ELECTROLYTE IMBALANCES 1. HYPONATREMIA – a sodium deficit or serum sodium level of less than 135 mEq/L.

 This may result from excessive sodium loss or excessive water gain.  Because of sodium’s role in determining the osmolality of ECF, hyponatremia typically results in a low serum osmolality.  Water is drawn out of the vascular compartment into the interstitial tissues and the cells, causing the clinical manifestations associated with this disorder. ETIOLOGIC AND RISK FACTORS: a. Loss of sodium  Gastrointestinal fluid loss  Sweating  Vomiting  Use of diuretics b. Gain of water  Hypotonic tube feedings  Drinking water  Excess IV D5W administration c. Syndrome or inappropriate ADH  Cause by Head injury resulting to increase ADH  AIDS  Malignant tumors PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Lethargy, confusion, apprehension b. Muscle twitching c. Abdominal cramps d. Anorexia, nausea, vomiting e. Headache f. Seizures, coma LABORATORY FINDINGS: a. Serum sodium below 135 mEq/L b. Serum osmolality below 280 mOsm/kg 2. HYPERNATREMIA – is excess in sodium in ECF, or serum sodium greater than 145 mEq/L.  There is a gain of sodium in excess of water or a loss of water in excess of sodium.  Because the osmotic pressure of extracellular fluid is increased, fluid moves out of the cells into the ECF.  As a result, the cells become dehydrated. ETIOLOGIC AND RISK FACTORS: a. Loss of fluids  Insensible water loss  Diarrhea b. Water deprivation c. Excess salt intake  Parenteral administration of saline solutions  Hypertonic tube feedings without adequate water  Excessive use of table salt (1 tsp contains 2300 mg of sodium) d. Diabetes mellitus e. Heat stroke f. Sea water ingestion g. Near drowning in ocean h. Malfunction of dialysis PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Thirst b. Dry, sticky mucous membranes c. Tongue red, dry, swollen d. Weakness e. Postural hypotension f. Dyspnea

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Severe hypernatremia:  Fatigue, restlessness  Decreasing level of consciousness  Disorientation  Convulsions LABORATORY FINDINGS: a. Serum sodium above 145 mEq/L b. Serum osmolality above 300 mOsm/kg c. Urine specific gravity and osmolality increased or elevated HYPOKALEMIA – is a potassium deficit or a serum potassium level of less than 3.5 mEq/L. ETIOLOGIC AND RISK FACTORS: a. Loss of potassium  Vomiting and gastric suction  Diarrhea  Heavy perspiration b. Use of potassium wasting drugs (diuretics)  Thiazide  Loop diuretics (furosemide) c. Hyperaldosteronism PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Muscle weakness, leg cramps b. Fatigue, lethargy c. Anorexia, nausea, vomiting d. Decreased bowel sounds, decreased bowel mobility e. Cardiac dysrhythmias f. Depressed deep tendon reflexes LABORATORY FINDINGS: a. Serum potassium level below 3.5 mEq/L b. Arterial blood gases may show alkalosis c. T wave flattening and ST segment depression on ECG d. U wave on ECG, prolonged PR interval HYPERKALEMIA – is a potassium excess or serum potassium greater than 5.0 mEq/L.  Less common than hypokalemia and rarely occurs in clients with normal renal function.  It is more dangerous than hypokalemia and can lead to cardiac arrest. ETIOLOGIC AND RISK FACTORS: a. Decreased potassium excretion  Renal failure  Hypoaldosteronism  Potassium-conserving diuretics b. High potassium intake  Excessive use of potassium containing salt substitutes  Excessive or rapid IV infusion of potassium c. Potassium shift out of the tissue cells into the plasma (infections, burns, acidosis) PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Gastrointestinal hyperactivity, diarrhea b. Irritability, apathy, confusion c. Cardiac dysrythmias or arrest d. Muscle weakness, areflexia e. Paresthesia and numbness in extremities LABORATORY FINDINGS: a. Serum potassium above 5.0 mEq/L b. Peaked and narrow T wave, widened QRS on ECG c. ST segment depression and shortened QT interval d. Prolonged PR interval e. Prolonged QRS complex f. Disappearance of P wave g. Acidosis

