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SODIUM (Na+) 135 – 145 mEq/L most prevalent cat ion in ECF controls osmotic pressure transmits nerve impulses aids in maintenance of acid-base Balance necessary for glucose to be transported into cells maintained via regulation of water intake and excretion.
deficit resulting from either a sodium loss or water excess serum-sodium level below 135 mEq/L Neurologic symptoms usually does not occur until below 120 mEq/L or unless there’s rapid drop in serum sodium level. Permanent neurologic damage occurs when plasma sodium level is less than 115 mEq/L.
CAUSES Sodium deficit resulting from either a sodium loss or water excess Excessive diaphoresis,diuretics,vomiting, diarrhea, GI wound drainage, renal disease, decreased secretion of aldosterone. Inadequate sodium intake: Dilution of Serum Na: Excessive admin of hypotonic IVF, excessively dilute enteral feeding,
Cardiovascular: Neuromascular: Gastrointestinal: *Normovolemic: * ⇩ DTR, skeletal * Increased rapid pulse rate;ms. weakness motility, Normal BP hyperactive bowel Renal: *Hypovolemic: * Decreased urinesounds, abdominal Thready, weak,spec. grav,cramping, diarrhea rapid, pulse; flatincrease UO. neck veins, Normal to low CVP *Hypervervolemic; rapid bounding pulse, BP normal to elevated. CVP: Respiratory: Normal to * Shallow elevated Ineffective
NURSING CARE PLAN GOAL: obtain normal sodium level prevent further sodium loss prevent injury INTERVENTIONS: Increase oral intake Replacement of sodium and fluid losses Replacement of other electrolytes IV hypertonic saline Removal of underlying cause Diuretics Water restriction.
Sodium Values of Common Foods
Food Source Table salt (1tsp) Soy sauce (1 tbsp) Pork, cured (4oz) Cheddar cheese (1oz) Ketchup (1 tbsp) Skim milk (8oz) White bread ( 1 slice) Butter (1tsp) Whole milk (8oz0 Chicken, light meat (4oz) Chicken, dark meat (4oz) Beef, lean (4oz) Pork, lean fresh (4oz) Amount (mg) 2000 1029 850 176 156 126 123 123 120 70 70 60 60
sodium in the blood, resulting from either high sodium intake, water loss, or low water intake *Hypernatremia causes hypertonicity which may cause shift of water out of the cells causing cellular dehydration and increased ECF volume.
sodium intake: Excessive oral sodium or admin of Na containing IVF. Low water intake; NPO Increased water loss; Increased Metabolic Rate, fever, hyperventilation, infection, excessive diaphoresis, DI, diarrhea Decreased sodium excretion: use of corticosteroids, cushing syndrome, RF, hyperaldosteronism
CARDIOVASCULAR: NEUROMASCULAR: CNS: *HR and BP responds *Early; Spontaneous *Altered cerebral fxn to vascular volume ms. Twitches; is the most status Irreg. ms. common Contaction manifestation. Late: Skeletal ms. Normovolemia or Weakness; ⇩DTR hypovolemia: Agitation, confusion, seizures RENAL: INTEGUMENTARY: Hypervolemia: *Inc. Urine spec. grav *Dry skin Stupor, lethargy, Decreased UO Presence or absence coma of edema depending on fluid volume changes.
NURSING CARE PLAN INTERVENTIONS: 1.Monitor CV, Resp, NM, cerebral, renal and integumentary status of patient. 2. Decreased oral intake 3. Diuretics, IV or water replacement ( Sodium correction is corrected slowly over approximately 2 days to avoid great shift of fluid into brain cells) 4. promote safety to patient
POTASSIUM (K+) 3.5 – 5.0 mEq/L
a direct effect on excitability of nerves and muscles. Along with Ca, Mg, controls rate and force of contraction of the heart thus the CO. contributes to intracellular osmotic pressure and influences acid-base balance. major cat ion of the cell required for storage of nitrogen as muscle protein.
is related to dehydration, starvation, vomiting, diarrhea, diuretics. Symptoms may not occur until below 2.5 mEq/L Potentially life threatening because every body system is affected.
