Electrolyte Imbalance Overview.ppt

1. 1
Electrolyte Imbalance, Fluid
Regulation, and ABG’s
Overview
By: Donna Hess RN, MS

2. 2
Contents:
• Hyponatremia 5
• Hypernatremia 6
• Hypokalemia 7
• Hyperkalemia 8
• Hypocalcemia 9
• Hypercalcemia 10

3. 3
Contents:
• Hypomagnesemia 11
• Hypermagnesemia 12
• Hypophosphatemia 13
• Hyperphosphatemia 14
• Hypocholoremia 15
• Hyperchloremia 16

4. 4
Content:
• Body Volume Regulators 17-21
• Euvolemic State 22
• Hypervolemic State 23
• Hypovolemic State 24
• Quick Arterial Blood Gas 25-28
Interpretation

5. 5
Hyponatremia:
< 135 mEq/L
FUNCTION OF Na+:
-determinant of plasma
OSMOLALITY
-regulates water balance and
distribution
-helps maintain electrolyte
balance by exchanging
potassium and attracting
chloride
-promotes neuromuscular
response
-stimulates conduction of
nerve impulses & muscle
fiber transmission through
the SODIUM &
POTASSIUM PUMP
CAUSE:
DIURETICS
GI FLUID LOSS
HYPOTONIC TUBE
FEEDINGS
D5W OR HYPOTONIC IV
SOLUTIONS
DIAPHORESIS
S&S:
Anorexia
N&V
Weakness
Lethargy
Confusion
Muscle cramps
Twitching
Seizures
TREATMENT:
*Restrict fluids (safest)
*Very slow administration of
hypertonic saline solution
(3% NaCl)
*Medications that decrease
Na+:
-diuretics
-lithium
-cisplatin, vincristine
-elavil, mellaril
-diabenase, orinase
-morphine, barbituates
-motrin
-nicotine
-pitocin

6. 6
Hypernatremia:
> 145 mEq/L
FUNCTION OF Na+:
**SEE HYPONATREMIA
CAUSE:
WATER DEPRIVATION
HYPERTONIC TUBE
FEEDING
DIABETES INSIPIDUS
HEATSTROKE
HYPERVENTILATION
WATERY DIARRHEA
RENAL FAILURE
CUSHING’S SYNDROME
S&S:
Thirst
Hyperpyrexia
Sticky mucus membranes
Dry mouth
Hallucinations
Lethargy
Irritability
Seizures
TREATMENT:
*Restrict sodium from diet
*Increase water intake
*Check foods for hidden
sodium
*Medication that increase
Na+:
-prednisone, cortisone
-sodium bicarbonate
-penicillin Na, ticarcillin
-amphotericin B
-declomycin
-lactulose
-davron

7. 7
Hypokalemia:
< 3.5 mEq/L
FUNCTION OF K+:
-maintaining action potential
of excitable cells of muscles,
neurons, & other tissues
-extracellular K+ helps
control cardiac rate, rhythm,
conduction of nerve impulses,
skeletal muscle contraction,
function of smooth muscles,
endocrine tissue
-intracellular metabolism and
regulation of protein &
glycogen synthesis
-some intracellular control
over cellular osmolarity &
volume (sodium-potassium
pump)
CAUSE:
DIURETICS
DIARRHEA
VOMITING
GASTRIC SUCTION
STEROIDS
HYPERALDOSTONISM
AMPHOTERICIN B
BULIMIA
CUSHING’S SYNDROME
S&S:
Fatigue
Anorexia
N&V
Muscle weakness
Reduced GI motility
Dysrhythmias
Paresthesia
Flat T wave on EKG
Anxiety
Dyspnea
Confusion
Depression
Hypoactive bowel sounds
Leg cramps
TREATMENT:
*Administer K+ IV or orally
*Oral K+ =do not give on
empty stomach (GI
irritation)
*IV given drip over at least
60 minutes
*Assess renal status and
urinary output before
administration
*Encourage food high in K+
*Foods high in K+:
-vegetables: spinach,
broccoli, carrots, green
beans, tomato, squash,
potato
-fruit: bananas, cantaloupe,
watermelon, grapefruit,
strawberries
-milk, meat, legumes, nuts,
whole grains, seeds
*Medications that decrease
K+:
-laxative/enemas
-steroids -Beta2 agonists
-digoxin
-insulin & glucose
-diuretics -some antibiotics

