Fluids & Electrolytes Imbalances - BMH/Tele


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Fluids & Electrolytes Imbalances - BMH/Tele

  1. 1. Fluids & Electrolytes Imbalances
  2. 2. Body Fluid Compartments <ul><li>2/3 (65%) of TBW is intracellular fluid (ICF) </li></ul><ul><li>1/3 extracellular fluid (ECF) </li></ul><ul><ul><li>25 % interstitial fluid (ISF) </li></ul></ul><ul><ul><li>5- 8 % in plasma [(IVF) intravascular fluid] </li></ul></ul><ul><ul><li>1- 2 % in transcellular fluids – CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space) </li></ul></ul>
  3. 3.
  4. 4. Function of Body H 2 O <ul><li>Transports nutrients, electrolytes, & O 2 </li></ul><ul><li>Excretion of Waste Products </li></ul><ul><li>Regulates Body Temperature </li></ul><ul><li>Lubrication of Joints & Muscles </li></ul><ul><li>Medium for Food Digestion </li></ul><ul><li>(Kee & Paulanka, 2000, p. 2) </li></ul>
  5. 5. <ul><li>Fluid compartments are separated by membranes that are freely permeable to water. </li></ul><ul><li>Movement of fluids due to: </li></ul><ul><ul><li>Diffusion </li></ul></ul><ul><ul><li>Osmotic pressure </li></ul></ul><ul><ul><li>Active transport </li></ul></ul><ul><ul><li>Hydrostatic pressure </li></ul></ul><ul><ul><li>Reabsorption </li></ul></ul>Movement of Fluids
  6. 6. DIFFUSION <ul><ul><ul><li>Solutes shift from an area of greater concentration to an area of higher concentration </li></ul></ul></ul><ul><ul><ul><li>Passive process </li></ul></ul></ul>
  7. 7. OSMOSIS <ul><ul><ul><li>Movement of fluid across membrane from a lower solute concentration to a higher solute concentration </li></ul></ul></ul><ul><ul><ul><li>Passive process </li></ul></ul></ul>
  8. 8. ACTIVE TRANSPORT <ul><ul><ul><li>Solutes move from an area of lower concentration to an area of higher concentration </li></ul></ul></ul><ul><ul><ul><li>Process requires energy </li></ul></ul></ul>
  9. 9. Hydrostatic Pressure <ul><li>Capillary filtration </li></ul><ul><li>Movement of fluid through capillaries results from blood pushing against walls of the capillary. It forces fluids and solutes through the capillary wall </li></ul>
  10. 10. REABSORPTION <ul><ul><ul><li>Prevents too much fluid from leaving capillaries no matter how much hydrostatic static pressure is inside them </li></ul></ul></ul>
  11. 11. <ul><li>Capillary colloid osmotic pressure </li></ul><ul><ul><li>Colloids do not cross the membrane and pull water into the blood stream </li></ul></ul><ul><ul><li>Aka plasma expander </li></ul></ul><ul><ul><ul><li>Albumin, plasma protein fraction, dextran, hetastarch </li></ul></ul></ul><ul><li>Interstitial hydrostatic pressure </li></ul><ul><li>Tissue colloid osmotic pressure </li></ul>
  12. 12. Solutes – Dissolved Particles <ul><li>Electrolytes – charged particles </li></ul><ul><ul><li>Cations – positively charged ions </li></ul></ul><ul><ul><ul><li>Na + , K + , Ca ++ , H + </li></ul></ul></ul><ul><ul><li>Anions – negatively charged ions </li></ul></ul><ul><ul><ul><li>Cl - , HCO 3 - , PO 4 3- </li></ul></ul></ul><ul><li>Non-electrolytes - Uncharged </li></ul><ul><ul><ul><li>Proteins (i.e. albumin), urea, glucose, O 2 , CO 2 </li></ul></ul></ul>
