FLUIDS AND ELECTROLYTES
Prepared by: Prof. Luth M. Mondano, RN, MAN
OBJECTIVES
1. Differentiate between osmosis , diffusion,
filtration and active transport.
2. Describe the role of the kidneys, lungs , &
endocrine glands in regulating body fluid
volume and composition.
3. Discuss the mechanisms and effects of deficits
and excess.
4. Describe the mechanisms that maintain acid-
base balance.
5. Compare metabolic and respiratory acidosis
and alkalosis with regard to causes, clinical
manifestations , diagnoses & management.
6. Plan effective care of patients with different
fluid volume excess and deficits.
7. Describe the cause, clinical manifestations ,
management, & nursing interventions of
imbalances.
8. Explain the role of the lungs, kidneys and
chemical buffers in maintaining acid-base
balance
9. Use ABG findings in formulating the care of
the patient with an acid-base imbalance.
10. Describe the management of patients with
fluid, electrolyte, or acid-base imbalance.
FLUID
 Serve as a medium for carrying nutrients to
and waste products from the cells
 Means for carrying the chemical
communicators that coordinate activities
among cells
 Transport substances such as hormones,
enzymes, blood platelets, red and white
blood cells
 Helps maintain normal body temperature
 60% or 42 liters of adult’s total body weight
 Younger people have a higher % of body fluid
than older people
o INFANTS – 80%
o ELDERLY – less muscle; thirst center
diminished
 Men have proportionately more body fluid
than women
o MALES – more muscle (muscle is 80%
water)
o FEMALES – more adipose tissue (fat is
only 15% water)
AMOUNT AND COMPOSITION OF BODY FLUIDS
INTRACELLULAR FLUIDS ( ICF ) -28L
• Inside the cells
• 2/3 of body fluid in ICF compartment is
located in the skeletal muscle mass
• 55% of total body water
Extracellular fluid (ECF)-14L
• Outside the cells
• 45% of total body water
Divisions:
1. Intravascular space (the fluid within the
blood vessels)
 6L of blood volume is made up of
plasma
 remaining 3L is made up of
erythrocytes, leukocytes, and
thrombocytes
2. Interstitial space
 contains the fluid the surrounds the
cell and totals about 11-12L in an
adult. Lymph is an interstitial fluid
3. Transcellular fluid space
 the smallest division of the ECF
compartment and contains
approximately 1L
 Examples: cerebrospinal, pericardial,
synovial, intraocular, and pleural
fluids; sweat; and digestive secretions
ELECTROLYTES
 Are active chemicals in body fluids (have
electrical charges)
 Potassium and phosphate are the major
electrolytes in ICF
 Sodium and chloride are the major
electrolytes in ECF
o Sodium level is the primary determinant of
ECF concentration
o Electrolyte concentration in the body is
expressed in terms of milliequivalents per
liter (mEq/L)
APPROXIMATE MAJOR ELECTROLYTE CONTENT ex: exchange of oxygen and carbon dioxide
IN BODY FLUID in between the pulmonary capillaries and
Electrolytes mEq/L alveoli
Extracellular Fluid (Plasma) Active transport – physiologic pump that moves
Cations fluid from an area of lower concentration to an area
Sodium (Na+) of higher concentration
142
Potassium (K+) - active transport requires adenosine
5
Calcium (Ca++) triphosphate for energy
5
Magnesium (Mg ++) ex: sodium potassium
2
Total cations o Sodium concentration is greater in the ECF
154
Anions than in the ICF, and because of this, sodium
Chloride (Cl -) tends to enter the cell by diffusion.
103
Bicarbonate (HCO3-) o This tendency is offset by the sodium-
26
Phosphate (HPO4-) potassium pump that is maintained by the
2
Sulfate (SO4-) cell membrane and actively moves sodium
1
Organic acids from the cell into the ECF.
5
Protenaite o Conversely, the high intracellular potassium
17
Total anions concentration is maintained by pumping
154
potassium into the cell.
Filtration – removal of particles from a solution
Electrolytes mEq/L through movement of fluid across a membrane
Intracellular Fluid ex: passage of water and electrolytes from the
Cations
arterial capillary bed to the interstitial fluid.
