Mr. X, an 80-year-old male, presented with altered mental status, irrelevant speech, decreased urine output, dry skin, nausea, and vomiting for the past two days. This suggests fluid volume deficit (hypovolemia) likely due to fluid losses from vomiting and diarrhea. Physical assessment should include vital signs, skin turgor, capillary refill time, orthostatic blood pressure, and urine specific gravity. Laboratory tests may show increased BUN and hematocrit. Intravenous isotonic fluids should be given to expand plasma volume along with electrolyte replacement as needed. Nursing care involves monitoring intake and output, daily weights, and signs of circulatory compromise.

1. FLUID AND ELECTROLYTE
IMBALANCE

2. INTRODUCTION
• Water is found everywhere on earth
including human body
• In an adult 60% of the weight is water
• Two third of the body’s water is found in
the cell
• Water content vary according to gender,
body mass and age.
• Fat cells contains less water

3. FACTORS AFFECTING BODY
FLUIDS
• Age-infants &elderly
• Gender, body size
• Environmental temperature: high
temperature increases fluid loss eg: heat
stroke.
• Lifestyles: Diet, exercise, stress; increases
ADH and increases urine production.

4. Fluid compartments
TWO MAJOR COMPARTMENTS
1. Intra cellular space[fluid in the cells]
2. Extra cellular space[fluid outside the
cells]
*Intravascular
*Interstitial
*Transcellular fluid spaces

5. Intracellular body fluids:
 Body fluid located within the cells.
 Constitutes approximately two thirds of the
body water and 42% Of the body weight.

6. Extra cellular fluid :
Water found outside the cell
1. Interstitial space
2. Intravascular space eg:- plasma
3. Transcellular space eg:- CSF
Interstitial fluid:- fluid that surrounds the cells.It
totals about 11 to 12 L in an adult.
 Eg. lymph

7. Intravascular space:
 It is the fluid within the blood vessels which
contains the plasma.
 Approximately 3L of the average 6L of
blood volume is made up of plasma.
 Remaining 3L is made up of thrombocytes
, erythrocytes and leucocytes.

8. Transcellular space
• It is the smallest division of ECF
compartment and contains approximately
1L of fluid.
• Eg –cerebrospinal, pericardial, synovial,
intraocular, pleural fluids, sweat and
digestive secretions.

9. Fluid spacing:- This is the term used to describe
the distribution of body water
First space:- describe the normal fluid distribution
between ECF and ICF.
Second spacing:- abnormal accumulation of
interstitial fluid (edema)
Third spacing:- occurs when fluid accumulation is
in a portion of the body which is not easily
exchanged with the rest of the extra cellular fluid.
Eg:- Ascites, Peritonitis

10. Cont…….
• Body fluids shift between two major
compartment to maintain equilibrium between
the spaces.
• Sometimes fluid is lost from the body, but is
unavailable for use either by ICF or ECF.
• Loss of ECF into a space that does not
contribute to equilibrium between the ICF and
ECF is third space fluid shift or third
spacing.
• Eg] decrease in urine output, with adequate
intake.

11. Signs and symptoms of third
spacing
 heart rate, body weight
 blood pressure, central venous pressure
 Edema
 Imbalances in fluid intake and output.
DISEASE CONDITIONS:
Ascites, peritonitis, bowel obstruction and massive bleeding
into bone or joint cavity.

12. Electrolyte imbalance
Electrolytes are various chemicals that can
carry positive or negative electrical charges.
CATIONS:
 Sodium Na+ - major ECF
 Potassium K+ - Major ICF
 Calcium Ca+
 Magnesium Mg+
 Hydrogen ions H+

13. ANIONS:
• Chloride Cl-
• Bicarbonate Hco3 -
• Phosphate Po4 -
• Sulfate SO4 -
• Protienate ions

14. Movement of body fluids
The body fluids compartments are separated
from one another by cell membranes and the
capillary membranes, these membranes are
permeable
Small particles such as ions, oxygen and carbon
dioxide easily move across these membranes.
But, larger molecules like glucose and proteins
have more difficulty moving between fluid
compartments

15. REGULATION OF BODY FLUID
COMPARTMENTS
1. Osmosis
2. Diffusion
3. Filtration
4. Sodium potassium pump-Na is greater
in ECF than ICF, Na enters the cell by
diffusion…..this is set by the Na-K pump
located in the cell membrane

17. Diffusion
• The process by which solute molecules
move from an area of high solute
concentration to an area of low solute
concentration to become evenly
distributed.
Examples: exchange of oxygen and carbon
dioxide

18. Filtration
• It is a process by which water and
dissolved substances move from an area
of high hydrostatic pressure to an area of
low hydrostatic pressure.
• Examples: Filtration allows the kidneys to
filter 180 L of plasma per day.

