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![MANAGEMENT
Drug therapy
• Lowering of serum sodium levels by infusion of hypotonic
electrolyte solution
• Diuretics also may be prescribed to treat sodium gain
• Desmopression acetate to treat diabetes insipidus if it is
cause of hypernatremia
Diet therapy
• Mild-ensure water intake
• The amount of water necessary to replace existing deficits
may be estimated by the following formula
free water deficit= dosing factor ×total body weight×
[(serumNa+/40)]
Dosing factor- 0.6if male , 0.5 if female](https://image.slidesharecdn.com/advancenursingpractice-210608154508/75/FLUID-ELECTROLYTE-IMBALANCE-61-2048.jpg)
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FLUID & ELECTROLYTE IMBALANCE
- 1. ADVANCE NURSING PRACTICE PRESENTATIONON FLUID & ELECTROLYTE IMBALANCE Presented by, Ms.Flavia Dass 1st year MSc.Nursing KIMS, Hubli
- 2. INTRODUCTION Fluid & electrolytebalance is a dynamic process that is crucial for life . It plays an important role in homeostatis. Imbalance may result from money factors & it is associated with illness Fluid & electrolyte balance is mandatory to maintain the stability of the body.
- 3. The body containslots of fluid & electrolyte which are the transporters & catalysts as well as solvents & solution for various reactions in our body. There is a required limit for every fluid type & electrolyte in our body, an increase or a decrease in the total or independent volume or concentration will result in the abnormalities contributing to systemic results.
- 4. COMPOSITION OF BODYFLUID Total body fluid 60% of body weight Intracellular fluids Extracellular fluids Interstitial Fluid ( 15% of body wt) Transcellular Fluid (plasma) Intravascular Fluid (CSF)
- 5. Intracellular spaceor compartment Most of the body fluids are in the intra cellular compartment (inside the cells). Electrolyte prevalent are K+ & PO4 3- Extracellular space or compartment (fluid outside the cells) a) Interstitial fluid – fluid between the cells b) Intravascular fluid – fluid inside blood vessels c) Transcellular fluid – fluid in CSF, GI tract, pleural space, synovial space etc.
- 6. ELECTROLYTES • Electrolyte arechemicals in the body that have an electric charge • Maintain body’s blood chemistry, muscle action & other processes • Electrolyte includes sodium, calcium, phosphate, chloride, potassium & magnesium • Electrolyte that are positively charged are called cations • Electrolyte that are negatively charged are called anions • The unit of measure of electrolyte is milliequivalent (mEq)
- 7. Edema Edema is anexcess accumulation of fluid in the interstitial space. ANASARCA Generalized edema due to excessive accumulation of fluid in the interstitial space throughout the body & occur as a result of condition such as cardiac, renal or liver failure.
- 8. REGULATION OF BODYFLUID COMPARTMENTS DIFFUSION- The movement of a substance from an area of high concentration to an area of low concentration
- 9. FACILITATED DIFFUSION Alsoknown as facilitated transport or passive mediated transport is the process of spontaneous passive transport of molecules or ions across a biological membrane via specific transmembrane integral protein
- 10. ACTIVE TRANSPORT Movementof molecules across a cell membrane from a region of lower concentration to a region of higher concentration against the concentration gradient
- 11. OSMOSIS movement of asolvent across a semi permeable membrane towards a higher concentration of solute to lower concentration until the concentrations become equal on either side of the membrane
- 12. HYDROSTATIC PRESSURE Isthe pressure that is exerted by a fluid at equilibrium at a given point within the fluid, due to the force of gravity.
