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fluids & electrolites
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NUR 335 Fluid & ElectrolytesSharon Y. Rafalko, MS, RN
1
Objectives
Identify clients who are at risk for fluid, electrolyte imbalance.
Asses a client experiencing fluid, electrolyte imbalance.
Formulate nursing diagnoses for a client experiencing fluid, electrolyte imbalance.
State expected outcomes for the client experiencing fluid, electrolyte imbalance.
Review the pathophysiology of and pharmacology use in various types of fluid, electrolyte imbalances.
Discuss the nursing and collaborative management for the client experiencing an imbalance in fluid, sodium, potassium, calcium, magnesium or phosphate levels.
Explain the educational needs for the client, family and/or significant other regarding imbalances in fluid, sodium, potassium, calcium, magnesium or phosphate levels.
Evaluate the nursing and collaborative management for the client experiencing an imbalance in experiencing an imbalance in fluid, sodium, potassium, calcium, magnesium or phosphate levels.
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Inspiration
“The most rewarding things you do in life are often the ones that look like they cannot be done.”
Arnold Palmer
Electrolyte Imbalance Nursing Actions
Hyper and hypokalemia, hypo and hyper Mg, hyper Ca-EKG changes, cardiac monitor
Replace fluids and electrolytes
Treat panic values
Assess lab values
Monitor I & O
Assess for medications that influence electrolytes
Function of Body Water
Needed to maintain homeostasis
Internal equilibrium needed to stay alive
Transport (02, nutrients, electrolytes and waste products, etc)
Body temperature regulation
Lubricant - joints
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Fluid and Electrolyte Balance
Necessary for life, homeostasis
Nursing role: help prevent, treat fluid, electrolyte disturbances
Body Fluid Compartments
Water occupies two main fluid compartments
Intracellular fluid (ICF) – about two thirds by volume, contained in cells
Extracellular fluid (ECF) – consists of two major subdivisionsPlasma – the fluid portion of the blood Interstitial fluid (IF) – fluid in spaces
between cells
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Fluid Compartments
8Figure 26.1
General Rules
Younger people have higher percentage of body fluid than older people
Men have higher percentage of body fluid than women
Obese people have less fluid than thinner people – fat cells contain little water
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The Elderly Increased risk for fluid and electrolyte and
acid-base imbalancesDecreased total body volume Decreased renal blood flow leading to
decreased creatinine clearance Decreased secretion of aldosterone, ADH,
Natriuretic peptides Tend to consume less fluid due to decreased
thirst sensitivity and accessibility to fluidHypernatremia
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Memorize Values
Important to know the ranges
If it is too high, need to remove it
If it is too low, need to give/replace it
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.Sodium Na+ 135-145
Potassium K+ 3.5-5.0
Calcium Ca+ 9.0-11
Magnesium Mg+ 1.5-2.5
Chloride Cl- 96-106
Bicarbonate HCO3-
22-26
Phosphate PO4-
2.8-4.5
Electrolytes
What is an electrolyte?
A substance that, when dissolved in water, dissociates (separates) into electrically charged particles
Table salt or Sodium Chloride when dissolved in water becomes Na+ and Cl-
13
Major Electrolytes
Cations (+ charge)
Sodium Na+
Potassium K+
Calcium Ca+
Magnesium Mg+
Anions (- charge)
Chloride Cl-
Bicarbonate HCO3-
Phosphate HPO4-
Sulfate SO4-
Protein14
• Present in body fluids
• Concentrations in intracellular differ from extracellular
Extracellular and Intracellular Fluids
Extracellular fluids are similar (except for the high protein content of plasma)
Sodium is the chief cation
Chloride is the major anion
Intracellular fluids have low sodium and chloride
Potassium is the chief cation
Phosphate is the chief anion
15
Osmolarity
Used to describe the number of solute particles in a volume of fluid
Normal osmolarity is contributed to mostly by sodium, chloride, potassium, urea and glucose, as well as other ions and substances in the blood.
