Water daily consume: 2,250 mL

Reasons why we need to drink:

1. All chemical reactions occur in liquid medium.
2. It is crucial in regulating chemical and electrical
distributions within cells.
3. Transports substances such as hormones and
nutrients.
4. O2 transport from the lungs to body cells.
5. CO2 transport in the opposite direction.
6. Dilutes toxic substances and waste products and
transports them to the kidneys and the liver.
7. Distributes heat around the body.
1.1 Interstitial Fluid
All water goes to.. 15% of body weight.
Water constitute an average 50 to 70% of total body ● IF surrounds the cell, but does not circulate,
weight because IF fills the spaces between cells and
facilitates the exchange of nutrients and waste
Young Males 60% of the TBW
without circulating like blood.
Older Males 52% of the TBW ● Found in the tissue spaces
Composition of IF
Young Females 50% of the TBW
● Water solvent ● Neurotransmitters
Older Females 47% of the TBW amino acids ● Salts
● Sugars ● Waste products
● Variation or lesser or greater than 15% is normal. from the cells
● Obese people have 25 to 30% less body water ● Fatty acids
● Lymph is
than lean people. ● Coenzymes considered a part of
● Infants’ 75 to 80% ● Hormones the IF
○ Gradual physiological loss of body water. Function of IF
○ 65% at one year of age. ● Intracellular communication
● Interstitial fluid bathes the cells of the tissues
Water Distribution in Body ● Removal of metabolic waste
● Brain consists of 90% of water.
● Muscle consists 73% of water. 1.2 Plasma
● Bone consists of 22% of water. 5% of total body weight
● Blood consists of 83% of water. ● Yellowish liquid part of blood that carries blood cells
● Transports nutrients and oxygen into cell and other substances throughout the body.
● Moisturizes the air in our lungs and helps with
● Water (90% by ● Clotting factors
metabolism.
volume) ● Mineral ions
Systemic ● Dissolved proteins ● Hormones
1. Detoxing the body ● Glucose ●
2. Water help regulate ● Carbon dioxide
3. Helps our organs to absorb nutrients better
Function of Plasma
4. Protects
● Main medium for excretory product transportation
● Blood serum is the liquid part of blood that remains
Components of Body Fluids
after it has clotted, meaning it doesn’t contain
Total body fluid (60% of total body weight)
clotting proteins like fibrinogen.

Extracellular fluid (20% of total body weight)

1.3 Transcellular Fluid
● Interstitial fluid 15% of total body weight
● The portion of total body water contained within the
● Plasma 5% of total body weight
epithelial lines spaces.
● Transcellular fluid
● The smallest compartment and 2.5% of the total
○ Fluid in potential spaces
body water.
■ Pleural cavity
■ Pericardial cavity
2. Intracellular fluid
■ Peritoneal cavity
Total 40% of total body weight
○ Fluid in GIT and Respiratory Tract
● Comprises ⅔ of the body water.
○ Intraocular fluid CSRF
● If body has 60% water, ICF is about 40% of the
weight.
Intracellular fluid (40% of total body weight)
● OF is composed of: water, dissolved ions (K+,
Magnesium) proteins, and various nutrients and
metabolites.
1. Extracellular fluid
Total 20% of body weight
PHYSIOLOGY OF FLUID AND ELECTROLYTE
● ECF is primarily a NaCL and NahCO3 solution.
REGULATION
○ Maintaining homeostasis, supporting cellular
Mechanisms of Fluid Balance: Osmoregulation (the
functions, and ensuring proper physiological
process that helps maintain the right balance of water and
responses.
salts in the body)
 1. Detecting changes: impaired blood circulation → Pathophysiology (Hypovolemia)
detection of osmoreceptors in the hypothalamus → Fluid loss or decreased intake:
release of ADH → Regulation for fluid balance ● Hemorrhage (Na, K, Cl)
2. Detecting level of concentration: Increased ● Diarrhea (Na, K, Cl, HCO3)
blood concentration → brain releases Antidiuretic ● Vomiting (Cl, Na, K, HCO3)
hormone → kidneys hold onto more water and make ● Excessive Sweating (Na, Cl, K, Ca, Mg)
urine less concentrated → decreased blood ● Inadequate fluid intake (Na, K, Cl, HCO3)
concentration → antidiuretic hormone drops → All of these → decreased blood volume then reduced tissue
kidneys release more water to normalize urine perfusion and oxygen delivery → activation of the body’s
concentration. compensatory mechanisms:
3. Thirst response ● Renin-Angiotensin-Aldosterone System
Renin release → converts angiotensinogen
Mechanisms of how the hormones involved in fluid to Angiotensin I → transform Angiotensin II
and electrolyte regulation: → Vasoconstriction → aldosterone release
1. ADH → promotes sodium and water retention
2. Aldosterone (secreted by the adrenal glands) ● Antidiuretic Hormone (ADH) Release
○ Hypovolemia + hypotension → sodium Pituitary gland releases ADH → increases
reabsorption in the kidneys → increased water reabsorption in the kidneys →
blood volume and pressure retention of fluid → decrease in circulating
3. Natriuretic Peptides (released by the heart, blood volume →
particularly from the atria upper chamber.
low blood pressure, bradycardia, reduced
○ Hypovolemia + hypotension → atrial
urine
natriuretic peptide → sodium excretion in
the kidneys → increased urine production →
and reducing blood volume Immediate care and interventions

