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Copy of Electrolyte Concept Map

By: Stephanie Barendt
by

helle brantley

on 6 September 2013

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Transcript of Copy of Electrolyte Concept Map

Electrolyte Concept
Map

by: Helle Brantley

Sodium
Na

Normal lab values
135- 145 mEq/L
Differentiation between increased and decreased lab values
HYPOnatremia
Na+ is less than 135mEq/L

HYPERnatremia:
Na+ is greater than 145 mEq/L
Identifying patient's at risk for hyponatremia & hypernatremia
Identifiable risk factors that can potentially lead to Hyponatremia:
Loss of sodium from sweat
Fluid retention-water excess caused by the use of hypotonic IV fluids not containing Na
An altered LOC
Surgery or trauma
Renal failure
Excess water intake
Vomiting/diarrhea
Stress
Identifiable risk factors than can potentially lead to Hypernatremia:
Dehydration
Impaired LOC
Water deficiency
deficiency in the synthesis/release of ADH form the posterior pituitary gland
Kidney dysfunction
Excessive sweating
Hyperglycemia
Uncontrolled diabetes mellitus
Osmotic diureses-dilute urine is lost and Na is left
High fever, burns or sepsis
Excessive dietary sodium intake
Sodium-containing drugs
ACE inhibitors
Signs and symptoms associated with hyponatremia & hypernatremia
Hypornatremia:
Apprehension, dizziness, Irritability , confusion, and personality changes
Tremors, coma and seizures
Dry mucus membranes
Decreased Jugular venous filling and postural hypotension
thready pulse and tachycardia
cold/clammy skin
Headache, apathy, muscle spasms, nausea, vomiting and diarrhea
Weight gain, elevated blood pressure,and abdominal cramps

Hypernatremia:
Agitation, twitching, coma, seizure and restlessness
Thirst, dry/swollen tongue, sticky mucous membranes
Weakness and lethargy
Weight loss
Postural hypotension
Peripheral/pulmonary edema
Lab & Diagnostic tests to determine underlying cause of hyponatremia & hypernatremia
Na+, K+, Mg, BUN, creatine, pH and blood glucose labs
Urinalysis or Na in urine and urine osmolarity
ECG
Renal function test
Metabolic panel
Osmolarity blood test
Physical examination
Cardiac monitoring
Anticipated prescriptions
The provider may prescribe water replacement by increasing fluid intake
IV solutions of 5% dextrose in water and/or a hypotonic saline solution
The physician could order diuretics which would promote the excretion of Na
Fluid restriction may be ordered
IV hypertonic saline solution, NaCl, conivaptan (Vaprisol) and/or tolvaptan (Samsca) could be prescribed for a hyponatremia patient
A physician may order a Na restricted diet
Nursing Assessment

Assess neurological status, LOC
Assess cranial nerves
Assess for signs and symptoms of hyponatremia and hypernatremia
Auscultate lung sounds and heart tones
Physical assessment
Assess patient/family medical history
Assess for jugular vein
Skin assessment for turgor, clamminess and edema
Complete pain assessment
Nursing Interventions
Monitor vital signs frequently
Notify provider of any changes in patient status
Monitor cardiac function and respiratory function
Intake and outputs
Take daily weights
Palpate and observe for abdominal distention and discomfort
Administer parenteral fluids
Administer all drugs as prescribed by physician
Provide client and family teaching of signs and symptoms of hypernatremia or hyponatremia
Teach client/family of Na+-rich foods
Teach client/family sign and symptoms dehydration
Promote compliance
teach client/family about the warning signs of dehydration, the importance of hydration, and the signs and risks of high and low sodium
Interrupt lab values, urinalysis and ECG's
Encourage or restrict fluids
Geriatric Considerations
Elderly population are at higher risk for dehydration
High risk for renal dysfunction-kidneys can't excrete enough Na+, and lower doses of medication may be required.
Typically take a lot of medications, possibly effecting ADH and aldosterone
High risk for malnourishment and fluid loss
Decreased skin turgor and skin elasticity-be careful inserting IV's
Generally the geriatric patients are more likely to be on diuretic medications which effects fluid volume
Elderly people have a decreased total water volume which leaves them at high risk for hypernatremia
Potassium
K+
Normal Values
3.5-5.5 mEq/L
**within cells concentration is about 140 mEq/L
Potassium's action in the body:
Assembles proteins
Builds muscle mass thus aids in maintaining normal growth
Regulates intracellular osmolarity
Vital for the electrical functioning of the heart
Plays a role in the formation and breakdown of body tissues
Assists in the pH balance
Crucial for multiple cellular and metabolic functions
Cell growth
Amount of K+ in the body affects urine output
Utilizes and depletes carbohydrates
Major ICF cation
Increased lab values
vs.
decreased lab values
HYPOkalemia is indicated when lab values are less than 3.5 mEq/L