  13. 13. <ul><li>Body fluids are: </li></ul><ul><ul><li>Electrically neutral </li></ul></ul><ul><ul><li>Osmotically maintained </li></ul></ul><ul><ul><ul><li>Specific number of particles per volume of fluid </li></ul></ul></ul>
  14. 14. Homeostasis maintained by: <ul><li>Ion transport </li></ul><ul><li>Water movement </li></ul><ul><li>Kidney function </li></ul>
  15. 15. TONICITY: <ul><ul><li>Isotonic – A solution that has the same solute concentration as another solution to which it’s being compared </li></ul></ul><ul><ul><ul><li>i.e. sodium in blood vs. 0.9% NSS </li></ul></ul></ul>
  16. 16. <ul><ul><li>Hypertonic - A solution that has a higher solute concentration than another solution to which it’s being compared </li></ul></ul><ul><ul><ul><li>Dextrose 5% in NSS </li></ul></ul></ul>TONICITY:
  17. 17. <ul><ul><li>Hypotonic - A solution that has a lower solute concentration than another solution to which it’s being compared </li></ul></ul><ul><ul><ul><li>0.45%NSS </li></ul></ul></ul>TONICITY:
  18. 18. Balance <ul><li>Fluid and electrolyte homeostasis is maintained in the body </li></ul><ul><li>Neutral balance: input = output </li></ul><ul><li>Positive balance: input > output </li></ul><ul><li>Negative balance: input < output </li></ul>
  19. 19. Fluid Gain & Loss <ul><li>Routes of Gain and Loss: </li></ul><ul><li>Kidneys (urine) </li></ul><ul><li>Skin (perspiration) </li></ul><ul><li>Lungs (respiration) </li></ul><ul><li>GI Tract (feces) </li></ul><ul><li>(Smeltzer et al, 2008) </li></ul>
  20. 20. Fluid Gain & Loss <ul><li>Average Intake of Body H 2 O </li></ul><ul><li>= 2600 ml/day </li></ul><ul><li>Liquid = 1500 ml </li></ul><ul><li>Solid Foods = 800 ml </li></ul><ul><li>Oxidation = 300 ml </li></ul><ul><li>(Priff, 2006, p.6) </li></ul>
  21. 21. Fluid Gain & Loss <ul><li>Sensible Loss </li></ul><ul><li>Fluid loss that can be measured </li></ul><ul><ul><li>Urination </li></ul></ul><ul><ul><li>Defecation </li></ul></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Wound drainage </li></ul></ul><ul><ul><li>Gastric drainage </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><li>(Priff, 2006, p.6) </li></ul>
  22. 22. Fluid Gain & Loss <ul><li>Insensible Loss </li></ul><ul><li>Fluid loss that cannot be measured </li></ul><ul><ul><li>Perspiration </li></ul></ul><ul><ul><li>Respiration </li></ul></ul><ul><ul><li>Changes in humidity levels, respiratory rate and depth, and fever affect insensible loss </li></ul></ul><ul><li>(Priff, 2006, p.6) </li></ul>
  23. 23. Fluid Gain & Loss <ul><li>Average Output of Body H 2 O </li></ul><ul><li>= 2600 ml/day </li></ul><ul><li>Urine = 1500 ml </li></ul><ul><li>Feces = 100 ml </li></ul><ul><li>Lungs = 400 ml </li></ul><ul><li>Skin = 600 ml </li></ul><ul><li>(Priff, 2006, p.6) </li></ul>
  24. 24.
  25. 25.