- 13. ONCOTIC PRESSURE Is aform of osmotic pressure induced by the proteins in a blood vessel’s plasma that displaces water molecules
- 14. Body Fluids Excretion Dailybody fluid excretion occurs by several routes Skin – 400ml/day Lung – 350ml/day GI tract – 150ml/day Kidney – 150ml/day
- 15. Body Fluids Replacement Fluidenters the body through three sources Orally ingested liquid Water in food Water formed by oxidation of food
- 16. Maintaining Fluid &Electrolyte Homeostasis is a term that indicates the relative stability of the internal environment of the body. The kidneys play a major role in controlling the fluid & electrolyte balance. Normal kidneys can adjust the amount of water & electrolytes leaving the body
- 17. • The adrenalglands, through the secretion of aldosterone also help in controlling the extra cellular fluid volume by regulating the amount of sodium reabsorbed by the kidneys. • Pituitary gland secrets anti diuretics hormone which regulates the osmotic pressure of extracellular fluid by regulating the amount of water reabsorbed by the kidney
- 18. INTRAVENOUS FLUIDS It isalso known as intravenous solution are supplemental fluid used in intravenous therapy to restore or maintain normal fluid volume & electrolyte balance when the oral route is not possible
- 19. Types of IVFluids IV FLUIDS Crystalloids Isotonic Hypertonic Hypertonic Colloids Blood products
- 20. CRYSTALLOIDS Solutions (electrolyte) withsmall molecules that can diffuse freely throughout the extracellular space.
- 21. Types of Crystalloids Isotonic crystalloids When the concentration of the particles(solutes) is similar to that of plasma, it doesn’t move into cells & remain within the extra cellular compartment thus increasing intravascular volume.
- 22.
- 23. NORMAL SALINE(NS) It contains water, sodium & chloride USES • Isotonic solution of choice for expanding ECF volume • Infused to correct extracellular fluid volume deficit • Used along side administration of blood products • Used to replace large sodium losses such as burns injuries CAUTION • Should not be used for patients with heart failure, pulmonary edema & renal impairment
- 24. DEXTROSE 5% INWATER(D5W) It contains water & glucose USES • Initially isotonic & provides free water when dextrose is metabolized • Expands the ECF & ICF, helps in rehydrating & excretory purpose • Used to treat hypernatremia CAUTION • Should not be used for fluid resuscitation because hyperglycemia can result & client at risk for increased intracranial pressure
- 25. LACTATED RINGER’S SOLUTION5% DEXTROSE(D5LRS) It contains water, sodium, potassium, calcium, chloride & lactate USES • Used to correct dehydration, sodium depletion & replace GI tract fluid losses • Also used in fluid losses caused by burns, fistula drainage & trauma • Often administered for patient with metabolic acidosis because it is an alkalizing solution CAUTION • Should not be given to patients who cannot metabolize lactate • Used in caution for patient with heart failure & renal failure
- 26. RINGER’S SOLUTION(RL) It containssodium, chloride, lactate, potassium, calcium &water USES • Deficit , intra operative fluid loss • Severe hypovolemia CAUTION • Severe metabolic acidosis • Don’t give with blood products (reduces anticoagulant activity)
- 27. HYPOTONIC SOLUTION A hypotonicsolution is one in which the concentration of solutes is greater inside the cell than outside of it
- 28. TYPES OF HYPOTONICSOLUTION
- 29. 0.45% SODIUM CHLORIDE SOLUTION(0.45%Nacl) It contains water, sodium & chloride USES • Used for replacing water in patients who have hypovolemia with hypernatremia CAUTION • Excessive use may lead to hyponatremia due to the dilution of sodium
- 30. 0.33% SODIUM CHLORIDESOLUTION (0.33%Nacl) It contains water, sodium, chloride & glucose USES • Used to allow kidneys to retain needed amount of water. Free water helps kidneys eliminates solutes • Typically administered with dextrose to increase toxicity CAUTION • Used in caution for patients with heart failure & renal insufficiency
- 31. 0.225% SODIUM CHLORIDE SOLUTION(0.255%Nacl) It contains water, sodium, chloride & glucose USES • Used as maintenance fluid for pediatric patients as it is the most hypotonic fluid available • Typically administered with dextrose to increase toxicity
- 32. 2.5% DEXTROSEIN WATER (D2.5W) It contains water & glucose USES • Used to treat dehydration & decrease the levels of sodium & potassium CAUTION • Should not be administered with blood products as it can cause hemolysis of red blood cells
- 33. HYPERTONIC SOLUTION A hypertonicsolution is one where the concentration of solutes is greater outside the cell than inside it.
