ELECTROLYTE IMBALANCE Easy to remember

Normal potassium level= 3.5 to 5.0 mEq/L

What is hypokalemia?

It is a serum potassium level less then 3.5 mEq/L. It is potentially life threatening because whole body system is affected.

WHAT ARE THE CAUSES OF HYPOKALEMIA?

• Actual total body potassium loss.
  • Excessive use of medication such as diuretics and corticosteroids
  • Cushing’s syndrome (Increased secretion of aldosterone)
  • Vomiting
  • Diarrhea
  • Wound drainage especially gastrointestinal
  • Prolonged nasogastric suction
• Inadequate potassium such as fasting, nothing by mouth status
• Movement of potassium from extracellular to the intracellular fluid such as incase of alkalosis and Hyperinsulinism
• Dilution of serum potassium in case of water intoxication and IV therapy with potassium deficient solution

What are the assessment findings of Hypokalemia?

What are the nursing interventions of hypokalemia?

• Monitor electrolyte values.
• Administer potassium supplements orally or intravenously as prescribed.
• Oral potassium supplements
  • (a) Oral potassium supplements may cause nausea and vomiting and should not be taken on an empty stomach, if the client complains of abdominal pain, distention, nausea, vomiting diarrhea, or gastrointestinal bleeding, the supplement may need to be discontinued.
  • (b) Liquid potassium chloride has an unpleasant taste and should be taken with juice or another liquid.
• Intravenously administered potassium.
• Institute safety measures for the client experiencing muscle weakness.
• If the client is taking a potassium-losing diuretic, it may be discontinued, a potassium sparing (retaining) diuretic may be prescribed.
• Instruct the client about foods that are high in potassium content.

What is Hyperkalemia?

1. Hyperkalemia is a serum potassium level that exceeds 5.0 mEq/L (5.0mmol/L)
2. Pseudo hyperkalemia is a condition that can occur due to methods of blood specimen collection and cell lysis; if an increased serum value is obtained in the absence of clinical symptoms, the specimen should be redrawn and evaluated.

Causes of hyperkalemia:

• Excessive potassium intake:
  • Over ingestion of potassium containing foods or medications, such as potassium chloride or salt substitutes.
  • Rapid infusion of potassium containing IV solutions
• Decreased potassium exertion
  • Potassium sparing (retaining) diuretics
  • Kidney disease
  • Adrenal insufficiency, such as in Addison’s disease
• Movement of potassium from the intrasaccular fluid to the extracellular fluid
  • Tissue damage
  • Acidosis
  • Hyperuricemia

What are the assessment findings of hyperkalemia?

Interventions of the hyperkalemia:

• Discontinue IV potassium and withhold oral intake of potassium supplements.
• Initiate a potassium-restricted diet
• Administer potassium excreting diuretics if renal function properly
• If renal function impaired, administer sodium polystyrene sulfonate (oral or rectal route), a cation-exchange resin that promotes gastrointestinal sodium absorption and potassium excretion.
• If the potassium is critically high, then prepare the client for dialysis.
• Administer IV calcium to avert myocardial excretion
• IV administration of hypertonic glucose with regular insulin to move excess potassium.
• When blood fusions are prescribed for a client with a potassium imbalance, the client should receive fresh blood, if possible. Because of the transfusions of the stored blood, it may increase the level of the potassium (the breakdown of the older blood cells releases potassium)
• Teach the client to avoid foods high in potassium.
• Instruct the patients to avoid the use of the salt substitutes or other potassium-containing substances.
• Monitor the serum potassium level closely when a client is receiving a potassium-sparing diuretics.

SODIUM SERUM LEVEL 135-145mEq/L

HYPONATREMIA

It is serum sodium level lower than 135mEq/L.

CAUSES OF THE HYPONATREMIA

• Increased sodium excretion:
  • Diuretics
  • Vomiting
  • Diarrhea
  • Wound drainage especially gastrointestinal
  • Kidney disease
  • Decreased secretion of aldosterone
  • Excessive diaphoresis
• Inadequate sodium intake:
  • Fasting; nothing by mouth status
  • Low-salt diet
• Dilution of serum sodium
  • Excessive ingestion of hypotonic fluids
  • Excessive irrigation with hypotonic fluids
  • Kidney disease
  • Freshwater drowning
  • Syndrome of inappropriate antidiuretic hormone secretion
  • Hyperglycemia
  • Heart failure

ASSESSMENT FINDINGS OF THE HYPONATREMIA:

INTERVENTIONS OF THE HYPONATREMIA

• If hyponatremia is accompanied by fluid volume deficit (hypovolemia), IV sodium chloride infusions are administered to restore sodium content and fluid volume.
• If hyponatremia is accompanied by fluid volume excess (hypervolemia) osmotic diuretics may be prescribed to promote the excretion of water rather than sodium.
• If hyponatremia is caused by inappropriate or excessive secretion of antidiuretic hormone, medications that antagonize antidiuretic hormone may be administered.
• Instruct the client to increase oral sodium intake as prescribed and inform the client about the foods to include in the diet.
• If the client is taking lithium, monitor the lithium level, because hyponatremia can cause diminished lithium exertion, resulting in toxicity.