  26. 26. Balancing Systems <ul><li>Renal System (kidneys) </li></ul><ul><ul><li>RF = difficulty maintaining fluid balance </li></ul></ul><ul><ul><li>Na + & K + are either filtered or reabsorbed via the renal system </li></ul></ul>
  27. 27. Balancing Systems <ul><li>Antidiuretic Hormone (ADH) </li></ul><ul><ul><li>Water-retaining hormone </li></ul></ul><ul><ul><li>Hypothalamus senses low blood volume & increased serum osmolality; triggers its release from the pituitary gland </li></ul></ul><ul><ul><li>Prompts kidneys to retain H 2 O </li></ul></ul><ul><ul><li>Increases concentration of urine </li></ul></ul>
  28. 28. Balancing Systems <ul><li>Renin-Angiotensin-Aldoseterone System (RAAS) </li></ul><ul><ul><li>Release of renin triggered by low pressures </li></ul></ul><ul><ul><li>Angiotensin II potent vasoconstrictor and triggers the release of aldosterone from the adrenal cortex </li></ul></ul><ul><ul><li>Aldosterone = fluid retention and secretion of K + ; triggers the thirst center </li></ul></ul>
  29. 29. Balancing Systems <ul><li>Atrial Natriuretic Peptide (ANP) </li></ul><ul><ul><li>Released when atrial pressures increase </li></ul></ul><ul><ul><li>Opposes the RAAS (shuts it off) </li></ul></ul><ul><ul><li>Key Functions of ANP: </li></ul></ul><ul><ul><ul><li>Suppresses serum renin levels </li></ul></ul></ul><ul><ul><ul><li>Decreases aldosterone release </li></ul></ul></ul><ul><ul><ul><li>Increases glomerular filtration rate (excretion of Na + and H 2 O) </li></ul></ul></ul><ul><ul><ul><li>Decreases ADH release </li></ul></ul></ul><ul><ul><ul><li>Decreases vascular resistance by causing vasodilation </li></ul></ul></ul>
  30. 30. Balancing Systems <ul><li>Thirst Mechanism </li></ul><ul><ul><li>Simplest mechanism in maintaining fluid balance </li></ul></ul><ul><ul><li>Increases after even small fluid loss </li></ul></ul><ul><ul><li>Increase in salty foods dries mucous membranes, which stimulates the thirst center in the hypothalamus </li></ul></ul>
  31. 31. Hypovolemia <ul><li>A decreased blood volume that may be caused by internal or external bleeding, fluid losses, or inadequate fluid intake. </li></ul><ul><li>(Taber’s Online Dictionary, 2007) </li></ul><ul><li>A.K.A. Fluid Volume Deficit (FVD) or Extracellular Fluid Volume Deficit (ECFVD) </li></ul>
  32. 32. Hypovolemia <ul><li>FVD occurs when the loss of ECF exceeds the intake of fluid. </li></ul><ul><li>(Smeltzer et al, 2008) </li></ul><ul><li>Hypovolemia or FVD ≠ dehydration </li></ul><ul><li>Dehydration is loss of H 2 O only!! </li></ul><ul><li>FVD -> Fluid Loss = Electrolyte Loss </li></ul><ul><li>Ratio Remains the Same (usually) </li></ul>
  33. 33. Hypovolemia <ul><li>Signs & Symptoms </li></ul><ul><li>Weight Loss </li></ul><ul><li>Decreased Skin Turgor </li></ul><ul><li>Oliguria </li></ul><ul><li>Concentrate Urine </li></ul><ul><li>Postural Hypotension </li></ul><ul><li>Weak, rapid pulse </li></ul><ul><li>Flattened Neck Veins </li></ul>Signs & Symptoms Increased Temp Cool, clammy skin Thirst Anorexia Nausea Muscle Weakness Muscle Cramps
  34. 34. Hypovolemia <ul><li>Treatment: </li></ul><ul><li>Infusion of Isotonic IV solutions for hypotensive patients </li></ul><ul><li>Infusion of Hypotonic IV solutions for normotensive patients </li></ul><ul><li>Hypovolemia d/t blood loss – blood transfusion </li></ul>
  35. 35. Hypervolemia <ul><li>ECF -> H 2 O gain is balanced with retention of sodium </li></ul><ul><li>Usually secondary to retention of sodium </li></ul><ul><li>Concentration of sodium to H 2 O is balanced – serum sodium levels usually WNL </li></ul><ul><li>A.K.A. Extracellular Fluid Volume Excess (ECFVE) </li></ul>