- 34. TYPES OF HYPERTONICSOLUTION
- 35. HYPERTENSION SODIUMCHLORIDE SOLUTION 3% Nacl – sodium & chloride 5% Nacl – sodium & chloride USES • Used in the acute treatment of severe hyponatremia & should only be used in critical situations to treat hyponatremia • Used in patient with cerebral edema • Some patients may need diuretic therapy to assist in fluid excretion CAUTION • Should be infused at a very low rate to avoid risk of pulmonary edema • If administered in large quantities & rapidly, they cause ECF excess & circulatory overload
- 36. DEXTROSE 10% (D10W) Itcontains water & glucose USES • Used in the treatment of ketosis of starvation & provides calories & free water CAUTION • Should be administered using a central line if possible • Do not infuse using the same line as blood products as it can cause RBC hemolysis
- 37. DEXTROSE 20% (D20W) Itcontains water & glucose USES • Used as an osmotic diuretic that causes fluid shifts between various fluid compartments to promote diuresis
- 38. DEXTROSE 50% (D50W) Itcontains water & glucose USES • Used to treat severe hypoglycemia • Administered rapidly via IV bolus
- 39. FLUID VOLUME DISTURBANCE Itis an abnormally decreased or increased fluid volume or rapid shift one compartment of the body fluid to another Hypovolemia Hypovolemia
- 40. HYPOVOLEMIA Hypovolemia or fluidvolume deficit occurs from a loss of fluid into the third space or from a reduced fluid intake CAUSES • Inadequate fluid intake • Active fluid loss • Failure of regulatory mechanism • Increased metabolic rate ( chronic illness,fever) • Fluid shifts (edema or effusion)
- 41. PATHOPHYSIOLOGY Decreased fluid volume Stimulationof thirst center in hypothalamus Person complains of thirst Increase ADH secretion Increased water resorption Decreased urine output Increased urine specific gravity expect with osmotic diuresis Renin – Angiotension aldosterone system Increased sodium & water resorption
- 42. CLINICAL MANIFESTATION • Acuteweight loss • Oliguria • Low BP • Sunken eyes • Dizziness • Weakness • Decreased skin turgor • Concentrated urine LABORATORY FINDINGS • increased hematocrit • Increased serum sodium level & BUN level • Increased serum osmolarity
- 43. MANAGEMENT Fluid management • Oralrehydration therapy – solutions containing glucose & electrolytes • IV therapy – type of fluid ordered depends on the type of dehydration & the clients cardiovascular status • Diet therapy – mild to moderate dehydration, correct with oral fluid replacement.
- 44. Nursing management • Monitor& measure fluid at least every 8 hours & sometimes hourly • Monitor daily body weight • Monitor vital signs • Observe for weak, rapid pulse & orthostatic hypotension • Monitor urine concentration • Assess degree of oral & mucous membrane moisture
- 45. HYPERVOLEMIA Hypervolemia or fluidvolume excess occurs from an increased total body water and an increase in total body sodium content
- 46. CAUSES • Excessive sodium& fluid intake • Sodium & water retention Renal failure Steroid therapy Liver cirrhosis Hormonal disturbance Cardiac failure • Fluid shift to intravascular space Administration of hypertonic fluid Administration of plasma protein
- 47. CLINICAL MANIFESTATION • IncreasedBP • Weight Gain • Bounding pulse • Venous distention • Pulmonary edema • Dyspnea • Orthopnea • Crackles on auscultation
- 48. LABORATORY FINDINGS • Decreasedhematocrit • Decreased serum osmolality • Decrease urine specific gravity • Decreased BUN level MANAGEMENT • Diuretics such as thiazide diuretics & loop diuretics • Potassium supplement • Correct electrolyte imbalance • Mild to moderate fluid restriction • Dialysis to remove nitrogenous waste
- 49. NURSING MANGEMENT • I/Ochart at regular intervals to identify excessive fluid retention • Breath sound are assessed at regular intervals in at risk patient particularly if parenteral fluid are being administered • Monitor the degree of edema in most dependent parts of body such as feet & ankles • Restrict fluid & sodium intake as prescribed • Monitor body weight daily
