugar and water and they can become diluted

-SIADH-will become diluted b/c they are retaining water

-S&S-Na affects the brain!

-headache

-seizure

-coma

-treatments

-need Na and not water.

-if you have a pt with neuro changes b/c they are so diluted, they may need a
big dose of Na: hypertonic NS (3% NS, 5% NS)-if it’s a hypertonic saline, then you
know its packed with Na

-if we give pt large amount of Na into their vascular space, it will act like a
sponge and thus we are worried here: that Na will be pulling fluid into the
vascular space and putting client at risk for FVE

-thus giving 3% NS is a dangerous solution and in some hospitals, this fluid will
only be given in ICU or may have very specific protocols to follow
 -if we give large doses of Na IV, we have to give it slowly. The brain doesn’t
handle big shifts in the serum Na

We have a pt who is a marathon runner and they are drinking 1 L of water every 15 min-trying
to get pre-hydrated. Now they are at the race and running and sweating and drinking more
water. What would we anticipate the Na levels to be? Low-they are just drinking water so
they are diluting their blood. (diluting their Na, specific gravity, and hematocrit)

Say we have pt 2: granny and has Alzheimer’s and sometimes forgets to drink water. Is she
hyper or hyponatremic? She is hypernatremic. She can be thirsty, hypotensive, and weak.
This can lead to renal failure: no volume to perfuse those kidneys

Potassium (K)

-is excreted by the kidneys

-If the kidneys are not working well, the serum K levels will go up

-Hyperkalemia

-causes

- kidney problems

-Aldactone-makes you retain K

-S&S

-begins with muscle twitching

-proceeds to weakness

-then flaccid paralysis

-could develop a life threatening arrhythmia-could kill you

-treatments

-dialysis b/c the kidneys are not working

-calcium glutamate to decrease arrhythmia

-glucose and insulin: the insulin will carry the glucose and K into the cell, therefore the serum K
will drop

-anytime we give IV insulin, we are worried hypokalemia and hypoglycemia

-Kayexalate (Sodium Polystyrene Sulfonate)

-only time we will give this is when someone already has hyperkalemia
 -it works by exchanging Na for K in the GI tract: the pt has high K so we are giving
Kayexalate and are now exchanging K for Na in the GI tract-we are increasing their Na
and bringing down their K

-Na and K have an inverse relationship

-b/c we are increasing their Na, they can now become dehydrated. What can you do to
offset the dehydration-give them fluids

Hypokalemia

-causes

-vomiting

-NG suction

-we have lots of K in our stomach

-diuretics

-not eating

-S&S

-muscle cramps

-then muscle weakness

-then arrhythmias

-treatment

-give K

-aldactone to help them retain some K

-encourage to eat more K

ECG changes with Hyperkalemia:

Bradycardia, tall and peaked T waves, prolonged PR intervals, flat or absent P waves, and widened QRS,
conduction blocks, ventricular fibrillation

ECG changes with Hyppkalemia:

U waves, PVCs, and ventricular tachycardia

Miscellaneous Info:

-a major problem with PO K: GI upset thus want to give with food

-assess urine output before and during IV K-if urine drops during IV infusion, they are retaining K and this
could kill the client
 -be certain pt has good urine output when giving IV K

-always put IV K on a pump and mix it well and never give IV K push

-it will burn in the infusion especially if it is a strong concentration-K eats up peripheral veins

-foods high in K:

-spinach, kale, mustard greens, Brussel sprouts, broccoli, eggplants, cantaloupe, tomatoes, parsley,
cucumber, bell pepper, apricots, ginger root, strawberries, avocado, banana, tuna, halibut,
cauliflower, kiwi, oranges, lima beans, potatoes (white or sweet), cabbage