  36. 36. Hypervolemia <ul><li>Hormonal Imbalances - ADH </li></ul><ul><li>Can occur secondary to heart failure, renal failure, or cirrhosis of liver </li></ul><ul><li>Fluid overload related to administration of excessive IV fluids </li></ul><ul><li>Dietary: Excessive sodium intake </li></ul>
  37. 37. Hypervolemia <ul><li>Signs & Symptoms </li></ul><ul><li>JVD </li></ul><ul><li>Edema </li></ul><ul><li>Crackles </li></ul><ul><li>Tachycardia </li></ul><ul><li>Elevated B/P </li></ul><ul><li>Weight Gain </li></ul><ul><li>Increased Urine Output </li></ul><ul><li>SOB/Wheezing </li></ul>
  38. 38. Hypervolemia <ul><li>Treatment: </li></ul><ul><li>Treat the underlying cause!!! </li></ul><ul><li>Renal Failure – dialysis </li></ul><ul><li>Heart Failure – diuretics, etc. </li></ul><ul><li>Dietary – low-salt diet and/or fluid restriction </li></ul><ul><li>Discontinuation of IV infusions </li></ul>
  39. 39. Intracellular Fluid Volume Excess <ul><li>A.K.A. Water Intoxication </li></ul><ul><li>An excess of H2O or decrease in solute concentration in the intravascular space </li></ul><ul><li>(Kee & Paulanka, 2000, p.34) </li></ul><ul><li>Causes cellular edema </li></ul><ul><li>Usually occurs in cerebral cells first </li></ul>
  40. 40. Intracellular Fluid Volume Excess <ul><li>Causes: </li></ul><ul><li>Excessive non-solute water intake </li></ul><ul><li>Solute deficit (electrolyte & protein) </li></ul><ul><li>Increased secretion of ADH </li></ul><ul><li>Kidney Dysfunction </li></ul>
  41. 41. Intracellular Fluid Volume Excess <ul><li>Signs & Symptoms </li></ul><ul><li>Headaches & ↑ Perspiration (early s/s) </li></ul><ul><li>Apprehension, irritability </li></ul><ul><li>Confusion, disorientation </li></ul><ul><li>Increase ICP -> ↑ B/P, ↓ HR, ↑ RR </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Weight Gain </li></ul>
  42. 42. Intracellular Fluid Volume Excess <ul><li>Treatment: </li></ul><ul><li>Goal: Decrease excess H 2 O intake and promote H 2 O excretion </li></ul>
  43. 43. Extracellular Fluid Volume Shift <ul><li>A.K.A. “Third-spacing” </li></ul><ul><li>Permanent fluid shift from intravascular space to interstitial space </li></ul><ul><li>Nonfunctional fluid shift & physiologically useless </li></ul>
  44. 44. Extracellular Fluid Volume Shift <ul><li>Simple: Blister or Sprain </li></ul><ul><li>Serious: Massive injuries, burns, ascites, abdominal surgery </li></ul>
  46. 46. ELECTROLYTES Compounds, that when placed in a solution, conduct an electric current and emit dissociated particles of electrolytes (ions) that carry either a positive charge (cation) or negative charge (anion) (Kee & Paulanka, 2000, p. 42)
  47. 47. ELECTROLYTES Na + & Cl - -> ECF K + -> ICF Mg + = -> ICF Ca + -> almost equal in ICF & ECF (Kee & Paulanka, 2000, p. 42)
  48. 48. ELECTROLYTES Terms: Anabolism -> formation of new tissue Catabolism -> tissue breakdown (Kee & Paulanka, 2000, p. 46)
  49. 49. Potassium <ul><li>Reference Range: </li></ul><ul><li>3.5 – 5.1 mEq/L </li></ul>
  50. 50. Potassium <ul><li>Potassium is gained by intake and lost by excretion. </li></ul><ul><li>If either is altered, hyperkalemia or hypokalemia may result! </li></ul><ul><li>Regulated by aldosterone and insulin </li></ul>
  51. 51. Potassium <ul><li>Potassium levels directly affect cell, nerve, & muscle function: </li></ul><ul><ul><li>Maintains the electrical neutrality and osmolality of cells </li></ul></ul><ul><ul><li>Aids in neuromuscular transmission of nerve impulses </li></ul></ul><ul><ul><li>Assists skeletal and cardiac muscle contraction and electrical conductivity </li></ul></ul><ul><ul><li>Affects acid-base balance in relationship to hydrogen (another cation) </li></ul></ul>