19. Hydrostatic pressure
It is the pressure caused by water volume in
the vessels
Oncotic pressure
It is pressure exerted by plasma proteins

20. HOMEOSTASIS

21. • The body is equipped with remarkable homeostatic
mechanisms to keep the composition and volume of body
fluid within narrow limits of normal.
• Organs involved in homeostasis include the kidneys, lungs,
heart, adrenal glands, parathyroid glands, and pituitary
gland.
• Water and electrolytes are gained in various ways. A
healthy person gains fluids by drinking and eating.
• In patients with some disorders, fluids may be provided by
the parenteral route (intravenously or subcutaneously) or by
means of an enteral feeding tube in the stomach or
intestine.

23. Regulation of fluid balance:-
• Thirst:- hypothalamus is activated by the
increase in ECF osmolarity. Thirst leads to-
drinking more water.ADH acts on renal
distal and collecting tubules causes water
reabsorption
• Hormonal influence:- Antidiuretic
hormone and aldosterone influence-
balance of body water

24. Cont….
• Renal regulation:- Kidneys are primary organ
for regulating fluid and electrolyte balance
• GI regulation:- Small amount of water is
eliminated in stool, but diarrhea and vomiting
can cause significant fluid and electrolyte
balance
• Lymphatic influence:- Assist in returning the
excess fluid and protein from the interstitial
space to blood

25. cont,…
• CV:- Baroreceptors are nerve receptors
that detect changes in pressure within the
blood vessel and transmit information to
CNS
• Insensible water loss:- This is the
invisible vaporization from the lungs and
skin, assist in regulating the body
temperature, normally about 900 ml/day is
lost

26. Average daily intake and output
in adult
• INTAKE
• Oral liquids 1300 ml
• Water in food 1000 ml
• Metabolism 300ml
• Total 2600ml
• OUTPUT
• Urine 1500 ml
• Stool 200 ml
• Insensible loss 900 ml
• Total 2600 ml

27. FLUID VOLUME DISTURBANCES
HYPOVOLEMIA[ FLUID VOLUME DEFICIT]
• Occurs when there is loss of ECF volume
which exceeds the intake
• Occurs alone or in combination with other
imbalances

28. RISK FACTORS
1.Abnormal fluid loss-
• Vomiting diarrhea
• GI suctioning
• Sweating
2.Decreased intake
• Nausea,lack of access to fluid
3.Third space fluid shift-
Burns,ascites
4.DI – DIABETES INSIPIDUS
5.Adrenal insufficiency
6.Hemorrhage
• Coma

29. Clinical manifestations
• Acute weight loss
• Decreased skin turgor
• Oliguria
• Concentrated urine
• Orthostatic hypotension
• Weak rapid heart rate
• Flattened neck veins
• Delayed capillary refill
• Decreased CVP
• Cold clammy skin
• Muscle cramps

30. LAB VALUES
• BUN elevated
• Hematocrit value increased
• Hypokalemia-GI and renal losses
• Hyponatremia-increased thirst and ADH release
• Hyperkalemia-adrenal insufficiency
• Hypernatremia-diabetes insipidus
• Urine specific gravity increased
• Urine osmolality more than 450 osm/kg

31. Medical management
• Increase oral fluids
• If severe IV ROUTE
• Isotonic solutions-ringer lactate,0.9%NS
• Expands plasma volume
• Electrolyte replacement

32. Nursing management
• Monitor Intake output
• Check weight-acute 0.5kg -500ml fluid loss
• Vital signs-temp,pulse,B.P
• Orthostatic hypotension-systolic pressure
exceeding 15mm Hg-
• CVP, breath sounds, skin colour and turgor
• Fluid challenge test
• S/S of shock
• Urine concentration

33. Prevention
• Identify patient a risk
• Administer antidiarrhoeal drugs
• Administer oral fluids
• Administer ORS
• Antiemetics

34. HYPERVOLEMIA
• Fluid volume excess refers to an isotonic
expansion of the ECF caused by abnormal
retention of water and sodium

35. Risk factors
• Heart failure
• Renal failure
• Cirrhosis of liver
• Consumption of excessive salt

36. Signs and symptoms
• Edema
• Distended neck veins
• Crackles
• Tachycardia
• Increased BP, pulse pressure and CVP
• Increased weight
• Increased urine output
• Shortness of breath,wheezing

37. LAB VALUES
• Altered BUN and hematocrit values-
decreased due to plasma dilution
• Anemia-Hb
• Hyponatremia-
• Urine Na is increased
• X rays-pulmonary congestion

38. MANAGEMENT
• Diuretics – Lasix
• Dietary restriction of Na
• Hypokalemia-can occur due to diuretics,if
so administer K supplements
• Hemodialysis
• Maintain Intake output
• Monitor daily weight
• Degree of edema
• NSAID

