Electrolytes Imbalances

Prepared By: Mr. Charlie C. Falguera, RN

Hyponatremia
Types:

Sodium Imbalances

- A plasma sodium level below 135 mEq/L.

1. Hypovolemic hyponatremia - When sodium loss is greater than water loss. 2. Euvolemic hyponatremia - When the total body water is moderately increased and the total body sodium remains at a normal level. 3. Hypervolemic hyponatremia - When a greater increase occurs in TBW than in total body sodium.

4. Redistributive hyponatremia
- No change occur in TBW or total body sodium; water merely shifts between the intracellular & extracellular compartments relative to the sodium concentration.

 1.

Etiology: Hypovolemia hyponatremia - Renal loss of sodium from diuretic use, diabetic glycosuria, aldosterone deficiency, intrinsic renal disease - Extrarenal loss of sodium from vomiting, diarrhea, increased sweating, burns, high-volume ileostomy. 2. Euvolemic hyponatremia - Sodium deficit resulting from SIADH or the continuous secretion of ADH due to pain, emotion, medications, cancers, CNS disorders 3. Hypervolemic hyponatremia - Edematous disorder resulting in sodium deficit, CHF, liver cirrhosis, nephrotic syndrome, acute & chronic renal failure 4. Redistributive hyponatremia - Pseudohyponatremia, hyperglycemia, hyperlipidemia

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Pathophysiology: Decreased excitability of the membranes. ECF becomes hypo-osmolar.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Clinical Manifestations: Headache Apprehension Confusion Hallucinations Behavioral changes Seizures Hypotension Weak thready pulse Tachycardia Crackles

11. Tachypnea, dyspnea 12. Cheyne-stokes respi, neurogenic hyperventilation apneustic breathing ataxic breathing 13. Nausea & vomiting 14. Hyperactive bowel sounds 15. Abdominal cramping 16. Diarrhea 17. Dryness of skin & mucous

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Diagnostic Findings; Plasma sodium level below 135 mEq/L Plasma chloride level below 98 mEq/L. Plasma osmolality less than 275 mOsm/kg.

1. 2. 3. 4. 5. 6.
1.

Management: Treat the underlying cause. Restrict fluid intake. Dietary supplementation. IV infusion PNSS or LR solution, 3% NaCl Meds: Diuretics, Demeclocycline Safety precautions.
Complications: Brain herniation, coma, death

Hypernatremia
- A plasma sodium level above 145 mEq/L. Types: 1. Hypovolemic hypernatremia - When TBW is greatly decreased relative to sodium. 2. Euvolemic hypernatremia - When the total body water is decreased relative to the normal total body sodium. 3. Hypervolemic hypernatremia - When TBW is increased but the sodium gain exceeds the water gain.

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2.

3.

Etiology: Hypovolemia hypernatremia - Renal loss of, osmotic diuresis, diuretics, severe hyperglycemia - Extrarenal loss: profuse diaphoresis, decreased thirst, diarrhea occuring with inadequate volume replacement or fluid replacement with hyperosmolar solutions, burns. Euvolemic hypernatremia - Excess fluid loss from the skin & lungs, hypodipsia in the elderly & infants, DI Hypervolemic hyponatremia - Administration of concentrated saline solutions, hypertonic feedings, excess mineralocorticoids, accidental or intentional salt ingestion, commercially preapred soups & canned vegetables.

 1. 2.

Pathophysiology: Water shift from ICF to ECF. Na competes with Ca in the Ca channels for cardiac muscle contraction..

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Clinical Manifestations: Polyuria, oliguria 13. Weight gain Anorexia, N & V, weakness 14. Edema Restlessness, agitation, irritability 15. Dysrhythmia Dry, flushed skin 16. Crackles Dry, sticky mucous mem 17. Dyspnea Tongue furrows 18. Pleural effusion Increase thirst Fever Orthostatic hypotension/HPN Tachycardia Jugular vein distention S3 gallop

 1. 2. 3.

Diagnostic Findings; Plasma sodium level above 145 mEq/L Plasma chloride level above 106 mEq/L. Plasma osmolality more than 295 mOsm/kg.

1. 2. 3. 4. 5. 6. 1.

Management: Treat the underlying cause. Increase fluid intake. Restrict sodium. IV infusion 0.3%, 0.45% NaCl, or D5W Meds: Diuretics, Desmopressin acetate Safety precautions. Complications: Coma, irreversible brain damage, death

Potassium Imbalances
Hypokalemia
- A plasma potassium level below 3.5 mEq/L.