HYPERkalemia is indicated when lab values are greater than 5.5 mEq/L
Identifying patients at risk for hypokalemia/hyperkalemia
Identifiable risk factors that can potentially contribute to
hypokalemia:
Excess/abnormal loss of K+ from the kidneys or GI tract
Deficient dietary intake (a rare risk factor)
Elevated aldosterone levels, causing excessive K+ loss while diuresing
Excessive K+ loss in urine due to diuretics, a depletion of mg, or dialysis
GI losses of K+ such as; diarrhea, vomiting and ileostomy drainage
K+ shifting into the cells from metabolic alkalosis
Sudden onset of cell formation (less common)
Renal disease
Identifiable risk factors than can potentially contribute to
hyperkalemia:
Excessive dietary intake of K+ (rare)
Insufficient renal excretion
Impaired renal function/renal failure (most common)
K+ shift to ECF from ICF related to metabolic acidosis
Extreme destruction of cells in the body, for example a burn
K+ retention due to adrenal impairment in combination with aldosterone deficiency
K+ sparring diuretics and ACE inhibitors impair the kidneys of excreting K+
severe infection
Signs and symptoms of hypokalemia & hyperkalemia:
Hypokalemia:
Abnormal heart rhythms
Paralysis or muscle weakness
Increased blood pressure
Increased negative charge, also known as hyperpolarization, which results with decreased excitability in the cells.
Skeletal muscle weakness and paralysis commonly affecting the lungs causing shallow respirations
Ventricular dysrhythmias
Impaired function of smooth muscle
Altered non-muscle tissue function, which can cause an alteration in insulin release that leads to hyperglycemia.
Fatigue, leg cramps,nausea and vomiting, muscle weakness
Hyperkalemia:
Increased cell excitability due to altered ICF and ECF ratio
Abnormal heart rhythms
leg cramps/pain
Skeletal muscle paralysis
Ventricular fibrillation
Cardiac standstill
Smooth muscles have hyperactivity which may cause abdominal cramping and/or diarrhea
Irritability and anxiety
Labs & diagnostic studies

Complete blood count, renal function tests, BUN & Creatine, mg, glucose, cortisol and acid-base balance
Check vital signs, listen to heart and lungs, monitor blood pressure and perform a physical assessment
Urinalysis
Look at dietary intake and current medications
Consider family history and patient history
Assess for pain, leg cramps, nausea, vomiting or diarrhea
Monitor ECG
Assess patient's stress level and perform a pain assessment
Obtain a urinalysis and 24 hour urine aldosterone test
Anticipated prescriptions
Hypokalemia:
Providers may prescribe oral K+ supplements and order a potassium-rich diet
KCl may be prescribed via IV at a maximum rate of 10mEq/hr
Patients may be prescribed a K+ sparing diuretic, which acts to inhibit aldosterone effects in the renal tubule, thus increasing K+ retention and sodium and water excretion.
Hyperkalemia:
**Typically high potassium levels are maintained without requiring hospitalization
For less-severe cases a provider may prescribe a low potassium diet
Provider may prescribe an IV of glucose and insulin in order to promote return of potassium into the cells from the ECF
Calcium may be given intravenously to protect the heart muscles from hyperkalemia effects
Providers might order sodium bicarbonate to help with acidosis and also to aide in moving K+ back in the cells from the ECF
Albuterol or epinephrin
Nursing Assessment
Monitor vitals, especially vitals representing cardiac and respiratory changes
Listen to heart and lungs
Asses LOC and patient's cognitive function
Assess patient's inputs and outputs
Assess dietary intake on potassium
Perform urinalysis, and monitor regular labs looking especially at BUN, creatine, K+, mg, Ca+ and CBC's
Assess bowel movements, time, frequency, and formation
Assess patient and family history
Nursing Intervention

