Electrolyte Imbalance

Electrolytes are minerals: – regulate fluid balance and hormone production, – strengthen skeletal structures, and – act as catalysts in nerve response, muscle contraction, and the metabolism of nutrients. Electrolytes may be (cations – magnesium, potassium, sodium, calcium) or (anions – phosphate, sulfate, chloride, bicarbonate) Electrolytes are distributed between ICF and ECF

Reasons for Electrolyte Imbalances Abnormalities occur when electrolyte concentrations are imbalanced between intercellular and extracellular fluids Kidney Dysfunction Lack of Water: Dehydration or Diarrhea Medication Side Effects 7

Sodium Imbalances Sodium (Na+) is the major electrolyte found in extracellular fluid. It is essential for maintenance of acid-base balance, active and passive transport mechanisms, and maintaining irritability and conduction of nerve and muscle tissue. Normal serum sodium levels are between 135 to 145 mEq/L.

Hyponatremia (<135mEq/L) Net gain of water or loss of sodium- rich fluids It leads to cellular edema Contributing Factors – Excessive diaphoresis – Wound Drainage - Diarrhea – NPO - CHF - Low salt diet – Renal Disease - Diuretics – Compensatory mechanisms include the renal excretion of sodium-free water.

10 Cell in a hypotonic solution

Diagnostic Procedures and Nursing Interventions Expected Findings – Serum sodium < 135 mEq/L – Serum osmolarity < 270 mOsm/L Nursing Interventions Report abnormal findings to the primary care provider

Assessment Clinical indicators depend on whether it is associated with a normal, decreased, or increased ECF volume. Vital signs: Hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension

Hyponatremia (<135mEq/L) Assessment findings: – Neuro - Generalized skeletal muscle weakness. Headache / confusion, fatigue, personality changes. – Resp.- Shallow respirations – CV - Cardiac changes depend on fluid volume – GI – Increased GI motility, Nausea, Diarrhea (explosive) – GU - Increased urine output

NANDA Nursing Diagnoses Excess fluid volume Deficient fluid volume Impaired memory

Hyponatremia (<135mEq/L) Interventions/Treatment – Restore Na levels to normal and prevent further decreases in Na. – Drug Therapy – (FVD) - IV therapy to restore both fluid and Na. If severe may see 2-3% saline. (FVE) – Administer osmotic diuretic (Mannitol) to excrete the water rather than the sodium. – Increase oral sodium intake and restrict oral fluid intake.

Foods High in Sodium 1. Cheese 2. Celery 3. Dried fruits 4. Ketchup 5. Mustard 6. Olives 7. Pickles 8. Preserved meats 9. Sauerkraut 10. Soy sauce 11. All prepared foods (canned and packaged) and fast foods are very high in sodium 16

Hyponatremia (<135mEq/L) Monitor I & O and daily weight. Monitor VS & LOC, report abnormal findings. Encourage the client to change positions slowly. Complications – Seizures, coma, and respiratory arrest – Seizure precautions and management – Life support interventions

Hypernatremia (>145mEq/L) Hypernatremia is a serious electrolyte imbalance. It can cause significant neurological, endocrine, and cardiac disturbances. Increased sodium causes hypertonicity of the serum. This causes a shift of water out of the cells, making the cells dehydrated.

Cell in a hypertonic solution

Hypernatremia (>145mEq/L) Contributing Factors – Hyperaldosteronism – Renal failure – Corticosteroids – Increase in oral Na intake – Na containing IV fluids – Decreased urine output with increased urine concentration

Hypernatremia (>145mEq/L) Contributing factors (cont’d): – Diarrhea – Dehydration – Fever – Hyperventilation – Diaphoresis – Burn – DI

Diagnostic Procedures and Nursing Interventions Expected Findings – Serum sodium: Increased: > 145 mEq/L – Serum osmolarity: Increased: > 300 mOsm/L Nursing Interventions Report abnormal findings to the primary care provider.

Hypernatremia (>145mEq/L) Assessment findings: – Neuro - Spontaneous muscle twitches. Irregular contractions. Skeletal muscle weakness. Diminished deep tendon reflexes – Resp. – Pulmonary edema – CV – Diminished CO. HR and BP depend on vascular volume. Compensatory mechanisms include increased thirst and increased production of ADH.

