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Normal Values:
135 - 145 mEq/L
ACTION IN THE BODY:
Sodium in the body controls the concentration and volume of the extracellular fluid.
Changes in sodium levels affect the distribution of water between intracellular and extracellular fluids
Vital in transmitting nerve impulses and regulating the body’s acid base balance.
(Lewis et al., 2011)
HYPERNATREMIA - levels >145
Caused by: excessive sodium intake, inadequate water intake, excessive water loss, diseases (diabetes insipidus, Cushing’s syndrome, uncontrolled DM, primary hyperaldosteronism)
HYPONATREMIA - levels <135
Caused by: excessive sodium loss, inadequate sodium intake, excessive water gain, and diseases (SIADH, heart failure, primary hypoaldosteronism)
(Lewis et al., 2011)
CLIENTS AT RISK FOR:
Hypernatremia: diabetes insipidus, Cushing’s syndrome, uncontrolled DM, primary hyperaldosteronism
Hyponatremia: SIADH, heart failure, primary hypoaldosteronism
(Lewis et al., 2011)
SIGNS AND SYMPTOMS
Hypernatremia: intense thirst, CNS deterioration, increased interstitial fluid, restlessness, agitation, twitching, seizure, coma, weakness, lethargy, easily activated neurons, postural hypotension, weakness, decreased skin turgor
Hyponatremia: CNS deterioration, irritability, apprehension, confusion, dizziness, seizures, coma, nausea, vomiting, diarrhea
Lewis et al., 2011)
HEALTHCARE PROVIDER PRESCRIPTIONS
Hypernatremia: Hypotonic fluid or dietary sodium restriction
Hyponatremia: Hypertonic salt solution or sodium supplement, drugs that block the activity of ADH (vasopressin), tolvaptan (Samsca) treats hyponatremia related to heart failure, liver cirrhosis and SIADH
(Adams, Holland, & Urban, 2011)
NURSING ASSESSMENTS
Monitor for:
Twitching
Seizure
Hallucinations
Mental status
Irritability
Restlessness
Apprehension
Nausea
Vomiting
Diarrhea
(Lewis et al., 2011)
LAB VALUES & DIAGNOSTIC STUDIES
Serum sodium levels
Serum osmolarity
Serum Creatinine levels
(ATI, 2010)
NURSING INTERVENTIONS:
Identify and treat underlying cause
Increase/decrease IV fluids containing sodium
Restrict/Increase fluid intake
Administer tolvaptan (if necessary)
(Lewis et al., 2011) (ATI, 2010)
GERIATRIC CONSIDERATIONS
Older adults are at a greater risk for hyponatremia due to increased chronic illness, use of diuretics, and potential insufficient sodium intake.
Older adults at are a greater risk for hypernatremia due to decreased total body water content and inadequate fluid intake
(ATI, 2010)
ACTION IN THE BODY
Second most abundant intracellular cation
50-60% Contained in bone
Coenzyme in the metabolism of protein and carbohydrates
Involved in metabolism of cellular nucleic acids and proteins
Acts directly on myoneural junction – affects neuromuscular excitability
Important for normal cardiac function - associated with cardiac dysrhythmias
(Lewis et al., 2011)
HYPERMAGNESEMIA - levels >2.1
Caused by: increased magnesium intake coupled with renal failure or renal insufficiency as well as adrenal insufficiency
HYPOMAGNESEMIA - levels <1.3
Caused by: prolonged fasting, starvation, chronic alcoholism, fluid loss is GI tract (interferes with absorption), prolonged parenteral nutrition without supplementation, diuretics, diarrhea, vomiting, large urine output, NG suction, hyperaldosteronism, poorly controlled DM.
(Lewis et al., 2011)
SIGNS AND SYMPTOMS
Hypermagnesemia: lethargy, drowsiness, nausea vomiting, loss of deep tendon reflex, somnolence, respiratory arrest, cardiac arrest
Hypomagnesemia: confusion, hyperactive deep tendon reflex, tremors, seizures, cardiac dysrhythmias, development of hypocalcaemia, hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus
(Lewis et al., 2011)
CLIENTS AT RISK FOR:
Hypermagnesemia: Clients with chronic kidney disease who ingest products containing magnesium (Maalox, milk of magnesia)
Hypomagnesemia: Clients with uncontrolled DM, their high glucose levels cause osmotic diuresis, which increases renal excretion of magnesium.