Increases with dehydration and decreases with over-hydration
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Osmosis
Net movement of water across a selectively permeable membrane
Driven by a difference in solute concentrations on the two sides of the membrane.
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“Water Follows Solutes”
Blood: Few solutesLots of water Cell:
Many solutesLess water
H2O
Osmosis
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“Water Follows Solutes”
Blood: Many solutesLess of water Cell:
Less solutesMore water
H2O
Osmosis
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Fluid Shifts
Edema Imbalances in hydrostatic and oncotic pressure
Cause fluid to shift into the interstitium (tissue spaces)
Conditions that can cause fluid shifts:Heart failure
Low plasma protein seen in liver and renal diseases and malnutrition
Leakage of protein resulting in loss seen with severe trauma and burns.
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Fluid Spacing
First spacing normal distribution of fluids in the ICF & ECF compartments
Second spacing abnormal accumulation of interstitial fluid as seen in edema
Third spacing accumulation of fluid in portions of the body which is not
easily exchanged with the rest of the ECF fluid is trapped and unavailable for use
AscitesPeritonitis intestinal obstructionedema associated with severe burns
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Regulation of Water Balance
Hypothalamic and Pituitary
Release of ADH Increase in plasma osmolality or decrease in blood volume will stimulate
thirst and the release of ADH
More ADH: s/p surgery
Opioid analgesics
Increased ADH production: SIADH
Decreased ADH production: DI
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Regulation of Water Balance
Adrenocortical and Renal Aldosterone: retain Na+ and excrete K+
Cortisol: in large amts- Na+ and H2O retention
Renin Angiotensin Aldosterone (RAA)
Cardiac Atrial Natriuretic Peptides (ANP)
Antagonist to the renin-angiotensin-aldosterone system.
Released in response to ↑blood volume, ↑BP and ↑Na+ levels
Act on the renal tubules to enhance excretion of Na+ & H20, leading to decreased blood volume and pressure.
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Regulation of Water Balance
Gastrointestinal
Oral intake accounts for most intake
2000 – 3000 mL/day
Usual output 100-200 mL /day
Insensible loss
Fluid loss from skin and lungs due to invisible vaporization
900 ml/day (~600 skin evaporation; ~300 water vapor from lungs)
Diaphoresis not included in insensible loss
Amount Ingested = Amount Eliminated
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Fluid and Electrolyte Disturbances
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Fluid Volume Excess
Causes Increased intake or excessive retention
HF, RF, cirrhosis
Long term steroid use
NA+ retention
Excessive administration of Na+-containing fluids
Clinical Manifestations ↑BP, JVD, edema, crackles, dyspnea…SOB,
wheezing
weight gain (simple most important indicator)
NA+ < 135 -- ↓BUN, ↓Hct
Serum Osmo < 280
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Fluid volume Excess
TreatmentRemove excess fluid without disturbing
electrolyte balance
Main therapy: diuretics and fluid restriction
NA+ restriction
Drainage of fluid in cavities:Third spacing in peritoneal space (ascites)
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Fluid volume Excess
Nursing careAssessmentPt teaching
-Nursing DiagnosesExcess fluid volume r/t compromised regulatory
mechanisms as evidenced by…Impaired gas exchange r/t altered oxygen
supply as evidenced by…
- GoalsClient’s fluid and electrolyte status will return to
normal levels within (timeframe)
Fluid Volume DeficitCauses
Excessive fluid loss (both water & electrolytes): diarrhea, third spacing (burns, ascites), excessive diaphoresis (fever), DI, inadequate fluid intake
Dehydration is loss of water without Na+lossClinical Manifestations
Drowsiness, restlessness, thirst, dry mouth, Decreased skin turgor (elderly= forehead tenting)Postural hypotension Weight loss Decreased UOP with increased BUN NA+ > 150Osmo > 305
33
Nursing Interventions: I & O