Potassium (K+) 150
Magnesium (Mg++) 40 Sources of normal fluid loss
Sodium (Na+) 10 Kidneys
Total cations 200 • Usual daily urine volume in the adult is 1-2 L
Anions • Output is approximately 1 mL of urine per
Phosphates and sulfates 150 kilogram of body weight per hour (1 mL/kg/h)
Bicarbonate (HCO3-) 10 Skin
Proteinate 40 • Sensible perspiration – visible water and
Total anions 200 electrolyte loss (sweat) - 0-1,000 ml
• The chief solutes in sweat are sodium, chloride,
Normal Electrolyte Values and potassium
• Sodium – 135-145 mEq/L • Insensible water loss – water loss by
• Potassium – 3.5-5 mEq/L evaporation (fever)-600ml/day
• Calcium – 4.5-5.5 mEq/L Lungs
• Phosphorous – 1.7-2.6 mEq/L • The lungs normally eliminate water vapor
• Chloride – 98-108 mEq/L (insensible loss) at a rate of 300 mL every day
• Magnesium – 1.5-2.5 mEq/L • The loss is much greater with increased
respiratory rate or depth, or in a dry climate
Regulation of Body Fluid Compartments Gastrointestinal Tract
Osmosis – fluid moves across a semipermeable • usual loss through the GI tract is 100-200 mL
membrane from an area of low to an area of high daily
solute concentration • 8L of fluid circulates through the GI system
ex: homeostasis every 24 hours
Diffusion – is the natural tendency of a substance to
move from an area of higher concentration to one of Laboratory Test for Evaluating Fluid Status
lower concentration 1. Osmolality – measures the solute
- occurs through random movement of concentration per kilogram in blood and urine
ions and molecules • Serum Osmolality
- reflects the concentration of Na
- 280-300 mOsm/kg
 • Urine Osmolality
- is determined by urea, creatinine, and
uric acid
- is the most reliable indicator of urine
concentration
- 200-800 mOsm/kg
2. Urine specific gravity
- measures the kidney’s ability to excrete or
conserve water
- Normal range of urine specific gravity is
1.010 to 1.025
- Specific gravity varies inversely with urine
volume; normally, the larger the volume of
urine, the lower the specific gravity
3. BUN (Blood Urea Nitrogen)
- test checks kidney function by measuring
how much urea nitrogen is in the blood
- Urea nitrogen is a waste product from the
breakdown of protein in the body
- filtered by the kidneys and leaves the body
through urine
- The normal BUN is 10-20 mg/dL (3.6-7.2
mmol)
4. Hematocrit
- measures the number of blood cells per
volume of blood
- Ranges from 42% to 52% for males and 35%
to 47% for females
- Value increases during dehydration &
polycythemia while decreased during
anemia & overhydration
5. Urine sodium
- Used to assess volume status
- Useful in diagnosis of hyponatremia and
acute renal failure
- Range: 75-200 mEq/24 hrs
Homeostatic Mechanisms
• Keep the composition and volume of body
fluid within narrow limits of normal
• Organs involved in homeostasis include the
kidneys, heart, lungs, pituitary gland, adrenal
glands, and parathyroid glands
Kidney Functions
• Vital to the regulation of fluid and electrolyte
balance
• normally filter 180 L of plasma every day in
the adult while excreting only 1-2 L of urine
• Reabsorb bicarbonate (HCO3) secrete
hydrogen ions (H+) in proximal and distal
tubules, and produce ammonia
• Compensate for imbalances more slowly than
the lungs
Heart and Blood Vessel Functions
• Circulates blood through the kidneys under
sufficient pressure to allow for urine
formation
• Failure of this pumping action interferes with
renal perfusion and thus with water and
electrolyte regulation
• Normal arterial blood gas values reflecting
homeostasis include:
o pH: 7.35 to 7.45
o Partial pressure of oxygen (PO2): 80 to
100 mm Hg
o Partial pressure of carbon dioxide
(PCO2): 35-45 mm Hg
o HCO3: 22-26 mEq/L
Lung Functions
• Through exhalation, the lungs remove
approximately 300 mL of water daily in the
adult
• hyperpnea (abnormally deep respiration) and
continuous coughing, increase this loss
• mechanical ventilation with excessive
moisture decreases it
• lungs have a major role in maintaining acid—
base balance by controlling carbon dioxide
(CO2) and carbonic acid (H2CO3) excretion
Pituitary Functions
• The hypothalamus manufactures ADH, which
is stored in the posterior pituitary gland and
released as needed
• ADH maintain the osmotic pressure of the
cells by controlling the retention or excretion
of water by the kidneys
• regulate blood volume
Adrenal Functions
• Aldosterone –produced in outer zone of the
adrenal cortex that has a profound effect on
fluid balance
• Increased secretion of aldosterone causes
sodium retention (and thus water retention)
and potassium loss
• decreased secretion of aldosterone causes
sodium and water loss and Potassium
retention
• Cortisol - another adrenocortical hormone,
has only a fraction of the mineralocorticoid
potency of aldosterone; however when
secreted in large quantities, it can produce
sodium and fluid retention
Parathyroid Functions
• The parathyroid glands regulate calcium and
phosphate balance by means of parathyroid
hormone (PTH)
 • PTH influences - Male-42-52% Female-35-47%
- bone resorption • Urine sodium level-used to assess volume
- calcium absorption from the intestines status, diagnosis of hyponatremia ,and acute
- calcium reabsorption from the renal renal failure
tubules - normal Urine Na level - (75-200mEq/24
hours)
FLUID VOLUME DISTURBANCES - As Na+ intake increases,excretion increases
1.) HYPOVOLEMIA ; as circulating volume decreases, Na+ is
- Fluid volume deficit (FVD), or hypovolemia, conserved
occurs when loss of ECF volume exceeds the • Hypokalemia-occurs with GI & renal losses
