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Electrolytes

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Amanda Cangialosi

on 7 September 2013

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Transcript of Electrolytes

Sodium

Electrolytes & The Body
Amanda Cangialosi
09/06/2013
NUR 311 - Professor Evinrude

Potassium
Magnesium
Calcium
Phosphorus
Sodium

Sodium

Sodium

Na+
Normal Values: 135 - 145 mEq/L
K+
Potassium
Potassium
Potassium
Mg 2+
Ca 2+
Magnesium
Magnesium
Magnesium
Calcium
Calcium
Calcium
Phosphorus
Phosphorus
Phosphorus
PO4
hypernatremia
Balance is primarily regulated by the kidneys
Excreted through urine, sweat, and feces
Absorbed from food in GI tract
Controls water distribution between ECF and ICF
Determines osmolality of extracellular fluids
Important component to the process of nerve impulse transmission
Important in the balance of acids and bases in the body
Causes
May be caused by water loss or sodium gain
IV sodium intake
Inadequate water intake
Insensible water loss (fever, diarrhea)
Diabetes Insipidus
Cushing Syndrome
Symptoms
Signs & Symptoms are a result of cell shrinkage
Polydipsia
Lethargy
Seizure/Coma
Easily activated neurons
Treatment
Nursing Interventions treat underlying cause
Use hypotonic IV solution to replenish fluids
Limit dietary sodium intake
Decrease sodium levels gradually to avoid cerebral edema
Promote sodium excretion with use of diuretics
Clients at Risk
Patients receiving tube feedings
Patients at risk for developing fevers
Patients suffering from diarrhea and/or vomitting
Patients with diseases such as Diabetes Insipidus, Cushings Syndrome, and Diabetes Mellitus
Patients who are unable to access water
Poverty, inability to ambulate, cognitive impairment
Likely Physician Orders
Water Replacement:
Increased oral fluid intake
IV 5% Dextrose in water
IV Hypotonic Saline
Sodium Reduction
Diuretics
Dietary sodium intake restriction
Nursing Assessment
Observe extremities
Twitching, seizures, agitation
Edema may be present with increased ECF volume
Psychological assessment
Restlessness, agitation, lethargy
Cardiac assessment
Blood pressure & central venous pressure may be increased with elevated ECF volume
Blood pressure and central venous pressure may be decreased with decreased ECF volume
Hypotension may be present with decreased ECF volume
Skin assessment
Mucus membranes may be dry with decreased ECF volume
Skin may be flushed with increased ECF volume
hyponatremia
Symptoms
Symptoms result from cellular swelling as water moves from ECF to ICF in order to attempt to compensate for the sodium imbalance
The first symptoms are noted in the Central Nervous System as brain cells begin to swell
Irritability, confusion, dizziness, personality changes
Several symptoms vary according to ECF volume changes
Increased ECF volume: blood pressure and central venous pressure will increase, weight gain, headache, and abdominal cramps may occur
Decreased ECF volume: blood pressure and central venous pressure will decrease, cold/clammy skin, tachycardia, nausea, vomiting, diarrhea and dry mucus membranes may occur
Life threatening symptoms include seizures and coma
Causes
Overall loss of fluid
Diarrhea
Vomiting
Diuretics
Burns
Wound drainage
Water excess (dilutes ECF)
Overuse of hypotonic IV fluid
Excessive thirst (leading to excessive water intake)
May occur with disease processes such as SIADH and hypoaldosteronism
Clients at Risk
Patients with problems causing polydipsia
Such as SIADH
Patients with disease processes such as heart failure and liver failure
Patients who have suffered an overall fluid loss
Vomitting
Diarrhea
Trauma resulting in large wounds and/or burns
Patients who do not have access to adequate foods
Poverty, immobility, cognitive deficiencies
Treatment
Treatment depends on underlying cause
Water excess
fluid intake is restricted
Fluid loss
IV solutions may be used to replenish sodium and fluids
Hypertonic solutions will do this
Drugs may be used to block ADH - thus stopping the body from retaining water and excreting sodium
Specific drugs will be used to treat and prevent hyponatremia associated with chronic diseases
Likely Physician Orders
The physician may order several different interventions depending on the underlying cause of the sodium imbalance
With water excess, the physician will most likely order a fluid restriction on the patient's diet
In cases of severe fluid loss, the physician will likely order a 3% Normal Saline IV solution to replenish fluids and sodium
A vasopressin drug such as Vaprisol may be ordered to inhibit ADH activity
In the case of a chornic disease, (i.e. heart failure, liver failure, SIADH) a drug such as Samsca will most likely be ordered
Nursing Assessment
Observe neurological system to assess CNS function - indicative of cellular swelling in brain
is patient confused, irritable, and/or apprehensive?
has personality changed?
Are muscle spasms, tremors, cramps, or seizures present?
Observe cardiac system - indicative of ECF volume excess or deficit
Is patient hypo or hypertensive?
Is central venous pressure too high/low?
Is jugular vein filling normally?
Is pulse thready?
Is pulse too fast or too slow?
Observe skin - indicative of fluid loss or water excess
Are mucus membranes dry?
Is skin cold and/or clammy?
Has abnormal weight gain occured?
Is edema present?
Geriatric Considerations
Immobility
Inability to access necessary foods containing sodium
Inability to access water, resulting in dehydration
Cognitive deficiencies
Inability to feed oneself necessary foods containing sodium or drink enough water
Heart and/or liver failure
geriatric patients are more likely to suffer from bodily systems not working properly, such as the heart and liver
Insufficient thirst mechanism
with age the thirst mechanism may not work properly, causing a geriatric patient to drink too much or too little water
Insufficient hunger mechanism
with age, bodily mechanisms triggering one to feel hungry may be diminished, causing one to eat less, leading to malnutrition
The following problems are concerns for elderly patients, but are not considered normal findings!
Normal values: 3.5 - 5.0 mEq/L
Main cation in the intracellular fluid!
Main cation of the extracellular fluid!
Plays an important role in the sodium-potassium pump
Balances of K+ are directly responsible for resting potential of nerve and muscle cells
Intracellular osmolality depends on potassium
Acid-base balance is affected by potassium balance
Mainly obtained through dietary means
Potassium is mainly excreted by renal system
Balance between extracellular and intracellular potassium concentration is crucial to potassium working correctly in the body
Hyperkalemia
Symptoms
Many symptoms are a result of increased cellular excitability
Muscular: weakness in legs, abdominal cramping
Affect: Anxious, irritable
Cardiac: Irregular pulse, Cardiac arrest
GI: diarrhea
ECG Changes:
Peaked T Wave
Loss of P wave
Widened QRS
Ventricular fibrillation or standstill
Causes