- 50. ELECTROLYTE IMBALANCE Electrolyte imbalanceis an abnormality in the concentration of electrolyte in the body. It can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte
- 51. HYPONATREMIA Hyponatremia is anelectrolyte disturbance in which the sodium concentration in the serum is lower than normal. Normal serum sodium level 135 – 145mEq/L Hyponatremia – less than 135mEq/L
- 52. CAUSES • Excessive diaphoresis •Diuretics • Vomiting • Diarrhea • Renal disease/ failure • SIADH (syndrome of inappropriate antidiuretic hormone secretion) • Hyperglycemia • Congestive heart failure • Fresh water drowning
- 53. PATHOPHYSIOLOGY Sodium loss fromthe intravascular compartment ↓ Diffusion of water into the interstitial spaces ↓ Sodium in the interstitial space is dilated ↓ Decreased osmolarity of ECF ↓ Water moves into the cell as a result of sodium loss ↓ Extracellular compartment is depleted ↓ Clinical symptoms
- 54. CLINICAL MANIFESTATION • Headache •Confusion & altered mental state • Seizures • Restlessness • Diminished deep tendon reflexes • Muscle spasm or cramps • Nausea • Weakness & tiredness LABORATORY FINDINGS • Serum sodium level will be greater than 135mEq/L • Serum osmolality will be decreased • Urine osmolality will be increased • Urine sodium level will be elevated
- 55. MANAGEMENT • Restore Nalevels to normal & prevent further decreases in Na • Drug therapy IV therapy to restore both fluid & Na If severe may see 2-3% saline Administer osmotic diuretic (mannitol) to excrete the water rather than the sodium Increased oral sodium intake & restrict oral fluid intake
- 56. NURSE’S INTERVENTION • Strictlymonitor fluid intake & output • If it is accompanied by a fluid deficit ,IV sodium chloride infusion is administered to restore sodium content & fluid volume as prescribed • If the hyponatremia is accompanied by fluid excess, osmotic diuretics are administered to promote the excretion of water • Observe for dehydration & also observe fro neuromuscular changes • Instruct the patient to increase oral sodium intake & inform the patient about the food to include in the diet • If the patient is taking lithium, monitor the lithium level, because hyponatremia can cause diminished lithium excretion, resulting intoxicity
- 57. HYPERNATREMIA When serum sodiumlevel exceeds 145mEq/L, then the condition is called hypernatremia CAUSES • Decreased sodium excretion Corticosteroids Cushing’s syndrome Renal failure Hyperaldosteronism • Decreased water intake
- 58. • Increased sodiumintake Increased oral intake Administration of sodium containing IV fluids • Increased water loss Diabetes insipidus Diarrhea Excessive diaphoresis Fever Hyperventilation burns
- 59. PATHOPHYSIOLOGY Increased sodium concentrationin ECF ↓ Osmolarity rises ↓ Water leaves the cells by osmosis & enters the extracellular compartment ↓ ↓ Dilution of fluids cells are water in ECF depleted ↓ ↓ Suppression of aldosterone → sodium is excreted in the urine Secretion Clinical symptoms
- 60. CLINICAL MANIFESTATIONS • Lethargy •Irritability • Confusion • Altered cerebral function • Seizures • Spontaneous muscle twitches • Absent deep tendon reflexes • Increased thirst • Decreased urine output • Dry skin • Edema LABORATORY FINDINGS • Serum sodium level will be elevated
- 61. MANAGEMENT Drug therapy •Lowering of serum sodium levels by infusion of hypotonic electrolyte solution • Diuretics also may be prescribed to treat sodium gain • Desmopression acetate to treat diabetes insipidus if it is cause of hypernatremia Diet therapy • Mild-ensure water intake • The amount of water necessary to replace existing deficits may be estimated by the following formula free water deficit= dosing factor ×total body weight× [(serumNa+/40)] Dosing factor- 0.6if male , 0.5 if female