Renal function and fluid regulation: A Review → further severe blood loss of 20% (1L) or
1. Filtration more → inability of the body to maintain
The kidneys filter blood in structures called glomeruli, where adequate tissue perfusion and oxygen
waste products, excess salts, and water are removed, delivery → inability of the compensatory
forming a fluid called filtrate. mechanisms to maintain normal BP and CO
2. Reabsorption →
As the filtrate passes through the renal tubules, the kidneys Organ failure is the deterioration of an
reabsorb essential substances back into the bloodstream, organ’s function to the point where it can
including: no longer sustain the body’s needs
● Water: controlled by hormones like ADH, which ● Confusion
● Rapid heart rate
increases water reabsorption when needed
● Weak pulse
● Electrolytes: Na and K levels are regulated to
● Low blood pressure
maintain balance. Aldosterone increases NA ● Decreased urine output
reabsorption which also helps retain water.
→
3. Secretion
The kidneys can also actively secrete additional waste Hypovolemic shock (Life-threatening)
products and excess ions into the filtrate, ensuring that →
harmful substances are eliminated from the body.
4. Urine Formation Place victim in shock position:
The final product, urine, is composed of the substances not
reabsorbed.
5. Regulation of Blood Pressure
The kidneys help regulate BP through the
renin-angiotensin-aldosterone system (RAAS)
● Blood pressure drops → kidneys release renin →
production of angiotensin II (constricts blood vessels
and stimulates aldosterone release) → sodium and Nursing Process and Hypovolemia
water retention. Assessment
1. Hx, etiology of hypovolemia
Kidney
● Diarrhea, Oliguria ● Weak rapid
● Essential for filtering blood, reabsorbing necessary
● Inadequate fluid intake heartbeat
fluids and electrolytes, and regulating fluid balance,
● Vomiting ● Flattened neck
and blood pressure, helping maintain overall
● Bleeding or hemorrhage veins
homeostasis in the body.
● Excessive sweating ● High body
● Sudden weight loss temperature
FLUID VOLUME DISTURBANCES
● Decreased skin turgor ● Polydipsia
HYPOVOLEMIA ● Orthostatic hypotension (increased thirst)
Loss of both water and electrolytes in the same proportions ● Infant: sunken ● Clammy skin
(isotonic), leading to a decrease in overall fluid. fontanelle ● Muscle cramps
Dehydration ● Capillary refill >3 ● Chronic fatigue
● Loss of water alone, which results in an increased seconds ● Anorexia
concentration of electrolytes, particularly in the ● Dry mucous memb.
sodium in the body.
 2. PE: Assess: Fluid volume deficit (measure I&O at Nausea present: Antiemetics used before
least q8h or qhr) oral fluid replacement.
➢ Daily body weight (loss of 0.5kg/1lb) is considered
fluid loss: 600 mL (1L = 1kg = 2.2 lb)
HYPERVOLEMIA
➢ V/S monitor: rapid pulse and orthostatic hypotension
➢ Skin and tongue turgor An isotonic expansion of the ECF caused by the abnormal
➢ Mental function (esp. in FVD due to decreased retention of H2O and Na with the same proportions in which
cerebral perfusion) they normally exist in the ECF.
➢ Decreased peripheral perfusion = cold extremities Overhydration
➢ Px with low cardiopulmonary function: low central ● Excess of total body water, which can dilute
venous pressure = sign of hypovolemia electrolytes and may result in conditions like
hyponatremia, regardless of bloody status
Diagnostic Findings/Laboratory Exam
1. Bun and Creatinine Pathophysiology (Hypervolemia)
Indication: dehydration and hypovolemia ● Increased fluid intake (oral fluid or IVF)
● >20:1 = renal impairment due to reduced ● Decreased fluid excretion: conditions that impair
perfusion. kidney function, such as acute or chronic kidney
● Normal BUN to serum creatinine concentration ratio disease, can lead to decreased glomerular
is 10:1 filtration rate (GFR) resulting in retention of
● K and Na levels can be reduced (hypokalemia, sodium and water.
hyponatremia) or elevated: hyper. ● Hormonal Regulation in fluid balance
● Urine specific gravity is increased: attempt to ○ Renin-Angiotensin-Aldosterone System
conserve water (RAAS)
○ Increased Secretion of Antidiuretic
Nursing Diagnosis: Hormone
Fluid volume deficit related to excessive fluid loss as ● Liver Cirrhosis can lead to altered production of
evidenced by dry mucous membranes, hypotension, albumin that maintain oncotic pressure, resulting in
tachycardia, and decreased urine output. fluid shift into the interstitial space and perceived
volume depletion, prompting fluid retention.
Goal and Outcome Criteria ● In CHF, the heart's reduced pumping ability leads to
The patient will maintain adequate fluid volume status as fluid accumulation. The body compensates by
evidenced by stable vital signs, normal urine output, and activating RAAS and retaining more fluid
appropriate electrolyte levels within 48 hours. exacerbating the overload.
● Capillary Permeability Changes. Conditions like
Independent Care for Hypovolemia sepsis or inflammation can increase capillary
➢ Preventing/correcting HV, early detection, measures permeability, allowing fluid to leak into surrounding
and control to minimize fluid losses. tissues, which may trigger compensatory
➢ I&O, weight, V/S, CVP, LOC, breath sounds, mechanisms to retain more fluid.
skin/tongue color and turgor (sternum, dorsal hand, ● Accumulation of fluid in the interstitial spaces
inner thigh) ○ Edema
Diarrhea Intervention ○ Distended neck veins
● Volume per volume replacement ○ Crackles (abnormal lung sounds)
● BRAT diet (Banana, Rice, Apple sauce, Toast) ● Other manifestations