Excessive potassium intake
Parenteral administration
Use of drugs containing potassium
Over-consumption of foods containing salt substitutes
Insufficient renal excretion of potassium
Kidney failure or disease
Use of diuretics that spare potassium (i.e. spironolactone)
Use of ACE Inhibitors (i.e. lisinopril)
Aldosterone deficiency
Potassium shift from intracellular to extracellular fluid
Metabolic Acidosis
Massive tissue/cell destruction
Treatment
Dietary potassium intake restriction
Increased elimination of potassium
Shift potassium back into intracellular fluid
Reverse membrane excitability
Clients at Risk
Clients receiving parenteral nutrition
Clients on low-sodium diets
Sodium substitutes often contain potassium
Clients taking certain drugs
potassium-sparing diuretics
ACE Inhibitors
Cleints receiving blood transfusions
Clients with renal insufficiencies and/or diseases
Clients with adrenal insufficiencies and/or diseases
Clients with aldosterone deficiency
Clients with fevers, severe burns, and sepsis
Clients with Tumor lysis syndrome
Likely Physician Orders
Elimination of potassium intake
Cessation of dietary intake
Cessation of parenteral intake
Elimination of Potassium
Non-potassium sparing diuretics
Dialysis
Ion-exchange resins
Increased fluid intake
Shift Potassium from extracellular to intracellular fluid
IV Insulin & glucose
IV sodium bicarbonate
Epinephrine
Reverse membrane excitability
IV calcium gluconate
Nursing Assessment
Neurological Assessment
Is patient anxious or irritated?
Muscular Assessment
Is patient experiencing weakness in lower extremities?
Is patient experiencing muscular leg cramps?
Is patient experiencing paralysis in leg muscles?
Cardiac Assessment
Is pulse irregular?
Beware of possible cardiac arrest in severe cases
GU/GI Assessment
Is the patient experiencing abdominal cramping or diarrhea?
hypokalemia
Symptoms
Many symptoms are related to reduced excitability of cells
Affect: Fatigued
Muscular: Weakness, leg cramps, muscle "flabbiness" , decreased reflexes
GU: Excessive urination, parlytic ileus
GI: Nausea, vomiting
Cardiac: Weak pulse, irregular pulse, dysrhythmias, bradycardia
ECG: Flattened T wave, presence of U wave
Causes
Shift of potassium from ECF to ICF
Deficient dietary intake of potassium
Elevated aldosterone levels
Magnesium deficiency
GI losses of potassium
Metabolic alkalosis
Treatment
Potassium chloride supplementation
Increased dietary intake of potassium
Prevention is essential
Obtain enough potassium through dietary means
Clients at Risk
Patients with GI problems such as nausea and vomitting
Patients with fistulas
Patients that are sweating excessively
Fever, heat stroke, excessive exercise, etc.
Patients taking diuretics
Patients with hyperaldosteronism
Patients with hypomagnesmia
Patients on dialysis
Patients with increased insulin
Patients experiencing metabolic alkalosis
Patients under high stress
Patients that do not have adequate access to food
Starvation or malnourishment
Patients that are NPO
Likely Physician Orders
Potassium Supplements
Either IV or Oral
IV is only used in severe cases
Dietary intake orders
Salt substitutes can be used to raise potassium
If patient is taking potassium-losing diuretics
Dietary potassium must be increased
If patient is taking diuretics and is suffering from hypokalemia
Physician may choose to change orders to a potassium-sparing diuretic
Nursing Assessment
Neurological Assessment
Observe affect: Is patient fatigued?
Is patient experiencing paresthesias or decreased reflexes?
Muscular Assessment
Is patient experiencing muscle weakness?
Is patient experiencing muscular cramping?
Is patient experiencing flabby muscles?
GI Assessment
Is patient experiencing nausea and/or vomiting?
GU Assessment
Monitor I/O: Is patient urinating excessively?
Cardiac Assessment
Take pulse: is it weak and/or irregular?
Take heart rate: is it fast and/or irregular?
Observe ECG:
Look at T wave: is it flattened?
Look for presence of U wave
Look at ST segment: is it depressed?