- 62. NURSING INTERVENTION • Assessthe signs & symptoms • Prepare to administer IV infusion if prescribed • If the cause is inadequate renal excretion of sodium, administer diuretics that promote sodium loss as prescribed • Advice the patient to restrict sodium intake as prescribed
- 63. HYPOKALEMIA Hypokalemia is ametabolic disorder that occurs when the level of potassium in the blood drops down Potassium is needed for the proper functioning of nerve & muscle cells Normal level of K+ - 3.5 to 6.1mEq/L Hypokalemia –K+ level lower than 3.5mEq/L
- 64. CAUSES • Medications (diuretics,antibiotics) •Hyperaldosteronism • Vomiting & diarrhea • Chronic kidney failure • Excessive sweating • Water intoxication • Prolonged nasogastric suction • Magnesium deficiency
- 65. PATHOPHYSIOLOGY Low extracellular K+ ↓ Increasedin resting membrane potential ↓ The cell becomes less excitable ↓ Aldosterone is secreted ↓ Sodium is retained in the body thorough resorption By the kidney tubules ↓ Potassium is excreted
- 66. Use of certaindiuretics such as thiazides & furosemide & corticosteroids ↓ Increased urinary output ↓ Loss of potassium in urine
- 67. CLINICAL FINDINGS • Abnormalheart rhythm • Constipation • Fatigue • Muscle weakness or spasms • Nausea & vomiting • Increased urinary output LABORATORY FINDINGS • Serum potassium level decreased • Serum magnesium • ECG • Aldosterone level
- 68. MANAGEMENT • Administration of40-80mEq/day of potassium is adequate in adult if there are abnormal losses of potassium • Dietary intake of potassium in average adult is 50-100meq/day • When dietary intake is inadequate for any reason, oral or IV potassium supplement may be prescribed
- 69. NURSE’S INTERVENTION • Monitorthe signs & symptoms & place the patient on a cardiac monitor • Monitor electrolyte values • Administer potassium supplements orally or IV as prescribed • Oral potassium supplements should not be given on an empty stomach & advised to take juice or another liquid due to its unpleasant taste
- 70. • When potassiumis added to an IV solution, rotate & mix the solution to ensure that the potassium is distributed evenly • The maximum recommended infusion rate is 5-10mEq/hour & never to exceed 20mEq/hour • If the patient is in diuretics, ensure that they are taking diuretics which are potassium sparing • Instruct the patient regarding the food that are rich in potassium
- 71. HYPERKALEMIA Hyperkalemia is ametabolic disorder in which the potassium level exceeds 5.1mEq/L. CAUSES • Renal failure • Adrenal insufficiency • Excessive use of potassium supplement • Potassium sparing diuretics • Tissue damage
- 72. PATHOPHYSIOLOGY Aldosterone signalling defects •Receptor antagonism: Spironolactone • Parenchymal renal disease ↓ Hyperkalemia ← Aldosterone effect reduction ↑ ↑ Reduced sodium concentration Aldosterone synthesis In distal collector tubules reduction • low cardiac output Renal disease with less • Diet sodium restriction renin synthesis Drugs(ACE inhibitors, Beta blockers)
- 73. CLINICAL MANIFESTATION • Abnormalheart rhythm • ECG changes – Tall peaked – T waves Flat P waves Widened QRS complex Prolonged PR intervals • Muscles fatigue & weakness • Nausea • Paralysis • Increased motility & diarrhea LABORATORY FINDINGS • Serum potassium increased • ECG • Other electrolyte levels
- 74. MANAGEMENT • In nonacute situations, restriction of dietary potassium & potassium containing medication may correct the imbalance • Administration either orally or by retention enema of cation exchange resins • Emergency pharmacologic therapy o If serum potassium level are dangerously elevated, it may be necessary to administration IV calcium gluconate o Monitor blood pressure
