Sodium Imbalance (Na+)

Normal level- 135-145mEq/L

Na regulates ECF vol and distrubution and contributes to neuromuscular activity and A/B balance.

Disorders of fluid vol and sodium balance often occur together

When Sodium is low, water is drawn into the cells of the body, causing them to swell.

High level of Sodium levels in ECF draws water out of the body cells, causing them to shrink.

Regulatory mechanisms help maintain sodium conc. w/in usual range.

Hyponatremia- less than 135mEq/L.

Causes: Ecess Na+ loss thru kidneys, skin, of GI tract, (V/ D, gastric suctioning or irrigation, enemas w/ water) Excess Na+ excretion due to Diuretics, kidney or endocrine disorders, water gain r/t kidney disease, heart failure or cirrhosis of the liver. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Excess hypotonic IV’s

Clinical Manifestations: Anorexia, n/ v, d, & abd. cramps, headache, mental status changes, seizures, coma. Hyperreflixia, muscle twitching and tremors!    

Interdisciplinary care serum electrolytes (low values, reflecting Excess water in realation to Na+ level), 24hr urine col. (evaluate Na+ excretion to help identify cause of hyponat). Increase intake in foods high in Na+ may restore balance, oral fluids restricted, If pt is unable to eat or drink, IV fluid may be given (using NS 0.9%NaCl, 3% or 5% NaCl sol. used to replace Na+ and draw fluids out of the ICF compart. Diuretics may be admin. with sodium replacement to remove water.

 PC: Significant nurologic effects, low levels cause the brain cells to swell adn cerebral edema develops, lead to change in MS & potentially, convulsions and coma.

Hypernatremia- greater than 145mEq/L.

Causes: Result from Na+ gain or loss of water. Pts recieving Enternalfeeding at high risk if additional water is not given. (water moves out of the cell = dehydration= neurologic s/s. Inability to access fluids. Altered thirst or inability to respond to thirst (Elderly!!!)

 Hyperventilation, profuse sweating, diarrhea, diabetes insipidus, oral electrolyte sol or hyperosmolar tube-feeding, excess IV’s such as normal saline.

Manifestations: Thirst, restlessness, weakness, altered mental status, dec. LOC, seizure, muscle irritability, dry mm, postural hypotension, hot dry skin, fever, dec sweating.

INTER-care:treat by addin water oral or IV sol (D5W or 0.45%NaCl) correct water deficit. Diuretics given toincrease Na+ exretion and Low Na+ diet.

Potential Complications:!!!

Altered Na+ levels can have significant neurological effects on pts can lead to coma! Identify pts at risk for Na+ imbalance, elderly, people who labor in hot weather. Replace fluids w/ e-lytes, not just water and offer fluids at regular intervals to the elderly!

Nursing care/Health Promotion

r/t

Sodium imbalance

A risk for imbalanced fluid vol. and its consequences are the highest priority therefore, Nurses need to identify pt at risk, identify ways to prevent prob. teach pt who frequently labor or strenuously exercise in hot weather to replace fluid losses with Na+ containing fluids (sports drinks and/or pedialyte) not pure water. 

Instruct caregive to give pt fluids at regular interval. carefully monitor pts recieving enteral nutrition for adequate fluid intake and provide additonal water as needed.

Potassium Imbalance (K+)

Normal level- 3.5-5.3mEq/L

Hypokalemia- Less than 3.5 mEq/L

K+ is primary IC ion, vital for cell metabolism & cadiac & neuromuscular function. Must be replaced daily for normal level b/c kidneys get rid K+ very efficiently, continuously. Aldosterone contirbutes to K+ regulation by the kidneys, excreting K+. pH, changes in hydrogen ion conc affect K+.

Causes of hypo: excess loss of K+: Inc. Lost thru kidneys (diuretics, corticosteroids, antibiotics, hyperaldosteronism) or GI loss: (v/d, gastric suction, ileostomy drainage), or inadequate intake (pt who are NPO for extended periods, & pts with anorexia). K+ shifting into the cells during alkalosis or tissue repair (post-burn/trauma). high blood insulin levels.

Manifestations: affects transmission of nerve impulses & normal contractility of smooth, skeletal, & cardiac muscles. s/s may not appear until K+ level fall below 3.0. serious, life threatening Dysrhythmias and ECG changes MOST IMPORTANT!!  N/V, anorexia, muscle weakness or leg cramps, decrease bowl sounds or ileus.

 Hyperkalemia- More than 5.3mEq/L

Causes: r/t inadequate K+ excretion, inc. intake, or a shift or K+ from the ICF to ECF. Major cause is impaired renal excretion RF, adrenal insufficiency, excess potassium intake (occurs when people use salt subs while taking K+-sparing diuretics (replacement), Admin aged blood (b/c K+ conc inc during storage), Burns or crush injuries release K+ from cells into ECF. IN acidosis: H+ moves into cells & K+ shift out of the cells to maintain pH.