Geriatric Considerations
Elderly patients are more likely to experience hypokalemia
Many elderly patients take diuretics and are thus at risk to develop a potassium imbalance
Elderly patients are more likely than other populations to experience GI infections and diarrhea, making them more prone to develop a potassium imbalance
Elderly patients are at a higher risk than other populations for malnutrition, making them more at risk to develop hypokalemia
1.5 - 2.5 mEq/L
Second most abundant intracellular cation!
Much magnesium is found in bone
Magnesium is important in the process of metabolizing carbohydrates and protein
Magnesium is absorbed by the GI tract
Magnesium is excreted by the kidneys
Magnesium imbalances can very easily be mistaken for calcium imbalances!
Magnesium is essential for the cardiac system to function normally, which makes imbalances dangerous and potentially life threatening
Hypermagnesemia
Causes
Excessive magnesium intake
Renal insufficiency
Renal failure
Magnesium sulfate supplementation
as used to treat pregnant women with eclampsia
Hypothyroidism
Addison disease
Lithium therapy
Excessive vitamin D intake
Symptoms
Affect: Lethargic, drowsy
Diminished deep tendon reflex
Nausea and vomiting
Neuromuscular symptoms are the most common
Deep tendon reflex attenuation is one of the earliest symptoms
High concentrations can lead to somnolence, bradycardia, hypotension, heart block, and cardiac arrest
Clients at Risk
Patients with renal insufficiency or renal failure
Pregnant women with eclampsia
Patients with hypocalcemia
Alcoholics
Patients who are prescribed or who abuse laxatives
Premature babies
Treatment
Most treatment is focused on prevention
If kidneys do not function properly, do not take
Renal excretion may be increased
IV administration of calcium chloride or calcium gluconate opposes the effects of magnesium on cardiac muscle
If a patient's kidneys are not working properly, dialysis may be needed to remove magnesium
Nursing Assessment
Neurological Assessment
Are CNS functions depressed?
Is affect drowsy, lethargic, or somnolent?
Muscular Assessment
Are deep tendon reflexes present?
GI Assessment
Is patient nauseous and/or vomiting?
Cardiac Assessment
Assess heart rate: is it fast?
Assess blood pressure: is it low?
Beware that high concentrations can lead to cardiac arrest
Are there ECG changes?
Respiratory Assessment
Are respirations decreased?
Beware that apnea may develop with high concentrations
Likely Physician Orders
A physician dealing with a patient with chronic kidney disease will focus on prevention of hypermagnesmia by teaching the patient about the risks of toxicity and what sort of drugs and foods are to be avoided
In emergency situations, a physician will order IV calcium chloride or calcium gluconate in order to oppose the effects of excess magnesium on the heart - which can lead to cardiac arrest if left untreated
The doctor may promote increased fluid intake in order to promote urinary excretion of magnesium in patients with functioning kidneys
In patients with impaired renal function, dialysis will most likely be needed in order to remove magnesium as the kidneys will be unable to excrete it
Hypomagnesemia
Causes
Malnourishment is one major cause of hypomagnesemia
This may be a result of fasting or starvation
Chronic alcoholism may contribute to malnourishment
Parenteral nutrition without proper magnesium supplementation
Losses are generally gastrointestinal or renal
GI losses include diarrhea, vomiting, and impaired absorption ability of GI tract
Renal loses may be caused by diabetes mellitus (resulting in osmotic diuresis) and use of diuretics
Symptoms
Confusion
Apathy
Delirium
Nystagmus
Hyperactive deep tendon reflexes
Tremors
Seizures
Coma
Cardiac dysrhythmias
Resemblance to hypocalcemia
Treatment
Oral magnesium supplements
Increased dietary intake of magnesium
Magnesium sulfate may be administered by IV or IM routes in critical situations