Administer medication as prescribed
Follow provider written dietary restrictions
Promote fluid intake
Prepare IV's at the correct dosage and rate
Monitor patient's response to treat and notify provider if there is a change in status
Monitor patient for dysrhythmias
assess IV sites for patients undergoing potassium chloride for phlebitis
Provide patient and family teaching for the signs and symptoms of hypokalemia and hyperkalemia
Teach patient and their family the importance of following prescribed diet limiting or promoting K+
Monitor ECG
Perform physical examinations, and pain assessments
Considerations for geriatric patients
Greater risk for malnutrition
Lower doses may be necessary
Consider code status, review advanced directives if they are in place
Be aware of GI changes in older adults
Be knowledgeable in physical and physiological changes in geriatric patients
Be aware of renal and hepatic function, and absorption rate
Calcium
Ca+

Action of Ca+ in the body
Our bodies obtain Ca+ from foods eaten
Our bones store Ca+ in the body, and Ca+ concentrations are regulated by the transport of Ca+ ions into and out of the body
Calcium's purpose in the body controls nerve impulses, blood clotting, myocardial contractions, formation of teeth and bones, and contractions of the muscles.
99% of Ca+ in the body is combined with phosphorus
Normal Lab Values
HYPOcalcemia:
Ca+ is less than8.6 mg/dL

HYPERcalcemia:
Ca+ is greater than 10.2 mg/dL
Differentiation between increased and decreased lab values
Total Ca+8.6- 10.2 mg/dL

ionized Ca+- 4.6-5.3 mg/dL
Identifying patients at risk for hypocalemia and hypercalemia
The following factors will put an individual at risk for Hypocalcemia:
Chronic renal disease
High phosphorus levels
Hypothyroidism, relating to altered PTH
Deficiency in vitamin D, serum albumin and mg
Acute pacreatitis
Loop diuretics
Chronic alcoholism
Diarrhea
Bone destruction

The following factors will put an individual at risk for Hypercalcemia:
Multiple myeloma malignancies
Malignancies with bone metastasis
Prolonged immobilization
Hyperparathyroidism
Overdose of vitamin D
Thiazide diruetics
Milk-alkali syndrom
Acidosis can
Signs and Symptoms associated with hypocalcemia & hypercalcemia
Hypocalemia:
Sudden alkalosis, fatigue, depression and anxiety
Increased nerve excitability and seizures
Tetany-Trousseau's sign , which becomes apparent when a blood pressure cuff placed on the arm is inflated for 3 minutes and Chvostek's sign, which becomes evident when the facial nerve is tapped in front of the ear.
Laryngeal stridor, dysphagia, numbness and tingling around mouth are and/or extremities, muscle cramps and hyperflexia
Diminished cardiac contractility
Changes in ECG
Ventricular tachycardia
Hypercalemia:
Decreased muscle and nerve excitability
Lethargy, weakness
Reflexes may become depressed
Memory loss, confusion, changes in personality, psychosis
Anorexia, nausea, vomiting
Bone fractures, bone pain
Polyuria, dehydration
Nephrolithiasis
Stupor, coma
ECG changes showing a shortened ST segment and QT interval, ventricular dysrhythmias, increased digitalis effect
Lab/Diagnostic Studies
Hypercalcemia
Lab and diagnostic tests that may be helpful in identifying the cause include:
Ca+, high vitamin D level, CBC and pH
Vitamin D, Ca+, Mg, low or high pH,
ECG and X-Ray
Urinalysis, 24 hour urine collection
PTH blood test
Physical examination
Medication assessment
Patient/family health history

Hypocalcemia:
Lab and diagnostic tests that may be helpful in identifying the cause include:
Ca+, high phosphorus levels, low Mg levels, pH greater than 7, decreased albumin, high BUN and creatine levels, and low vitamin D levels
Liver and kidney function tests
Medication assessment
Patient/family health and social history
Physical examination
Palpation/X-ray of thyroid
ECG