8. 8
Hyperkalemia:
> 5.0 mEq/L
FUNCTION OF K+:
*SEE HYPOKALEMIA
CAUSE:
HEMOLYZED SERUM
SAMPLE
OLIGURIA
ACIDOSIS
RENAL FAILURE
ADDISON’S DISEASE
MULTIPLE BLOOD
TRANSFUSIONS
EXCESSIVE K+ INTAKE
K+ SPARING DIURETICS
GI BLEEDING
INSULIN DEFICIENCY
S&S:
Muscle weakness
Muscle twitching
Bradycardia
Dysrhythmias
Tall, peaked T waves &
widened QRS on EKG
Ectopic beats on EKG
Flaccid paralysis
Intestinal colic
Irritability
Increase GI motility
TREATMENT:
*Stop any medication
administrations with K+
*Administer dextrose 50%
with regular insulin
*Administer kayexalate
*Monitor EKG
*Administer calcium
gluconate
*Administer IV loop diuretic
*Renal dialysis
*Medications that increase
K+:
-potassium supplements
-ACE inhibitors
-heparin
-barbiturates, sedatives,
amphetamines
-NSAID
-Beta blocker & alpha
agonists
-cyclophosphamide
-K+ sparing diuretics

9. 9
Hypocalcemia:
< 8.5 mg/dL
FUNCTION OF Ca++:
-important role in skeletal &
heart muscle relaxation,
activation, excitation,
contraction
-important enzyme activation
to stimulate chemical
response for hormone
secretion and function of
cell receptors
-sedating, calming effect on
nerves
-major role in nerve impulse
transmission
-cofactor in blood clotting
(conversion of prothrombin
to thrombin)
-assists with acid-base
regulation
-firmness & rigidity to bones
-hold cell body together
-essential in lactation
CAUSE:
RENAL FAILURE
HYPOPARATHYROIDISM
MALABSORPTION
PANCREATITIS
ALKALOSIS
HYPOMAGNESEMIA
MULTIPLE BLOOD
TRANSFUSIONS
VITAMIN D DEFICIT
BURNS
HYPOALBUMINEMIA
ALCOHOLISM
SOME CANCERS
GRAM NEGATIVE SEPSIS
MEDICATIONS
S&S:
Diarrhea
Numbness
Tingling of extremities
Hyperactive bowel sounds
Seizures
Tetany
Hyperactive DTR
Positive Trousseau
Chvostek Sign
Decrease myocardial
contractions
Increase bleeding
Confusion
Irritability
Depression
Memory impairment
Dry, brittle hair & nails
Prolonged QT interval &
longer ST segment on EKG
TREATMENT:
*Administer calcium
supplement orally or IV
*Increase foods high in Ca++:
-milk & by products
-canned salmon,
-broccoli, rhubab, spinach
-almonds, figs
-tofu
*Medications that decrease
Ca++:
-loop diuretics
-anticonvulsants
-blood product additives
-steroids
-antacids
-heparin
-antineoplastics
-phosphates
-radiographic contrast media

10. 10
Hypercalcemia:
> 10.5 mg/dL
FUNCTION OF Ca++:
*SEE HYPOCALCEMIA
CAUSE:
HYPERPARATHYROIDISM
MALIGNANT BONE
DISEASE
METASTATIC CANCER
THYIAZIDE DIURETIC
PROLONGED IMMOBILITY
EXCESS CALCIUM
SUPPLEMENTS
HYPOPHOSPHATEMIA
LITHIUM THERAPY
VITAMIN D OVERDOSE
S&S:
Muscle weakness
Constipation
Anorexia
N&V
Polyuria
Polydipsia
Neurosis
Dysrhythmias
Depressed DTR
Hypotonic bowel sounds
Confusion
Lethargy
Personality change
Hypertension
Heart blocks
Shortened QT interval &
shortened ST segment on
EKG
Kidney stones/colic
TREATMENT:
*Eliminate parenteral Ca++
*Administer agent to reduce
Ca++ (calcitonin)
*Renal dialysis
*Medication that increase
Ca++:
-calcium supplements
-antacids with calcium base