Medication to relieve symptoms while magnesium levels are brought back up to normal ranges
Clients at Risk
Alcoholics
Patients with anorexia and/or bulimia
Patients who are fasting or do not have access to adequate foods
Patients receiving parenteral nutrition
Patients taking diuretics
Patients with hyperaldosteronism
Patients with celiac disease or irritable bowel syndrome
Patients taking aminoglycocide antibiotics
Patients recovering from acute renal failure
Patients with polyuria
Likely Physician Orders
Oral magnesium supplements
Increased dietary intake of magnesium
Doctor will recommend foods such as green vegetables, bananas, nuts, and oranges
In severe case scenerios, the doctor will likely order parenteral IV or IM magnesium sulfate to be administered
the doctor and nurse should be careful with administration of magnesium in this manner, as administering too rapidly can lead to cardiac and/or respiratory arrest
Nursing Assessment
Neurological assessment
Assess cognitive status: is patient confused or delirious?
Is the patient experiencing any numbness?
Beware that this patient is at risk for seizures and coma
Muscular assessment
Are deep tendon reflexes hyperactive?
Is the patient experiencing muscle cramping and/or weakness?
Is the patient experiencing tremors?
Cardiac assessment
Assess heart rate: is it irregular?
Geriatric Considerations
The geriatric population is at a higher risk to experience imbalances
Diuretic use is more common in older adults, and may cause magnesium imbalances through urinary loss
The elderly population is more likely to suffer from renal insufficiency, making the susceptible to magnesium imbalances as kidenys may be unable to properly excrete magnesium
Elderly adults may be more likely to suffer from absorption problems in the bowel due to disorders such as IBS
Elderly adults are more likely to suffer from malnourishment than other populations, making them susceptible to magnesium deficiencies
8.6 - 10.2 mg/dL
Calcium is mainly obtained through dietary means
Calcium movement must be regulated from bones to serum and vise versa to maintain normal serum levels
The ionized form of calcium is the active form
Total serum calcium levels reflect three different forms of calcium found in serum:
Free
Bound to albumin
Complexed with phosphate, citrate, or carbonate
99% of calcium is stored in the skeletal system!
Hypercalcemia
Causes
Hyperparathyroidism
Cancers
Breast cancer
Lung cancer
multiple myeloma
Prolonged immobilization
Excessive vitamin D ingestion
Use of thiazide diuretics
Milk-alkali syndrome
Metabolic Acidosis
Symptoms
Many symptoms result from reduced excitability of muscles and nerves
Neurological: Lethargy, confusion, psychosis, personality changes, decreased memory, coma
GI: Nausea, vomiting, reduced apatite
GU: nephrolithiasis, polyuria
Musculoskeletal: Depressed reflexes, overall weakness, bone pain, fractures
Cardiac: Shortened ST segment, shortened QT interval, dysrhythmias
Treatment
Promote the excretion of calcium in urine
Loop diuretics
Increased water intake
Patient may be hydrated with saline infusions
Synthetic calcitonin
Decreased dietary intake
If patient is immobilized, mobilization is encouraged
Osteclast activity may need to be inhibited through drug therapy
Clients at Risk
Clients with hyperparathyroidism
Clients with lung cancer, breast cancer, and/or multiple myeloma
Patients who are immobile for long periods of time
Patients in recovery from trauma/surgery
Elderly patients who have lost full mobility
Patients taking thiazide diuretics
Patients with impaired renal function or patients with SIADH
Patients in metabolic acidosis
Nursing Assessment
Neurological assessment
Assess affect: Is patient confused? Is patient lethargic? Is patient suffering from memory impairment? Do you notice any personality changes and/or psychosis?
Assess reflexes: are reflexes depressed?