intake of fluid • Hyperkalemia-occurs with adrenal insufficiency
- Excessive loss of water and electrolytes in • Hyponatremia-occurs with increased thirst and
equal proportion; vascular, cellular, or adrenal release
intracellular dehydration • Hypernatremia-results from insensible losses &
Causes: diabetes insipidus
• abnormal fluid losses, such as those resulting Medical Management
from vomiting, diarrhea, GI suctioning, and • Correction of fluid loss through oral route if
sweating patient can drink
• decreased intake, as in nausea or lack of • For acute or severe loss, IV route is required
access to fluids - Isotonic electrolyte solutions (e.g., lactated
• third-space fluid shifts, or the movement of Ringer’s solution, 0.9% NaCl) are used to
fluid from the vascular system to other body treat hypotensive patients with FVD
spaces (eg, with edema formation in burns, - Once normotensive, hypotonic electrolyte
ascites with liver dysfunction) solution (e.g., 0.45% NaCl)
Clinical Manifestations ; Signs and Symptoms of FVD: • Enteral or parental nutrition if oral rehydration
• Acute weight loss are not tolerated
• Decreased skin turgor Nursing Management
• Oliguria • Monitor, measure fluid I&O at least
• Concentrated urine hourly/every 8 hours
• Orthostatic hypotension • Daily body weight monitoring
• due to volume depletion • Observe for weak, rapid pulse and orthostatic
• Weak, rapid heart rate hypotension
• Flattened neck veins • Observe for body temperature
• Increased temperature • Assess for other vital signs, level of
• Thirst consciousness, CVP, breath sounds and skin
• Decreased or delayed capillary refill color
• Decreased central venous pressure • Skin and tongue turgor is monitored on a
• Cool, clammy, pale skin related to peripheral regular basis
vasoconstriction • Provide frequent oral care
• Anorexia
• Nausea 2.) HYPERVOLEMIA
• Lassitude - Fluid volume excess (FVE), or hypervolemia,
• Muscle weakness refers to an isotonic expansion of the ECF
Assessment and Diagnostic Findings - caused by the abnormal retention of water
• Urine specific gravity is above 1.020-indicating and sodium in approximately the same
healthy renal conservation of fluid proportions in which they normally exist in
- Measures the kidneys ability to excrete or the ECF
conserve urine - secondary to an increase in total body
• BUN elevated out of proportion to the serum sodium content , in turn , leads to an
creatinine (ratio greater than 20:1) increase in total body water
- normal BUN - 10-20 mg / dL Contributing factors:
- normal Creatinine - 0.7-1.4 mg/ dL • FVE may be related to simple fluid overload/
• Hematocrit level -greater than normal excessive fluid intake
 • Diminished function of the homeostatic
mechanisms responsible for regulating fluid
balance
• Heart failure, renal failure, and cirrhosis of the
liver
• Consumption of excessive amounts of table or
other sodium salts
• Excessive administration of Na+-containing
fluids in a patient with impaired regulatory
mechanism
Clinical Manifestations
• Clinical manifestations of FVE stem from
expansion of the ECF include edema,
distended neck veins, and crackles (abnormal
lung sounds)
• Other manifestations include:
o Tachycardia
o Increased blood pressure, pulse pressure,
and central venous pressure
o Increased weight
o Increased urine output
o Shortness of breath and wheezing
Assessment and Diagnostic Findings
• BUN and hematocrit levels - decreased
because of plasma dilution
- Also caused by low protein intake &
anemia
• Serum osmolality & sodium level are
decreased due to excessive retention of water
in chronic renal failure
• Increased urine sodium level since the kidney
is attempting to excrete excess volume
• Chest x-ray may reveal pulmonary congestion
Management
• Symptomatic treatment –administering diuretics
restricting fluids and sodium
1. Nutritional Therapy
- Treatment of FVE usually involves
dietary restriction of sodium
o mild restriction to as little as 250 mg of
sodium per day
o 6-15g of salt average daily diet w/o sodium
restriction
o Avoid foods high in sodium (canned fruits &
vegs, sauces, cured meat & bacon , cheese,
instant soups)
o Use distilled water if water supply is high in
sodium
o Salt substitute contain potassium & should
not be used at all in advanced renal disease
because of potassium retention
2. Pharmacologic Therapy
• Diuretics are prescribed when dietary
restriction of sodium alone is insufficient to
reduce edema
- choice of diuretic is based on severity of
hypervolemic state, degree of renal
impairment and the potency of the
diuretic
• Thiazide diuretics - prescribed for mild to
moderate hypervolemia
- block sodium reabsorption in the distal
tubule (5-10% of filtered Na+ )
- -g.HydroDIURIL , spironolactone
(Aldactone)
• Loop diuretics - severe hypervolemia
- can cause greater loss of both water and
sodium
- block reabsorption in ascending limb of
the loop of Henle ( 20-30%)
- eg.furosemide ( Lasix ) , torsemide (
Demadex
• Thiazide diuretics block sodium reabsorption
in the distal tubule where only 5-10% of
filtered sodium is reabsorbed
• Ascending loop of Henle can cause greater
loss of both sodium and water (20-30% of
filtered sodium is normally reabsorbed)
Side effect of diuretics
• Electrolyte imbalances-result from the effect
of diuretic
• Hypokalemia
• Hyperkalemia
• Hyponatremia
• Hypomagnesemia
• Azotemia-(increased nitrogen level)
• High uric acid levels (hyperuricemia)
3. Dialysis
Hemodialysis -to remove nitrogenous wastes and
control potassium and acid–base balance , and to
remove sodium and fluid.