  52. 52. Potassium <ul><li>Hypokalemia is K + < 3.5 </li></ul><ul><li>Hyperkalemia is K + > 5.1 </li></ul>
  53. 53. Hypokalemia <ul><li>Levels < 3.5 </li></ul><ul><li>Mildly Low Levels usually asymptomatic </li></ul><ul><li>If level < 3.2, usually accompanied by symptoms </li></ul>
  54. 54. Hypokalemia <ul><li>Causes of Hypokalemia: </li></ul><ul><li>Increased Urine Output </li></ul><ul><li>Malnutrition </li></ul><ul><li>Vomiting and/or Diarrhea </li></ul><ul><li>Hypomagnesemia </li></ul><ul><li>DKA </li></ul>
  55. 55. Hypokalemia <ul><li>May be a result of acid-base imbalances = alkalosis </li></ul><ul><li>In alkalosis, potassium moves into the cell to maintain balance, which may lead to hypokalemia </li></ul>
  56. 57. Treatment <ul><li>Oral or IV Potassium Chloride Replacement </li></ul><ul><li>D/C or adjust medications that may cause hypokalemia </li></ul><ul><li>Reverse alkalosis, if cause </li></ul><ul><li>Monitor closely for arrhythmias </li></ul><ul><li>Monitor Respiratory Status </li></ul><ul><li>Monitor LOC </li></ul><ul><li>Monitor GI symptoms </li></ul>
  57. 58. Hyperkalemia <ul><li>Levels > 5.1 </li></ul><ul><li>Mildly elevated levels usually asymptomatic </li></ul>
  58. 59. Hyperkalemia <ul><li>Causes of Hyperkalemia: </li></ul><ul><li>Renal Failure </li></ul><ul><li>Meds (ACEIs, ARBs, K + sparing diuretics, NSAIDs) </li></ul><ul><li>Addison’s Disease </li></ul><ul><li>Aldosterone Insufficiencies </li></ul><ul><li>Dig Overdose </li></ul><ul><li>Beta-Blocker Therapy </li></ul>
  59. 60. Hyperkalemia <ul><li>May be a result of acid-base imbalances = acidosis </li></ul><ul><li>In acidosis, excess hydrogen ions move into cells and push potassium into ECF, which may lead to hyperkalemia as potassium moves out of the cell to maintain balance. </li></ul>
  60. 62. Treatment <ul><li>Medications: </li></ul><ul><ul><li>Cation-exchange resins (bind with K + and excreted via feces) </li></ul></ul><ul><ul><li>IVP insulin and glucose (K + binds to insulin) </li></ul></ul><ul><ul><li>IV Ca ++ (protect the heart from the effects of hyperkalemia) </li></ul></ul><ul><ul><li>Sodium bicarbonate (to reverse acidosis) </li></ul></ul><ul><ul><li>Diuretics (non-K + sparing) </li></ul></ul><ul><ul><li>Beta 2 Adrenergic agonists (epinephrine, albuterol) </li></ul></ul><ul><li>D/C meds that may cause hyperkalemia </li></ul><ul><li>Restrict foods with K + </li></ul><ul><li>Dialysis for renal failure </li></ul><ul><li>Monitor closely for arrhythmias </li></ul><ul><li>Monitor Blood Pressure </li></ul><ul><li>Monitor GI symptoms </li></ul>
  61. 63. Sodium <ul><li>Reference Range: </li></ul><ul><li>136 – 145 mEq/L </li></ul>
  62. 64. Sodium <ul><li>Accounts for 90% of ECF cations </li></ul><ul><li>Almost all Na + is found in ECF; 10% in ICF </li></ul><ul><li>Na + attracts fluid and helps preserve ECF volume and fluid distribution </li></ul><ul><li>Na + helps transmit impulses in nerve and muscle fibers and combines w/ Cl - abd HCO 3 to regular acid-base balance </li></ul>
  63. 65. Sodium <ul><li>Excreted mainly via the kindeys (GU) </li></ul><ul><ul><li>Also via the GI tract and perspiration </li></ul></ul><ul><li>Increased Na+ levels trigger thirst and the ADH </li></ul><ul><li>Sodium-Potassium pump helps maintain normal Na+ levels </li></ul><ul><ul><li>Pump also creates an electrical charge for both cardiac and neuromuscular function </li></ul></ul>