39. Mr.X ,80 years old male presented to ED
With altered sensorium,irrelevant
talk,decreased urine output,dry
skin,nausea,vomiting and loose stools for
past two days.
Identify the imbalance
Physical Assessment &investigations
Nursing measure

40. • Mr.R 56 years old man presents with
breathlessness,decreased urine output
and pedal edema.
• Known case of chronic kidney disease and
heart failure
Identify the imbalances
Assessments
Management

41. ELECTROLYTE
IMBALANCES

42. SODIUM
SIGNIFICANCE OF SODIUM
• Most abundant electrolyte in ECF
• Normal range -135 to 145 mEq/L
• Decreased Na causes changes in osmolality
• Loss or gain of sodium is accompanied with
gain or loss of water
• Transmission of nerve impulse
• Establishes electro chemical state for
muscle contraction

43. HYPONATREMIA
RISK FACTORS
• Loss of sodium
• Use of diuretics
• Loss of GI fluids
• Renal diseases
• Renal insufficiency
• Medications associated with water retention
• Hyperglycemia
• Heart failure

44. Dilutional hyponatermia
Water intoxication
increase in ratio of water to sodium
ECF volume excess
hyponatremia [hyperglycemia, improper
administration of parentral fluid, tap water enema,
irrigation of NG tube with water instead of NS,
compulsive water drinking-psycogenic polydipsia]

45. SIADH
• Syndrome of inappropriate antidiuretic
hormone
• Head injuries, endocrine or pulmonary disorders,
physiological or psychological stress , medications-
oxytocin , cyclophosphamide , vincristine , amptripline
Excessive ADH activity water retention dilution
hyponatremia
Inappropriate urine excretion of sodium

46. Signs & symptoms
• Anorexia
• Nausea &vomiting
• Headache
• Lethargy
• Confusion
• Muscle cramps &
weakness
• Muscular twitching
• Seizures, pulse, BP
• Papilledema ,dry skin
• Salt loss
• Stupor/coma
• Anorexia,n&v
• Lethargy
• Tendon reflexes
decreased
• Limp muscles(weakness)
• Orthostatic hypotension
• Seizures/headache
• Stomach cramping

47. Laboratory findings
• Serum and urine sodium
• urine specific gravity and osmolality
• increase in body weight
• Finger printing
• In SIADH ,urine sodium is greater than
20mEq/L, urine specific gravity is greater
than 1.012

48. Medical management
1.Assessment
2.Sodium replacement-PO, NG ,IV
* Diet
* Lactated Ringers solution or 0.9 % sodium
chloride
* To avoid neurogenic damage-Sr.sodium
should not be increased greater than 12mEqL
in 24 hrs
* normal Na requirement is 100mEqL per
day

49. Cont…….
3.Water restriction
* If excess fluid volume, water is restricted to
800ml in 24 hrs
* Small amounts of hypertonic sodium chloride.
* 1L of 3% sodium chloride- 513 mEq/L of
sodium;5% sodium chloride-855mEq /L .
* If edema and hyponatremia occurs then Na
and water is restricted
* loop diuretic –to prevent ECF volume overload
and increase water excretion.

50. Nursing management
• Early detection and treatment to prevent
complication
• Monitor intake and output chart
• Daily body weights
• CNS changes-lethargy,confusion, seizures,
muscle twitching.
• GI changes-anorexia, nausea,vomiting,
abdominal cramps
• Monitor Sr.Na blood levels
• Urine Na and specific gravity

51. Cont……
• CVS patients-check for signs of circulatory
overload [cough ,dyspnea, puffy eyelids,
Wt gain in 24 hrs, dependant edema,
crepts]
• For patients on Lithium therapy- adequate
salt must be given , diuretics should be
avoided . because it causes Na loss.

52. HYPERNATREMIA
RISK FACTORS
• Water deprivation
• Hypertonic tube feeding without adequate water
supplements
• Diabetes insipidus
• Hyperventilation
• Watery diarrhea
• Excess corticosteroid ,sodium bicarbonate, &
sodium chloride administration
• Salt water drowning.

53. Signs & symptoms
• Thirst *
• Elevated body temperature
• Swollen dry tongue
• Sticky mucus membrane
• Hallucinations, pulse, BP
• Lethargy, nausea, vomiting,anorexia
• Restlessness, hyperreflexia , twitching
• Irritability , pulmonary edema
• Focal or grandmal seizures

54. Fried salt
• Flushed skin ,low grade fever
• Restlessness,irritability,anxious,confused
• Increased BP,FLUID RETENTION
• Edema-peripheral and pitting
• Decreased urine outputand dry mouth
• S-skin flushed
• Agitation
• Low grade fever
• Thirst

55. Laboratory finding
• Increased serum sodium
• Urine sodium
• Urine specific gravity and osmolality

56. Medical management
• Gradual lowering of Sr.sodium by administering
hypotonic solution.[0.45% sodium chloride]
• Isotonic non saline solution[5%dextrose].this is
used when water needs to be replaced without
sodium.
Safe…..there is gradual decrease in Sr.sodium
level, thus cerebral edema is reduced