Nursing Management
• Measure l&O at regular intervals to identify
excessive fluid retention
• Weigh patient daily to note rapid weight gain
(acute weight gain of 1 kg represents a gain of
1L of fluid)
• Monitor the degree of edema in the most
dependent parts of the body
Pitting edema
- press the finger into the affected
part creating a pit or indentation
evaluated on a scale of 1 (minimal)
to 4 (severe)
- check feet and ankles in
ambulatory patients and the sacral
region in bedridden patient
Peripheral edema - monitored by
measuring the circumference of the
extremity with a tape marked in mm
• Assess breath sounds at regular intervals in
at-risk patients, particularly when parenteral
fluids are being administered
- If pulmonary edema occurs, elevate the
head of the bed and have the client
turn, cough, and deep-breathe every 2
hrs
• Turn the client every 2 hrs to prevent skin
breakdown
Nursing Alert
When administering fluids to patients with
cardiovascular disease, the nurse assesses for signs
of circulatory overload. The lungs are auscultated for
crackles.
• Cough
• Dyspnea
• puffy eyelids
• dependent edema
• weight gain in 24 hours
ELECTROLYTE IMBALANCES
1.) Sodium Imbalances
Sodium is the most abundant electrolyte In ECF
- Concentration ranges from 135 to 145 mmol/L
- Primary determinant of ECF volume and
osmolality
- Has a major role in controlling water distribution
throughout the body
- Regulated by ADH, thirst, and the renin-
angiotensin-aldosterone system
- A loss or gain of sodium is usually accompanied
by a loss or gain of water
- Necessary for muscle contraction and the
transmission of nerve impulses
- Syndrome of inappropriate antidiuretic
hormone (SIADH) excretion is associated with
sodium imbalance
Causes of SIADH
• Excessive ADH activity
• Hyponatremia
• Hypernatremia
• Conditions affecting the CNS
HYPONATREMIA (Sodium Deficit)
• Sodium level that is below normal (less than
135 mmol/L)
• Total sodium concentration represents the
ratio of total body sodium to total body
water:
- Low total body sodium with a lesser
reduction in total body water
- Normal total body sodium content with
excesss of total body water
- Excess total body sodium with an even
greater excess of total body water
• Can be superimposed on an existing FVD or
FVE
Causes:
• Vomiting, diarrhea, diaphoresis, and
nasogastric suctioning
• Diuretic use
• Adrenal insufficiency
• Use of certain anticonvulsant medications:
carbamazepine (Tegretol ) , levetiracetam
(Keppra ) ,fluoxetine ( Sarafem )
• SIADH-abnormal water retention
Clinical Manifestations
Clinical manifestations of hyponatremia depend on
the cause, magnitude, and speed with which the
deficit occurs
• Poor skin turgor
• dry mucosa
• decreased saliva production
• nausea
• vomiting
• abdominal cramping
• orthostatic fall in blood pressure -
• Altered mental status
• Status epilepticus: epileptic seizures follow
one another without recovery of
consciousness bet them
• Coma
• Lethargy
• Confusion
• Muscle twitching
 • Hemiparesis: one-sided muscle weakness or
paralysis
• seizures
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Serum osmolality –decreased
• Serum sodium –less than 135 mEq/ L ;
lower than 100 in SIADH
• Hyponatremia due to Sodium loss-
- Urinary Sodium-less than 20 mEq/ L &
low specific gravity (1. 002- 1.004) due
to SIADH
- Urinary Sodium-greater than 20mEq / L
& specific gravity greater than 1.012
• ECF volume increased without any edema
• Anorexia
• Muscle cramps
• Exhaustion
 Acute decrease in sodium in less than 24hrs-
associated with brain herniation &
compression of midbrain structures
 Chronic decrease in sodium over 48hrs can
occur in status epilepticus
Medical Management
• IV conivaptan hydrochloride (Vaprisol) for
patients with moderate to severe
symptomatic hyponatremia
• Hypertonic saline for patients with delirium
or coma
• Lithium ( Eskalith ) to antagonize the
osmotic effect of ADH
Nursing Management
• Monitoring fluid I&O for patients at risk
• Daily body weighing to note abnormal losses
of sodium or gains of water.