Hypernatremia (>145mEq/L) GU – Dec. urine output. Inc. specific gravity Skin – Dry, flaky skin. Edema r/t fluid volume changes. Vital signs: Hyperthermia, tachycardia, orthostatic hypotension Other signs: Edema, warm flushed skin, oliguria

NANDA Nursing Diagnoses Deficient fluid volume Impaired memory Risk for injury Impaired oral mucous membrane

Hypernatremia (>145mEq/L) Interventions/Treatment – Drug therapy (FVD).45% NSS. If caused by both Na and fluid loss, will administer NaCL. If inadequate renal excretion of sodium, will administer diuretics. – Diet therapy: Mild – Ensure water intake and discourage sodium intake. Monitor LOC and maintain client safety. Provide oral hygiene. Monitor intake and output and alert the primary care provider of inadequate renal output.

Hypernatremia Complications and Nursing Implications – Cellular dehydration, convulsions, and death – Seizure precautions and management – Life support interventions

Potassium The major cation in ICF. It plays a vital role in cell metabolism, transmission of nerve impulses, functioning of cardiac, lung, and muscle tissues, and acid-base balance. Potassium has reciprocal action with sodium. Normal serum potassium levels are 3.5 to 5.0 mEq/L.

Hypokalemia (<3.5mEq/L) Hypokalemia is the result of increased loss of potassium from the body or movement of potassium into the cells. Pathophysiology – – Decrease in K+ causes decreased excitability of cells, therefore cells are less responsive to normal stimuli

Hypokalemia (<3.5mEq/L) Contributing factors: – Diuretics - Inadequate dietary intake – Shift into cells - Suction – Digitalis – Water intoxication – Corticosteroids – Diarrhea – Vomiting – Laxatives – Wound drainage

Diagnostic Procedures and Nursing Interventions Expected Findings Serum potassium: Decreased: < 3.5 mEq/L Arterial Blood Gases: Metabolic alkalosis: pH > 7.45 Electrocardiogram: Dysrhythmias Nursing Interventions – Report abnormal findings to the primary care provider.

Assessment VS: Hyperthermia, weak irregular pulse, hypotension, respiratory distress Neuromusculoskeletal:(res.collapse & paralysis), muscle cramping, decreased muscle tone and hypoactive reflexes, paresthesias, mental confusion ECG: Premature ventricular contractions (PVCs), bradycardia, blocks, ventricular tachycardia

Assessment GI: Decreased motility, abdominal distention, constipation, ileus, nausea, vomiting, anorexia Other signs: Polyuria (dilute urine)

NANDA Nursing Diagnoses Decreased cardiac output Ineffective breathing pattern Risk for injury Constipation

Hypokalemia (<3.5mEq/L) Interventions – Treat the cause – Encourage potassium-rich foods – K+ replacement (IV or PO) – Monitor lab values – D/c potassium-wasting diuretics – Monitor for breathing. – Monitor the client’s cardiac rhythm – Monitor LOC and maintain client safety. – Monitor bowel sounds and abdominal distention.

Foods Rich in Potassium 1. Artichokes(أرض شوكي) 2. Apricots 3. Avocado 4. Banana 5. Beans 6. Chocolate 7. Carrots 8. Cantaloupe 9. Green Leafy Veggies 10. Mushrooms 11. Melons 12. Nuts 13. Oranges 14. Prunes 15. Potatoes 16. Pumpkins 17. Spinach 18. Tomatoes 38

Administering potassium iv IV potassium supplementation: Never IV push (high risk of cardiac arrest). The maximum recommended rate is 5 to 10 mEq/hr. Monitor for phlebitis (tissue irritant). Monitor for and maintain adequate urine output.

Complications and Nursing Implications Respiratory Failure – Monitor for hypoxemia and hypercapnia. – Intubation and mechanical ventilation may be required. Cardiac Arrest – Perform continuous cardiac monitoring. – Treat life-threatening dysrhythmias.

Hyperkalemia (>5.0mEq/L) Hyperkalemia is the result of: – increased intake of potassium, – movement of potassium out of the cells, or – inadequate renal excretion. Pathophysiology – An inc. in K+ causes increased excitability of cells.