I&O and… Fluids that cannot be measured can be estimated (scant, small,
medium, large) Urine specific gravity Maintain IV at correct rate (use caution with renal, cardiac, neuro
problems) Add supplemental water to enteral feeds to prevent hyperosmolality
and abnormal fluid shifts Clients with NGT suction should not be given water (increases loss of
electrolytes)
Irrigate NGT with NS only to prevent loss of electrolytes
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Fluid Volume Deficit
Collaborative care
Goal is to correct underlying cause and replace needed fluid and electrolytes
Fluid replacement with isotonic IV fluids
LR or NS
Blood transfusion
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Fluid Volume Deficit
Nursing careAssessment: SOAP
Nursing DiagnosesDeficient fluid volume r/t excessive ECF losses as
evidenced by decreased fluid intake
Decreased cardiac output r/t excessive losses as evidenced by…
GoalsClient’s fluid and electrolytes will return to normal levels
within (time frame)
FVD: Laboratory Data
elevated BUN in relation to serum creatinine,
increased hematocrit
Serum electrolyte changes may occur
Nursing Interventions for Fluid Extracellular Imbalances Intake & Output
Accurate record of I and O Urine Specific gravity
concentrated urine >1.020 Diluted urine
Cardiovascular Excessive: bounding pulse, HTN, JVD, Deficit: postural hypotension, decreased BP, weak -
thready pulse, ↓CVP Respiratory
Excessive: Pulmonary congestion, SOB, crackles, moist cough
Deficit: increased RR r/t hypoxia from decreased circulating volume
38
FVD: Manifestations
.
Medical management: provide fluids to meet body needs
Oral fluids
IV solutions
FVD: Medical ManagementFVD: Medical Management
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Nursing Interventions for Fluid Extracellular ImbalancesNeurological
Excessive: cerebral edema
Deficit: decreased cerebral perfusion
Daily Wt.Single most important measurement for fluid
volume statusSame time, same scale, same clothing
1 L (2.2 lbs) = 1 liter of fluid (lost or retained)
Skin assessment & careTurgor in elderly = over sternum or forehead
42
Fluid & Electrolyte Replacement
Oral
Preferred route to correct mild imbalances
IV
Common route for acute moderate to severe imbalances and if unable to take PO
Fluid challenge
Isotonic solutions initially
Can change to hypotonic once normotensive
Nursing interventions: Elderly
Access to fluids: assist with fluid intake
Offer drinks at the client’s preferred temperature
Offer the majority of fluids with meals (80%)
Decrease fluids at least 2 hours before bedtime to prevent nocturia and incontinence
Accurate I & O
Tonicity in the RBC
An IV solution’s effect on body fluid movement depends in part on its tonicity, or concentration.
REMEMBER: THERE IS GREATER NA+ CONCENTRATION IN THE ECF VERSUS THE ICF
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IV Types
IsotonicTonicity falls within (or near) the normal range for
blood serum275 to 295 mOsm/kg
No change in the concentration of solute and water in the bloodstream
Osmosis neither moves water into the circulation nor pulls it out.
0.9 NACL ; LR; D5W (functions as hypotonic once glucose is metabolized)
Treatment for ECF deficits – expands ECF volume
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Isotonic
A solution with exactly the same water concentration as the cell
There will be no net movement of water across the cell membrane.
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“Water Follows Solutes”
Blood: Na+ Con. 0.9%
Cell: Na+ Conc. 0.9%H2O
Isotonic
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IV TypesHypotonic
Lower osmolality than blood serumMore water (relative to solute) is being infused than
is already present in the vessel and inside the cells. Therefore, water moves into the cells Indicated for hypernatremia and hyperosmolar
conditions Replaces cellular fluid & provides free water
Can cause cerebral edema and Hypotension from intravascular depletion
Contraindicated in edema and third spacing0.45 NS (1/2 NS) , D5 .45
Hypotonic
A dilute solution, with a higher water concentration than the cell
The cell will gain water through osmosis.