57. Cont…..
Rapid reduction in Sr.sodium
Decreases the plasma osmolality below that
of the fluid in the brain tissue
Cerebral edema

58. Management cont…..
• Diuretics
• Sr.sodium is reduced at the rate of 0.5 to 1
mEq/L
Allows sufficient time for readjustment
through diffusion across fluid
compartments
• Desmopressin acetate is administered in
diabetes insipidus

59. Nursing management
• Intake and output
• Medication history-some medications have
high sodium content.
• Monitor changes in behaviour-
restlessness, disorientation, lethargy
etc….
• Preventing hypernatremia-fluid
plan[enteral feed or parentral feed]
• Higher osmolality of enteral feed, >er
water supplementation is needed

60. Nsg management cont…..
• DI patients-adequate water consumption
• Monitor Sr.sodium levels daily
• With gradual decrease in Sr.Na
neurological symptoms will improve

61. POTASSIUM
SIGNIFICANCE OF POTASSIUM
• 3.5 to 5.5mEq/L
• Intracellular electrolyte
• 98% of body’s potassium is in the cells
• 2% is in ECF-neuromuscular function
• Influences both skeletal and cardiac
muscle activity
• Alteration causes myocardial irritability and
changes in rhythm

62. cont,……
• Associated with various diseases, injuries
,medications(diuretics,laxative,antibiotics),
parental nutrition, chemotherapy
• 80% of potassium is excreted from urine
• Aldosterone increases the excretion of
potassium by kidney
• Kidneys do not conserve potassium as
sodium.

63. HYPOKALEMIA
RISK FACTORS
• Diarrhea
• Vomiting
• Gastric suction
• Corticosteroid administration , Diuretics – Lasix
(potassium depleting diuretic)
• Digoxin toxicity,alcoholics,
• Hyper aldosteronism
• Bulimia,anorexia nervosa
• Osmotic diuresis, Alkalosis,penicillins
• Starvation

64. Signs & symptoms
• Fatigue
• Anorexia
• Nausea and vomiting
• Muscle weakness
• Polyuria, abdominal distention
• Decreased bowel motility
• Ventricular asystole , Paralytic ileus
• Paresthesia
• Leg cramps, hypoactive reflexes

65. Assessment and diagnostic
findings
• ECG changes-flat T waves,depressed ST
segments,elevated U waves
• Metabolic alkalosis is associated with
hypokalemia
• 24 hrs urine potassium-distinguishes
between renal and extra renal loss
• If urinary K- >20meq/l …suggestive of
renal potassium loss

66. MEDICAL MANAGEMENT
• Increased dietary intake
• Average dietary K- 50 to 100meq/l per day
• K sources-
fruits,raisins,banana,apricot,oranges,
vegetables,legumes,whole grain,milk,meat
• Salt contains-50 to 60meq/l
• Oral or IV replacement therapy

67. Cont………
• K loss must be corrected daily-40 to
80meq/l per day
• KCL is used for correction
• Potassium acetate or potassium phospate
is used.

68. NURSING MANAGEMENT
• Can be life threatening-monitor for early
sign and symptoms
• Fatigue,anorexia,decreased bowel motility,
muscle weakness,paresthesia and
dysrhythmias-signals to check K values
• ECG
• Patient on digitalis-check for hypo kalemia

69. PREVENTION OF HYPOKALEMIA
• Eat foods rich in K
• Patient education in abuse of laxatives or
diuretics
• ECG
• ABG values
• Monitor intake and output

70. CORRECTING HYPOKALEMIA
• ALERT:
• Oral k- can cause small bowel lesions-
asses abdominal distention, pain, GI
bleeding
• Older adults with lean body mass
• Loss of renal function with years
• K should be administered only after
adequate urine flow.
• If oliguria occurs stop K until situation is
evaluated

71. Cont……..
• Never administer by IV push, or IM
• Administer by infusion pump
• Should not be administered more than
20meq/l per hour-cause dysrhythmias
• KCL must be mixed well from pooling at
the insertion site
• If administered through peripheral vein-
burning
• If >60meq/l concentration is administered
can cause necrosis

72. HYPERKALEMIA
• Dangerous because cardiac arrest is
associated with high Sr.K
• Pseudohyperkalemia-tight tourniquet
causing hemolysis of sample before
analysis
• Drawing of blood from same arm of
infusion

73. RISK FACTORS
• Oliguric renal failure
• Potassium sparing diuretics - ALDACTONE
(Spironolactone)
• Renal insufficiency
• Metabolic acidosis
• Addison's disease
• Crush injury
• Burns, rapid IV administration of K
• Stored bank blood transfusion