- 75. NURSES INTERVENTION • Patientat risk for potassium excess need to be identified & closely monitored for signs of hyperkalemia • Nurse should monitor I/O & observe for signs of muscle weakness & dysrythmias • Serum potassium level as well as BUN, creatinine, glucose & arterial blood gas values are monitored for patient at risk for developing hyperkalemia
- 76. HYPOCALCEMIA Hypocalcemia is acondition in which the blood calcium level becomes normally low. Calcium is the salt that help the heart & muscles work Normal calcium level → 8.6 to 10mg/dl hypocalcemia → less 8.6mg/dl
- 77. CAUSES • Decrease absorptionof calcium from the gastrointestinal tract eg.vitamin D deficiency hypoparathyroidism magnesium depletion severe hypermagnesemia • Increased calcium excretion e.g. Renal failure Diarrhea Acute pancreatitis Malignancy(prostate & breast cancer) Other causes • Sepsis • Surgery • chemotherapy
- 78. PATHOPHYSIOLOGY Decrease in extracellularCa+2 ↓ The membrane potential on the outside becomes less negative ↓ Less amount of depolarisation is required to initiate action potential ↓ Increased excitability of muscles & nerve tissue
- 79. CLINICAL MANIFESTATION • Decreasedheart rate • ECG- prolonged ST segment prolonged QT segment • Seizures • Muscle cramps • Painful muscle spasms in the calf or foot during periods of inactivity • Positive Trousseau’s & chvostek’s sign • Anxiety , irritability • Hyperactive deep tendon reflexes • Diarrhea
- 80. Trausseau’s sign Eliciting carpalspasm by inflating the blood pressure cuff & maintaining the cuff pressure above systolic
- 81. Chovstek’s sign Tapping ofthe inferior portion of the zygoma will produce facial spasms
- 82. LABORATORY FINDINGS • Serumcalcium level & ionized calcium levels decreased • Parathyroid hormone levels • Vitamin D levels • Other electrolyte levels • ECG MANAGEMENT • Drug therapy calcium supplements vitamin D
- 83. • Diet therapy Highcalcium diet • Prevention of injury Seizure precautions • Severe hypocalcemia Administer calcium supplements IV (10ml of Ca gluconate in of 5% dextrose in water to be administered over 5-10minutes) Treat the cause of hypocalcemia
- 84. NURSES INTERVENTION • Monitorsigns & symptoms of hypocalcemia • Administer calcium supplements orally or IV as prescribed • While administering calcium IV be cautions & monitor for hypercalcemia • Administer medication that increase calcium absorption e.. Vitamin D, Aluminum hydroxide • Initiate seizure precautions • Instruct the patient to consume food high in calcium
- 85. HYPERCALCEMIA Hypercalcemia occurs whenthe serum calcium level is more than 10mg/dl. It is a dangerous imbalance when severe in fact, hypercalcemic crisis has a mortality rate as high as 50% if not treated promptly.
- 86. CAUSES • Hyperparathyroidism • Adrenalgland failure • Hyperthyroidism • Renal failure • Hypervitaminosis D (vitamin D excess) • Cancerous tumors (e.g. lung, breast cancer) • Calcium excess in diet • Being bed bound for a long period of time • Certain medications such as thiazides diurectics
- 87. CLINICAL MANIFESTATION Abnormal heartrhythm Muscle twitches Constipation Bone pain & fracture Nausea & vomiting Poor appetite Abdominal pain Dementia Frequent thirst Depression Frequent urination Memory loss Curving of the spine & loss of height LABORATORY FINDINGS Serum calcium levels increased Urine calcium PTH levels Vitamin D levels X-ray ECG
- 88. MANAGEMENT • Primary hyperparathyroidism-surgical removal of abnormal parathyroid gland cure the hypercalcemic • Severe hypercalcemia that causes symptoms is treated in a hospital setup with the following calcitonin Diuretics drugs that stop bone breakdown e.g. pamidronate etidronate IV fluids Glucocorticoids Hemodialysis • Cardiac monitoring
- 89. NURSES INTERVENTION • Increasingpatient mobility & encouraging fluids • Encourage to drink 2.8 to3.8 L of fluid daily • Adequate fiber in diet is encouraged • Safety precautions are implemented.