(Lewis et al., 2011)
LAB VALUES & DIAGNOSTIC STUDIES
Serum Magnesium
Serum Creatinine
(ATI, 2010)
NURSING ASSESSMENT
Monitor for:
Lethargy/drowsiness
Nausea or vomiting
Respiratory depression
Respiratory arrest
Tremors
Seizures
Bowel sounds
Reflexes
(Lewis et al., 2011)
HEALTHCARE PROVIDER PRESCRIPTIONS
Hypermagnesemia: IV administration of calcium chloride or calcium gluconate to reverse the effects of magnesium on the cardiac muscle. Promoting urine excretion to lower serum magnesium levels
Hypomagnesemia: Oral supplements, increased dietary intake of foods high in magnesium (green vegetables, nuts, bananas, oranges, peanut butter, chocolate), IV or IM magnesium sulfate, discontinue magnesium-losing medications (loop diuretics)
(Adams, Holland, & Urban, 2011)
NURSING INTERVENTIONS
Reverse underlying cause
Administer oral or IV magnesium sulfate (hypo)
Discontinue oral or IV magnesium sulfate (hyper)
Encourage foods high in magnesium
Monitor ECG, vitals, apical pulse
(Lewis et al., 2011) (Adams, Holland, & Urban, 2011)
GERIATRIC CONSIDERATIONS
Commonly prescribed diuretics for hypertension can cause hypomagnesemia in geriatric patients
(Craven & Hirnle, 2009)
ACTION IN THE BODY
Most abundant ICF cation
Critical for cellular and metabolic function
Critical for neuromuscular and cardiac function and transmission of impulses
Reciprocal action with sodium
Regulates intracellular osmolality
Promotes cellular growth
Large role in acid-base balance in the body
(Lewis et al., 2011)
HYPERKALEMIA - levels > 5.0
Caused by: excess potassium intake (parenteral administration, drugs, potassium containing salt substitute), shift of potassium out of the cells (acidosis, fever, burn, sepsis, crush injuries, tumor lysis syndrome), failure to eliminate potassium (renal disease/RENAL FAILURE, potassium sparing diuretics, adrenal insufficiency, ACE inhibitors)
HYPOKALEMIA - levels <3.5
Caused by: Potassium loss (diarrhea, vomiting, fistulas, NG suction, diuretics, hyperaldosteronism, magnesium depletion, diaphoresis, dialysis), shift of potassium into cells (increased insulin, METABOLIC ALKALOSIS, tissue repair, stress/epinephrine), lack of potassium intake (starvation, low potassium diet, lack of potassium supplements in IV fluid if NPO)
(Lewis et al., 2011)
SIGNS AND SYMPTOMS
Hyperkalemia: irritability, anxiety, abdominal cramping, cramping leg pain, diarrhea, weakness or paralysis of skeletal muscles, paresthesias, irregular pulse/ventricular fibrillation, cardiac arrest (sudden or severe)
Hypokalemia: fatigue, muscle weakness, leg cramps, nausea, vomiting, paralytic ileus, weakness of respiratory muscles, impaired regulation of arterial blood flow, PVC, bradycardia, soft/flabby muslces, paresthesias, decreased reflexes, weak/irregular pulse, polyuria, hyperglycemia
(Lewis et al., 2011)
CLIENTS AT RISK FOR
Hyperkalemia: Clients with impaired kidney function, burns, severe dehydration, taking potassium sparing diuretics, ACE inhibitors, NSAIDS, adrenal insufficiency
Hypokalemia: Clients with low blood volume or increased aldosterone levels, diets low in potassium, excessive use of diuretics
(Lewis et al., 2011)
LAB VALUES & DIAGNOSTIC STUDIES
Serum potassium,
Arterial blood gases: metabolic alkalosis/acidosis
ECG
Serum creatinine
(ATI, 2010)
NURSING ASSESSMENT
Monitor for:
Phlebitis
Intake and urine output
Respirations and breathing patterns
Heart rhythm
Level of consciousness
Bowel sounds
Kidney function
(BUN, GFR, Creatinine)
Other electrolytes
(Ca+, Mg, P)
Assist with ADLs if needed
(Lewis et al., 2011)
HEALTH PROVIDER PRESCRIPTIONS
Hyperkalemia: calcium gluconate, calcium chloride, potassium restricted diet, Administer IV dextrose and regular insulin, sodium bicarbonate to reverse acidosis, Loop diuretics, Kayexalate, dialysis
Hypokalemia: Encourage high potassium foods, IV or oral potassium supplementation, disuse of loop diuretics.