• Encourage foods and fluids with a high
sodium content, such as beef broth and
tomato juice
• Prevent injury
- Central nervous system (CNS) changes:
lethargy, confusion, muscle twitching
and seizures
• Watch for neurologic sign :
- muscle weakness
- partial or complete loss of sensation
- poor cognitive abilities
- decreased alertness
- difficulty reading and writing
• Watch for increased risk for hyponatremia
among elderly
- changes in renal function
- subsequent decreased ability to excrete
excessive water loads
- diminished sense of thirst
- loss of access to food or fluids
HYPERNATREMIA (Sodium Excess)
- Sodium level higher-than 145 mEq/L or 145
mmol/L
- Can occur in patients with normal fluid
volume or in those with FVE or FVD
Causes:
 Gain of sodium in excess of water or by a loss
of water in excess of sodium
 Fluid deprivation in unconscious patients
who cannot perceive, respond to, or
communicate their thirst
 Administration of hypertonic enteral
feedings without adequate water
supplements
 Watery diarrhea
 Insensible water loss (hyperventilation,
denuding effects of burns)
Clinical Manifestations
The clinical manifestations of hypernatremia are
primarily neurologic
• Restlessness and weakness in moderate
hypernatremia
• Disorientation, delusions, and hallucinations
in severe hypernatremia
• In severe hypernatremia, permanent brain
damage can happen due to hemorrhages
from brain contraction
• Dehydration
• Thirst ( primary characteristic of
hypernatremia)
• Central and nephrogenic diabetes insipidus
• Less common causes:
• Heat stroke
• Near drowning in sea water
• Malfunction of hemodialysis or peritoneal
dialysis system
• IV administration of hypertonic saline
• Excessive use of sodium bicarbonate: antacid
for heartburn and indigestion
Other Signs:
• dry swollen tongue
• sticky mucous membranes
• flushed skin
• Body temperature may rise mildly
• peripheral and pulmonary edema: fluid
retention & accumulation
• postural hypotension: ↓ blood volume in
ECF
• increased muscle tone and deep tendon
reflexes
Assessment and Diagnostic Findings
• In HYPERNATREMIA, the serum sodium
level exceeds 145 mEq/L. and the serum
osmolality exceeds 300 mmol/L
• The urine specific gravity and urine
osmolality are increased
• Patients with nephrogenic or central
diabetes insipidus (caused by insufficient
levels of antidiuretic hormone
(ADH)/Arginine Vassopressin) produce a
dilute urine with a urine osmolality > 250
mmol/kg
Medical Management
• Hypotonic electrolyte solution (e.g, 0.3%
sodium chloride): allows a gradual
reduction in the serum sodium level and
thereby decreases the risk of cerebral
edema
• Isotonic non saline solution (e.g. 5%
dextrose in water): D5W is indicated when
water needs to be replaced without sodium
• Diuretics also may be prescribed to treat
the sodium gain
Nursing Management
• Intake and output measurement
• Advise client to avoid over-the-counter
medications with a high sodium content
(such as Alka-Seltzer)
• Educate on foods rich in sodium to avoid:
- canned fruits & vegetables
- processed foods
- instant soups
- sauces & dressings
- cheese
- fastfood fries & burgers
• Note the patient’s thirst or elevated body
temperature
• Monitor for changes in behaviour, such as
restlessness, disorientation, and lethargy
• Provide fluids at regular intervals,
particularly in debilitated patients unable to
perceive or respond to thirst
• Protect client from injury
2.) Potassium Imbalances
- Potassium is the major intracellular
electrolyte
- 98% of the body’s potassium is inside the
cells.
- The remaining 2% is in the ECF that is
important in neuromuscular function
- Potassium influences both skeletal and
cardiac muscle activity
- Normal serum concentration level- 3.5-5.0
mEq/ L
- 80% of the potassium is excreted daily from
the body by way of the kidneys
- 20% is lost through the bowel & in sweat
- Alterations in its concentration change
myocardial irritability and rhythm
- Potassium imbalances are commonly
associated with:
 various diseases, injuries
 medications (NSAIDs , ACE inhibitors)
 special treatments such as parenteral
nutrition and chemotherapy
 Kidneys maintain K+ balanc
 As serum potassium levels increase, so does
the potassium level in the renal tubular cel
 Aldosterone also increases the excretion of
potassium by the kidne
 Kidneys do not conserve potassium as well as
they conserve sodium
HYPOKALEMIA (Potassium Deficit)
- Hypokalemia (below-normal serum
potassium concentration 3.5 mEq/L)
- usually indicates an actual deficit in total
potassium stores
- When alkalosis is present, a temporary shift
of serum potassium into the cells occurs
Causes:
• Use of diuretics
• Other medications that can lead to
hypokalemia include: corticosteroids, sodium
penicillin, carbenicillin, and amphotericin
• Vomiting
• Diarrhea
• Prolonged intestinal & gastric suctioning
• Recent ileostomy
• Villous adenoma
• Alterations in acid—base balance
• Respiratory or metabolic alkalosis
• Hyperaldosteronism increases renal potassium
wasting
• Anorexia nervosa
• Bulimia
Clinical Manifestations
• Decreased bowel motility
• Anorexia, nausea, and vomiting
• Muscle weakness
• Leg cramps
• Paresthesias(numbness & tinggling)
• Polyuria ,nocturia & excessive thirst
• Glucose intolerance
 • Dysrhythmias
• Increased sensitivity to digitalis
• Decreased muscle strength & DTRs
ASSESMENT and DIAGNOSTIC FINDINGS
• ECG changes
• Digitalis toxicity
• Symptoms of digitalis toxicity:
 Confusion
 Irregular pulse
 Loss of appetite
 Nausea, vomiting, diarrhea
 Fast heartbeat
 Vision changes (unusual), including blind
spots, blurred vision, changes in how
colors look, or seeing spots)
• Metabolic alkalosis
• 24-hour urinary potassium excretion test ( to
determine between renal and extrarenal loss)
• Changes on an electrocardiogram (ECG) can
include flat T waves and/or inverted T waves,
suggesting ischemia, and depressed ST
segments
• An elevated U wave is specific to hypokalemia
Medical Management
• Conventional measure –increase oral intake
• Oral K+ supplements
• IV supplements: KCL, potassium acetate ,
potassium phosphate
• Potassium loss must be corrected daily
(administration of 40-80 mEq of potassium in
the adult)
Nursing Management
• Monitor for its early presence in patients at
risk
• Monitor closely for signs of digitalis toxicity,
because hypokalemia potentiates the action
of digitalis
• Assess for abdominal distention, pain, or GI
bleeding (dark tarry stool & coffee ground
vomitus) which may indicate bowel lesions
• Monitor intake and output accurately
• Intake of potassium-rich foods: fruits, fruit
juices, dried fruits, fresh or frozen
vegetables, legumes. whole grains, milk,
eggs, meat, and poultry
• Maintain a safe environment
NURSING ALERT
• Oral potassium can produce small bowel
lesions; therefore , the patient must be
assessed for and cautioned about abdominal
distention
• Potassium supplements are extremely
dangerous for patients who have impaired
renal function and thus decreased ability to
excrete potassium.