HYPERNATREMIA

It is a serum sodium level that exceeds 145mEq/L

CAUSES OF HYPERNATREMIA:

• Decreased sodium excretion
  • Corticosteroids
  • Cushing syndrome
  • Kidney disease
  • Hyperaldosteronism
• Increased sodium intake
  • Excessive oral sodium ingestion
  • Excessive administration of sodium
• Decreased water intake
  • Fasting
  • nothing by the mouth status
• Increased water loss
  • Increased rate of metabolism
  • fever
  • Hyperventilation
  • Infection
  • Excessive diaphoresis
  • Watery diarrhea
  • Diabetes insipidus

ASSESSMENT FINDING OF THE HYPERNATREMIA:

INTERVENTIONS FOR THE HYPERNATREMIA:

• Administer IV infusions, if the cause is fluid loss
• Administer diuretics to promote sodium loss, in case of inadequate renal excretion of sodium.
• Restrict sodium and fluid intake as prescribed

NORMAL CALCIUM LEVEL IS 9-10.5mg/dl

HYPOCALCEMIA:

It is serum calcium level lower than 9.0 mg/dL

CAUSES OF THE HYPOCALCEMIA:

• Inhibition of calcium absorption from the gastrointestinal tract
  • Inadequate oral intake of calcium
  • Lactose intolerance
  • Malabsorption syndrome such as celiac sprue or Crohn ‘s disease
  • Inadequate intake of vitamin D
  • End stage kidney disease
• Increased calcium excretion
  • Kidney disease, polyuric phase
  • Diarrhea
  • Steatorrhea
  • Wound drainage, especially gastrointestinal
• Conditions that decrease the ionized fraction of calcium
  • Hyperproteinemia
  • Alkalosis
  • Medications such as calcium chelators or binders
  • Acute pancreatitis
  • Hyperphosphatemia
  • Immobility
  • Removal or destruction of the parathyroid glands

ASSESSMENT FINDINGS OF THE HYPOCALCEMIA:

INTERVENTIONS OF THE HYPOCALCEMIA:

• Administer calcium supplements orally or calcium intravenously
• When administering calcium intravenously, warm the injection solution to body temperature before administration and administer slowly
• Monitor for electrocardiographic changes
• Observe for infiltration
• Monitor for hypercalcemia
• Administer medications that increase calcium absorption:
  • Aluminum hydroxide reduces phosphorus levels, causing the countereffect of increasing calcium levels
  • Vitamin D helps in absorption of calcium from the intestinal tract
• Provide a quiet environment to reduce environmental stimuli
• Initiate seizures precautions
• Move the client carefully and monitor for signs of a pathology fracture
• Keep 10% calcium gluconate available for treatment of acute calcium deficit
• Instruct the client to consume foods high in calcium

HYPERCALCEMIA

It is a serum calcium level that exceeds 10.5mg/dL

CAUSES OF HYPERCALCEMIA:

• Increased calcium absorption
  • Excess oral intake of calcium
  • Excess oral intake of vitamin D
• Decreased calcium excretion
  • Kidney disease
  • Use of thiazide diuretics
• Increased bone resorption of calcium
  • Hyperparathyroidism
  • Hyperthyroidism
  • Malignancy (bone destruction from metastatic tumors
  • Immobility
  • Use of glucocorticoids
• Hemoconcentration
  • Dehydration
  • Use of lithium
  • Adrenal insufficiency

ASSESSMENT FINDINGS OF THE HYPERCALCEMIA:

INTERVENTIONS OF THE HYPERCALCEMIA

• Discontinue IV infusions of the solutions containing calcium and oral medications containing calcium and vitamin D
• Thiazide diuretics may be discontinued and replaced with diuretics that enhance the excretion of the calcium
• Administer prescribed medications that inhibit calcium resorption from the bone, such as phosphorus, calcitonin, bisphosphonates, and prostaglandin synthesis inhibitors (acetylsalicylic acid, NSAIDS)
• Prepare the client for the Dialysis in case of the hypercalcemia, if medications fail.
• Move the client carefully
• Monitor for signs of a pathological fracture
• Monitor for flank or abdominal pain and strain the urine to check for the presence of the urinary stones.
• Instruct the client to avoid foods high in calcium.

NORMAL MAGNESIUM LEVEL: 1.8 to 2.6mEq/L

HYPOMAGNESEMIA

It is a serum magnesium level lower than 1.8mEq/L

Causes of the Hypomagnesemia:

• Insufficient magnesium intake
  • Malnutrition and starvation
  • Vomiting or diarrhea
  • Malabsorption syndrome
  • Celiac disease
  • Crohn’s disease
• Increased magnesium excretion
  • Medications such as diuretics
  • Chronic alcoholism
• Intracellular movement of magnesium
  • Hyperglycemia
  • Insulin administration
  • Sepsis

ASSESSMENT FINDINGS OF THE HYPOMAGNESEMIA:

INTERVENTIONS OF THE HYPERMAGNESEMIA:

• Because hypocalcemia frequently accompanies hypomagnesemia, interventions also aim to restore normal serum calcium level
• Oral preparations of magnesium may cause diarrhea and increase magnesium loss
• Magnesium sulfate by the IV route may be prescribed when magnesium level is low
• Initiate seizures precautions
• Monitor serum magnesium levels frequently
• Monitor for diminished deep tendon reflexes, suggesting hypermagnesemia, while administering magnesium
• Instruct the client to increase the intake of foods that contain magnesium

HYPERMAGNESEMIA

It is a serum magnesium level that exceeds 2.6mEq/L

CAUSES OF HYPERMAGNESEMIA

• Increased magnesium intake
  • Magnesium-containing antacids and laxatives
  • Excessive administration of magnesium intravenously
• Decreased renal excretion of magnesium as a result of renal insufficiency

ASSESSMENT FINDINGS OF THE HYPERMAGNESEMIA:

INTERVENTIONS OF THE HYPERMAGNESEMIA

• Diuretics are prescribed to increase renal excretion of magnesium
• Administered IV calcium chloride or calcium gluconate to reverse the effects of magnesium on cardiac muscle
• Instruct the client to restrict dietary intake of magnesium containing foods
• Instruct the client to avoid the laxatives use and antacids containing magnesium.

HYPOPHOSPHATEMIA

It is a serum phosphate level less than 3.0mg/dL

A decrease in serum phosphate level is accompanied by an increase in the serum calcium level

CAUSES OF HYPOPHOSPHATEMIA

• Insufficient phosphorus intake
  • Malnutrition
  • Starvation
• Increased phosphate excretion
  • Hyperparathyroidism
  • Malignancy
  • Use of magnesium based or aluminum hydroxide-based antacids
• Intracellular shift
  • Hyperglycemia
  • Respiratory alkalosis

ASSESSMENT FINDINGS OF THE HYPOPHOSPHATEMIA

INTERVENTIONS OF THE HYPOPHOSPHATEMIC PATIENT:

• Discontinue those medications which result in decrease in phosphate level
• Administer phosphorus orally with a Vitamin D supplement
• Administer phosphorus IV when it is below 1mg/dL
• Administer IV phosphorus slowly because of the risks associated with hyperphosphatemia
• Assess the renal system before administering phosphorus
• Move the client carefully, monitor for pathological fracture
• Instruct patients to increase the intake of the phosphorus containing foods while decreasing the intake of any calcium containing foods

HYPERPHOSPHATEMIA

It is a serum phosphorus level that exceeds 4.5mg/dL

An increase in phosphorus level is accompanied by the decreased in the serum calcium levels

CAUSES OF HYPERPHOSPHATEMIA:

• Decreased renal excretion resulting from renal insufficiency
• Tumor lysis syndrome
• Increased intake of phosphorus, including dietary intake or overuse of phosphate containing laxatives or enemas
• Hypoparathyroidism

ASSESSMENT FINDINGS ARE SAME AS HYPOCALCEMIA

INTERVENTIONS OF THE HYPERPHOSPHATEMIAC PATIENTS

• Interventions entail the management of the hypocalcemia
• Administer phosphate -binding medications that increase fecal excretion of phosphorus by binding phosphorus from food in the gastrointestinal tract
• Instruct clients to avoid phosphate-containing medications including laxatives and enema
• Instruct patient to avoid eating phosphorus containing food
• Instruct patients about medications administration. Take phosphate-binding medications which should be taken with meals or immediately after meals

IMPORTANT POINTS RELATED TO ELECTROLYTE IMBALANCE WHICH SHOULD BE KEEP IN MIND AS A NURSE:

• Magnesium 1.8 – 2.6 mEq/L
• Phosphorus 3.0 – 4.5 mg/dL
• Potassium 3.5 – 5.0 mEq/L
• Calcium 9 – 10.5 mg/dl
• Chloride 95 – 105 mEq/L
• Sodium 135 – 145mEq/L

• A client with acute kidney injury, chronic kidney disease, and heart failure is at high risk for fluid volume excess
• Potassium is never administered by the IV push, intramuscular, or subcutaneous routes, IV potassium is always diluted and administered using an infusion device.
• Monitor the client closely for signs of a potassium imbalance. A potassium imbalance can cause cardiac dysrhythmias that can be life threatening, leading to cardiac arrest.
• Hyponatremia precipitates lithium toxicity in a client taking this medication.
• A client with a calcium imbalance is at risk for a pathological fracture, Move the client carefully and slowly; assist the client with ambulation.
• Calcium gluconate is the antidote for magnesium overdose.
• A decrease in the serum phosphorus level is accompanied by an increase in the serum calcium level
• An increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level. (This is called a reciprocal relationship)

Potassium does the same as the prefix except for HEART RATE AND URINE OUTPUT Hyper means everything up except HR and UO

Calcium and Magnesium do opposite of prefix Hyper means everything down such as HR, BP, RR and Hypo means everything ups such as HR, BP, RR

Sodium Pay focus on E or O letter in HYPER and HYPO. HypEr means dEhydration and HypO  means Overload.