1.
-

Etiology & Risk Factors: Inadequate K-intake.

Debilitated, confused, restrained, or lack access to dietary intake. Malnourished, anorexic, bulimic, K-restricted diets, K-free IV solutions, older adults

2.
-

Excessive K-loss.
Vomiting & diarrhea, nasogastric suctioning, intestinal fistulae, ileostomy. Osmotic diuresis, post-op clients, alcoholism, Meds: K-wasting diuretics, cathartics, steroids, aminoglycosides, amphotericin B, digitalis preparations, betaadrenergic drugs, cisplatin, bicarbonate, natural licorice

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2.

Etiology & Risk Factors: Redistribution of potassium

- Increased levels of insulin, alkalosis, burns, sever tissue injury

Others
- Cushings syndrome, diuretic phase of renal failure, hyperaldosteronism, liver disease, cancer, wounds, Bartters syndrome

1. 2.

Pathophysiology: Decreased gradient between ICF & plasma. Increase excitability.

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Clinical Manifestations: Anorexia Abdominal distention Constipation Muscle weakness Flabbiness Leg cramps Fatigue Paresthesias Hyporeflexia Irritability Dysrhythmias Hypotension Slow, weakened pulse Shallo respirations SOB

16. Apnea 17. Dysphasia 18. Areflexia 19. Confusion 20. Vomiting 21. Ileus 22. Polyuria 23. Nocturia

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Diagnostic Findings: ECG results:

Depressed & prolonged ST segment Depressed & inverted T wave Prominent U wave

2.
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Lab test:
Plasma potassium level below 3.5 mEq/L

1. 2. 3.

Management: Treat the underlying cause. Foods high in K. K-supplementation.

(eg. K-chloride, K-gluconate IV or PO)

4.

Safety precautions.

Hyperkalemia
- A plasma potassium level above 5.0 mEq/L.
1. 2. Etiology & Risk Factors: Retention of K by body because of decreased or inadequate urine output. Excessive release of potassium from the cells during the first 24-72 hours after traumatic injury or burns, or from cell lysis or acidosis Excessive infusion of IV solutions that contain K or excessive oral intake, especially in a person who has renal disaese.

3.

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Pathophysiology: Increase cell membranes excitation threshold. Clinical Manifestations: Paresthesia Tachycardia Intestinal colic Diarrhea Hypotension Convulsions Impaired cardiac conduction Muscle weakness Paralysis Flaccid muscles

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Diagnostic Findings; Plasma potassium level above 5 mEq/L Plasma BUN above 20 mg/dL. Plasma creatinine more than 2.5 mg/dL. ECG reveals: Peak T-wave Management: Treat the underlying cause. Dietary restriction of foods high in K. Infusion of IV Calcium gluconate. Infusion of insulin & glucose. IV Beta-agonist albuterol. Na-polystyrene sulfonate (Kayexalate) PO or rectal Allopurinol & diuretics Safety precautions Complications: Cardiac arrest, respiratory muscle paralysis

Calcium Imbalances
Hypocalcemia
-A plasma calcium level below 4.5 mEq/L or 8.5 mg/dL.

1.

Etiology & Risk Factors: Inadequate intake

- Older adult, decreased Vit. D, lactose intolerance, GI disease, liver disease, alcoholism, anorexia, bulimia, prolong NPO, prolong intsitutionalization

2.

3.

Hypoparathyroidism, inadvertent removal of PT gland, Pancreatitis, open wounds, Cushings disease, alkalosis, multiple BT. Meds: Mg So4, colchicine, neomycin, aspirin, anticonvulsants, estrogen, phosphate preps, steroids, loop diuretics, antacids & laxatives

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Pathophysiology: Decrease in threshold potential. Clinical Manifestations: Numbness & tingling sensations Emotional lability Cardiac insufficiency Hypotension Dysrhythmias Trousseaus sign Chvosteks sign Prolonged bleeding time Seizures Catarcts Dry, sparse hair Rough skin Laryngeal stridor Tetany Hemorrhage Cardiac collapse

17. Fractures 18. Diarrhea

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Diagnostic Findings; Plasma calcium level below 4.5 mEq/L or 8.5 mg/dL ECG: Prolonged QT interval

1. 2. 3. 4. 5. 6.