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“Water Follows Solutes”
Blood: Na+ Con. < 0.9%
Cell: Na+ Conc. 0.9%H2O
Hypotonic
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IV Types
Hypertonic
Higher osmolality than blood serum
Osmosis pulls water out of the cells
Cell shrinkage
Increased osmolality of ECF - expands it
Indications: Hyponatremia
3% NACL, D10W, D50W
Hypertonic
A concentrated solution, with a lower water concentration than the cell —
The cell will lose water by osmosis.
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“Water Follows Solutes”
Blood: Na+ Con. > 0.9%
Cell: Na+ Conc. 0.9%H2O
Hypertonic
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Other IVF Types
Plasma Volume Expanders
Stays in the intravascular compartment and increases oncotic pressure
Colloids Protein solutions - albumin (5% or 25%)
Synthetic molecules - Dextran, Hespan (Hetastarch)
Whole blood or packed red blood cells [PRBCs] Indicated for fluid losses from ECF (hemorrhage or
sepsis)
Complications of IV Therapy
Fluid overload
Air embolism
Septicemia, other infections
Infiltration, extravasation
Phlebitis
Thrombophlebitis
Hematoma
Clotting, obstruction
Electrolyte ImbalancesElectrolyte Imbalances
56
Sodium Overview
Normal value : 135 – 145 mEq/L
Functions Na determines ECF osmolality
Affects distribution of water between ECF & ICF
Necessary for muscle contraction and nerve impulse transmission
Regulated by ADH, thirst, & RAA system
Gains - taken in via GI tract in food, fluids, medications
Loses - excreted in sweat, urine and feces57
Hypernatremia
Definition [Na > 145 mEq/L] Elevated serum Na level either due to water loss or too
much Na gain. Hyperosmolality causing shift of water out of the cell
and cellular dehydration. Causes
Common in elderly/cognitively impaired Hypertonic enteral feeding w/o water supplementation Excessive Na intake (can be too much Na+ IVF too!!!) Increase insensible water loss such as fever or
heatstroke, osmotic diuretic and diarrhea Disease states such as diabetes insipidus, Cushing
syndrome, uncontrolled DM, hyperaldosteronism 58
59
Hypernatremia
Clinical Manifestations
Shifts water out of cell into ECF…cellular dehydration…neurological manifestations!
With decreased ECF volume
Intense thirst, dry, swollen tongue, postural hypotension, decreased CVP, wt loss, oliguria, weakness, ↓DTRs
With normal or increased ECF volume
As above with peripheral and pulmonary edema, increased BP
Hypernatremia
Clinical Manifestations
Neurological changes related to cerebral cellular dehydration
Stupor, coma, death
Labs
Serum Na >145 mEq/L
Serum Osmo >300 mmol/L
Urine SG & urine osmo: ↑
Unless…DI= dilute urine
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Hypernatremia
Nursing care Goals
determine underlying cause
prevent further water loss and replace fluids
Interventions Hypotonic IV fluids (D5W or ½ NS reduce Na level)
Promote excretion of excess Na with diuretics
Dietary Na restrictions (foods, fluids, medications, etc).
Reduce Na level no faster than 0.5-1 mEq/L/h
Hyponatremia
Definition [<135 mEq/L] Deficient Na in due to loss of NA+ or excessive fluid
gain or a combination of both. Hypo-osmolality with resultant water shift into the cells
(swelling) Causes
Excessive Na loss (diarrhea, vomiting, fistulas, NGT suctioning, diuretics, adrenal insufficiency, burns, wound drainage);
Inadequate Na intake (fasting diets); Excessive water gain leading to low Na concentration
(excessive hypotonic IV fluids, polydypsia) Disease states (SIADH, heart failure,
hypoaldosteronism from adrenal insufficiency)
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Hyponatremia
Clinical Manifestations
With decreased ECF volume
irritability, tremors, seizures, coma
postural hypotension, ↓ CVP, tachycardia, thready pulse
With normal or increased ECF volume
headache, confusion, seizure, coma
wt gain, increased BP and increased CVP
N/V, anorexia, muscle cramps, weakness
Na <115 mEq/L = severe
64
Hyponatremia
Nursing care
– usually only fluid restriction is needed to correct the problem.