Reduction in total body potassium -Excessive use of diuretics, corticosteroids, ⇧secretion of aldosterone, vomiting, diarrhea, wound drainage, burn, NGT suctioning, excessive diaphoresis renal disease. Inadequate K intake STRESS Shift of potassium from ECF to ICF Alkalosis, Hyperinsulinism Dilution of of serum potassium Water intoxication, IV therapy with potassium poor solution
CARDIOVASCULAR: NEUROMASCULAR: GI: *Thready, weak, *Anxiety, lethargy, Decreased motility, irregular pulse, confusion, coma, hypoactive or Orthostatic skeletal ms. absent bowel hypotension, ECG Weakness, sounds. Changes; ST eventual flaccid NV, constipation, depression, paralysis. Loss of abdominal shallow flat or inv. tactile distention, T wave and discrimination, paralytic ileus. prominent U wave hyporeflexa
RESPIRATORY: RENAL: *Shallow ineffective ⇩ Urine spec grav respiration 2 to ⇧UO profound weakness of skeletal ms, diminished breath
Prominent U waves after T waves in hypokalemia
NURSING CARE PLAN INTERVENTIONS:
CV, NM, Resp, GI,Renal status and place in cardiac monitor. Monitor Electrolyte Values increase potassium in diet liquid PO potassium medications > dilute in juice to aid taste > give only if kidneys functioning prevent infiltration, pain, tissue damage prevent potassium loss - irrigate NGTs with saline, not water
PRECAUTIONS for IVF administered potassium •Potassium is never given by IV push, IM or SQ route. •In adding K in a IV solution, rotate, invert the bag. It should be properly labeled. •Max infusion rate 5-10 mEq/hr. •Should be placed on cardiac monitor •Check IV site. •Assess renal function before
Potassium Values of Common Foods
Food source Avocado (1 medium) Raisins (1/2 c) Pork, fresh (4oz) Cantaloupe (1c pieces) Beef (40z) Banana (1 medium) Potato, white (1 medium) Skim milk (8oz) Tuna fish (4oz) Whole milk (8oz) Tomato (1 medium) Carrot (1 large) Cauliflower (1c pieces) Beef liver (3 1/2oz)
Amount (mg) 1097 700 525 494 480 451 407 406 375 370 366 341 295 281
Overingestion of K containing foods or medications such as KCl or salt substitutes, rapid infusion of K containing IV solutions
K excretion from ICF to ECF
K sparing diuretics, RF, Adrenal insufficiency such as Addison’s dse. Tissue damage, acidosis, hypercatabolism.
CARDIOVASCULAR: *Slow, irregular HR, ⇩BP, ECG changes: Tall peaked T waves, widened QRS conplexes, prolonged PR interval NEUROMASCULAR: *Early: Ms. Cramps, paresthesias Late: Profound ms. Weakness, ascending flaccid paralysis in the arms and legs( trunk, head and Resp ms. When K level reaches lethal level. GI: Increased motility, hyperactive bowel sounds. Diarrhea NEUROLOGIC: apathy, lethargy, fatigue, weakness irritability, mental confusion
RESPIRATORY: *Profound weakness of skeletal ms leading to respiratory failure.
Peaked T waves in hyperkalemia
Widened QRS complexes in a patient whose serum potassium level was 7.8 mEq/L.
ECG of a patient with pretreatment potassium level of 7.8 mEq/L and widened QRS complexes after receiving 1 ampule of calcium chloride. Notice narrowing of QRS complexes and reduction of T waves.
NURSING CARE PLAN INTERVENTIONS •Monitor CV, Respi, NM, Renal, and GI status. •Use Cardiac Monitor. •Identify and treat cause of imbalance. • Cat ion exchange resins (Use of Kayexalate) •Give foods low in K+. •Avoid drugs or IVFs containing K+ •Use of IV calcium gluconate, IV glucose with Insulin, Serum bicarbonate. •If kidney failure present, may need to prepare for dialysis
CALCIUM (Ca2+) 4.5 – 5.5 mEq/L
bone formation coagulation of blood (conversion of thrombin to prothrombin) excitation of cardiac and skeletal muscle conduction of neuro muscular impulses. regulation of endocrine and exocrine glands
by parathyroid hormone Reciprocal relationship between calcium and phosphorus
Inhibition of Ca absorption from GIT
Inadequate intake of Ca, Lactose intolerance, malabsorption syndrome, inadequate intake of vit. D. ESRD. RF, polyuric phase, diarrhea, wound drainage esp. GI Hyperproteinemia, hyperphosphatemia, removal of parathyroid gland immobility,
Increased renal excretion
Conditions that decrease ionized fraction of Ca
Cardiovascular: Neuromascular: Gastrointestinal: ⇩HR, Hypotension Irritable skeletal * Increased Diminished ms: twitches, motility, peripheral cramps, tetany, hyperactive pulses seizures bowel sounds, ECG changes; Painful ms spasms abdominal Prolong ST interval, in calf or foot cramping, prolonged QT Paresthesias diarrhea interval followede by numbness that Respiratory: affects lips, Not directly nose, ears affectedmay (+) Trosseau’s and cause Chvostek’s signs respiratory Hyperactive DTR’s arrest Anxiety, Irritability
NURSING CARE PLAN INTERVENTIONS
GOALS monitor patient status prevent tetany increase calcium intake • Monitor patients CV, NM, respi, CNS status; place in cardiac monitor. •Administer Calcium supplements. •Calcium gluconate IV, 2.5-5.0 ml 10% solution; repeated q10min to maximum dose of 30ml. Administer slowly to avoid infiltration. Warm injection sol’n to body temperature. •Monitor Calcium level caution: drug interaction with carbonate, phosphate, digitalis
Administer meds that may increase Ca absorption; Al hydroxide decrease phosphorous level which may cause increase Ca level; Vit. D enhances absorption if Ca from the GIT. Provide quite environment. Siezure precaution Move client carefully Instruct patient to consume foods high in Ca.