Anticipated Prescriptions
Hypercalcemia
Loop diuretics (furosemide(Lasix))
Isotonic saline solutions
Providers may order patient's to drink 3000-4000 mL of fluid per day in order to prevents a kidney stone form forming and also to aide in Ca+ excretion in the urine
A provider may order a form of synthetic calcitonin to be administered
Low-Ca+ diet
Cyotoxic antibiotics ( plicamycin (Mithracin)) may be prescribed to inhibit the resorption of bone
Pamidronate( Aredia) may be ordered in malignancy cases because it inhibits osteoclast activity.
Weight-bearing activities

Hypocalcemia:
Ca+ supplementation by mouth or through IV is typically prescribed along with a calcium-rich diet
Prescribed medications for anxiety and pain can sometimes be necessary for the patient to avoid a hyperventilation causing respiratory alkalosis.
Nursing Assessment
Physical and physiological assessments including full muscular skeletal assessment, LOC, and cognitive function
Pain assessment
Patient/family health and social history
Vital signs, and cardiac functions
Assess dietary intake
Assess urinary output
Assess lab work, diagnostic test results and ECG
Assess patient's signs and symptoms
Nursing Interventions

Administer prescribed medications as directed by patient's provider
Monitor vital signs
Implement all ordered dietary/fluid restrictions
Prepare IV's at the right time and as directed
Monitor for pain and anxiety
Report changes in patient status to the provider immediately
Record all of the patient's In-puts and out-puts
Document thoroughly and correctly
Encourage fluid intake when necessary
Encourage weight bearing exercise if requested per provider
Promote patient safety
Be aware of signs and symptoms of hypocalcemia and hypercalcemia
Know patient's code status and review patient's advanced directives if they have them
Encourage patient compliance


Geriatric Considerations
Geriatric population have a higher risk of developing hypocalcemia
Impaired renal/hepatic functioning, thus lower doses may be necessary
Decrease in bone mass
More at risk for bone injury
Higher cancer rate
Elderly people often take more medications and supplements so they have a higher risk for drug-drug interactions
More often prescribed thiazide diuretics, leaving those patient's at a higher risk of hypercalcemia
Geriatric patients experience skin changes such as thinning, delicate skin so IV's need to be inserted carefully.

Phosphorous
Action of Phosphorus in the body
Phosphorus is necessary for muscle function, RBC'S as well as the nervous system.
Helps with bone and tooth structure
Aids in the buffering of acid and bases
Phosphorus helps with mitochondrial production of ATP
Uses glucose and uptakes carbohydrates
Metabolizes fats, proteins and carbohydrates
Phosphate levels affect Calcium concentration on the body





Normal Values
HYPOphosphatemia:
phosphate less than 2. mg/dL

HYPERphosphatemia:
phosphate greater than 4.4 mg/dL
Differentiation between increased & decreased lab values:
2.4-4.4 mg/dL
Identifying patient's at risk for hypophosphatemia & hyperphosphatemia
Hypophosphatemia:
Malabsorption syndrome
Secondary effect to recovery of starvation
Administration of glucose
Withdraw from alcohol
Respiratory alkalosis
Secondary effect of diabetic ketoacidosis
Phosphate-binding antacids

Hyperphosphatemia:
Kidney failure
Phosphorus-containing enemas
Excessive vitamin D intake
Excessive ingestion of phosphate (milk, laxatives that contain phosphate)
Hypoparathyroidism
Chemotherapeutic agents
Signs and symptoms of Hypophosphatemia & Hyperphosphatemia
Hypophosphatemia:
Phosphate less than 2.4 mg/dL
Rhabdomyolysis
Osteomalacia
Cardiac dysfunction (dysrhythmias)
Mg, Bicarbonate and Ca+ wasting at renal tubules
Muscle weakness
CNS dysfunction
Deficiency in cellular ATP and/or 2,3-diphosphatemia
Impaired oxygen delivery to tissues
Decreased cellular function that may lead to death
Hyperphosphatemia:
Hypocalcemia
Tetany and other muscle issues
decrease in Calcium-phosphate, precipitates in the skin, cornea, soft tissues,viscera and blood vessels
Neuromuscular irritability
Laboratory and Diagnostic Tests
Lab and diagnostic tests that may be helpful in identifying the cause of Hypophosphatemia:
Phosphate levels grater than 4.4 mg/dL
Ca+ levels greater than 5.28 mg/dL
Elevated Vitamin D and Mg levels
ECG
Glucose levels, blood alcohol levels
liver/kidney function test
Alkaline pH
Glosgow coma scale