GI assessment
Assess dietary patterns: Is patient suffering from loss of apatite, nausea, and/or vomiting?
GU assessment
Assess I/O: is patient urinating more than normal?
Musculoskeltal assessment
Assess strength: is patient experiencing muscle weakness?
Assess recent medical history for fractures
Assess pain: is patient experiencing bone pain?
Likely Physician Orders
The doctor will most likely prescribe a loop diuretic such as Lasix to promote excretion of calcium through urine
If the patient is dehydrated, the doctor may order IV administration of isotonic saline to re-hydrate ECF
The doctor may inform the nurse to promote increased fluid intake in order to support renal excretion of calcium
The doctor may order the patient to increase water intake to 3,000 - 4,000 mL daily
The doctor may order synthetic calcitonin in cases of very high serum concentration of calcium
Mithracin may be ordered to to inhibit bone resorption
If hypercalcemia is a result of malignancy, the doctor may order a drug such as Aredia to inhibit osteoclasts from breaking down bones
Hypocalcemia
Causes
Conditions that cause a decrease in the production of PTH
Injury to parathyroid gland
Acute pancreatitis
Multiple blood transfusions
Metabolic alkalosis
Low dietary intake of calcium
Laxative abuse
Malabsorption of calcium
Symptoms
Muscular: Increased nerve excitability, Tetany, Trousseau's sign (carpal spasms), Chvostek's sign (facial muscle contraction) Laryngeal stridor, Dysphagia, muscle cramps
Neurological: Numbness/tingling, Easily fatigued, Depression/anxiety/confusion
Cardiac: Elongation of ST segment, Prolonged QT interval, Tachycardia
Treatment
Treat the underlying cause of deficiency!
Calcium supplementation
Calcium gluconate
Increased dietary intake of calcium
Vitamin D supplementation
Calcium carbonate
Treatment of symptoms such as pain and anxiety
Clients at Risk
Patients with chronic kidney diseases
Patients with hypoparathyroidism
Patients with acute pancreatitis
Chronic alcoholic patients
Patients taking loop diuretics such as Lasix
Patients experiencing metabolic alkalosis
Patients recieving multiple blood transfusions
Patients that have lost a lot of blood (trauma, surgery, etc.)
Patients with increased phosphorus levels
Patients with magnesium deficiencies
Likely Physician Orders
The physical may order either oral or IV calcium supplements if deficiency is serious
The doctor will not order IM calcium because it damages tissues
The doctor will order a diet with many calcium rich foods
The doctor may order vitamin D supplements to aid in calcium absorption
If patients are unable to obtain calcium through dietary means, the doctor will likely order a supplement to be taken long term
The physician will treat pain and anxiety if he suspects hypocalcemia because the symptoms for hypocalcemia reflect respiratory alkalosis
The doctor will order patients to be observed for symptoms of hypocalcemia after surgery on the thyroid or neck
Nursing Assessment
Neurological Assessment
Assess affect: is patient confused, anxious, and/or depressed? Is patient easily fatigued?
Assess reflexes: Are they hyperactive?
Muscular Assessment
Assess for Chvostek's sign, Trousseau's sign
Assess for muscular cramping
Assess for tetany
Cardiac Assessment
Asses ECG: Look for ST segment elonglation, prolonged QT intraval
Take heart rate: is it faster than normal?
Geriatric Considerations
Geriatric populations are more likely to experience calcium imbalances
Hypercalcemia is often caused by malignancies, which become much more common with age
Hypercalcemia is also associated with immobility and increased osteoclast activity, which are both prevalent issues in many older adults
Hypocalcemia and hypercalcemia can both result from diuretic use, which is common in elderly adults
Elderly adults are more likely to experience kidney disease than other populations, putting them at risk for hypocalcemia