(Adams, Holland, & Urban, 2011) (ATI, 2010)
NURSING INTERVENTIONS
Maintain open airway and monitor vital signs
Treat dysrhythmias and perform continuous cardiac monitoring
Monitor level of consciousness
(Lewis et al., 2011)
GERIATRIC CONSIDERATIONS
Greater risk for hypokalemia due to prominent use of diuretics and laxatives
(ATI, 2010)
ACTION IN THE BODY
Transmits nerve impulses
Myocardial contractions
Blood clotting
Formation of bone and teeth
Muscle contractions
Calcium balance controlled by PTH, Calcitonin and Vitamin D
Lewis et al., 2011)
HYPOCALCEMIA - level <9.0 Caused by: Decreased total calcium (chronic kidney disease, elevated phosphorus, primary hypoparathyroidism, vitamin D deficiency, magnesium deficiency, acute pancreatitis, loop diuretics, chronic alcoholism, diarrhea, decreased serum albumin levels), decreased ionized calcium (alkalosis)
HYPERCALCEMIA - level >10.5
Caused by: Increased total calcium levels (prolonged immobilization, vitamin D overdose, thiazide diuretics, milk-alkali syndrome, hyperparathyroidism, multiple myeloma), increased ionized calcium (acidosis)
(Lewis et al., 2011)
SIGNS AND SYMPTOMS
Hypercalcemia: lethargy, weakness, depressed reflexes, decreased memory, confusion, personality changes, anorexia, vomiting, nausea, bone pain, fractures, polyuria, dehydration, nephrolithiasis, stupor, coma) (Med Surg)
Hypocalcemia: paresthesia of fingers and lips, muscle twitching, resting muscle spasm, hyperactive DTR, positive Chvostek’s sign, positive Trousseau’s sign, decreased myocardial contractility, hyperactive bowel sounds, diarrhea, abdominal Cramping
(ATI, 2010)
CLIENTS AT RISK
Hypocalcemia: Chron’s disease, hypoalbuminemia, end stage kidney disease, post-thyroidectomy, hypoparathyroidism, pancreatitis, sepsis, patients on medications that block parathyroid function
Hypercalcemia: Patients taking thiazide diuretics, hyperparathyroidism, milk-alkali syndrome, multiple myeloma, patients with malignancies with bone metastasis
(Lewis et al., 2011)(ATI, 2010)
HEALTHCARE PROVIDER PRESCRIPTIONS
Hypocalcemia: IV/oral calcium supplements, vitamin D supplements
Hypercalcemia: Hypotonic fluid or calcitonin
(Adams, Holland, & Urban, 2011)
LAB VALUES & DIAGNOSTIC STUDIES
Serum Calcium levels
ECG – prolonged QT interval
Serum creatinine
(ATI, 2010)
NURSING ASSESSMENTS
ECG changes
(ET, QT segment is shortened or lengthened)
Tachycardia
Dysrhythmia
Seizure
Spasm
Heart failure
Chvostek sign
Trousseau sign
(ATI) (Lewis et al., 2011)
NURSING INTERVENTIONS
Reversing underlying cause
Administer/stop administering IV or oral calcium supplements
Encourage foods high/low in calcium
Lewis et al., 2011)
GERIATRIC CONSIDERATIONS
Aging adults have gradual loss of calcium in their bones, which can lead to osteoporosis in some patients. This can cause fractures and hypocalcemia if not treated with calcium supplements
(Craven & Hirnle, 2009)
ACTION IN THE BODY
Primary anion in ICF
Essential in muscle function, red blood cell function and a functioning nervous system
Works with calcium for tooth and bone structure and formation
Involved with acid-base system
Involved with ATP production
Involved in cellular uptake of glucose
(Lewis et al., 2011)
HYPOPHOSPHATEMIA - level >4.5
Caused by: renal failure, chemotherapeutic agents, and enemas containing phosphorus, excessive ingestion of phosphorus, large vitamin D intake, and hyperparathyroidism.