  64. 66. Sodium <ul><li>Hyponatremia is Na + < 136 </li></ul><ul><li>Hypernatremia is Na + > 145 </li></ul>
  65. 67. Hyponatremia <ul><li>Causes an osmotic fluid shift from plasma into brain cells </li></ul>
  66. 68. Hyponatremia <ul><li>Signs & Symptoms: </li></ul><ul><li>Nausea/Vomiting </li></ul><ul><li>Headache </li></ul><ul><li>Malaise </li></ul><ul><li>Confusion </li></ul><ul><li>Diminished Reflexes </li></ul><ul><li>Confusion </li></ul><ul><li>Convulsions </li></ul><ul><li>Stupor or Coma </li></ul>
  67. 69. Hyponatremia <ul><li>Causes of Hyponatremia: </li></ul><ul><li>↑ Vasopressin/ADH </li></ul><ul><li>SIADH </li></ul><ul><li>Adrenal Insufficiency </li></ul><ul><li>Diuretics </li></ul><ul><li>Hypervolemia </li></ul><ul><li>Liver Failure </li></ul><ul><li>Heart Failure </li></ul>
  68. 70. Treatment <ul><li>Administration of oral or IV Na + (3%) Supplements </li></ul><ul><li>Encourage foods high in Na + </li></ul><ul><li>Fluid restriction </li></ul><ul><li>Monitor Neuro Status </li></ul><ul><li>Monitor for Arrhythmias </li></ul><ul><li>Normovolemic hyponatremia </li></ul><ul><ul><li>Vaprisol (conivaptan) – IV infusion </li></ul></ul><ul><ul><li>Samsca (tolvaptan) - PO </li></ul></ul>
  69. 71. Hypernatremia <ul><li>Causes </li></ul><ul><li>Dehydration/Hypovolemia </li></ul><ul><li>Diabetes Insipidus </li></ul><ul><li>Ingestion of Hypertonic Solutions </li></ul><ul><li>IV Infusion of Hypertonic Solutions </li></ul><ul><li>Cushing’s Syndrome </li></ul><ul><li>Hyperaldosteronism </li></ul><ul><li>Loss of pure water </li></ul><ul><ul><li>(excessive sweating or respiratory infections) </li></ul></ul>
  70. 72. Signs & Symptoms <ul><li>Thirst </li></ul><ul><li>Lethargy </li></ul><ul><li>Neurologic Dysfuntion </li></ul><ul><ul><li>Due to dehydration of brain cells </li></ul></ul><ul><ul><li>Irritablility </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><li>Edema </li></ul><ul><li>Decreased vascular volume </li></ul>
  71. 73. Treatment <ul><li>Administration of IV Fluids </li></ul><ul><ul><li>(Isotonic Salt-Free) </li></ul></ul><ul><li>Encourage foods low in Na + </li></ul><ul><li>Push P.O. Fluids </li></ul><ul><li>Monitor Neuro Status </li></ul><ul><li>Monitor for Arrhythmias </li></ul>
  72. 74. Magnesium <ul><li>Reference Range: </li></ul><ul><li>1.8 – 2.4 mEq/L </li></ul>
  73. 75. Magnesium <ul><li>2 nd most abundant ICF cation (K + #1) </li></ul><ul><li>60% Mg+ found in bones, < 1% ECF </li></ul><ul><li>Mg+ performs the following functions: </li></ul><ul><ul><li>Promotes enzyme reactions in carbohydrate metabolism </li></ul></ul><ul><ul><li>Helps produce ADP (adenosine triphosphate) </li></ul></ul><ul><ul><li>Helps with protein synthesis </li></ul></ul><ul><ul><li>Influences vasodilation (normal CV function) </li></ul></ul><ul><ul><li>Helps Na + and K + ions cross cell membranes </li></ul></ul>
  74. 76. Magnesium <ul><li>Mg+ performs the following functions: </li></ul><ul><ul><li>Regulates muscle contractions </li></ul></ul><ul><ul><li>Affects irritability and contractility of cardiac and skeletal muscle </li></ul></ul><ul><ul><li>Influences Ca ++ levels </li></ul></ul><ul><ul><ul><li>maintain Ca ++ levels in ECF </li></ul></ul></ul>
  75. 77. Magnesium <ul><li>Hypomagnesemia is Mg + < 1.8 </li></ul><ul><li>Hypermagnesemia is Mg + > 2.4 </li></ul>
  76. 78. Hypomagnesemia <ul><li>Results in cardiac dysrhythmias and irritates the nervous system (tetany) </li></ul>