11. 11
Hypomagnesemia:
< 1.5 mEq/L
FUNCTION OF Mg++:
-powers the Sodium-
Potassium Pump in the body
-aids in converting ATP to
ADP for energy
-important in transmitting
electrical impulses across
nerves & muscles
-important for skeletal
muscle relaxation after
contraction
-maintains normal heart
rhythms
-needed for thiamine activity
& Ca++/B12 absorption and
utilization
-necessary for release of
PTH
-cofactor in carbohydrate
metabolism & protein
synthesis
-role in secretion & action of
insulin
CAUSE:
ALCOHOLISM
MALABSORTION
DIABETIC KETOACIDOSIS
PROLONGED GASTRIC
SUCTION
DIURETICS
PROLONGED DIARRHEA
ILEOSTOMY
BURNS
GI CANCER
CHRONIC PANCREATITIS
SHORT BOWEL
CONDITIONS
S&S:
Anorexia
Abdominal distention
N&V
Tremors
Neuromuscular irritability
Larngeal stridor
Confusion
Apathy
Mood swings
Disorientation
Dysrhythmias
EKG changes
Diarrhea
*Children=growth failure
Positive Chvosteks Sign
TREATMENT:
*Administer Magnesium
Sulfate IV
*Encourage foods high in
Mg++:
-meat -cocoa
-fish
-legumes
-nuts, whole grain cereal
-vegetables (dark green)
*Medications that decrease
Mg++:
-diuretics (lasix or edecrin)
-gentamicin (antibiotic)
-cisplatin (antineoplastic)

12. 12
Hypermagnesemia:
> 2.5 mEq/L
FUNCTION OF Mg++:
*SEE HYPOMAGNESEMIA
CAUSE:
RENAL FAILURE
ADRENAL INSUFFICIENCY
(ADDISON’S)
EXCESS REPLACEMENT
LITHIUM
VOLUME DEPLETION
UNTREATED DIABETIC
KETOACIDOSIS
TREATMENT FOR PR
PRE-ECLAMPSIA
S&S:
Flushing
Hypotension
Drowsiness
Lethargy
Hypoactive reflexes
Depressed respirations
Bradycardia
Depressed neuromuscular
activity
EKG changes
Coma
TREATMENT:
*Stop any Mg++ supplements
or medications with Mg++
*Restrict foods high in Mg++
-legumes
-whole grain cereals
-nuts
-dark green vegetables
-cocoa
*Medications with increase
Mg++:
-Mg++ supplements
-antacids with Mg++
-some laxatives/enemas

13. 13
Hypophosphatemia:
< 1.8 mEq/L
FUNCTION OF PO4-:
-essential for muscle
function
-essential for RBC
-essential for nervous
system function
-role in metabolism of
carbohydrates, fats &
proteins
-critical for teeth & bone
formation
-role in cellular metabolism
of DNA & ATP (stored in
muscle & produces energy)
-assists in Ca++ regulation
-aid kidney in acid-base
-helps maintain cellular
membrane integrity
-required for release of
Oxyen from Hemoglobin
CAUSE:
REFEEDING AFTER
STARVATION
ALCOHOL WITHDRAWAL
DIABETIC KETOACIDOSIS
RESPIRATORY ALKALOSIS
PROLONGED USE OF
ALUMINUM AND
MAGNESIUM
ANTACIDS
SEVERE VOMITING AND
DIARRHEA
TPN WITH ADEQUATE
PHOSPHORUS
SEVERE BURNS
HYPERCALCEMIA
DIURETICS
S&S:
Paresthesia
Muscle weakness
Muscle pain
Bone pain
Tremors
Spasms
Tetany
Confusion
Seizures, coma
Hypoactive bowel sounds
Mental changes
Cardiomyopathy
Respiratory failure
Fatigue
Anemia
Bruising
Slurred speech
TREATEMENT:
*Administer phosphorus
supplements oral or IV
*Stop medication that bind
phosphorus
*Treat the underlying cause
*Encourage foods high in
PO4-:
-soft drink
-animal meat
-milk products
*Medication that decrease
PO4-:
-some antacids
-diuretics
-TPN (total parental
nutrition)

14. 14
Hyperphosphatemia:
> 2.6 mEq/L
FUNCTION OF PO4-:
*SEE
HYPOPHOSPHATEMIA
CAUSE:
RENAL FAILURE
EXCESS INTAKE OF PO4-
RHABDOMYOLYISI
HYPOCALCEMIA FROM
DRUG THERAPY
CHEMOTHERAPY
MASSIVE BLOOD
TRANSFUSION
PROLONGED OR EXCESS
ADMINISTRATION OF:
-VITAMINE D
-ANTACIDS
-HEPARIN
-TETRACYCLINE
-ASA
-PITUITARY
HORMONES
INFANT FED COW’S MILK
S&S:
Tetany
Calcium deposits in non-bone
tissue like kidney/heart
Numbness & tingling >mouth,
finger tips
N&V
Anorexia
Muscle weakness
Hyperreflexia
EKG changes, tachycardia,
conduction disturbances
TREATMENT:
*Stop medications or OTC
medications with PO4-
*Avoid foods high in PO4-
-soft drink
-animal meat
-milk products
*Administer aluminum
hydroxide with meals to bind
phosphorus
*Renal dialysis
*Medications that increase
Po4-:
-laxatives/enema with PO4-