● Avoid dairy products, fatty, spicy, high fiber and ○ Tachycardia and HPN
caffeine ○ Increased pulse pressure and CVP
Hemorrhage Intervention ○ Increased weight and urine output
● Determine source and evaluate severity ○ Shortness of breath
● If wound: cleaning, disinfecting, and dressing ○ Wheezing
● If severe: bring to nearest hospital ● Long term effects: Pulmonary congestion, heart
Vomiting Intervention failure exacerbation, and potential organ dysfunction
● Volume per volume replacement and failure.
● Ice chips
● BRAT diet Nursing Process and Hypervolemia
● Avoid dairy products, fatty, spicy, acidic and caffeine Assessment
Excessive Sweating, Inadequate Water Intake ● Hx.
● V/V replacement ● P.E: Polyuria
➢ Measure I&O
Dependent Interventions ➢ Weigh daily and note for rapid weight gain:
● Replace fluids and electrolytes. Isotonic electrolyte 2.2 lb (1kg) = approx. 1L of fluid
crystalloid solutions fluids (Lactated Ringers Solution ➢ Assess breath sounds @reg intervals (esp. If
or 0.9% sodium chloride) are prescribed to increase IVF administered.
ECF volume. ➢ Monitor: edema (lower extremities) and
● Once px becomes normotensive: hypotonic sacral region in px confined in bed
electrolyte solution (0.45% sodium chloride) to ➢ Peripheral edema: measure circumference of
provide both electrolytes and water for renal extremity
excretion.
● Oral rehydration solutions (provides glucose, fluid)
Indication: diarrhea, vomiting, heat stress, and mild
to moderate dehydration from various causes.
Diagnostic Findings/Laboratory Exam Water balance plays in sodium concentration
1. BUN and Hematocrit 1. Sodium’s role in Osmotic Balance
Indication: Decreased because of malnutrition, low protein, a. Ensures water moves in and out from cells
and severe anemia. correctly = function properly
2. Chest X-ray may reveal pulmonary congestion due b. For body to maintain proper concentration
to aldosterone stimulation of substances in fluids
2. Mechanism of Dilution
Nursing Diagnosis Body retains excessive amounts of water relative to sodium
Excess fluid volume related to accumulation and retention of → dilutes the serum sodium concentration → diluted serum
body fluids in the interstitial spaces as evidenced by weight sodium (water reabsorption in the kidneys) → excessive
gain, edema, elevated BP, and shortness of breath. water in the bloodstream
3. Sodium loss vs. Water Retention
Independent Interventions Diuretics, GI losses → hyponatremia (Na Loss) → due do
➢ Turn/reposition at regular intervals excess water retention that is more significant in causing the
➢ Promote rest, restrict salt intake, monitor IVF, meds dilution of sodium.
as prescribed 4. Homeostasis and Compensation
➢ Fluid volume excess: edema → elevate lower Increase in total body water → kidneys attempt to excrete
extremities above your heart (helps improve venous the excess water → if kidneys fail to execute compensatory
return to the heart, enhances circulation) mechanisms (excessive ADH) → sodium levels drop
Dependent Interventions
➢ Anti embolic/compression stockings (help reduce risk Types of Hyponatremia
of complications, improve circulation) 1. Hypovolemic Hyponatremia (low total body
➢ Administer diuretics water and sodium)
a. Gastrointestinal Losses
Surgery Vomiting, diarrhea, or excessive sweating can lead to loss of
1. Paracentesis (ascitic fluid tapping) both water and sodium.
Indication: remove excess fluid in the abdominal b. Renal Losses
cavity, alleviating pressure, discomfort, and potential Conditions such as acute kidney injury can lead to Na loss.
respiratory distress c. Diuretics
Two types: Thiazide diuretics can cause significant sodium loss through
1. Diagnostic paracentesis or urine.
diagnostic ascitic tap d. Adrenal Insufficiency
2. Therapeutic paracentesis or Conditions like Addison's disease can impair sodium
therapeutic ascitic tap reabsorption
2. Dialysis (4 hours) 2. Euvolemic Hyponatremia (normal total body
Indication: remove excess fluid and waste products sodium but excess water)
from blood stream, restoring fluid balance and a. Syndrome of Inappropriate Antidiuretic
preventing complications associated with fluid Hormone (SIADH): excessive ADH leads to
overload. increased water retention and dilution of sodium.
3. Continuous Renal Replacement Therapy b. Psychogenic Polydipsia excessive water intake
(CRRT) dialysis modality (seen in psychiatric disorders)
Indication: for patients with AKI, allowing gradual c. Certain Medications
removal of excess fluid and toxins from the blood Antidepressants, antiepileptics (Carbamazepine, Valproic
over a 24-hour period, minimizing hemodynamic acid ) can increase ADH levels
instability and better supporting fluid and electrolyte Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine,
balance. sertraline, paroxetine, citalopram, escitalopram
Tricyclic antidepressants (TCAs): Amitriptyline, nortriptyline,
ELECTROLYTE IMBALANCES imipramine
Sodium Imbalances 3. Hypervolemic Hyponatremia (increased total
body sodium and water, but water overload is
HYPONATREMIA
greater)
A serum sodium level that is less than 135 mEq/L (135 a. Heart Failure
mmol/L) Impaired circulation leads to water retention and dilution of
Sodium most abundant electrolyte in the ECF; its sodium
concentration ranges from 135 to 145 mEq/L/mmol/L) b. Nephrotic Syndrome
○ Primary determinant if ECF volume and Loss of protein in urine leads to edema and water retention,
osmolarity. The concentration of particles diluting sodium.
like salts and sugars in blood or urine c. Liver Cirrhosis
helps indicate how thick or thin a fluid is, Fluid accumulation in the abdomen and water retention can