Management: Assess for chvosteks & trousseaus sign. Assess cardiac status. Monitor blleding. Prevent fractures. Encourage food high in Ca & Vit D. Meds: Calcium gluconate, Ca lactate, Ca Chloride
Complications: Cardiac arrest, death

Hypercalcemia
- A plasma calcium level over 5.5 mEq/L or 11 mg/dL.

1. 2. 3. 4. 5. 6. 7. 8.

Etiology & Risk Factors: Metastatic malignancy Hyperparathyroidism. Thiazide diuretic therapy Excessive intake of Ca & vit D supplements. Calcium-containing anatcids Prolonged immobilization Metabolic acidosis Hypophosphatemia

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Pathophysiology: Increase in threshold potential. Clinical Manifestations: Anorexia Nausea & vomiting Polyuria Muscle weakness Fatigue Lethargy Dehydration Constipation Colicky pain Bone pain Diagnostic Findings: Plasma calcium levelabove 5.5 mEq/L or 11.5 mg/dL ECG: widened T wave, shortened QT interval.

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Management: Assess V/S, & ECG. Assess bowel sounds & renal function. Increase fluid intake. Sodium intake is increased. Consumption of high fiber foods. Safety precautions. Meds: IV normal saline Cortocosteroids IV phosphate Calcitonin Etidronate disodium (Didronel) Gallum nitrate Complications: Renal stones, renal failure, coma

1.

Phosphate Imbalances
Hypophosphatemia
A plasma phosphorous level less than 1.2 mEq/L.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Etiology & Risk Factors: Loss or long-term lack of intake Increased growth or tissue repair Recovery from malnourished state. Prolonged & excessive intake of antacids Admin of high levels of glucose via tube feedings or IV line Cushings syndrome Hyperparathyroidism Respiratory/Metabolic Alkalosis Lead poisoning Burns

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1. 2. 3. 4. 5. 6. 7.

Pathophysiology: Impairs the conversion of glucose & other substances to ATP.

Clinical Manifestations: Decreased cardiac or respiratory functions Muscle weakness Fatigue Brittle bones Bone pain Confusion Seizures

 1. 2.

Management: Diet & dietary supplementation. TPN

 Hyperphosphatemia
A plasma phosphorous level greater than 3 mEq/L.
1. 2. 3. 4. 5. Etiology & Risk Factors: Excessive intake of high-phosphate foods Excess vitamin D Impaired colonic motility Hypoparathyroidism Addisons disease

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Clinical Manifestations: Tachycardia Palpitations Restlessness Anorexia Nausea & vomiting Hyperreflexia Tetany

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Management: Limit high-phosphate foods Treat underlying cause

Magnesium Imbalances
Hypomagnesemia
A plasma megnesium level less than 1.5 mEq/L.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Etiology & Risk Factors: Alcoholism Severe or chronic malnutrition Malabsorption syndrome GI losses (vomiting, GI suction, diarrhea, fistulae, laxative-abuse) Acute renal failure Prolonged TPN w/o Mg replacement Hyperthyroidism, Cushings syndrome, Hyperaldosteronism Diabetic ketoacidosis Alkalosis Drugs: Diuretics, antibiotics, corticosteroids, digitalis Cocaine abuse

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Manifestations: Anorexia Nausea Abdominal distention Depression Psychosis Confusion Chvosteks sign Trousseaus sign Tetany Convulsion Vasospasm

 1.

Diagnostic Tests: ECG Prolonged QT intervals, widened QRS complex, broadening T waves Management: Increase intake of Mg rich foods. Safety & seizure precautions. Assess DTR. Supplementation: 1. Oral magnesium replacement 2. Parenteral Mg So4

1. 2. 3. 4.

 Hypermagnesemia
A plasma megnesium level above 2.5 mEq/L.
1. 2. 3. 4. 5. Etiology & Risk Factors: Renal insufficiency Excessive use of Mg-containing antacids or laxatives Potassium-sparing diuretics Dehydration from ketoacidosis Overuse of IV MgSO4

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Manifestations: Peripheral vasodilation Hypotension Severe muscle weakness Lethargy Drowsiness Loss of DTR Respiratory paralysis PVC

Diagnostic Test: ECG Prolonged PR, QT intervals

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4. 5. 6.

Management: Assess V/S, respiratory function, ECG recordings, urine output. Safety & seizure precaution. Drugs: 1. IV calcium salts 2. Albuterol Avoid constant use of laxatives & antacids containing Mg. Diet: High fiber. Increase fluid intake.

Thank You!!!