Manifestations: Tall peaked T waves, dysrhythmias, heart block, cardiac arrest! Strength of cariac contraction dec., & K+ levels inc., N/D, abdominal cramps, muscle weakness, paralysis.

Potential Complications!!! Identify patients at risk for potassium imbalances such as patients taking diuretics, severely restricted diet, kidney disorders, anorexia nervosa, steroids for body building. Place clients on a cardiac monitor who have alterations in serum potassium; no questions asked!  They need to be monitored, can result in serious, even fatal dysrhythmias!!! 

Calcium Imbalance (Ca+)

Normal: 4.5 to 5.5mEq/L

Most is found in the bones and teeth, small amt in the ECF. Half of this EC calcuim is IONIZED, essential to a # of body porcesses. it affects neuromuscular irritability, nerve impulse transmission, muscle contraction and relaxatio, blood clotting and hormone secretion. it is vital in maintaining heart rhythm and contraction. Three hormones interact to regulate Ca+ levels: PTH (when ca fall PTH is secreted by parathyroid gland), calcitriol (also inc serum Ca+ levels) and calcitonin (secreted by Thyroid gland in response to high Ca+).

Hypocalcemia- Less than 4.5 mEq/L

Causes: Parathyroidectomy or Neck Surgery (thyroid surgery)! Older adults R at risk b/c they consume less milk & milk prod, and less exposure to sun, less active and loss of Ca+ from bones, they take drugs that interact with Ca+ absorption. Women at particular risk after menopause b/c of Estrogen deficiency (inc risk for fractures). Alcoholics (reduce intestinal absorption of Ca+). Also result from dec. total body calcium stored in the bone. Acute pancreatitis, inadequate dietary intake, lack of sun exposure, lack of weight bearing exercise, loop diuretics such as Lasix, hypomangesemia, alcohol abuse and some chemotherapy agents.

Manifestations: Tetany, paresthesias (numness or tingling, around the mouth and in the hands and feet), muscle spasms, laryngospasm, seizures, positive Chvostek’s sign (facial muscle spasm), Positive Trousseau’s sign (carpal spasm that occurs when blood flow to lower arm is restricted)!!! Anxiety, confusion, psychoses, decreased cardiac output, decreased BP, dysrhythmias, abdominal cramps, diarrhea

IC: serum levels (Ca+ and Mg2+, Phosphate), PTH measured, ECG. Replacement: oral preparations, inc dietary intake (ca+ and vit D), IV to prevent or treat tetany. caution with digitalis toxicity.

Hypercalcemia- More than 5.5mEq/L

Causes: result from inc cal releaes from the bones, increase intake (exces milk or antacid intake), RENAL FAILURE! (decrease renal exretion) Hyperparathyroidism, lung cancer, multiple myeloma, prolonged immobilization, Paget’s disease,  Manifestations: Muscle weakness, decrease in DTR, confusion, impaired memory, psychoses, dysrhythmias, increased BP, increased urine output, constipation, anorexia, nausea, vomiting

COMPS: Affects behavior, lead to kidney stones, peptic ulcer disese and pancreatitis. Critically high serum levels can cause complete heart block adn cardiac arrest!!!! REPIRATORY DISTRESS, MUSCLE TWITHING. FLACCID, WEAK MUSCLES, CHNG IN MENTAL STATUS, IRREGUALR HEART RHYTHMS.

IC: serum cal, serum PTH, ECG. MEDS: IV (NS 0.9%) ti restore fluid vol adn dilute plasma calcium. Diuretics given to excrete cal by kidneys. if excess bone resorption, bisphosphonates given to inhibit bone resorption and reduce cal levels. NC: neuromuscular effects puts pts at risk for injury due to fall, airway, dysrhythmias or seuzures. pt teaching about bone health, adequate intak and exercise. 

CALCIUM HAS A SEDATIVE EFFECT ON NUROMUSCULAR TRANSMISSION

 HypoCa: increase neuoromuscular excitability, muscle twitching, spasms, and tetany.

HyperCa: decrese neuoromuscular excitability, muscle weakness, and fatigue.

Foods High in Ca+: milk & products,canned salmon & sardines, rhubarb, broccoli, collard greens, spinach, soy flour, tofu.

Magnesium Imbalance (Mg)

2/3 in the body is in the bones; 1/3 w/in the cells, 1% in ECF. Mg2+ is critical to intracellular metabolism. ECMg affects neuromusclular irritablility adn contractility. Inc. depresses skeletal muscle contraction and CNS activity. A deficity cause dysrhythmias, and peripheral vasodialation.

IN Foods: green vegie, legumes,bananas, oranges, grapfruit, dairy, grains, nuts, meats, and seafood
Kidneys regulate ECMg levels by conserving or excreting.

Hypomagnesemia- Less than 1.5mEq/L

Causes:  Chronic alcoholism, GI losses ( intestinal suction, V/D ileostomy), impaired intestinal absorption, increased renal excretion: loop diuretics, aminoglycoside, some AB, KIDNEY DISEASE!!!!