15. 15
Hypocholoremia:
< 95 mEq/L
FUNCTION OF Cal-:
-used by the body to form
salts in the body (sodium
chloride or potassium
chloride)
-helps maintain cellular
integrity by traveling with
sodium to maintain a balance
between intracellular and
extra cellular fluids in the
body
-helps control osmotic
pressure
CAUSES:
METABOLIC ALKALOSIS
(INGESTION OF
ALKALINE SUBSTANCES)
HYPOKALEMIA
PROLONGED D5W IV
THERAPY
CHRONIC RESPIRATORY
ACIDOSIS (>PaCO2)
DIABETIC KETOACIDOSIS
PROLONGED VOMITING
PROLONGED GI SUCTION
PROLONGED DIARRHEA
BURNS
HEAT EXHAUSTION
ADDISON’S
SIADH
CHF
CIRRHOSIS
RENAL DISORDERS
S&S:
Slow, shallow respirations
Muscle tremors
Muscle twitching
Hypotension
TREATMENT:
*Administer salt tablets or
increase chloride in diet
-processed food
-salt
-dates
-canned vegetables
-milk products & eggs
-fish & seafood
*Administer IV
*Medications that decrease
Cl-:
-diuretics
-prednisione, ACTH
-sodium bicarbonate
-D5W prolonged
-aldosterone

16. 16
Hyperchloremia:
> 105 mEq/L
FUNCTION OF Cl-:
*SEE HYPOCHLOREMIA
CAUSE:
METABOLIC ACIDOSIS
SALICYLATE OVERDOSE
INCREASE K+ /Na+
RENAL DISORDER
ADRENOCORTICAL
HORMONE PRODUCTION
IV OR ORAL CORTISONES
HEAD TRAUMA
PROFUSE PERSPIRATION
S&S:
Deep rapid respirations
Weakness
Lethargy
Stupor
unconscious
TREATMENT:
*Stop Cl- supplements
*Administer diuretics
*Restore fluid & electrolyte
balance (0.45% NaCl)
*Monitor vital signs, I&O
*Monitor client safety
*Avoid foods high in Cl-:
-foods high in salt
-processed foods

17. 17
Body Volume Regulators:
• Antidiuretic
Hormone (ADH) is
synthesized by the
hypothalamus and
secreted by the
posterior pituitary,
which regulates
water.
• ADH is released by
a drop in BP, drop
in blood volume,
increase in
osmolality resulting
in a reabsorption
of water by the
kidney.

18. 18
Body Water Regulation:
• Aldosterone is a hormone
produced by the adrenal
gland that conserves
sodium in the body by
causing the kidney to
retain sodium and excrete
potassium. Water follows
sodium (due to osmosis),
thus aldosterone has an
indirect effect on water.
• Aldosterone is released by
a drop in BP, blood volume,
serum sodium or increase
in serum potassium.
Aldosterone causes the
kidney to reabsorb more
sodium (water follows
sodium by osmosis) and
increase vascular volume.
As more sodium is retained
in the blood, the kidney
must excrete potassium to
maintain a balance of
positive ions in the blood.

19. 19
Body Water Regulation:
• Cortisol is a
glucocorticoid
hormone produced
and released by
the adrenal gland
when the body is
stressed.
• Cortisol promotes
renal sodium and
water retention.

20. 20
Body Water Regulation:
• Atrial Natriuretic
Peptide (ANP) is a
cardiac hormone found
in the atria of the
heart that is released
when the atria are
stretched by high
blood volumes or high
BP.
• ANP has a role in
lowering the blood
volume and BP:
-vasodilation
-decreasing
aldosterone release
-decreasing ADH
release
-increasing glomerular
filtration rate

21. 21
Body Water Regulators:
• Thirst normally occurs
with even a small fluid
loss or increase in
serum osmolality.
Fluid loss stimulates
thirst receptors in the
hypothalmus (can
detect a change of
1 mOsm/L in plasma
concentration).
• Thirst stimulates ADH
and aldosterone
release to promote
water reabsorption.
• Thirst stimulation is
depress in clients
older than 60 years of
age.