74. SIGNS AND SYMPTOMS
• Vague muscular weakness
• Tachycardia-bradycardia
• Dysrhythmias
• Flaccid paralysis
• Paresthesias
• Intestinal colic
• Cramps
• irritability, anxiety

75. ASSESSMENT AND DIAGNOSTIC
FINDINGS
• ECG changes-tall tented T wave,
prolonged PR interval and QRS duration,
absent P waves,ST depression.
• ABG analysis-metabolic acidosis

76. MEDICAL MANAGEMENT
• ECG changes-if peaked T waves-repeat
Sr.K
• Restriction of dietary K and K containing
medications [K conserving diuretic]
• Cation exchange resins.eg.Kayexalate
• Cannot be given if patient has paralytic
ileus-cause intestinal perforation

77. PHARMACOLOGIC THERAPY
• IV calcium gluconate-does not reduce Sr.k but
antagonizes adverse effects on heart.
• Monitor BP- for hypotension[because of IV rapid
administration of calcium gluconate.
• Monitor ECG
• If bradycardia-stop infusion
• IV sodium bicarbonate-causes temporary shift of
K into the cells.
• IV insulin, hypertonic dextrose,B2 antagonist-
causes temporary shift of K into the cells.
• Peritoneal,hemodialysis

78. NURSING MANAGEMENT
• Signs of hyperkalemia-muscle weakness
and dysrhythmias
• Prolonged use of tourniquet while drawing
blood-hemolysis of blood

79. PREVENTING
HYPERKALEMIA
• Adhere to K restriction
• Foods with K-butter,beans,sauce,hard
candy, sugar and honey

80. CORRECTING
HYPERKALEMIA
• Monitor rate of K
• KCL-is never added to hanging bottle
• Do not administer K sparing diuretics
• Use salt substitutes sparingly- 1tsp
contains 50 to 60meq/l of K

81. CALCIUM
• SIGNIFICANCE OF CALCIUM
• 8.5 to 10.5 mg/dl
• 99% of body’s Ca is in skeletal system
• Major component of bones and teeth
• 1% of skeletal Ca is blood Ca.
• Helps-in transmission of nerve impulse
• Regulate muscle contraction and
relaxation
• Plays role in blood coagulation

82. Cont……
• Ca is absorbed in the presence of Vit D
and normal gastric acidity
• Ca level is controlled by PTH and
calcitonin.

83. HYPOCALCEMIA
RISK FACTORS
• Hyperparathyroidism
• Malabsorption
• Pancreatitis
• Alkalosis, diuretic phase of renal failure
• Vit D deficiency
• Excessive administration of citrated blood
• Massive subcutaneous infection
• Generalized peritonitis
• Chronic diarrhea

84. CLINICAL MANIFESTATION
• Numbness
• Tingling of toes and fingers
• Chvostek’s sign +ve, TROUSSEUS sign+ve
• Seizures
• Carpo pedal spasm
• Hyperactive deep tendon reflexes
• irritability
• bronchospasm
• Anxiety, impaired clotting time

85. ASSESSMENT AND DIAGNOSTIC
FINDINGS
• Low Sr. Ca levels
• Check Sr.albumin and arterial PH
• Decreased prothrombin level
• ECG-prolonged QT interval and
lengthened ST
• Hypocalcemia occurs in alkalosis
• PTH values
• Magnesium and phosphorous levels must
be checked

86. MEDICAL MANAGEMENT
• Its life threatening ,needs IV administering
of calcium
• Parenteral Ca salts include-calcium
gluconate,calcium chloride, and calcium
glucepate
• calcium chloride-not used often, since it
causes sloughing of tissue if it infiltrates
• Rapid IV administering of Ca can cause
cardiac arrest

87. Cont….
• IV Ca should be diluted and given as slow IV
bolus or infusion
• Check IV site for infiltration
• Solution containing phosphate and bicarbonate
should not be mixed with calcium as it causes
precipitation
• Ca can cause postural hypotension-monitor BP
• Vit D-should be administered ,it increases Ca
absorption from GI tract

88. Cont….
• Dietary intake-1000 to1500mg/day is
recommended
• Sources-milk products, green leafy
vegetables, canned salmon,sardines,fresh
oysters
• Check magnesium values-low Mg can
cause tetany

89. NURSING MANAGEMENT
• Status of airway is closely monitored-
laryngeal stridor can occur
• People at high risk for osteoporosis-
adequate dietary intake
• Regular weight bearing exercises-
decrease bone loss
• Alcohol and caffeine-inhibit Ca absorption

90. HYPERCALEMIA
• Dangerous imbalance
• Hypercalcemic crisis-malignancies
• Calcification of soft tissue occurs when Ca
and phosporous product increases to
70mg/dl