which can affect how water moves in and dilute serum sodium.
out of cells.
Nursing Process and Hyponatremia
Assessment
● Poor skin turgor, dry mucosa, headache, decreased
saliva production, orthostatic fall in blood pressure,
n/v, and abd cramping.
● Related to cellular swelling and cerebral
edema associated with hyponatremia):
Neurologic changes: altered mental status,
epilepticus, and coma.
 ● Sodium loss and water gain associated with Hypernatremia → increased extracellular sodium
hyponatremia: anorexia, muscle cramps, and a concentration (easier for sodium to enter the cell) →
feeling of exhaustion. difference in charge across the inside cell membrane
● Sodium level <115mEq/L (115 mmol/L): (membrane potential) from outside the cell → increased
increasing intracranial pressure, lethargy, confusion, excitability of the cell → increased muscle tone and deep
muscle twitching, focal weakness, hemiparesis tendon reflexes.
(weakness on one side of the body) , papilledema
(increased pressure in or around the brain causes Diagnostic Findings/Laboratory Exam
swelling of the optic nerve inside the eye), low BP, 1. Serum Sodium Level
weight gain, seizures, and death. Exceeds 145 mEq/L (145 mmol/L) and the serum osmolality
exceeds 300 mOsm/kg (300 mml/L)
Independent Interventions
➢ Restrict fluid, 800 mL in 24 hours. Nursing Diagnosis
➢ Monitor I&O, body weight. Risk for imbalance fluid volume related to excessive sodium
➢ Abnormal losses of water manifestations: anorexia, intake or fluid loss as evidenced by dehydration, increased
n/v, abd. cramping thirst, dry mucous membranes and changes in mental
status.
Dependent Interventions
➢ Administration of sodium: PO, NGT, IVF Independent Interventions
➢ SIADH: hypertonic saline solution (cannot change ➢ Prevent hypernatremia by: providing fluids at
the plasma sodium concentration. regular intervals. Esp. for debilitated (weak) or
Note: highly hypertonic solutions (2%-23% unconscious px who are unable to perceive or
NaCl) administered only in intensive care respond to thirst.
settings under close observation. ➢ Diabetes insipidus px (pee a lot and often feel
Administered slowly, px monitored closely. thirsty): adequate water must be ensured.
➢ Cannot consume sodium: Lactated Ringer’s ➢ Alert px/has tact thirst mechanism: providing access
solution or Isotonic saline (0.9% sodium chloride to water.
may be prescribed) ➢ Monitor px response to fluids: review serial sodium
➢ Furosemide (Lasix) levels and neurologic signs
➢ Severe Neurologic symptoms (seizure, delirium, ➢ Abnormal losses of water or low water intake r/t
coma, traumatic brain injury): administer small abuse of OTC meds (high in sodium content like
volumes of hypertonic sodium solution Alka-Seltzer.
○ Medications:
■ AVP receptor antagonists
Common Food Sources (Sodium)
(vasopressin receptor antagonists) ● Bacon, frankfurters, lunch meat, butter, cheese,
■ IV conivaptan hydrochloride canned food, ketchup, mustard, milk, processed
(Vaprisol) use is limited to tx of food, snack foods, soy sauce, table salt.
hosp. px.
HYPERNATREMIA Dependent Interventions
➢ Px c decreased LOC and other disabilities:
Serum sodium level higher than 145 mEqL (145 mmol/L)
interfering with adequate fluid intake, IVF
● Most affected: very young, very old, and cognitively
(parenteral) replacement may be prescribed.
impaired px.
➢ Gradual lowering of the serum sodium by infusion of
Causes of Hyponatremia
a hypotonic electrolyte solution (e.g., 3% sodium
● Fluid deprivation (common cause) in unconscious px
chloride) or an isotonic non saline solution (dextrose
who cannot perceive, respond to, or communicate
5% in water/D5W)
their thirst.
Note: D5W is indicated when water needs
● IV administration of hypertonic saline or excessive
to be replaced without sodium. D5W allows
use of sodium bicarbonate also causes
gradual reduction in serum sodium level →
hypernatremia.
decreasing risk of cerebral edema.
● Less common: heat stroke, near drowning sea water
➢ Enteral feeds (administer sufficient water) to keep
● Malfunction of hemodialysis or peritoneal dialysis
serum sodium and BUN w/n normal limits.
systems
○ Medications
■ Desmopressin acetate (DDVAP)
Nursing Process and Hypernatremia
synthetic antidiuretic hormone,
Assessment
prescribed to treat diabetes
● Hx. P.E
insipidus if the cause is
Note: high water content in the brain. High water
hypernatremia.
content and the need for precise osmotic balance
(290 to 300 mOsm/kg).
POTASSIUM IMBALANCES (3.5-5 mEq/L)
Clinical manifestations: (primary neurologic)
Role of Potassium in the body
Primary characteristic: thirst
● Concentration gradient is maintained by 98%
● Restlessness ● Sticky mucous membranes
● Weakness ● Peripheral, pulmonary Na+/K+ Potassium Pump
● Disorientation edema A protein found in cell membranes that helps maintain the
● Postural hypotension Na and K balance inside and outside the cell.
● Delusions
● Oliguria (<400mL)
● Hallucination ● It works by transporting three Na ions out of the
● ↑ muscle tone and Deep
● Dry swollen tongue cell and two K ions into the cell which uses ATP,
tendon reflexes
● Flushed skin
 an energy for regulating cell volume, electrical ➢ Liquid potassium chloride taken with juice or another
activity, and overall cellular health. fluid (due to unpleasant taste)
Potassium Role in the Body: (excreted thru e Kidney) ➢ IVF potassium (NO IV PUSH: IM, ID) is always
● Muscle and nerve activity diluted and administered using an infusion device.
● Regulate electrolyte balance, BP, acid-base balance, ○ Institute safely if px experiencing muscle
renal function (thru hormonal regulation) weakness