• Intravenous potassium is never administered
by IV push or intramuscularly to avoid
replacing potassium too quickly
• Aged ( stored ) blood should not be
administered to patients with impaired renal
function because the serum potassium
concentration of stored blood increases due
to red blood deterioration
• Potassium should be administered only after
adequate urine flow has been established
HYPERKALEMIA (Potassium Excess)
- Greater than normal serum potassium
concentration 5.0 mEq/L
- Cardiac arrest is more frequently associated
with high serum potassium levels
Causes:
• Three major causes:
• Decreased renal excretion of potassium
• Rapid administration of potassium
• Movement of potassium from the ICF
compartment to the ECF
Other causes:
• Infection –use of trimethoprim &
pentamidine
• Excessive intake of potassium in food or
medications
• Hypoaldosteronism/ Addison’s Disease
• Medications: potassium chloride, heparin,
ACE inhibitors, NSAIDs, beta-blockers, and
potassium-sparing diuretics
 • Acidosis: potassium moves out of the cells and
into the ECF
• Pseudohyperkalemia: the use of a tight
tourniquet around an exercising extremity
while drawing a blood sample, and producing
hemolysis of the sample before analysis
Clinical Manifestations
• Disturbances in cardiac conduction
- Peaked, narrow T-waves; ST-segment
depression; and a shortened QT interval
• Skeletal muscle weakness and even paralysis:
Hyperkalemia can cause ascending muscle
weakness that begins with the legs and
progresses to the trunk and arms
• Flaccid quadriplegia: paralysis caused by
illness or injury that results in the partial or
total loss of use of all four limbs
• Paralysis of respiratory and speech muscles
• GI manifestations
- nausea, intermittent intestinal colic, and
diarrhea
Assessment and Diagnostic Findings
• Serum potassium levels-elevated
• ECG changes –conduction disturbance
• Arterial blood gas analysis (reveal both a
metabolic and respiratory acidosis)
Medical Management
• Restriction of dietary potassium
• Potassium-containing medications (eg.
Kayexalate enema)
• IV Calcium gluconate –
• IV sodium bicarbonate and hypertonic
dextrose
• .Lasix
• Beta 2 agonist like albuterol ( Ventolin)
• Hemodialysis
Nursing Management
• Observe for signs of muscle weakness and
paresthesias
• Observe for GI symptoms such as nausea and
vomiting
• Encourage to adhere to the prescribed
potassium restriction
• Educate about potassium rich foods that they
have to avoid like:
- banana - Kiwi
- prune juice - Papaya
- Honeydew melon - Raisins
- orange & juice - Cantaloupe
• Salt substitutes should not be administered to
patients with renal dysfunction
3.) Calcium Imbalances
Calcium
- Plays a major role in transmitting nerve
impulses
- Helps regulate muscle contraction, and
relaxation, including cardiac muscle
- Activates enzymes & plays a role in blood
coagulation
• More than 99% of the body’s calcium is
located in the skeletal system
• 1% circulates in the serum, partly bound to
protein partly ionized
• Normal level- 8.6 to 10.2 mg/dL (2.2 to 2.6
mmol/L)
Calcium exists in plasma in three forms:
• Ionized
o active ionized – important for
neuromuscular activity & blood
coagulation
o normal ionized -4.5-5.1 mg/dL
 Bound to protein primarily albumin
• Complexed – combined with nonprotein
anions: phosphate , citrate & carbonate
 Absorbed with foods in the presence of
normal gastric acidity & Vitamin D
 Excreted primarily in the feces & the
remainder excreted in the urine
 Serum Ca+ level is controlled by PTH &
calcitonin
 As ionized serum Ca+ decreases , the
parathyroid glands secrete PTH
 The increase in Ca+ ion concentration
suppresses PTH secretion
 When Ca+ increases excessively, the
thyroid gland secretes calcitonin which
inhibits reabsorption from bone &
decreases the serum calcium
concentration
HYPOCALCEMIA (Calcium Deficit)
- Lower than 8.6 mg/dL (2.15 mmol/L)
- May have a total body calcium deficit but
with a normal serum calcium level
- Increased amount of time in bed
Causes:
• Primary hypoparathyroldism:
• Surgical hypoparathyroidism
• Radical neck dissection-24 to 48hrs after
surgery
• Transient hypocalcemia
• Pancreatitis
• Renal failure
• Hyperphosphatemia- causes a reciprocal drop
in the serum calcium level
 • Inadequate vitamin D consumption
• Alkalosis
• alcohol abuse
• Medications predisposing to hypocalcemia
include
- Aluminum-containing antacids
- Aminoglycosides
- caffeine
- cisplatin: chemotherapy drug
- Corticosteroids
- Phosphates
- Isoniazid
- loop diuretic
Clinical Manifestations
• Tetany- condition marked by intermittent
muscular spasms, tingling in fingers ,around
the mouth & feet
• Trousseau’s sign
- can be elicited by inflating a blood
pressure cuff on the upper arm to about
20 mm Hg above systolic pressure; within
2 -5 minutes, carpal spasm (an adducted
thumb, flexed wrist and
metacarpophalangeal joints, extended
interphalangeal joints with fingers
together)
• Chvostek’s sign
- consists of twitching of muscles supplied
by the facial nerve when the nerve is
tapped about 2 cm anterior to the
earlobe, just below the zygomatic arch
• Seizures
• Mental changes
- depression, impaired memory, confusion,