91. RISK FACTORS
• Hyper parathyroidism
• Prolonged immobilization
• Malignant neoplastic disease
• VIT D excess, cortico steroid therapy
• Oliguric phase of renal failure
• Use of thiazide diuretics
• Over dose of calcium supplement
• Digoxin toxicity
• Acidosis

92. CLINICAL MANIFESTATION
• Muscular weakness
• Constipation
• Anorexia
• Nausea
• Vomiting ,polyuria
• Hypoactive deep tendon reflexes
• Lethargy / tired
• Deep bone pain,Pathologic fractures, flank
pain, calcium stones

93. ASSESSMENT AND DIAGNOSTIC
FINDINGS
• ECG-shortened QT
interval,bradycardia,heart blocks
• Double antibody PTH test done to check
primary hyperparathyroidism and
malignancy cause of hypercalcemia
• X rays-reveal osteoporosis, bone
cavitation,and urinary calculi

94. MEDICAL MANAGEMENT
• Aim-decreasing Sr .Ca levels
• Treat underlying cause-eg] malignancy

95. PHARMACOLOGIC THERAPY
• Administer fluids to dilute Sr calcium
• Restrict dietary Ca
• IV 0.9% NaCL –dilutes Sr. Ca levels
• Diuretics-excretion of Ca
• Calcitonin- used to reduce Sr Ca levels,
administered IM
• IV phosphate therapy-in extreme
caution[causes calcification of various
tissues, hypotension and tetany]

96. NURSING MANAGEMENT
• Increasing mobility
• Encouraging fluids containing Na-
enhances excretion of Ca
• Adequate fiber
• ECG changes
• Digitalis toxicity

97. MAGNESIUM
SIGNIFICANCE OF MAGNESIUM
• Intracellular ion
• Helps in carbohydrate and protein
metabolism
• Activator of many intracellular enzymes
• Helps in neuromuscular function
• Mg produces sedative effect at the
neuromuscular junction

98. HYPOMAGNESEMIA
RISK FACTORS
• Chronic alcoholism
• Hyperparathyroidism
• Hyperaldosteronism
• Diuretic phase of renal failure
• Malabsorption syndrome
• Diabetic ketoacidosis DKA
• Refeeding after starvation
• Parenteral nutrition
• Chronic laxative use

99. Cont…………..
• Diarrhea
• Acute MI
• Heart failure

100. SIGNS AND SYMPTOMS
• Neuromuscular irritability
• Positive trousseau and chvostek’s sign
• Insomnia
• Mood changes
• Anorexia
• Vomiting
• Increased tendon reflexes
• Increased BP

101. ASSESMENT AND DIAGNOSTIC
FINDINGS
• Normal range-1.5 to 2.5meq/l
• ECG-inverted T wave, depressed ST segment
• Associated with hypocalcaemia and hypokalemia
• Decreased Sr albumin values
• Premature ventricular contractions, atrial
tachycardia can occur
• Nuclear magnetic resonance spectroscopy and
ion selective electrode- ionized Sr magnesium
levels

102. MEDICAL MANAGEMENT
• Diet
• Sources-green leafy
vegetables,nuts,legumes, whole grains,
sea food, peanut butter, chocolate.
• Magnesium salts administered orally-
excessive ingestion causes diarrhea
• IV magnesium sulphate-rate 150mg/min
• Rapid bolus dose can produce cardiac
arrest

103. Cont……
• Monitor urine output
• Calcium gluconate is given to treat
hypocalcemic tetany

104. NURSING MANAGEMENT
• Monitor S/S
• Patients on digitalis-toxicity
• Seizure precautions
• Dysphagia can be present
• Check deep tendon reflex
• Abuse of alcohol-hypomagnesemia-health
education

105. HYPERMAGNESEMIA
RISK FACTORS
• Oliguric phase of renal failure
• Adrenal insufficiency
• Excessive IV mag administration
• Hemodialysis with hard water or diasylate
high in Mg
• Excessive use of antacids.

106. SIGNS AND SYMPTOMS
• Flushing
• Hypotension
• Drowsiness
• Hypoactive reflexes
• Depressed respirations
• Cardiac arrest coma
• Diaphoresis / sweating / perspiration

107. ASSESMENT AND DIAGNOSTIC
FINDINGS
• ECG-bradycardia, prolonged PR interval
and widened QRS
• Atrio ventricular blocks

108. MEDICAL MANAGEMENT
• Avoid Administering Mg to patients
• IV calcium in emergency-respiratory
depression, defective cardiac conduction
• Hemodialysis-Mg free dialysate
• Loop diuretics
• IV calcium gluconate-antagonizes the
neuromuscular effects of Mg

109. NURSING MANAGEMENT
• Monitor vitals- shallow respirations,
hypotension
• Change in consciousness
• Decreased patellar reflexes