22. 22
Euvolemic State:
DESCRIPTION:
Decrease in fluids in both
the intravascular and
interstitial space.
Results in a normal serum
osmolality (275-295)
Use of Na+ free solutions
that result in dilution of
extracellular space.
CLINICAL
PRESENTATION:
SIADH
HYPOTHYROIDISM
PSYCHIATRIC DISORDERS
MEDICATIONS
TREATMENT:
*Water restriction
*Increase dietary salt
*Treat SIADH
*Correct underlying cause
COMMENTS:

23. 23
Hypervolemic State:
DESCRIPTION:
High glucose state that pulls
water from cells leading to
cellular dehydration as seen
in Diabetic Ketoacidosis.
Fluid loss from extracellular
space greater than solute
loss leading to increase
serum osmolality > 295.
CLINICAL
PRESENTATION:
CHF
CIRRHOSIS
NEPHROTIC SYNDROME
RENAL FAILURE
TREATMENT:
*Water restriction
*Loop diuretic
*Restrict dietary salt
*Treat underlying cause
COMMENTS:

24. 24
Hypovolemic State:
DESCRIPTION:
Glucose in isotonic solution
oxidized leading to cellular
swelling.
Loss of solute from
extracellular space is
greater than excess of
water resulting in decrease
serum osmolality (< 275)
CLINICAL
PRESENTATION:
GI FLUID LOSS
DIURETICS
ADRENAL INSUFFICIENCY
BURNS
SWEATING
HYPOTONIC
DEHYDRATION
TREATMENT:
•IV Normal Saline to correct
the extracellular fluid
deficit
*Increase daily salt intake
*Hypertonic saline solution
to increase Na+ levels
COMMENTS:

25. Quick ABG
Interpretation:
• pH= normal 7.35-7.45
• PCO2 (Lungs=Respiratory)= 35-45
• HCO3- (Kidney=Metabolic)=22-26
• Evaluation:
• Step 1: look at pH and label *acid or *base
• Step 2: look at PCO2 and label *acid or *base
• Step 3: look at HCO3- and label *acid or *base
• Put them together!
25

26. ABG Example
• 1. pH=7.33 PCO2=47 HCO3-=26
• Step 1= pH= Acidosis
• Step 2= PCO2= Acidosis (respiratory)
• Step 3= HCO3-=normal (metabolic)
*Respiratory Acidosis
26

27. ABG Example
• 2. pH=7.52 PCO2=45 HCO3-=30
• Step 1= pH=alkalosis
• Step 2= PCO2=normal (respiratory)
• Step 3= HCO3-=alkalosis (metabolic)
*Metabolic Alkalosis
27

28. ABG Example:
• pH=7.48 PCO2=47 HCO3-=29
• pH= alkalosis acid < 7.35-7.45 > alkalosis
• PCO2=acidosis acid > 45-35 > alkalosis
• HCO3-=alkalosis acid < 22-26 > alkalosis
*pH=alkalosis problem (pH>7.45 or alkalosis) &
HCO3-=>26 or alkalosis)===Metabolic Alkalosis
**PCO2 is acidosis in an attempt to compensate for
the high HCO3- level=Metabolic Alkalosis
partiality compensated**
28

29. ABG Examples:
• A. pH=7.48 PCO2=30
HCO3=19
• 1. Metabolic Alkalosis partiality compensated
• 2. Metabolic Alkalosis completely compensated
• 3. Respiratory Alkalosis partiality compensated
• 4. Respiratory Alkalosis completely compensated
29

30. ABG Example:
• B. pH=7.30 PCO2=30 HCO3=18
1. Metabolic acidosis partiality compensated
2. Metabolic acidosis completely compensated
3. Respiratory acidosis completely
compensated
4. Metabolic acidosis
30

31. Answer Key
• A= 3
• B= 1
31

32. 32
References:
• Medical Surgical Nursing Critical Thinking
For Collaborative Care (2006)
Ignatavicius & Workman
• Fundamentals of Nursing Concepts,
Process, Practice (2004) Kozier, Erb,
Berman, Snyder
• Fluid, Electrolytes, and Acid Base Balance
(2003) Hogan & Wane
• HESI NCLEX Review (2006)