delirium, and even hallucinations
• Osteoporosis
• Dyspnea, laryngo & bronchialspasm
CHRONIC HYPOCALCEMIA:
• Hyperactive bowel sound
• Dry brittle hair & nails
• Abnormal clotting
Assessment And Diagnostic Findings
• Serum calcium levels
• PTH levels- decreased in hypoparathyroidism
• ECG
• Magnesium & Phosphorus levels
Medical Management
• IV administration of calcium
- calcium gluconate, calcium chloride, and
calcium gluceptate
• Vitamin D therapy may be instituted to
increase calcium absorption from the GI tract
• Aluminum hydroxide, calcium acetate, or
calcium carbonate antacids may be prescribed
to decrease elevated phosphorus levels
before treating hypocalcemia for the patient
with chronic renal failure
Nursing Alert: IV Calcium Administration
• dangerous in patients receiving digitalis-
derived medications
• can cause digitalis toxicity, with adverse
cardiac effects
• Too-rapid administration can cause cardiac
arrest, preceded by bradycardia
• IV calcium should be diluted in D5W and given
as a slow IV bolus or a slow IV infusion using a
volumetric Infusion pump
• A 0.9% sodium chloride solution should not
be used with calcium, because it will increase
renal calcium loss
• Solutions containing phosphates or
bicarbonate should not be used with calcium,
as they will cause precipitation when calcium
is added
• Calcium can cause postural hypotension;
monitor blood pressure
Nursing Management
• Seizure precaution
• Health teachings to avoid the following:
- Caffeine in high doses- inhibit calcium
absorption
- Cigarette smoking- increases urinary
calcium excretion
- overuse of laxatives and antacids-
decreases calcium absorption
• Increase dietary intake of calcium:
1500mg/day
- Foods rich in calcium: milk products,
green leafy vegetables, fresh oysters
• Instruct client on the value of regular
exercise- decreases bone loss
• Calcium supplements should be taken in
divided doses with meals
• Caution to avoid overuse of laxatives &
antacids that contain Phosphorus
• Check BP
• Auscultate lungs
HYPERCALCEMIA (Calcium Excess)
- Greater than 10.2 mg/dL (2.6 mmol/L)
- has a mortality rate as high as 50% if not
treated promptly
Causes:
• Hyperparathyroidism
• Malignant tumors
 • Prolonged immobilization
• Thiazide diuretics
• Vitamin A and D intoxication, as well as the
use of lithium
Clinical Manifestation
• Anorexia, nausea, vomiting
• Constipation
• Dehydration
• Abdominal and bone pain
• Abdominal distention and paralytic ileus
• Excessive urination
• Severe thirst
• Altered level of consciousness
- Slurred speech, confusion, lethargy, coma
• Hypercalcemic crisis- an acute rise in the
serum calcium level to 17 mg/dL (4.3 mmol/L)
or higher
Assessment and Diagnostic Finding
• Serum calcium level greater than 10.2 mg/dL
(2.6 mmol/L)
- Dysrhthmias- shortening of the QT
interval, and ST segment
• Double antibody PTH test- to differentiate
between primary hyperthyroidism and
malignancy as a cause of hypercalcemia
• X-rays reveal bone changes
• Sulkowitch urine test- analyzes amount of
calcium in the urine
Medical Management
• IV administration 0.9% sodium chloride
solution
• Administering IV phosphate
• Furosemide (Lasix) is often used in
conjunction with administration of saline
solution
• Calcitonin
• Surgery, chemotherapy, or radiation therapy
for patients with cancer
• Corticosteroids
• Mithramycin
• Inorganic phosphate salts ( Phospho-soda or
Neutra-Phos), rectally (as retention enemas),
or intravenously
• IV phosphate therapy
Nursing Alert: Calcitonin
• Skin testing for allergy to salmon calcitonin
is necessary before the hormone is
administered
• Systemic allergic reactions are possible
since this hormone is a protein
- Resistance to the medication may
develop later because of antibody
formation
• Administered by intramuscular injection
rather than subcutaneously
Nursing Management
• Institute injury prevention measures for
mental confusion
- Keep bedside rails up
- Keep bed brakes locked
• Increasing patient mobility and encouraging
fluids can help prevent hypercalcemia or at
least minimize its severity
• Fluids containing sodium should he
administered unless contraindicated
• Patients are encouraged to drink 3 to 4
quarts of fluid daily
• Adequate fiber should be provided
• Assess for signs and symptoms of digitalis
toxicity
• Monitor cardiac rate and rhythm for any
abnormalities- ECG changes can occur
4.) Magnesium Imbalances
- Next to potassium, magnesium is the most
abundant intracellular cation
- acts as an activator for many intracellular
enzyme systems
- plays a role in both carbohydrate and
protein metabolism
- Normal serum magnesium level is 1.3 to 2.3
mg/dL (0.62 to 0.95mmol/L)
• Magnesium balance is important in
neuromuscular function
• Approximately one third is bound to protein
;the remaining two thirds exists as free
cations
• Excess of Mg++ diminishes excitability of
muscle cells
• Deficit increases neuromuscular irritability
& contractility
• Mg status depends on 3 organs: uptake in
the intestine, storage in the bone and
excretion in the kidneys. Hypermagnesemia
is therefore often due to problems in these
organs, mostly intestine or kidney.