110. PHOSPHORUS
SIGNIFICANCE OF PHOSPHORUS
• 2.5 to 4.5mg/dl
• Essential for function of muscle and red
blood cells, formation of ATP
• Maintenance of acid base balance
• Intermediary metabolism of carbohydrate,
protein and fat
• Greater in children due to skeletal growth
• Ph-located in bones and teeth

111. Cont….
• Provides structural support to bones and
teeth
• Critical to nerve and muscle function
• Ph levels decrease with age

112. HYPOPHOSPHATEMIA
RISK FACTORS
• Refeeding after starvation
• Alcohol Withdrawal
• Diabetic keto acidosis
• Respiratory alkalosis
• Hyper parathyroidism
• Elderly patient who are unable to eat
• Hyperventilation

113. CONT……
• Decreased magnesium
• Decreased potassium
• Vomiting
• Diarrhea
• Vit D deficiency associated with
malabsorptive disorders.

114. SIGNS AND SYMPTOMS
• Paresthesia
• Muscle weakness
• Bone pain
• Tenderness
• Chest pain
• Confusion, tissue hypoxia
• Cardiomyopathy
• Respiratory failure
• Seizures, increased susceptibility to
infection

115. ASSESMENT AND DIAGNOSTIC
FINDINGS
• Glucose or insulin administration causes
slight decrease in Ph levels
• Sr Mg may decease-increased urinary
excretion
• X rays-changes of osteomalacia
• Alk-Ph –increased with osteoblastic
activity

116. MEDICAL MANAGEMENT
• Ph is added to parenteral solution
• IV Ph-tetany,metastatic calcification from
hyperphosphatemia
• rate of administration-not exceed 10meq/l
• Site monitoring-sloughing , tissue necrosis

117. NURSING MANAGEMENT
• Prevention of infection
• Monitor Sr.Ph levels, signs and
symptoms[confusion,change in
conciousness]
• Dietary sources-milk products, milk, organ
meat, nuts, fish, poultry and whole grains
• Supplements of Ph-neutra phos capsules

118. HYPERPHOSPHAEMIA
RISK FACTORS
• Acute and chronic renal failure
• Hypoparathyroidism
• Excessive intake of phosphorous
• Vitamin D excess
• Respiratory acidosis
• Volume depletion
• Leukemia
• Lymphoma treated with cytotoxic agents
• Increased tissue breakdown
• Rhabdomyolysis

119. SIGNS AND SYMPTOMS
• Tetany
• tachycardia
• Anorexia
• Nausea
• Vomiting
• Muscle weakness
• Signs and symptoms of hypocalcemia

120. ASSESMENT AND DIAGNOSTIC
FINDINGS
• Sr Ph levels normally higher in children-
skeletal growth
• X rays-skeletal changes, abnormal bone
development
• Sr.Ca levels

121. MEDICAL MANAGEMENT
• Respiratory or metabolic acidosis
• Restricting dietary resources
• Dialysis
• Phosphate binding antacids
• Vit D preparation-do not increase Ca
levels

122. NURSING MANAGEMENT
• Avoid Ph containing substances-laxatives
and enema
• Monitor urine output
• Signs and symptoms
• Dietary restriction

123. CHLORIDE
SIGNIFICANCE OF CHLORIDE
• Anion in ECF
• Present in sweat, gastric juices, pancreatic
juices
• Bicarbonate has inverse relationship with
chloride

124. HYPOCHLOREMIA
• RISK FACTORS
• Addisons disease
• Reduced chloride intake
• Diabetic keto acidosis
• Chronic respiratory acidosis
• Excessive sweating, vomiting, gastric suction
• Diarrhea, increased diuretic administration
• Overuse of bicarbonate, draining fistula and
ileostomies
• Cystic fibrosis

125. SIGNS AND SYMPTOMS
• Agitation
• Irritability
• Tremors
• Muscle cramps
• Hyperactive deep tendon reflexes
• Tetany
• Shallow respirations
• Seizures
• Dysrhythmias,coma

126. ASSESMENT AND DIAGNOSTIC
FINDINGS
• Normal- 69 to 106meq/l
• Sr Cl, Sr.Na is decreased
• PH,Sr bicarb is increased
• Decreased urine chloride levels
• ABG

127. MEDICAL MANAGEMENT
• IV NaCL-0.9%,0.45%
• Dietary sources-tomato,canned
vegetables, processed meat, fruits
• Ammonium chloride-treat metabolic
alkalosis

128. NURSING MNAGEMENT
• ABG
• Intake output
• Level of consciousness, muscle strength
and movement
• Dietary sources

129. HYPERCHLOREMIA
• RISK FACTORS
• Excessive NaCL
• Head injury
• Hypernatremia
• RF
• Dehydration
• Respiratory alkalosis
• Diuretics,overdose of salicylates
• Hyperparathyroidism,

130. SIGN AND SYMPTOMS
• Tachypnea
• Lethargy
• Weakness
• Deep rapid respiration
• Decreased CO
• Pitting edema
• Dysrhythmias
• coma