Clinical Manifestations: Neuromuscular: Muscle weakness, tremors, tetany, positive Chvostek’s and Trousseau’s signs!!!! Dysphagia, dysrhythmias, peripheral vasodilation, ECG changes, seizures, mental status changes 

IC: identify pt at risk, treatment, increase intake (food or supp), IV

Hypermagnesemia- Greater than 2.5mEq/L

Causes: Renal insufficiency or FAILURE!!!!! Excess intake of antacids, laxatives, excess magnesium admin, adn when given to treat complications of pregnancy.

Clinical Manifestations: Muscle weakness, decreased DTR, N/V, vasodilation, flushing, sweating, feeling of warmth, decreased BP, bradycardia, cardiac arrest, lethargy, drowsiness, respiratory depression, paralysis, coma.

IC: treat by w/holding allmeds and solutions, IV calcim given to counteract the cardiac affects of Mg2+. some pts may need mechanical ventilation.

Potential Complications: Identify pts at risk, Mg2+ enters the body in the foods we eat. The kidneys regulate extracellular magnesium by conserving or excreting it as needed. Assess s/s, implement safty measures, pt teaching.

Phosphorus Imbalance (PO4)

Normal level: 1.7-2.6mEq/L

Phosphorus found in all body tissues, most combine with calcium in bone and teeth. Primary ion in ICF. important for ATP production, metabolism, and RBC function. Essesntial for normal neruomusclular activity-responsible for physiologic effects:

Abundant in foods: Meat, fish, poultry, eggs, milk, legumes.

Kidneys regulate it. An inverse relationship bet Ca+ and Mg2+( as 1 inc the other dec.

Hypophosphatemia- Less than 2.5mg/dL (1.7mEq/L)

Causes: Decreased GI absorption or increased renal excretion, alcoholism, latrogenic (treatment related) causes, IV glucose administration, TPN without phosphorus, aluminum or magnesium based antacids, insulin administration, diuretic therapy.

Clinical Manifestations: Irritability, confusion, paresthesias, ataxia, lack of coordination, seizures, coma, anemia, decreased WBC function with increased risk of infection, muscle pain and weakness, respiratory failure, chest pain, dysrhythmias, decreased CO. 

IC: prevention, treat underlying disorder. improve nutrition, suppliments, IV solution.

Hyperphosphatemia- Greater than 4.5 mg/dl (2.6mEq/L)

Causes: Acute or chronic RENAL FAILURE!!! Impaired excretion, chemotherapy, muscle tissue trauma, sepsis, hypothermia, heat stroke.

 Manifestations: Circumoral and peripheral paresthesias, muscle spasms, tetany, soft tissue calcification.

IC: Aluminum hydroxide used to lower levels, dialysis, IV NS to promote excretion, glocose and insulin given to drive phospate into cells.

When serum Phosphate level are high, excess phosphate combines with Ca+.

Complications: When serum phosphate levels are high, the excess phosphate combines with calcium.  The primary manifestations of hyperphosphatemia relate to the resulting hypocalcemia rather than to high phosphate levels.  Identify patients at risk such as malnourished, alcoholics and patients with renal failure. Rpt s/s, protect pt from infection, give IV. Pt teaching how to prevent and look for s/s.

K+ Replacement/ pt teaching r/t hypoK+

IC: serum levels(dec), ABGs for A/B status, ECG to ck cardiac rhythm, BUN, Creatinine levels.

K+ replacement therapy (oral/IV) is given to prevent and treat hypokalemia.

For EX: K+ supplements, when giving oral K+: dilute or dissolve effervescent, souluble or liquid K+ in fruit or vegie juice or cold water and chill to increase palatability.

When giving Parenteral K+: admin slowly, never admin undiluted, assess injection site frequently for pain & inflammation, use a infusion control device. Monitor I&O, and serum K+, do not admin if K+ is greater than 5.0mEq/L.

PT teaching: take as prescribed, do not skip or double dose, take with food, do not chew or crush, do not use salt substitutes when taking K+, dont take K+ supplements if you r also taking a K+ sparing diuretic.

Meds/NC/HP r/t hyperK+

IC: serum K+ level, ABGs, ECG, renal function test (BUN, creatinine, CC, to find the cause)

MEDs: mild hyperk. may be reversed by treating the casue (correcting acidosis) or by discontinuing drugs that casue it. Loop diuretics (lasix) promote renal excretion of K+ & may be admin. Keyexalate may be given orally or rectally to remove excess K+ by exchanging Na+ for K+ in the intestinal tract.

IV, insulin and glucose may be give to drive K+ into the cells. IV Na+ HCO3 has a similar effect. Ca+ gluconate may also be given to block the effects of hyperK+ on the heart.  Pt teaching about K+ balance, teach about foods high in K+ and importance of regular monitoring, teach to read food and dietary supplment labels to avoid salt substitutes that contian K+

Foods high in K: Fuits( apricots, avocados, bananas, cantaloupe, dates, oranges, raisins. Vegi: carrots, cauliflower, mushrooms, peas, potatoes, spinach, tomatoes. Meat and fish, milk and milk products.