Lab and diagnostic tests that may be hekpful in identifying the cause of HYPERphosphatemia:
Phosphate levels lower than 2.4 mg/dL
Mg levels less than 1.5 mEq/L
low calcium levels of less than 4.6 mg/dL
ECG
Liver/kidney function tets
Elevated vitamin D levels
GI function
Anticipated Prescriptions
Hypophosphatemia:
Physicians may order a phosphate-rich diet
Oral supplementation of phosphate
IV administration of potassium phosphate or sodium phosphate
Oxygen
Hyperphosphatemia:
IV administration of CaCl or Calcium gluconate
Provider may order an increase in fluid intake
Dialysis may be prescribed for those patients with renal failure
Nursing Assessment

Assess labs of phosphate, Mg, Ca, pH, Ethinol, CBC and pH
Assess vital signs and cardiac and respiratory function,
Perform physical assessment and assess patient for pain
Assess for signs and symptoms of CNS dysfunction, LOC, cardiac dysrhythmias and cognitive function
Assess renal function
Assess nutritional status
Patient/family health and social history



Nursing Interventions
Monitor patient's LOC
Monitor cardiac rhythms and respiratory function
Promote ordered diet and diet restrictions
Encourage fluids when necessary
Monitor ECG's
Monitor labs
Notify physician when there is a change in patient's status
Administer drug as prescribed
Give IV medications carefully
Perform frequent vitals and physical assessments on patients
Perform dialysis when prescribed
Teach patient and their family about their condition and why they are receiving the treatment that they are
Provide patient safety
Assess fall risk in elderly or weak patients
Promote patient compliance
Interrupt labs, diagnostic tests and patient/family medical and social history
Encourage slow position change
Rotate patient frequently
Watch for signs and symptoms of hypophosphatemia and hyperphosphatemia



Geriatric Considerations
Diminished GI motility, renal and hepatic functions-may require lower doses of medications
Renal insufficiency leaves them at a higher risk for hyperphosphatemia
Careful IV administration due to thin, delicate skin
At greater risk for malnutrition and low body fat content
High risk of infection die to lower immunity-infection control
Greater risk for falls putting them at risk for injury and slower healing time
At risk for renal failure


Magnesium
Mg
The End!
Action of Magnesium
Mg acts as a co-enzyme in carbohydrate and protein metabolism
Metabolizes cellular nucleic acids and proteins
The concentration of phosphate affects neuromuscular excitability
50-60 percent of Mg is in the bone
Kidneys conserve Mg when necessary
Normal Values
1.5- 2.5 mEq/L
Differentiation between hypomagnesemia & hypermagnesemia
HYPOmagnesemia:
magnesium levels less than 1.5 mEq/L