Unless if hypovolemic hyponatremia from GI losses, diuretics, etc..
– If seizures develops, small amount of IV hypertonic solution (3% NaCl) to restore serum Na level
– Monitor 3% NACL carefully
Can lead to hypernatremia and cerebral dehydration
Potassium Overview Normal value: 3.5 – 5-0 mEq/L Functions – Major ICF cation
Necessary for skeletal and cardiac muscle contraction
Gains – Diet is main source Losses –
Kidneys are major route of K loss (90%) and remainder is loss in sweat and stool
Impaired kidneys will result in toxic level of K in body and potential for cardiac dysrrhythmias
Na and K has an inversed relationship (when one is excreted, the other is retained)
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K+ Movement in the ECF and ICH
K can move from ICF to ECF resulting in high serum K level
Acidosis, Trauma to cells
K can move from ECF to ICF resulting in low serum K level
Insulin, Alkalosis
66
Hyperkalemia
Definition [K >5.0 mEq/L]
Causes Massive intake of K (IV administration, K-
containing drugs, salt-substitute) Impaired renal excretion of K (renal disease, K-
sparing diuretics [e.g. Aldactone]) Adrenal insufficiency ACE inhibitors [Vasotec] Shift of K from ICF to ECF (Acidosis, tissue
breakdown or crushed injury) Pseudohyperkalemia
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Hyperkalemia
Clinical Manifestations
Irritability, anxiety, abdominal cramps, diarrhea, weakness of lower extremities, paresthesias, flaccid paralysis.
Ventricular dysrhythmias & cardiac arrest if condition is sudden or severe.
EKG Changes
69
Lewis al, 2007
70
Hyperkalemia
Medical & Nursing care Eliminate intake of K (oral & parenteral)
Increase elimination of K administrate diuretics
Dialysis
Kayexalate
Force K from ECF to ICF IV insulin [including glucose to prevent hypoglycemia]
NaHC03 [to correct acidosis]
IV calcium gluconate to antagonize deleterious effects of hyperkalemia on the heart
Hypokalemia
Definition [K <3.5 mEq/L]
Causes Abnormal K loss
diarrhea, vomiting, fistulas, NGT suction, diuretics
K shift into cells increased insulin, alkalosis,
Lack of K intake
Hyperadldosteronism
71
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Hypokalemia
Clinical Manifestations
Fatigue, muscle weakness, leg cramps, nausea, vomiting
Paralytic ileus, paresthesias, decreased reflexes, decreased bowel motility
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EKG Changes
Lewis et al, 2007
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Hypokalemia
Nursing care
Administrate K supplements orally
IV replacement
Ensure urine output is at lease 0.5 ml/kg
Add no more than 60 mEq/ L KCl in IV fluids (40 mEq/L is normal) and administer slowly
Always on an IV pump!!!!!
Encourage high K diet
Teach client how to prevent low K level
NURSE ALERT!!!
K+ is NEVER given IV push or ________!!!!!!