HYPOKALEMIA HYPERKALEMIA
Causes of Hypokalemia Causes of Hyperkalemia
● Vomiting and diarrhea: results in loss of gastric ● Excessive potassium intake: over ingestion of
contents, rich in K. potassium-containing foods or meds such as
● Frequent gastric suction: removes gastric contents potassium chloride or salt substitutes.
→ depletes potassium → lead to hypokalemia (due ● Rapid infusion of potassium-containing IV solutions.
to loss of this essential electrolyte) ● Decreased K excretion: potassium-retaining
● Excessive use of diuretics or corticosteroids diuretics, kidney disease, adrenal insufficiency:
● Wound drainage: GIT Addison’s disease.
● Increased secretion of aldosterone, such as ● Movement of potassium from intracellular fluid to
Cushing’s syndrome → heightened potassium the extracellular fluid:
excretion.
- Cellular injury
● Kidney disease: impairs kidney’s ability to regulate K - Acidosis
levels → excessive loss of potassium in the urine. - Rhabdomyolysis (damaged muscle
● Excessive diaphoresis (sweating) → loss of K along tissue releases harmful substances
with other electrolytes (prolonged PA and heat expo) into the blood, which can affect the
kidneys)
Nursing Process and Hypokalemia →
Assessment
Displacement of K ions into the extracellular
➢ Assess ECG changes
space from intracellular
○ Cardiovascular
■ Thready, weak, irregular pulse →
■ Weak peripheral pulses Increased concentration of potassium in the
■ Orthostatic hypotension bloodstream
■ ST depression; shallow, flat, or →
inverted T wave; and prominent U
wave Hyperkalemia
○ Respiratory Nursing Process and Hyperkalemia
■ Shallow ineffective respirations Assessment
(result from profound weakness of ➢ Assess ECG changes
the skeletal muscles of respirations ○ Cardiovascular
■ Diminished breath sounds ■ Slow, weak, irregular heart rate
○ Neuromuscular ■ Decreased blood pressure
■ Anxiety, lethargy, confusion, coma ■ Tall peaked T waves, Flat P waves,
■ Skeletal muscle weakness, leg Widened QRS complexes, Prolonged
cramps PR interval
■ Loss of tactile discrimination ○ Respiratory
■ Paresthesia ■ Profound weakness of the skeletal
■ Deep tendon hyporeflexia muscles leading to respiratory
○ Gastrointestinal failure
■ Decreased motility, hypoactive to ○ Gastrointestinal
absent bowel sounds ■ Increased motility
■ N/V, constipation, abd distention ■ Hyperactive bowel sounds
■ Paralytic ileus ■ Diarrhea
○ Neuromuscular
Diagnostic Findings/Laboratory Exam ■ Early: muscle twitches, cramps,
1. Serum Potassium >3.5 mEq/L (3.5 mmol/L) paresthesias followed by numbness
2. ECG ST depression; shallow, flat, or inverted T in the hands and feet and around
wave; and prominent U wave the mouth.
■ Late: profound weakness ascending
Independent Interventions flaccid paralysis in the arms and
➢ Instruct px about high potassium content. legs (trunk, head, respiratory
muscles) become affected when the
Common Food Sources (Potassium)
● Avocado, bananas, cantaloupe, oranges, serum potassium level reaches a
strawberries, tomatoes, carrots, mushrooms, lethal level.
spinach fish, pork, beef, veal, potassium, raisins
Nursing Diagnosis
Risk for impaired cardiac function related to elevated
Dependent Interventions
potassium levels as evidenced by ECG changes,
➢ Oral potassium supplements (may cause N/V) should
muscle weakness, and reports of palpitations.
not be taken in an empty stomach; if px complains
discomfort → discontinue.
Independent Interventions 2. Increased calcium excretion
➢ Discontinue IV potassium (keep IV catheter patent) a. Kidney disease polyuric phase → excessive urine
and withhold oral potassium supplements as output → significant loss of electrolytes, including
ordered. calcium → impaired renal activation of vitamin D →
➢ Initiate potassium-restricted diet reduce intestinal absorption of calcium →
➢ Prep to administer: K excreting diuretics if renal Hypocalcemia
function is not impaired as prescribed. b. Diarrhea: causes significant fluid and electrolyte
➢ Instruct: avoid use of salt substitutes and other loss
potassium containing substances. c. Wound drainage, especially gastrointestinal
d. Steatorrhea (excretion of excess fat in stool):
Dependent Interventions impair digestion and absorption of ats, which can
➢ Px c impaired renal function: sodium polystyrene also affect the absorption of fat-soluble vitamins,
sulfonate (oral, rectal route) is administered. A including vitamin D
cation-exchange resin which removes excess ions 3. Conditions that decrease the ionized fraction
such as potassium, from the body. of calcium
➢ An IV administration of hypertonic glucose with a. Hyperproteinemia → stimulate an increase in Ca
regular insulin is given (to remove excess K into the excretion by the kidneys → lowered serum calcium
cells) levels
➢ Blood transfusion: elevates the potassium level b. Alkalosis → stimulate an increase in Ca excretion
because the breakdown of older blood levels by the kidneys → binding of Ca to CHON (albumin)
releases K. → Ca+ albumin becomes a larger complex, making
➢ Critically high potassium: dialysis it unavailable for physiological process → high
albumin levels in conditions like alkalosis
CALCIUM IMBALANCES (9.0-10.5 mg/dL (2.25-2.75 c. Medications such as calcium chelators or
mmol/L) binders: has high affinity for calcium ions, which
Calcium is regulated by two hormones bind to and sequester (isolate) calcium, causing
1. Parathormone (Increases Blood Ca levels) hypocalcemia.
● Stimulates osteoclasts (destroy/breakdown of bone d. Acute pancreatitis → release of pancreatic
tissue) Ca in the bloodstream. enzymes due to the damage → binding of Ca to
● Increase reabsorption of Ca in the renal tubules, fatty acids → formation of a soap through
reducing Ca loss in urine saponification → reduced calcium in blood,
● Promotes the activation of vitamin D (calcitriol) in contributing to hypocalcemia.
the kidneys, enhancing intestinal absorption of e. Hyperphosphatemia → Ca precipitates with
calcium. phosphate → stimulates release of parathormone →
2. Calcitonin (Decreases Blood Ca levels) increased Ca mobilization rom bones → bone
● Inhibits osteoclast activity, slowing down the release resorption and reduced Ca availability → high
of calcium from the bones. phosphate and slow calcium → disruption of Na Ca
● Increases renal excretion of calcium, promoting its homeostasis → hypocalcemia