• Mg++ produces sedative effect at
neuromuscular junction
- It stimulates threshold in nerve fibers
- Affects the cardiovascular system to
produce vasodilation & decreased
peripheral resistance
- Found in bone & soft tissues
- Eliminated by the kidney
HYPOMAGNESEMIA (Magnesium Deficit)
 - Below normal serum magnesium
concentration- 1.3 mg/dL (0.62 mmol/L)
- Magnesium is similar to calcium in two
ways:
 Ionized Mg++ involved in
neuromuscular activity and other
physiologic processes
 Magnesium levels should be evaluated
in combination with albumin level
- About 30% of magnesium is protein bound,
principally to albumin
- A decreased albumin level can reduce the
measured total magnesium concentration
Causes:
• *An important route of Mg++ loss is the GI
tract
• Loss of magnesium from the GI tract may
occur with nasogastric suction, diarrhea, or
fistulas
• Disruption in small bowel function (eg.
intestinal resection or inflammatory bowel
disease)
• Withdrawal from alcohol and administration
of tube feedings or parenteral nutrition
• Enteral or parenteral feeding deficient in
Mg++
• Other causes include:
- Administration of aminoglycosides,
cyclosporine, cisplatin, diuretics, digitalis,
and amphotericin
- Rapid administration of citrated blood,
especially to patients with renal or hepatic
disease
• Diabetic ketoacidosis: serious complication
of diabetes that occurs when your body
produces high levels of blood acids called
ketones
• Other contributing causes: pregnancy,
lactation, sepsis, burns, and hypothermia
Clinical Manifestations
• Symptoms do not usually occur until the
serum magnesium level is less than 1 mEq/L
(0.5 mmol/L)
• Manifestations are largely confined to the
neuromuscular system
• Hyperexcitability with muscle weakness,
tremors, and athetoid movements (slow,
involuntary twisting )
• Others include:
 Tetany
 Nystagmus: involuntary, rapid and
repetitive movement of the eye
 Vertigo: sensation of spinning that is
related to problems with the inner ear
 Generalized tonic-clonic or focal seizures
- Tonic-clonic seizure A person loses
consciousness, muscles stiffen, and
jerking movements are seen.Involves
the whole body These types
of seizures usually last 1 to 3 minutes
and take much longer for a person to
recover
- Partial (focal) seizures occur when
this electrical activity remains in a
limited area of the brain
 laryngeal stridor
 Positive Chvostek’s and Trousseau’s signs
 Cardiac dysrhythmias
 Marked alterations in mood-apathy
,depression , ataxia , confusion
 Insomnia
 Dysphagia
Assessment and Diagnostic Findings
• Serum magnesium level- less than 1.3 mg/dL
(0.62 mmol/L)
• Urine magnesium after a loading dose of
magnesium sulphate
• Two newer diagnostic techniques:
- nuclear magnetic resonance spectroscopy
- ion-selective electrode
Medical Management
• Diet for mild magnesium deficiency
- Sources: green leafy vegetables, nuts,
legumes, whole grains, peanut butter,
cocoa, and seafoods
• Mg++ oral salts in oxide or gluconate forms
• IV parenteral administration with magnesium
sulfate not to exceed 150 mg/min or 67mEq
over 8 hours by infusion pump
Nursing Alert: Magnesium IV injection given slowly
• Rate: not to exceed 150 mg/min, or 67 mEq
over 8 hours
• Can produce alterations in cardiac conduction
• Assess vital signs frequently- hypotension,
respiratory distress
• Monitoring urine output is done before,
during, and after magnesium administration
• Calcium gluconate must be readily available to
treat hypocalcemic tetany or
hypermagnesemia