HYPERmagnesemia:
magnesium levels greater than 2.5 mEq/L
Identifying patient's at risk for hypomagnesemia & hypermagnesemia
Hyomagnesemia:
Excessive vomiting/diarrhea
Chronic use of alcohol
Altered GI absorption
Malabsorption syndrome
Malnutrition,prolonged poorly controlled diabetes mellitus
Excessive urinary out-put
Hyperaldosteronism
Hypermagnesemia:
Over-administration for the purpose of treating eclampsia and adrenal insufficiency
Pregnant women receiving Mg sulfate for eclampsia
Chronic kidney failure
Kidney disease
Signs and Symptoms of hypomagnesemia & hypermagnesemia
Hypomagnesemia
Confusion
Hyperactive deep tendon reflexes
Tremors and seizures
Cardiac dysrhythmias
Hypocalcemia is often seen with hypomagnesemia
Decreased action of the parathyroid
Hypokalemia is sometimes seen with hypomagnesemia
Hypermagnesemia
lethargy, drowsiness, nausea and vomiting
Deep tendon reflexes are often lost
Somnolence
Respiratory and/or cardiac arrest
Laboratory and Diagnostic Tests
Lab and diagnostic tests that may be helpful in identifying the cause of Hypomagnesemia:
Mg levels lower than 1.5 meq/L, Ca levels less than 4.6 mg/dL, K levels, Phosphorous levels less than 2.4 mg/dL, BUN and creatine labs, glucose, blood alcohol
ECG, LOC, cognitive function and cranial nerve test
Nutritional assessment
BMI, body weight
Listen to heart and lungs
GI function testing absorption
Urinalysis
24 Hr diet recall
Test reflexes of tendons
Lab and diagnostic tests that may be helpful in identifying the cause of Hypermagnesemia:
Mg levels more than 2.5 mEq/L, Ca levels greater than 5.28 mg/dL, Phosphorous levels greater than 4.4 mg/dL, BUN and creatine levels
ECG
Kidney function test
24 Hr diet recall
Pregnancy test
Test reflexes of tendons



Anticipated Prescriptions
Hypomagnesemia:
The physician may order a Mg-rich diet
Mg oral supplements
IV or IM supplementation of Mg of magnesium sulfate

Hypermagnesemia:
Physician may order a Mg restricted diet
IV administration of CaCl or calcium gluconate which physiologically opposes cardiac effects from Mg excess
Provider may order patient an increase in fluid intake to help excrete Mg concntration through th urine
Physican may order patient to be on dialysis if the cause of excess Magnessium is due to kidney function
Provider may stop all medications containing Mg
Nursing Assessment
Assess K, Ca, Mg, BUN creatine, ethanol, and glucose lab values
Assess current medications patient is taking
Physical assessment, physiological assessment, pain assessment
Vital signs, LOC and cognitive function
Assess patient/family health and social history
Assess kidney and GI function
Listen to bowel sounds, lung sound and heart tones
Assess BMI and nutritional status
Assess patient knowledge of Mg-containing foods
Assess I/O'S
Assess urinalysis report
Assess for allergies
Nursing Interventions
Monitor patient's vitals, cardiac rhythms, and LOC
Monitor cardiac and respiratory function
Promote fluid intake or fluid restriction
Implement physician's ordered dietary instructions
Report change in patient's status to physician
Look for signs and symptoms of hypomagnesemia and hypermagnesmia
Teach client about their condition and importance of compliance
Teach client and their family the foods that contain Mg
Administer drugs as provider prescribed
Promote patient safety
Interpret ECG's and labs
Document findings, medications, patient responses, I/O's and assessment data
Geriatric Considerations
Geriatric patient's have a higher risk for renal insufficiency, decreased GI motility
The elderly are at a higher risk for developing a Mg deficiency or excess
Greater risk for poor renal function leaving them at a greater risk for hypermagnesemia from poor kidney secretion
Often take more drugs and are at a greater risk for excess Mg by Mg-containing medications


References

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-Surgical Nursing: Assessment and Management of Clinical Problem. St. Louis, Missouri: Elsevier Mosby.

Hypomagnesemia: MedlinePlus Medical Encyclopedia. (2013, March 22). National Library of Medicine - National Institutes of Health. Retrieved September 6, 2013, from http://www.nlm.nih.gov/medlineplus/ency/article

Hyponatremia Medical Information. (2013, July 23). Drugs.com | Prescription Drug Information, Interactions & Side Effects. Retrieved September 6, 2013, from http://www.drugs.com/enc/hyponatremia.

Hypercalemia. (n.d.). Med.net. Retrieved September 6, 2013, from www.medicinenet.com/hypercalcemia/article.htm
The action of sodium in the body
Na maintains the concentration and the volume of the ECF
Determines ECF osmolarity
Affects Na distribution between the ECF and ICF
Transmits and generate nerve impulses
Regulates acid-base balance in the body
Kidneys excrete or retain Na based upon ADH influence
Na can be reabsorbed at the renal tubules when necessary, controlled by aldosterone
Sodium concentrations reflects water imbalance in the body
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