Risk Factors/Causes of Hyperkalemia Increased total body potassium: IV potassium administration, salt substitute. Extracellular shift: Decreased insulin, acidosis (DKA), tissue catabolism (sepsis, trauma, surgery, fever, MI) Hypertonic states: Uncontrolled diabetes Decreased excretion of potassium: Renal failure, severe dehydration, potassium-sparing diuretics, ACE Inhibitors, NSAIDs, adrenal insufficiency

Diagnostic Procedures and Nursing Interventions Expected Findings – Serum potassium: Increased: > 5.0 mEq/L – ABGs: Metabolic acidosis: pH < 7.35 – Electrocardiogram: Dysrhythmias Nursing Interventions – Report abnormal findings to the primary care provider.

Assessment: Hyperkalemia (>5.0mEq/L) VS: Slow, irregular pulse, hypotension Neuromusculoskeletal: Restlessness, irritability, weakness (ascending flaccid paralysis), paresthesias ECG: Ventricular fibrillation Gastrointestinal: N, V, D Other signs: Oliguria

NANDA Nursing Diagnoses Decreased cardiac output Risk for injury Diarrhea

Hyperkalemia (>5.0mEq/L) Interventions – Need to restore normal K+ balance: – Eliminate K+ administration – Inc. K+ excretion: Lasix, Kayexalate Promote movement of potassium from ECF to ICF: Administer dextrose and R insulin IV Administer sodium bicarbonate (reverse acidosis). Monitor the client’s cardiac rhythm and intervene promptly as needed. – Infuse glucose and insulin – Cardiac Monitoring

Complications and Nursing Implications Cardiac Arrest Perform continuous cardiac monitoring. Treat life-threatening dysrhythmias.

Hypocalcemia (<9.0mg/dL) Contributing factors: – Dec. oral intake – Lactose intolerance – Dec. Vitamin D intake – End stage renal disease – Diarrhea

Hypocalcemia (<9.0mg/dL) Contributing factors (cont’d): Acute pancreatitis Hyperphosphatemia Immobility Removal or destruction of parathyroid gland Malabsorption Post thyroidectomy

Hypocalcemia (<9.0mg/dL) Assessment findings: – Neuro –Irritable muscle twitches. – Muscle twitches/tetany – Frequent, painful muscle spasms at rest – Hyperactive deep tendon reflexes Positive Trousseau’s sign (hand/finger spasms with sustained BP cuff inflation). Positive Chvostek’s sign (tap on facial nerve triggers facial twitching)

Positive Trousseau’s Sign

Positive Chvostek’s Sign

Assessment Resp. – Resp. failure d/t muscle tetany. Cardiovascular – Decreased myocardial contractility: Decreased heart rate and hypotension ECG changes: Prolonged QT interval GI: Hyperactive bowel sounds, diarrhea, abdominal cramping

Hypocalcemia (<9.0mg/dL) Interventions/Treatment – Drug Therapy Calcium supplements Vitamin D – Diet Therapy High calcium diet – Prevention of Injury Seizure precautions

Foods High in Calcium 1. Cheese 2. Milk 3. Broccoli 4. Yogurt 5. Sardines 6. Mustard 7. Dark Greens (spinach, collards الملفوف, etc.) 8. Soybeans 9. Okra 10. Calcium fortified foods (such as some orange juice, oatmeal, and breakfast cereals ) 11. White beans 12. Almonds 13. Sesame Seeds 57

Hypercalcemia (>10.5mg/dL) Contributing factors: – Excessive calcium intake – Excessive vitamin D intake – Renal failure – Hyperparathyroidism – Malignancy – Hyperthyroidism

Hypercalcemia (>10.5mg/dL) Assessment findings: – Neuro – Disorientation, lethargy, coma, profound muscle weakness – Resp. – Ineffective resp. movement – CV - Inc. HR, Inc. BP., Bounding peripheral pulses, Positive Homan’s sign. Late Phase – Bradycardia, Cardiac arrest – GI – Dec. motility. Dec. BS. Constipation – GU – Inc. urine output. Formation of renal calculi

Hypercalcemia (>10.5mg/dL) Interventions/Treatment – Eliminate calcium administration – Drug Therapy – Isotonic NaCL (Inc. the excretion of Ca) – Diuretics – Calcium reabsorption inhibitors (Phosphorus) – Cardiac Monitoring