Calcium Values of Common Foods
Food Source Yogurt, low-fat (1c) Skim milk (8oz) Whole milk (8oz) Cheddar cheese Tofu (3oz) Broccoli, raw (1/2 c) Green beans (1c) Carrot (1 large) Amount (mg) 415 302 288 204 100 75 62 37
oral intake of Ca and Vit. D
bone resorption of Ca
use of glucosteroids
Cardiovascular: Neuromascular ⇧Increased heart : rate in early Profound ms. phase, then Weakness, bradycardia⇨ Diminished or CARDIAC ARREST absent DTR’s Increased Disorientation, bounding pulses lethargy, coma ECG changes: Renal: Shortened ST ⇧UO, formation segment, of renal calculi widened T wave Gastrointestina l: Decreased motility, hypoactive bowel sounds, abdominal distention, NV, anorexia, constipation Respiratory: Ineffective resp. movement
NURSING CARE PLAN GOALS
Monitor patient’s status Prevent Injury Reduce Ca Intake
Monitor CV, Respi, Renal and GI status; place patient in cardiac monitor DC IV infusions of sol’ns containing Ca and oral meds containing Ca and Vit D DC of thiazide diuretics Administer that inhibit calcium resorption from bone, such as calcitonin, phosphorous. Prepare for dialysis. Monitor for flank pain. Strain urine for urinary stones. Move client carefully to prevent fractures.
MAGNESIUM (Mg2+) 1.5 – 2.5 mEq/L
as index to determine metabolic activity and renal function. Concentrated in the bone, cartilage and within cell itself. Required for use of ATP. Necessary for Carbohydrate metabolism, protein synthesis, nucleic acid synthesis, contraction of muscular tissue. Regulates neuromuscular activity and clotting mechanism.
CAUSES deficit is related to;
impaired absorption in the GI tract excess loss through kidneys prolonged periods of poor nutritional intake Intracellular movement
Hyperglycemia Insulin administration Sepsis
Cardiovascular: Neuromuscular: ECG changes: Tall Twitches, T waves, depressed paresthesias, (+) ST segment Trousseau and Tachycardia Chvostek’s sign Hypertension Hyperreflexia Tetany siezures CNS: Irritability Confusion Respiratory: Shallow respiration
aim is to restore normal
calcium level. Admin MgSO4 Initiate seizure precautions. Monitor DTR, RR
is related to:
renal insufficiency overdose during replacement therapy severe dehydration repeated enemas with Mg2+ sulfate (epsom salts)
Cardiovascular: Bradycardia, dysrythmias Hypotension ECG changes: Prolonged PR interval, widened QRS complexes Neuromuscular CNS: : Drowsiness and Diminished lethargy which DTR’s progress to coma Skeletal ms. Weakness Respiratory: Respiratory insufficiency when skeletal ms are involved.
CV, Respi, NM, CNS status; place in cardiac monitor. Diuretics IV admin of Calcium Chloride or Calcium gluconate to reverse effect of Mg on cardiac ms. Avoid use laxatives and antacids containing Mg.
PHOSPHOROUS 2.7- 4.5 mg/dl
for generation of bone tissue. Functions in metabolism of glucose and lipids. Important in bone formation, energy storage and release, urinary acid base buffering. Absorbed from food and excreted by kidneys. High concentrations are stored in bone and skeletal muscle. Has an inverse relationship with CALCIUM.
oral intake Increased excretion
Hyperparathyroidism Malignancy Use
of aluminum hydroxide or magnesium based antacids
Hyperglycemia Respiratory alkalosis
Cardiovascular: CNS: Hematological: Decreased Irritability, Decreased contractility and Confusion, platelet CO. Seizure aggregation and Slowed Neuromuscular increased peripheral : bleeding. pulses. Weakness, Immunosuppressi decreased DTR’s, on decreased bone density, Respiratory: rhabdomyolysis Shallow respiration
CV, Respi, NM, p and hematological
status DC meds that contribute to hypophosphatemia. Prepare to administer phosphorous IV when level falls below 1 and when client exhibits critical clinical manifestations. Administer IV phosphorous slowly. Increase oral intake of foods high in phosphorous.
HYPERPHOSPHATEMIA CAUSES Decreased renal excretion Tumor Lysis Syndrome Increase oral intake Hypoparathyroidism
entail management of Ca. Administer phosphate binding medications that increase excretion by binding phosphorous from food in the GIT. Instruct patient to avoid phosphate containing meds. Phosphate binding meds are taken with meals or immediately after meals.
SOURCES:comprehensivereviewnclexrn/annsilvestri/saunders/4th Ed Manual of Critical Care/ Applying Nursing Diagnosis to Adult Illness/Swearingen and Keen/ 2nd Ed Google and Yahoo Images
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