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drowsiness g. Positive Chvostek’s and Trousseau’s sign d. Positive Chvostek’s sign – facial muscle twitching including eyelids and lips on side of stimulus when tapping over facial nerve about 2cm anterior to tragus of ear. AV block may occur PHOSPHATE DEFICIT: HYPOPHOSPHATEMIA  Serum phosphate level less than 2. Muscle tremors. 9. Hyperparathyroidism e.5 mEq/L  Occurs more frequently than hypermagnesemia. paralysis d.  Severe depletion of calcium can cause tetany with muscle spasms and paresthesias and can lead to convulsions. Numbness. Severe dehydration PATHOPHYSIOLOGY: CLINCIAL MANIFESTATIONS: (the same with hypercalcemia) a. serum calcium greater than 10. Polyuria.5 mEq/L b.5 mg/dl. Prolonged immobilization b. Nausea. flushing b. QT and QRS intervals c. Cardiac dysrhythmias.  This is frequently associated with total thyroidectomy or bilateral neck surgery for cancer. can progress to tetany and convulsions c. decreased cardiac output d. prolonged PR and QT intervals HYPERMAGNESEMIA – serum magnesium greater than 2. alcohol withdrawal and intense hyperventilation b. Depressed deep tendon reflexes c. Dysrhythmias. Prolonged QT interval b. Serum magnesium level greater than 2. Elevated blood pressure f. ETIOLOGIC AND RISK FACTORS: a. Neuromuscular irritability with tremors b. cramps. Severe dehydration a. 8. Thyroid carcinoma f. ETIOLOGIC AND RISK FACTORS: a. nausea. Long-term use of drugs (diuretics. Total parenteral nutritional administration g.  Clients at greatest risk for hypocalcemia are those whose parathyroid glands have been removed. Hyperparathyroidism c. vomiting d. Excessive calcium intake or administration f. anxiety. Respiratory depression. depressed ST segment. Poor nutrition d. Abnormal retention of magnesium  Renal failure  Adrenal insufficiency b. widened QRS.5 mEq/L c. Diabetic ketoacidosis c. Increased reflexes. malignancy and kidney stones HYPOMAGNESEMIA – serum magnesium less than 1. ECG reveals flattened T waves. Burns PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: (the same with hypocalcemia) a. weakness b. coma h. Xray reveals bone cavitations.5. Respiratory and cardiac arrest if severe LABORATORY FINDINGS: a.  Most often occurs when calcium is mobilized from the bony skeleton. or total serum calcium level of less than 8. Pancreatitis f. Peripheral vasodilation. convulsions c.5 mg/dl and an ionized calcium level of less than 4. and leaving it in place for 2 to 5 minutes. Confusion. Disorientation and confusion h. Hyperphosphatemia e. aminoglycoside antobiotics) c. Excessive loss from the gastrointestinal tract b. possible heart block LABORATORY FINDINGS: 7. tremors. 6. Prolonged PR. Hypotension. HYPOCALCEMIA – is a calcium deficit. Muscle weakness. Paget’s disease e. vomiting c. Anorexia. tingling of extremities and around the mouth b. Tachycardia e. hypercalciuria f.5 mg/dl or 4. if severe. Chronic alcoholism. Serum calcium level less than 8. Alcoholism – most common cause e. . Milk-alkali syndrome PATHOPHYSIOLOGY: CLINCIAL MANIFESTATIONS: a. Hypoparathyroidism c. such as delirium tremens.5 mEq/L b. Malignancy of the bone d. Vertigo LABORATORY FINDINGS: a. shortening of QT interval and bradycardia c. Constipation e. Elevated phosphate level HYPERCALCEMIA – serum calcium levels greater than 10. Lethargy.0 mg/dl. Overuse of magnesium containing antacids and laxatives/enemas e. Flank pain secondary to urinary calculi g. Thermal burns d. possible psychosis LABORATORY FINDINGS: a. Dysrhythmias g. Surgical removal of the parathyroid glands b.  This may be due to malignancy or prolonged immobilization ETIOLOGIC AND RISK FACTORS: a. Depressed deep tendon reflexes f. Lethargy.5 mEq/L ETIOLOGIC AND RISK FACTORS: a.5 mEq/L b. Serum magnesium level below 1. Treatment with magnesium salts c. f.5 mg/dl or 5. Untreated Dm d. Positive Trousseau’s Sign – carpal spasm or contraction of hand and fingers on affected side when inflating a blood pressure cuff on the upper arm to 20 mmHg greater than the systolic pressure. bradycardia e. Excess intake of phosphate binding drugs f.5mg/dL  Etiologic factors a. Acute pancreatitis d.  Aggravates the manifestations of alcohol withdrawal. Inadequate vitamin D intake  Malabsorption  Hypomagnesemia  Alkalosis  Sepsis  Alcohol abuse PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. e.