131. ASSESMENT AND DIAGNOSTIC
FINDINGS
• Sr Na ,and Cl is increased
• Sr bicarb and PH decreased
• Increased urinary chloride level
• Normal anion gap

132. Medical management
• Correcting underlying cause
• Lactated ringers solution –to correct
acidosis
• IV Na bicarb
• Diuretics

133. Nursing management
• Monitor vitals
• signs and symptoms
• ABG
• diet

134. MEDICAL MANAGEMENT
• Treat metabolic alkalosis
• Administer NaCl fluids
• H2 receptor antagonists- reduces HCL
production
• Intake output is monitored
• If hypokalemia-KCl is administered

135. ACID BASE DISTURBANCES
• Plasma PH is an indicator of H ions
• H concentration - high concentration,
more acidic the solution becomes and
lower the PH
• Lower H concentration-alkaline solution
and higher the PH

136. BUFFER SYSTEM
• Buffer systems prevent major changes in
the PH of body fluids by removing or
releasing H+ ions
• They act quickly to prevent excessive
changes in H+ concentration
• 2 buffers-extracellular and intracellular
buffer

137. KIDNEYS
• Regulate bicarbonate levels in ECF
• In acidosis the kidneys excrete hydrogen
ions and conserve bicarbonate ions
• In alkalosis the kidneys retain hydrogen
ions and excrete bicarbonate ions

138. LUNGS
• Control CO2 and carbonic acid content of
ECF
• This is done by adjusting the level of CO2
in the blood
• In metabolic acidosis-RR increases,>er
elimination of CO2
• In metabolic alkalosis-RR decreases,CO2
is retained

139. Acid-Base
imbalance
Definition Causes Clinical
manifestation
Lab findings Management
Respiratory
acidosis
Hypoventilatio
n
& excessive
CO2
production
It is a
clinical
disorder
in which
the pH is
less than
7.35 and
the
paCO2 is
greater
than
42mmHg
COPD,
neuromuscular
disorder,
Guillian-Barre
syndrome,
Myssthenia
gravis,
Respiratory
center
depression,
Drugs, late
ARDS,
Dyspnea ,
disorientation
, coma
PH lesser than
7.35,
Paco2 greater
than 45mmHg,
Hyperkalemia,
Hypoxemia
1.Treat underlying
cause
2.Support
ventilation
3.Correct electrolyte
imbalance
4.Intravenous
NaHCO3
Respiratory
Alkalosis
Hyperventilation
It is a clinical
condition in
which the
arterial Ph is
greater
than7.45 and
the paCO2 is
less than
38mmHg
Hypoxemia, impaired
lung expansion,
thickened alveolar –
capillary membrane,
Chemical stimulation
of respiratory center,
traumatic stimulation
of respiratory center
Tachypnea,
giddiness,
dizziness,
syncope,
convulsions
, coma,
weakness,
paresthesia
, tetany
PH greater
than 7.35
PaCO2 lesser
than 35
mmHg,
Hypokalemia,
Hypocalcemia
Increase CO2
retention
through CO2
rebreathing &
sedation and
mechanical
hypoventilation

140. Definition causes Clinical
manifestation
Lab findings Management
Metabolic
Acidosis
It is a
clinical
condition in
which the
HCO3 &
pH is
decreased
Renal failure,
Diabetic
ketoacidosis,
Lactic acidosis,
ingested toxins,
renal tubular
acidosis
Hyperventilatio
n confusion,
drowsiness,
coma,
headache
PH< 7.35,
HCO3<
22mEq/L
1.Treat the
underlying cause
2.Intravenous
NaHCO3
3.correct electrolyte
imbalance
Metabolic
Alkalosis
It is a
clinical
condition in
which PH is
raised
Hypokalemia,
gatric fluid loss,
massive
correction of
whole blood,
Overcorrection
of acidosis with
NaCO3
Hypoventilation
Dysrythmias
PH >7.45
Hypokalemia
Hypocalcemi
a
PaCO2
normal or
increased
1.Treat the
underlying cause
2.Administer KCL
3.intravenous
acidifying
salts[NH4CL]
4.Administer
acetazolamide

141. COMPENSATION
• Pulmonary and renal systems compensate
for each other to return to normal PH
• In respiratory acidosis-excess H+ ions are
excreted in exchange for bicarbonate ions.
• In respiratory alkalosis- H+ ions are
retained, and renal excretion of
bicarbonate ions increases

142. Example
• A patient is in intensive care because he
suffered a severe myocardial infarction 3
days ago. The lab reports the following
values from an arterial blood sample:
– pH 7.5
– HCO3- = 35mEq / L ( 22 - 26)
– pCO2 = 45 mm Hg (35 - 45)
142

143. Diagnosis
• Metabolic acidosis
• With compensation
143