- 90. HYPOMAGNESEMIA Hypomagnesemia is serum magnesiumlevel lower than 1.6 mg/dl Normal value – 1.6mg/dl to 2.6mg/dl
- 91. CAUSES • Malnutrition &starvation • Malabsorption syndrome • Celiac syndrome • Crohn’s disease • Medication such as diuretics • sepsis
- 92. PATHOPHYSIOLOGY Low serum magnesiumlevel ↓ Increased acetylcholine release ↓ Increased neuromuscular irritability ↓ Increased sensitivity to acetylcholine at the myoneural juction ↓ ↓ Diminished threshold of Enchancement of myofibril Excitation for the motor contraction nerve
- 93. CLINICAL MANIFESTATION Tachycardia Hypertension ConstipationAnorexia Abdominal distension muscle twitches Paresthesias Hyper reflexia Tetany , seizures Irritability Confusion Positive Trousseau's & Chvostek’s sign
- 94. LABORATORY FINDINGS • Serummagnesium levels decreased • Other electrolytes especially serum calcium • ECG MANAGEMENT • Mild cases – only dietary management • Severe cases – IV administration of magnesiumsulfate Initiate seizure precautions Increase food containing magnesium in diet
- 95. NURSE’S INTERVENTIONS • Monitorfor signs & symptoms of hypomagnesemia • Place the patient on a cardiac monitor • Hypocalcemia always accompanies hypomagnesemia. Interventions should aim to restore normal serum calcium levels • Administer magnesium sulfate IV in severe cases as prescribed • Monitor serum magnesium levels frequently & monitor for reduced deep tendon reflexes which is a feature of hypermagnesemia • Instruct the patient to increase the intake of magnesium rich foods
- 96. HYPERMAGNESEMIA Hypermagnesemia is serum magnesiumlevel that is greater than 2.6mg/dl It is a rare electrolyte abnormality because kidney efficiently excrete magnesium.
- 97. CAUSES • Hemolysis • Renalinsufficiency • Increased intake of magnesium as magnesium containing antacid & laxatives
- 98. PATHOPHYSIOLOGY Renal failure, excessiveIV infusion of magnesium, increased GI eliminination and/or absorption etc ↓ accumulation of Mg in the body ↓ Mg levels rises ↓ Altered electrical conduction ↓ ↓ Diminishing of reflexes slowed heart rate & Drowsiness lethargy AV block ↓ ↓ Severe respiratory peripheral vasodilation depression ↓ ↓ hypotension, flushing & Respiratory arrest may ↑sed skin warmth occur
- 99. CLINICAL MANIFESTATION • Bradycardia •Dysrhythmia • Hypotension • Respiratory insufficiency • Absent or decreased deep tendon reflexes • Skeletal muscle weakness • Hypercalcemia • Drowsiness & lethargy LABORATORY FINDINGS • Serum magnesium level increased
- 100. MANAGEMENT • IV calciumgluconate in severe cases- calcium antagonizes the action of magnesium • IV diuretics to increase the excretion of magnesium in the presence of normal renal function • Dialysis in case of renal insufficiency
- 101. NURSES INTERVENTION • Monitorfor sign & symptoms of hypermagnesemia • Diuretics are administered as prescribed • IV calcium gluconate may be administered as prescribed to reverse the effects of magnesium on cardiac muscles • Instruct the patient to restrict dietary intake of magnesium containing foods • Instruct the patient to avoid use of laxative & antacids containing magnesium
- 102. HYPOPHOSPHATEMIA This is anelectrolyte disturbance in which the serum phosphorus is abnormally low Normal value – 2.7 to 4.5mg/dl Hypophosphatemia – less than 2.7mg/dl
- 103. CAUSES • Malnutrition &starvation • Alcoholism, less vitamin D • Increased phosphorus excretion • Hyperparathyroidism • Malignancy • Use of magnesium based antacid • Intracellular shift • Respiratory alkalosis CLINICAL MANIFESTATION • Muscle dysfunction & weakness • Decreased cardiac output
- 104. • Diminished peripheralpulses • Shallow respirations • Decreased deep tendons reflexes • Decreased bone density • Irritability • seizures • White cell dysfunction • confusion
- 105. LABORATORY FINDING • Serumphosphorus level decreased • X-ray may show skeletal changes of rickets MANAGEMENT • Treat underlying cause • Oral replacement with vitamin D • IV phosphorus ( serve case) • Serum phosphorus level should be closely monitored • Diet therapy – food high in oral phosphate