cream. Hypoparathyroidism d. whole grain cereals. Hyperreflexia d. sardines. Hypernatremia. High phosphate intake e. Bruising and bleeding g. metabolic acidosis  Pathophysiology Hyperchloremia with hypernatremiacauses increased water retentionhypervolemiasigns of fluid excess Loss of bicarbonate acutelymetabolic acidosiskidney retains chloride acutelyhyperchloremiadeep and rapid respiration to compensate from the acidosis  Assessment a. Hypernatremia d. to avoid phosphate containing substances s/a laxatives and enemas 3. Phosphate serum level below 2. confusion k. Increased phosphate absorption  Assessment a. GI tube drainage c. Respiratory alkalosis related to hyperventilation f. vomiting  Laboratory findings a. b. Numbness j. Metabolic acidosis c. Normal anion gap . Instruct client to avoid phosphorous-rich foods s/a hard cheese.5 mg/dL b. Fatigue Laboratory findings a. Tachycardia c. Signs/symptoms of hyponatremia f.  Assessment a. sodium is also retainedhypochloremic metabolic alkalosis. c. Seizures and coma d. Anorexia. dried fruits & vegetables. kidneys. Muscle weakness and pain c. Teach pt. Muscle weakness c. Serum level below 96 mEq/L Sodium is also decreased Metabolic alkalosis 10. Paresthesias i. Twitching d. To compensate. CHLORIDE DEFICT: HYPOCHLOREMIA  Serum chloride level ids less than 96 mEq/L  Etiologic factors a. Hyperactive deep tendon reflexes c. Diarrhea  Pathophysiology Loss of chloride by the above factorshypochloremiabicarbonate is retained by the kidney acutely to maintain the (-). X-ray will show faulty bone development  Nursing interventions: 1. Lethargy d. to recognize the signs of impending hypocalcemia 4. Metabolic acidosis manifestations b. Administration of vitamin D preparations s/a calcitol (oral). sweetbreads and foods made with milk 2. Serum PO4 is above 4. Nausea and vomiting  Laboratory findings 12. Hypoxic signs leading to increased respiration e. CHLORIDE EXCESS: HYPERCHLOREMIA  Chloride level above 106 mEq/L  Etiologic factors a. Soft tissue calcification f. Chemotherapy for neoplastic disease c. nausea. Tetany e. body retains carbon dioxide to bring down the pH  Assessment a. Instruct pt. Hyperexcitability b. Serum calcium is low c.5 mg/dL  Etiologic factors a. calcijex (IV) 11. Serum chloride level above 109 mEq/L b. Hypertension  Laboratory findings a. Irritability b. Apprehension. Tingling sensation g. Severe vomiting b. X-ray may show rickets or osteoporosis a. Deep and rapid respirations e. PHOSPHATE EXCESS: HYPERPHOSPHATEMIA  Serum phosphate levels above 4. Loss of bicarbonate e contain via the kidney b. Tetany due to a high phosphate leading to low calcium b. Tachycardia e.5 mg/dL b. Increased administration of chloride containing drugs and IVF c. Renal failure b. Increased susceptibility to infection h. Profound muscle necrosis f. nuts.

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