  77. 79. Hypomagnesemia <ul><li>Causes of Hypomagnesia: </li></ul><ul><li>Malnutrition </li></ul><ul><li>Chronic Diarrhea </li></ul><ul><li>Malabsorption </li></ul><ul><li>ETOH Abuse </li></ul><ul><li>Diuretics </li></ul><ul><li>AMI </li></ul><ul><li>Pancreatitis </li></ul>
  78. 80. Hypomagnesemia <ul><li>Does not produce specific EKG changes </li></ul><ul><li>May contribute to arrhythmias caused by digoxin toxicity, ischemia, or potassium imbalances </li></ul><ul><li>(Woods et al, 2005, p. 358) </li></ul>
  79. 81. Hypomagnesemia <ul><li>Replacement of Mg – PO or IV </li></ul><ul><li>PO = Mg Oxide 400mg tabs </li></ul><ul><li>MgSo 4 IV administration is usually given at a rate of 1 gram/hr (1 gram/100 ml) </li></ul><ul><li>Encourage foods high in magnesium </li></ul>
  80. 82. Hypomagnesia <ul><li>Monitor… </li></ul><ul><li>Monitor EKG for Arrhythmias </li></ul><ul><li>Monitor for muscle cramps </li></ul>
  81. 83. Hypermagnesemia <ul><li>Severe hypermagnesemia is associated with AV blocks and intraventricular conduction disturbances </li></ul>
  82. 84. Calcium <ul><li>Reference Range: </li></ul><ul><li>8.5 – 10.1 mg/dl </li></ul>
  83. 85. Calcium <ul><li>99% Ca ++ in bones; 1% in serum & soft tissue (measured in blood serum levels) </li></ul><ul><li>Is found in both ECF and ICF </li></ul><ul><li>Can be measured in 2 ways: </li></ul><ul><ul><li>Total serum calcium (total Ca ++ in blood) </li></ul></ul><ul><ul><li>Ionized calcium level (various forms of Ca ++ in ECF) </li></ul></ul><ul><li>41% ECF Ca ++ is bound to protein; 9% bound to citrate or other organic ions </li></ul>
  84. 86. Calcium <ul><li>Ca ++ functions in the following ways: </li></ul><ul><ul><li>Responsible for formation of bones and teeth </li></ul></ul><ul><ul><li>Helps maintain cell structure & function </li></ul></ul><ul><ul><li>Plays a role in cell membrane permeability and impulse transmission </li></ul></ul><ul><ul><li>Affects contraction of cardiac muscle, smooth muscle, and skeletal muscle </li></ul></ul><ul><ul><li>Participates in blood-clotting process </li></ul></ul>
  85. 87. Calcium <ul><li>Calcium helps potassium & sodium move into and out cells in the sodium-potassium pump mechanism </li></ul>
  86. 88. Hypocalcemia <ul><li>Causes: </li></ul><ul><li>Vitamin D Deficiency </li></ul><ul><ul><li>Vitamin D promotes Ca ++ absorption in intestines, resorption from bones, and kidney resorption all of which raise Ca ++ levels </li></ul></ul><ul><li>Deficiency of parathyroid hormone </li></ul><ul><li>Inefficient parathyroid hormone </li></ul>
  87. 89. Hypocalcemia <ul><li>Causes: </li></ul><ul><li>Deficiency of parathyroid hormone (PTH) </li></ul><ul><ul><li>Calcitonin, secreted by PTH, helps regulate Ca++ </li></ul></ul><ul><ul><li>Decreases absorption of Ca++ and enhances its excretion by the kidneys </li></ul></ul>
  88. 90. Hypocalcemia <ul><li>Hypocalcemia May Cause… </li></ul><ul><li>Laryngospasm </li></ul><ul><li>Cardiac Arrhythmias </li></ul><ul><li>EKG Δ ’s -> prolonged QT interval </li></ul>
  89. 91. Hypocalcemia <ul><li>Management… </li></ul><ul><li>PO or IV calcium replacement </li></ul><ul><li>(depends on severity of symptoms or deficiency) </li></ul><ul><li>Vitamin D supplement </li></ul><ul><li>Encourage foods high in calcium </li></ul>
  90. 92. Hypercalcemia <ul><li>Causes of Hypercalcemia: </li></ul><ul><li>Excessive calcium release </li></ul><ul><li>Increased intestinal calcium absorption </li></ul><ul><li>** Decreased renal calcium excretion ** </li></ul>
  91. 93. Hypercalcemia <ul><li>Hypercalcemia May Cause… </li></ul><ul><li>Cardiac Arrhythmias </li></ul><ul><li>EKG Δ ’s -> shortened QT interval </li></ul>