- 106. NURSE’S INTERVENTION • Monitorthe signs & symptoms • Administer oral phosphorus & vitamin D supplements as prescribed • IV administered of phosphorus when serum phosphorus level falls below 1mg/dl • Monitor for signs of hyperphosphatemia while giving IV phosphorus • Assess the renal function before administrating phosphorus • Instruct the patient to increase phosphorus containing foods in diet
- 107. HYPERPHOSPHATEMIA Hyperphosphatemia is anabnormal increase in serum phosphorus level (<4.5mg/dl) CAUSES • Decreased renal excretion • Tumor lysis syndrome • Increased intake of phosphorus • Hypoparathyroidism
- 108. CLINICAL MANIFESTATIONS • Tetany •Tachycardia • Anorexia • Nausea & vomiting • Muscle weakness • Hyperactive reflexes LABORATORY FINDINGS • Serum phosphorus level increased • Serum calcium level decreased
- 109. MANAGEMENT • Administration ofvitamin D such as calcitriol which is available both oral (Rocaltrol) & parenteral (calajex, paricalcitol forms) • Calcium binding antacids • Administration of amphojel with meals • Restriction of dietary phosphate, forced diuresis with loop diuretics volume replacement with saline • Surgery may be be indicated for removal of large calcium & phosphorus deposits • Dialysis may also lower phosphorus
- 110. NURSE’S INTERVENTIONS • Interventionsof hypocalcemia • Administer phosphate binding medication as prescribed • Instruct to avoid phosphate containing medications & phosphorus rich food • Instruct in medication administration phosphate binding medications should be taken with meals or immediately after meals
- 111. HYPOCHLOREMIA Hypochloremia is aserum chloride level below 97mEq/L Normal value – 95 to 105mEq/L
- 112. CAUSES • Nasogastric suction •Vomiting • Kidney disease • Heart failure CLINICAL MANIFESTATION • Irritability • Tremors • Muscle cramps • Hyperactive deep tendon reflexes • Slow shallow respiration • Coma • seizures
- 113. LABORATORY FINDINGS • Serumchloride level ↓sed • Serum sodium level ↓sed • Serum potassium level ↓sed • If acid base imbalance is suspected, ABG is evaluated MANAGEMENT • Correcting the cause of hypochloremia & contributing electrolytes & acid base imbalance • Normal saline (0.9%Nacl) or half strength saline(0.45%Nacl) solution is administered by IV to replace the chloride
- 114. NURSE’S INTERVENTION • Monitorthe patients I/O, ABG values & serum electrolyte levels • Changes in patients level of consciousness, muscle strength & movement & reported to the physician promptly • Vital signs are monitored & respiratory assessment is carried out frequently • Educate the patient about food with high chloride content which include tomato juice, banana, eggs, cheese etc
- 115. HYPERCHLOREMIA Hyperchloremia is aserum chloride level above 105mEq/L (105mmol/L) Normal value – 95 to 105mEq/L
- 116. CAUSES • Severe dehydration •Kidney failure • Hemodialysis • Traumatic brain injury • Aldosteronism can also cause Hyperchloremia • Drugs such as Boric acid & ammonium chloride IV infusion of Nacl resulting in Hyperchloremic metabolic acidosis
- 117. CLINICAL MANIFESTATION • Weakness •Headache • Nausea • Tachypnea • Lethargy • Hypertension • If untreated leads to decreased cardiac output, dysrythmias & coma
- 118. LABORATORY FINDINGS • Serumchloride level increased • Serum sodium level greater than 145mEq/L • Serum PH is more than 7.35 • Serum bicarbonate level is < 22mEq/L • Urine chloride excretion increase MANAGEMENT • Correcting the underlying cause of hyperchloremia & restoring electrolyte fluid & acid base balance is essential • Hypotonic IV solution may be administered to restore balance • Lactated ringers solution may be prescribed to convert lacatate to bicarbonate in liver
- 119. • Diuretics maybe administered to eliminate chloride as well • Sodium chloride & fluid are restricted NURSE’S INTERVENTION • Monitoring vital signs, ABG values & I/O chart is important to assess the patient status & the effectiveness of treatment • Assess finding related to respiratory, neurological & cardiac system are documented & changes are discussed with physician • Educate about diet