loss in urine. f. Immobility → decreased mechanical loading on
bones → reduced the stimulation of osteocytes to
maintain bone density and calcium release into the
HYPOCALCEMIA
bloodstream → lack of weight-bearing activity
Causes of Hypocalcemia diminishes bone remodeling → low bone resorption
1. Inhibition of calcium absorption from the GIT and alterations of Ca metabolism affecting renal
a. Inadequate oral intake of calcium: decreased function.
serum Ca levels (homeostasis) → release of g. Removal or destruction of the parathyroid
parathormone glands → decreased in the production of
b. Lactose Intolerance: → deficiency of lactase parathyroid hormone → inability to mobilize calcium
(enzyme to digest lactose) → GI discomforts → from bones → increased intestinal absorption of
avoid dairy products (primary source of Ca) calcium, and reduced Ca excretion by the kidneys →
c. Malabsorption syndromes such as celiac hypocalcemia
spruce or Crohn’s disease → impairment of the
intestinal lining’s ability to absorb nutrients or Nursing Process and Hypocalcemia
calcium, due to inflammation or damage. Assessment
Celiac Sprue/Celiac Disease: disorder ➢ Assess
where ingestion of gluten leads to damage ○ Cardiovascular
in the small intestines. ■ Decreased heart rate
Crohn’s disease: a chronic inflammation ■ Hypotension
that can affect any part of the GIt, leading ■ Diminished peripheral pulses
to various digestive symptoms. ○ Respiratory
d. Inadequate intake of Vitamin D → reduced ■ Not directly affected; however,
intestinal absorption of Ca → low vitamin D levels → respiratory failure or arrest can
impair the regulation of parathyroid hormone result from decreased respiratory
e. End-stage kidney disease → impairs the kidneys’ movement because of muscle tetany
to excrete phosphate → hyperphosphatemia → (twitching) or seizure
deposition of Ca solids in tissues or structures, such ○ Neuromuscular
as bone not available in the bloodstream → inability ■ Irritable skeletal muscles: twitches,
of the kidneys to convert vitamin D into its active cramps, tetany, seizures
form (calcitriol) ■ Painful muscle spasms in the calf or
foot during periods of inactivity
 ■ Paresthesias followed by numbness ■ Increased blood pressure
that may affect the lips, nose, and ■ Bounding, full peripheral pulses
ears in addition to the limbs. ○ Respiratory
■ Positive Trousseau’s and Chvostek’s ■ Ineffective respiratory movement as
signs a result of profound skeletal muscle
■ Hyperactive deep tendon reflexes weakness
■ anxiety , irritability ○ Neuromuscular
○ Gastrointestinal ■ Profound muscle weakness
■ Increased gastric motility, ■ Diminished or absent deep tendon
hyperactive bowel sounds reflexes
■ Cramping, diarrhea ■ Disorientation, lethargy, coma
○ Renal ○ Renal
■ Urinary output varies depending on ■ Urinary output varies depending on
the cause. the cause.
○ Gastrointestinal
Diagnostic Findings/Laboratory Exam ■ Decreased motility and hypoactive
1. Serum calcium level bowel sounds
<9.0 mg/dL 92.25mmol/L) ■ Anorexia, n/v, abd. Distention,
2. Electrographic changes constipation
Prolonged ST interval, prolonged QT interval
Diagnostic Findings/Laboratory Exam
Test for Hypocalcemia 1. Serum calcium level
1. Chvostek’s sign: is contraction of facial muscles in >10.5 mg/dL (2.27 mmol/L)
response to light tap over the facial nerve in front of 2. Electrocardiographic changes
the ear. Shortened ST segment, widened T wave
● To assess neuromuscular excitability,
particularly in conditions like hypocalcemia Nursing diagnosis
and hypomagnesemia Hypercalcemia related to increased calcium loss as
○ A positive sign is indicated by evidenced by serum calcium levels above normal range and
twitching of the facial muscles on muscle weakness.
the same side which suggests
increased nerve excitability. Independent Interventions
2. Trousseau’s sign: a carpal spasm induced by ➢ Move px carefully
inflating a blood pressure cuff above the systolic ➢ Monitor for pathological fracture
pressure for a few minutes. ➢ Monitor for flank and abd pain, and strain the urine
to check the presence of urinary stones.
Nursing Diagnosis ➢ Avoid foods high in calcium
Hypocalcemia r/t inadequate intake of calcium and or
increased calcium loss as evidenced by serum calcium levels
Common Food Sources (Calcium)
below normal range and muscle cramps. ● Cheese, collard greens, kale, milk and soy milk,
rhubarb, sardines, tofu, yogurt.
Independent Interventions
➢ Provide quiet environment
Dependent Interventions
➢ Seizure precautions
➢ d/c IVF containing calcium and PO calcium/Vit D
➢ Move px carefully
➢ d/c Thiazide diuretics, replace with diuretics that
➢ Monitor for signs of pathological fracture
enhance the excretion of calcium (Loop diuretics)
include: Furosemide (Lasix)
Dependent Interventions
➢ Administer medications as prescribed that: inhibit
➢ Administer PO/IVF calcium supplements
calcium resorption from the bone: phosphorus,
Note: warm the injection solution to body temp.
calcitonin, bisphosphonates, and prostaglandin
Before administration and slowly. Monitor for ECG
synthesis inhibitors (acetylsalicylic acid, NSAIDS)
changes, observe for infiltration and monitor for
➢ Severe hypercalcemia: dialysis (failed to reduce
hypercalcemia.
the serum calcium level)
○ Medications
■ Aluminum hydroxide reduces
PHOSPHORUS IMBALANCES (3.0 TO 4.5 mg/dL) 0.97 to
phosphorus levels, causing the
1.45mmol/L
counterfeit of increasing calcium
Function
levels.
● Enzyme activity (Glycogen Synthase and
■ Vitamin D aids in the absorption of
Glycogen Phosphorylase) allows cells to switch
calcium from the intestinal tract.
between energy storage and mobilization based on
energy needs
HYPERCALCEMIA ● Phosphofructokinase: helps change
fructose-6-phosphate into fructose bisphosphate, in
Nursing Process and Hypercalcemia
breaking down glucose for energy
Assessment
● Protein/Pyruvate Kinases: influence cellular
➢ Assess
processes for growth, metabolism, and cell division.
○ Cardiovascular
● AMP-activated Protein Kinase (AMPK) an
■ Early phase: increased heart rate
energy sensor, regulates cellular metabolism.
■ Late phase: bradycardia that can
When activated by a deficit or excess AMPK
lead to cardiac arrest
 stimulates glucose uptake and lipid oxidation to causes redistribution of phosphate into cells
produce energy. = hypophosphatemia