  92. 94. Hypercalcemia <ul><li>Severe Hypercalcemia (> 15mg/dl) is a… </li></ul><ul><li>Medical Emergency </li></ul><ul><li>May result in </li></ul><ul><li>Coma or Cardiac Arrest </li></ul>
  93. 95. Hypercalcemia <ul><li>Signs & Symptoms… </li></ul><ul><li>Fatigue </li></ul><ul><li>Depression </li></ul><ul><li>Confusion </li></ul><ul><li>Anorexia </li></ul><ul><li>N/V </li></ul><ul><li>Constipation </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Increased Urination </li></ul>
  94. 96. Hypercalcemia <ul><li>Treatment… </li></ul><ul><li>Hydration </li></ul><ul><li>Increased Salt Intake </li></ul><ul><li>Diuretics </li></ul><ul><li>Dialysis (renal failure) </li></ul><ul><li>Glucocorticoids </li></ul>
  95. 97. Renal Function
  96. 98. Renal Function <ul><li>The main function of the renal system is to excrete bio-waste, regulate water and electrolyte levels, and release of hormones that affect RBC production, bone metabolism, and hypertension. </li></ul>
  97. 99. Renal Function <ul><li>Minimal urine output = 30 ml/hr </li></ul><ul><li>Output affected by fluid intake, hormones, & medications </li></ul><ul><li>Renal impairment causes imbalances of both fluids and electrolytes </li></ul>
  98. 100. Blood Urea Nitrogen <ul><li>Reference Range: 5 -20 mg/dl </li></ul><ul><li>An end-product of protein metabolism </li></ul><ul><li>Excreted by the kidneys </li></ul><ul><li>Elevated levels are indicators of possible dehydration, pre-renal failure, or renal failure </li></ul>
  99. 101. Blood Urea Nitrogen <ul><li>Reference Range: 5 -20 mg/dl </li></ul><ul><li>If BUN ↑ (up to 35 mg/dl) but the creatinine is WNL = DEHYDRATION </li></ul><ul><li>Usually as a result of… </li></ul><ul><li>Diarrhea, vomiting, and/or inadequate fluid intake </li></ul><ul><li>BUN WNL after hydration. If not, may indicate pre-renal or renal failure </li></ul>
  100. 102. Creatinine <ul><li>Reference Range: 0.8 – 1.3 mg/dl </li></ul><ul><li>A by-product of muscle catabolism </li></ul><ul><li>Excreted by glomerular filtration </li></ul><ul><li>More specific indicator of renal failure </li></ul><ul><li>Not influenced by diet or fluid intake </li></ul>
  101. 103. Creatinine <ul><li>Reference Range: 0.7 – 1.5 mg/dl </li></ul><ul><li>If creatinine ↑ (> 2.5 mg/dl) this could be indicative of renal impairment </li></ul><ul><li>IF both BUN and creatinine are elevated, then renal disorder is present </li></ul>
  102. 104. BUN/Creatinine Ratio <ul><li>Reference Range: 10 - 20 </li></ul><ul><li>Low – Suspect acute tubular necrosis , malnutrition, low protein intake, pregnancy, liver disease, hemodialysis </li></ul><ul><li>High – Reduced renal perfusion (dehydration, heart failure), glomerular disease , tissue or muscle destruction, high protein intake, azotemia (elevated urea levels) </li></ul>
  103. 105. References <ul><li>Kee, J. L. (2005). Laboratory and diagnostic tests with nursing implications (7th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. </li></ul><ul><li>Kee, J. L. & Paulanka, B. J. (2000). Handbook of fluid, electrolyte, and acid-base imbalances. Scarborough, Canada: Delmar Publishers. </li></ul><ul><li>Priff, N. (ed.). (2006). Nurse’s quick check: Fluids and electrolytes. Ambler, PA: Lippincott, Wilkins, and Williams. </li></ul><ul><li>Smeltzer, S. C. et al. (2008). Brunner and suddarth’s textbook of medical-surgical nursing (11 th ed.). Philadelphia, PA: Lippincott Williams and Wilkins. </li></ul><ul><li>Taber’s On-Line Medical Dictionary </li></ul>