HYPOPHOSPHATEMIA - level < 2.5
Caused by: malabsorption syndrome, increased carbohydrate calories (glucose administration), total parenteral nutrition, respiratory alkalosis, alcoholism/alcohol withdrawal, phosphate binding antacids, uncontrolled diabetes mellitus, renal phosphate wasting
(Lewis et al., 2011)
SIGNS AND SYMPTOMS
Hypophosphatemia: CNS dysfunction (confusion, coma), muscle weakness, respiratory weakness, cardiac problems (dysrhythmias, decreased stroke volume), osteomalacia, rhabdomylosis
Hyperphosphatemia: hypocalcemia, muscle problems (tetany), phosphate and calcium precipitates in skin, soft tissue, cornea, viscera and blood vessels.
(Lewis et al., 2011)
CLIENTS AT RISK FOR:
Hyperphosphatemia: Chronic kidney disease, patients receiving chemotherapy, patients recieveing enemas containing phosphorus, hyperparathyroidism, ketoacidosis
Hypophosphatemia: Alcoholics/alcohol withdrawal, patients taking phosphate binding antacids, uncontrolled diabetes mellitus, major burns, respiratory alkalosis, vitamin D deficiency
(Lewis et al., 2011)
HEALTHCARE PROVIDER PRESCRIPTIONS
Hyperphosphatemia: dietary phosphate restriction
Hypophosphatemia: phosphate supplements
(Adams, Holland, & Urban, 2011)
LAB VALUES & DIAGNOSTIC STUDIES
Serum phosphate
Serum creatinine
(ATI, 2010)
NURSING ASSESSMENTS
Precipitates in skin, soft tissue, cornea, viscera, blood vessels
Tetany
Pruritus
Monitor for muscle weakness
Dysrhythmias
Decreased stroke volume
Diarrhea
Nausea
Delirium
Apprehension
Tachypnea
Respiratory weakness
(Lewis et al., 2011)
NURSING INTERVENTIONS
Identify and treat underlying cause (both)
Administer oral phosphate replacement (hypo)
Encourage foods high (or low) in phosphorus
Monitor for dysrhythmias
(Lewis et al., 2011)
GERIATRIC CONSIDERATIONS
In older adults, when they are prepping for a colonoscopy if they use sodium phosphate it can cause hyperphosphatemia
(Craven & Hirnle, 2009)
REFERENCES
Adams, M.P., Holland, Jr., L.N., & Urban, C.Q. (2011). Pharmacology for nurses: A pathophysiologic approach (3rd ed.). Upper Saddle River: Pearson Education, Inc.
Assessment Technologies Institute, LLC. (2010). RN adult medical surgical nursing (8th ed.). USA: Assessment Technologies Institute
Craven, R.F., & Hirnlee, C.J. (2009). Fundamentals of nursing: Human health and function (6th ed). Philadelphia: Wolters Kluwer Lippincott Williams & Wilkins.
Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Camera, I.M. (2011). Medical-Surgical Nursing: Assessment and management of clinical problems (8th ed.). St Louis, Missouri: Elselvier Mosby.
by: Molly Ann Short
NUR311
May 10, 2012
Normal Values:
9.0 - 10.5 mg/dL
Normal Values:
3.5 - 4.5 mg/dL
Normal Values:
1.3 - 2.1 mEq/dL
Normal Values:
3.5 - 5.0 mEq/dL