● Cyclic AMP-dependent Protein Kinase (PKA):
involved in signaling pathways that mediate Nursing Process and Hypophosphatemia
responses to hormones like adrenaline. ➢ Assess
● Muscle contractions: ATP which w=contains ○ Cardiovascular
phosphorus, is essential in muscle contraction. ■ Decreased contractility and cardiac
○ The hydrolysis (breaking something down output
using water) of ATP releases energy needed ■ Slowed peripheral pulses (due to
for the interaction between the actin and impaired energy production and
myosin filaments. calcium handling, ultimately
● Nerve Signaling: Phosphorylation: crucial for resulting in slowed peripheral pulses
the functioning of many proteins involved in nerve as the body struggles to maintain
signaling. ATP also provides the energy needed for adequate circulation.)
the propagation of action potentials in neurons. ○ Respiratory
Phosphorylation: process of adding a phosphate ■ Shallow respiratory (related to
group to a molecule, often to activate or change the effects of muscle function and
function of proteins, and other compounds in the neuromuscular transmission, leading
body. to compromised respiratory
mechanics).
○ Neuromuscular
HYPOPHOSPHATEMIA
■ Low phosphate levels:
A serum phosphorus (phosphate) level lower than 3.0 mg/dL ● reduce ATP availability,
● A decrease in the serum phosphorus level is impairing muscle function
accompanied by an increase in the serum calcium and leading to weakness
level. (reciprocal relationship) ● Hinder the release of
Decreased serum phosphorus → increased parathormone neurotransmitters, leading
secretion → promotes the release of calcium from bones → to diminished reflex
rapid serum calcium levels → increases calcium reabsorption activity.
in the kidneys. ● Decreased bone density that
Causes of Hypophosphatemia can cause fractures and
a. Insufficient phosphorus intake: malnutrition and alterations in bone shape
starvation → reduced ability of phosphorus for the ● Impair the function of
body’s needs → disruption of energy production and osteoblasts(formation)
bone health, for P is crucial for ATP formation and contributing to weakened
overall cellular function → muscle weakness, bone bone structure
pain, nerve issues (numbness or tingling) ● Rhabdomyolysis →
b. Increased P excretion: breakdown of muscle →
i. Hyperthyroidism → elevated levels of release of myoglobin into
thyroid hormones → increased metabolic the bloodstream → kidney
activity : (1) higher release of phosphate damage
from the bones into the bloodstream → ■ Central nervous system
hypophosphatemia → high renal excretion ● Irritability, confusion,
of phosphate (2) increased bone resorption seizures
(breaking down bone tissue) and bone ■ Integumentary
formation→ heightened metabolic demands ● Easy bruising
of the kidneys work for balance. ● Prolonged bleeding time
ii. Malignancy (presence of cancer cells = ● Increased risk of
increased bone resorption) →production of hemorrhage
parathyroid hormone-related peptide →
mimics parathyroid hormone action and Independent Interventions
increases renal excretion of phosphate → ➢ Low platelet: monitor platelet function and
released o phosphate into the bloodstream bleeding tendencies
→ hypophosphatemia ➢ Increase intake of phosphorus containing
c. Use of magnesium-based or aluminum foods while decreasing the intake of
hydroxide-based antacids → bind to phosphate calcium-containing foods.
in the GIT → reduced absorption into the ➢ d/c meds that contribute to
bloodstream → increased renal excretion of hypophosphatemia (loop diuretics, thiazide,
phosphate → hypophosphatemia aluminum antacids, corticosteroids, insulin,
d. Intracellular shift some antibiotics)
i. Hyperglycemia → osmotic diuresis ➢ Phosphorus IVF slowly due to risk associated
eliminate excess glucose → loss of with hyperphosphatemia
phosphate along with water and other ➢ Move px carefully
electrolytes ➢ Monitor pathological fractures
ii. Respiratory alkalosis → increased RR →
Common Food Sources (Phosphorus)
excessive loss of carbon dioxide → higher
● Dairy products, fish, nuts, pork, beef, chicken,
blood ph → stimulate the kidneys to excrete organ meats, pumpkin, squash, whole grain
more phosphate to maintain acid base breads and cereals
balance + shift during respiratory alkalosis
Dependent Interventions ● Kidney function: Potassium helps regulate kidney
➢ Administer phosphorus PO along with Vit D function and the balance of fluids and electrolytes in
supplement the body.
➢ Phosphorus IVF if: px experiences critical clinical
manifestations and phosphorus levels fall below <1 Calcium (Ca):
mg/dL
● Bone health: Calcium is the primary mineral found
in bones and teeth. It is essential for bone strength
HYPERPHOSPHATEMIA and density.
A serum phosphorus level that exceeds 4.5 mg/dL ● Muscle function: Calcium plays a role in muscle
Causes of Hyperphosphatemia contraction, including heart muscle contraction.
1. Decreased renal excretion resulting from renal ● Blood clotting: Calcium is necessary for blood
insufficiency → compromised ability of the kidneys clotting.
to excrete phosphate effectively → accumulation of ● Nerve function: Calcium helps regulate nerve
the phosphate in the blood → hyperphosphatemia function, including the transmission of nerve
2. Tumor Lysis Syndrome → cancer cells rapidly impulses.
break down and release their intracellular contents
into the bloodstream including large amounts of Phosphorus (P):
phosphate plus uric acid
● Bone health: Phosphorus is another essential
3. Increased intake of phosphorus, including dietary
mineral for bone health. It works together with
intake or overuse of phosphate-containing laxatives
calcium to build and maintain strong bones.
or enemas
● Energy metabolism: Phosphorus is involved in the
4. Hypoparathyroidism (insufficient secretion of
metabolism of carbohydrates, fats, and proteins. It is
parathormone which helps regulate Ca and
essential for the production of energy in the body.
phosphate levels) → reduced mobilization of calcium
● Kidney function: Phosphorus levels in the blood
from bones and decreased renal excretion of
are regulated by the kidneys. High phosphorus levels
phosphate → elevated serum phosphate levels
can be a sign of kidney dysfunction.
Independent Intervention
➢ Instruct px to decrease intake of food high in
phosphorus