Calcium Overview Normal value
4.5 – 5.5 mEq/L or 9 – 11 mg/dl Functions
Transmission of nerve impulses, myocardial contractibility, blood clotting, formation of teeth and bone, and muscle contractions
Gains Foods (only 30% is absorbed via GI tract) 99% combines with phosphorus and stored in bones inverse relationship with phosphorus PTH increases serum CA++
Loses Low albumin results in low calcium level in serum Calcitonin decreases serum CA++ Decreased Vit D leads to decreased Ca++ absorption
76
Hypercalcemia
Definition
[Ca > 10.2 mg/dL]
Causes
multiple myeloma, prolonged immobilization, hyperparathyroidism, vitamin D overdose
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Hypercalcemia
Clinical Manifestations
Lethargy, weakness, depressed reflexes, decreased memory, confusion, personality changes, psychosis, anorexia, nausea & vomiting
Increased urine output and dehydration
79
Hypercalcemia
Nursing care
Treat underlying cause
Promote excretion
loop diuretic
Phosphate administration
Hydrate with isotonic saline
Promote Ca loss in urine
Prevent ca stone formation
Synthetic Calcitonin
Increased bone reabsorption, increases urinary Ca excretion
Hypocalcemia Definition
[Ca < 8.6 mg/dL]
Causes
– Decreased total CA++: hypoparathyroidism
chronic renal failure
Administration of Lg. amts of citrated blood
vitamin D deficiency
Pancreatitis
low serum albumin level
80
Hypocalcemia Assessment
Primarily affects nerve transmission and muscle (cardiac) functionNeuromuscular
Numbness, tingling
Muscle crampstwitching
Tetany
the involuntary contraction of muscles
Convulsions
81
Trousseau’s Sign
Apply BP Cuff Inflate to over 20mm
HG above BP Adducted thumb Flexed wrist Extended fingers May take 1 to 4
minutes to see the response
82
Chvostek’s sign
Tap facial nerve by earBrief
contraction of upper lip, nose, side of face
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Hypocalcemia
Nursing careAdminister oral or IV calcium gluconate as
prescribed (never give CA++ IM necrosis and tissue sloughing)
IV CA++ given in severe cases encourage diet high in calcium and vitamin D supplement
Suspect precipitated hypocalcemia in any client with neck surgery
radical neck dissection thyroidectomy [especial total]observe for manifestations of hypothyroidism in the
immediate post-operative period r/t decreased PTH production
Phosphate Overview
Normal value2.5 – 4.5 mg/dL
Functionsessential for proper functioning of muscle,
RBC, and nervous system Gains
low calcium level results in high phosphorus level and vice versa
Loseskidneys (major route) and feces
85
Hyperphosphatemia
Definition
[ P04 > 4.5 mg/dl]
Causes
Renal failure- most common
Chemotherapeutic agents
Excessive ingestion
TPN administration
Hypoparathyroidism
Decreased PTH leads to decreased CA++
86
87
Hyperphosphatemia
Clinical Manifestations
Hypocalcemia, tetany, deposition of Ca-P04 precipitates in skin, soft tissue, corneas, viscera and blood vessels
Nursing care
Restrict P04 in diet [dairy product]
Encourage fluids to increase P04 loss in urine
Give calcium supplements and P04-binding agents or gels
88
Hypophosphatemia
Definition[ P04 < 2.5 mg/dl]
Causesmalabsorption syndrome, P04-binding antacids,
recovery from DKA, respiratory alkalosis
Clinical Manifestationsconfusion, coma, muscle weakness
Nursing careadminister oral supplement or administer IV P04 for
severe cases;
Magnesium Overview
Normal value 1.5 – 2.5 mEq/L
Functions Important for neuromuscular function
Gains GI tract
Loses Kidney [conserves or excretes in response
to level]
89
Hypermagnesemia
Definition [Mg > 2.5 mEq/L]
Causes renal failure, excessive administration or intake
Clinical Manifestations lethargy, drowsiness, nausea, vomiting,
somnolence, loss of deep tendon reflexesloss of deep tendon reflexes respiratory and cardiac arrest
Nursing care promote renal excretion by pushing fluids
90
Hypomagnesemia Definition
[Mg < 1.5 mEq/L] Causes
diarrhea, vomiting, chronic alcoholism, impaired GI absorption
Clinical Manifestations confusion, hyperactive deep tendon reflexes,
tremors and seizures Nursing care
IV administration needed for severe cases Respiratory and cardiac arrest from rapid
administration
91