Phosphorus is the primary anion in the ICF!
2.4 - 4.4 mg/dL
Phosphorus plays important roles in the body such as muscle function, RBC function, and nervous system function
Phosphorus is a prevalant part of the acid-base buffer system
Phosphorus is involved in the production of ATP
Phosphorus is involved in the metabolism of carbs, proteins, and fats
Phosphorus is mainly excreted by the kidneys
Phosphorus and calcium are inversely related in serum values
Hyperphosphatemia
Causes
Renal failure
Kidneys are unable to excrete phosphate
Chemotherapy
Excessive phosphate ingestion
Milk, laxatives
Excessive vitamin D ingestion
Enemas
Hypoparathyroidism
Symptoms
Calcified deposits in soft tissue
joints, arteries, skin, kidneys, corneas
Hypocalcemia
Muscle problems such as tetany
Neuromuscular irritability
Treatment
Underlying cause is treated
Dietary intake of phosphate should be restricted
Increasing fluid intake may promote renal excretion of excess phosphorus
Hypocalcemic conditions should be corrected in order to allow for PTH to act on kidneys and cause phosphorus excretion
Calcium supplements & Phosphate binding agents may be used in the case of renal failure/insufficiency
Clients at Risk
Patients with renal failure
Patients with malignancies
chemotherapeutic agents contribute to hyperphosphatemia
Patients receiving enemas
some enemas contain phosphorus
Patients ingesting large amounts of vitamin D
Vitamin D enhances phosphorus absorption in GI tract
Patients with hypoparathyroidism
Likely Physician Orders
The physician will attempt to treat the underlying cause of hyperphosphatemia
The physician will most likely order a diet low in phosphorus
The physician may order increased fluid intake in order to assist with renal excretion of phosphate
The physician will most likely attempt to correct hypocalcemia if it is present, as hypocalcemia causes kidneys to retain phosphorus
If the physician is dealing with a patient with chronic renal failure, he may use calcium supplements and/or phosphate binding agents to prevent phosphate levels from elevating beyond normal limits
Nursing Assessment
Muscular Assessment
Is tetany present?
Skin Assessment
are there calcium-phosphate deposits present in skin/soft tissues?
Lab Assessment
Is hypocalcemia a current issue for this patient?
Hypophosphatemia
Causes
Mainly caused by malnourishment
Malabsorption syndromes
Nutritional recovery syndrome
Glucose administration
Total parenteral nutrtion
Alcohol withdrawal
Antacid use
Diabetic Ketoacidosis
Respiratory alkalosis
Symptoms
CNS dysfunction: confusion, coma
Muscular weakness
Muscle pain
Respiratory muscle weakness
Difficulty weaning
Renal tubular wasting
Impaired cellular energy and oxygen deliverly
Dysrhythmias
Decreased stroke volume
Cardiomyopathy
Osteomalacia
Rhabdomyolysis
Treatment
Oral supplementation
Increasing dietary intake of phosphorus
IV administration of sodium phosphate
Clients at Risk
Patients at risk for malnourishment
Poverty, anorexia, immobility, cognitive impairment
Patients with malabsorption syndromes
Celiac disease, lactose intolerance
Patients receiving total parenteral nutrition
Patients with non-working bowels as with bowel obsrutction, short bowel sydnrome, Crohn's disease, etc.
Patients going through alcohol withdrawal
Patients recovering from diabetic ketoacidosis
Patients experiencing respiratory alkalosis
Patients using large amounts of antacids
Patient with heartburn, gas, etc.
Nursing Assessment
Neurological assesment:
Assess affect: confusion, loss of consciousness, coma
Muscular assessment
Assess muscles for weakness
Respiratory assessment
Assess for difficulty breathing
Cardiac assessment
Take heart rate - is it slow?
Assess stroke volume - is it decreased?
Likely Physician Orders
The doctor will attempt to treat the underlying cause of deficiency
Oral supplementation of phosphate will most likely be ordered
The doctor may order increased dietary intake of foods with phosphorus in them
In severe cases, the doctor will most likely order IV administration of sodium phosphate or potassium phosphate
Geriatric Considerations
Geriatric patients are more likely to suffer renal failure than other populations, increasing their likelihood of hyperphosphatemia
Geriatric patients are more likely to suffer malignancies than other populations, making them more likely to use chemotherapeutic agents that may increase phosphate levels
Geriatric patients who are immobile or who have lost their appetite may suffer from malnutrition - which can cause hypophosphatemia
Geriatric patients are more likely than other populations to suffer from malabsorption syndromes which can interfere with GI abosrption of phosphate
References:
Sodium