Dependent Intervention
➢ Avoid phosphate-containing medications (including
laxatives and enemas, flecainide, fosfomycin)
➢ Take phosphate-binding medications (Calcium
carbonate, acetate, Sevelamer hydrochloride) with
meals or immediately after meals

Sodium (Na) 135 to 145 mEq/L/mmol/L)

Potassium (K) 3.5-5 mEq/L

Calcium (Ca) 9.0-10.5 mg/dL (2.25-2.75 mmol/L)

Phosphorus (P) 3.0 TO 4.5 mg/dL (0.97 to 1.45mmol/L)

Sodium (Na):

● Fluid balance: Sodium plays a crucial role in

maintaining fluid balance in the body. It helps
regulate the amount of water in the blood and
tissues.
● Nerve and muscle function: Sodium is essential
for the proper functioning of nerves and muscles. It
helps transmit nerve impulses and contract muscles.
● Blood pressure: Sodium levels in the blood can
affect blood pressure. High sodium intake is
associated with high blood pressure.

Potassium (K):

● Heart function: Potassium is essential for the

proper functioning of the heart. It helps maintain the
heart's electrical rhythm and prevents irregular
heartbeats.
● Muscle function: Potassium is also important for
muscle function, including the muscles of the heart,
intestines, and blood vessels.