Nursing Care Plan
NCP for Hypernatremia
1. Goal is to decrease total body sodium and replace fluid loss (***)
2.Monitor urine output, monitor I/O's, take daily weights
3. Monitor sodium levels daily
4. Administer water replacement slowly
5. Offer many fluids and water to the patient to encourage re-hydration of ECF
6. Seizure precautions may need to be utilized
7. Give oral care every two hours
8. Monitor skin condition and change patient positions regularly
9. Maintain fall risk preventions if patient is confused and/or disoriented
10. Ensure patient teaching on fluid/sodium intake is complete before discharge
NCP for Hyponatremia
1. Weigh patient daily to observe for changes in fluid volume
2. Monitor I/O's carefully to assess changes in fluid volume
3. Initiate and administer IV therapy if ordered
most likely isotonic saline
4. Assess regularly for s/s of weight gain, blood pressure changes, heart sounds, respiratory sounds, edema, CVP, ascites
5. Restrict sodium intake as ordered
6. Administer diuretics as ordered
7. Monitor patient closely and consult physician if signs and symptoms persist or worsen
Potassium
(Mosby & Saunders, 2012)
Nursing Care Plan
NCP for Hypokalemia
1. Administer potassium tablets as ordered
2. Teach and implement diet rich in potassium
3. Record fluid intake and output
4. Assess blood volume and venous pressure
5. Identify and record ECG changes
6. Observe for signs and symptoms of dehydration
7. Observe and record neuromuscular changes
8. Monitor patient closely and notify provider if symptoms persist or worsen
NCP for Hyperkalemia
1. Eliminate potassium supplementation
2. In emergent situations, initiate and administer IV calcium gluconate, insulin, and glucose
3. Teach patient to avoid foods high in potassium
4. Monitor potassium levels through blood draw
5. Ensure patient understands medications he is on and dietary recommendations before discharge
(Antipuesto, 2012)
(NCP Hyperkalemia, 2012)
Magnesium
Nursing Care Plan
NCP for Hypermagnesemia
1. Administer all physician orders
2. Monitor level of consciousness
3. Assess patellar reflexes
4. Monitor vital signs regularly
5. Monitor ECG changes
6. Encourage fluid intake
7. Teach patient about drugs and foods high in magnesium content before discharge
NCP for Hypomagnesemia
Initiate all therapies ordered by physician
Administer magnesium sulfate
Monitor level of conciousness
Monitor breathing for laryngeal stridor
Monitor ECG changes
Assess patient for digitalis toxicity
Teach patient about dietary means of magnesium and risks of using laxatives and/or diuretics
(Medical and Nursing Management of Magnesium Excess, 2007)
Calcium
NCP for Hypercalcemia
1. Administer fluids as ordered by physician
2. Monitor for signs of congestive heart failure
3. Encourage sufficient fluid intake
4. Encourage ambulation, be sure to reposition patients regularly
5. Discourage dietary intake of calcium
6. Institute safety precautions if confusion is present
7. Teach patient about calcium-rich foods to avoid and adequate fluid intake before dischrage
NCP for Hypocalcemia
Implement all orders from physician
Implement safety measures
Encourage dietary intake of calcium
Monitor for seizures and tetany
Monitor vital signs and heart sounds
Monitor dysrhythmias and ECG changes
Assess IV site frequently as calcium solutions easily infiltrate and irritate veins
Teach patient about foods rich in calcium and vitamin D before discharge
Nursing Care Plan
(NCP Hypercalcemia, 2012)
(Crawford & Harris, 2013)
Phosphorus
Nursing Care Plan
NCP for Hyperphosphatemia
Implement physician orders
Restrict dietary intake of phosphorus
Monitor for signs of tetany and notify physician if they present
Teach patient about use of OTC drugs that may contain phosphate
Teach patient about proper phosphate-binder use
NCP for Hypophosphatemia
Implement all physician orders
Administer IV phosphate with extreme caution - assess IV site regularly for infiltration and irritation
Monitor patient level of conciousness
Monitor for and take precautions for seizures
Monitor for bleeding and respiratory failure
Administer pain medication as needed
Teach patient about foods rich is phosphorus
(Mosby & Saunders, 2012)
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