ELECTROLYTE IMBALANCES 1. HYPONATREMIA a sodium deficit or serum sodium level of less than 135 mEq/L.

. This may result from excessive sodium loss or excessive water gain. Because of sodiums role in determining the osmolality of ECF, hyponatremia typically results in a low serum osmolality. Water is drawn out of the vascular compartment into the interstitial tissues and the cells, causing the clinical manifestations associated with this disorder. ETIOLOGIC AND RISK FACTORS: a. Loss of sodium Gastrointestinal fluid loss Sweating Vomiting Use of diuretics b. Gain of water Hypotonic tube feedings Drinking water Excess IV D5W administration c. Syndrome or inappropriate ADH Cause by Head injury resulting to increase ADH AIDS Malignant tumors PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Lethargy, confusion, apprehension b. Muscle twitching c. Abdominal cramps d. Anorexia, nausea, vomiting e. Headache f. Seizures, coma LABORATORY FINDINGS: a. Serum sodium below 135 mEq/L b. Serum osmolality below 280 mOsm/kg 2. HYPERNATREMIA is excess in sodium in ECF, or serum sodium greater than 145 mEq/L. There is a gain of sodium in excess of water or a loss of water in excess of sodium. Because the osmotic pressure of extracellular fluid is increased, fluid moves out of the cells into the ECF. As a result, the cells become dehydrated. ETIOLOGIC AND RISK FACTORS: a. Loss of fluids Insensible water loss Diarrhea b. Water deprivation c. Excess salt intake Parenteral administration of saline solutions Hypertonic tube feedings without adequate water Excessive use of table salt (1 tsp contains 2300 mg of sodium) d. Diabetes mellitus e. Heat stroke f. Sea water ingestion g. Near drowning in ocean h. Malfunction of dialysis PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Thirst b. Dry, sticky mucous membranes c. Tongue red, dry, swollen d. Weakness e. Postural hypotension f. Dyspnea

3.

4.

Severe hypernatremia: Fatigue, restlessness Decreasing level of consciousness Disorientation Convulsions LABORATORY FINDINGS: a. Serum sodium above 145 mEq/L b. Serum osmolality above 300 mOsm/kg c. Urine specific gravity and osmolality increased or elevated HYPOKALEMIA is a potassium deficit or a serum potassium level of less than 3.5 mEq/L. ETIOLOGIC AND RISK FACTORS: a. Loss of potassium Vomiting and gastric suction Diarrhea Heavy perspiration b. Use of potassium wasting drugs (diuretics) Thiazide Loop diuretics (furosemide) c. Hyperaldosteronism PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Muscle weakness, leg cramps b. Fatigue, lethargy c. Anorexia, nausea, vomiting d. Decreased bowel sounds, decreased bowel mobility e. Cardiac dysrhythmias f. Depressed deep tendon reflexes LABORATORY FINDINGS: a. Serum potassium level below 3.5 mEq/L b. Arterial blood gases may show alkalosis c. T wave flattening and ST segment depression on ECG d. U wave on ECG, prolonged PR interval HYPERKALEMIA is a potassium excess or serum potassium greater than 5.0 mEq/L. Less common than hypokalemia and rarely occurs in clients with normal renal function. It is more dangerous than hypokalemia and can lead to cardiac arrest. ETIOLOGIC AND RISK FACTORS: a. Decreased potassium excretion Renal failure Hypoaldosteronism Potassium-conserving diuretics b. High potassium intake Excessive use of potassium containing salt substitutes Excessive or rapid IV infusion of potassium c. Potassium shift out of the tissue cells into the plasma (infections, burns, acidosis) PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Gastrointestinal hyperactivity, diarrhea b. Irritability, apathy, confusion c. Cardiac dysrythmias or arrest d. Muscle weakness, areflexia e. Paresthesia and numbness in extremities LABORATORY FINDINGS: a. Serum potassium above 5.0 mEq/L b. Peaked and narrow T wave, widened QRS on ECG c. ST segment depression and shortened QT interval d. Prolonged PR interval e. Prolonged QRS complex f. Disappearance of P wave g. Acidosis

g.

5.

6.

HYPOCALCEMIA is a calcium deficit, or total serum calcium level of less than 8.5 mg/dl and an ionized calcium level of less than 4.0 mg/dl. Severe depletion of calcium can cause tetany with muscle spasms and paresthesias and can lead to convulsions. Clients at greatest risk for hypocalcemia are those whose parathyroid glands have been removed. This is frequently associated with total thyroidectomy or bilateral neck surgery for cancer. ETIOLOGIC AND RISK FACTORS: a. Surgical removal of the parathyroid glands b. Hypoparathyroidism c. Acute pancreatitis d. Hyperphosphatemia e. Thyroid carcinoma f. Inadequate vitamin D intake Malabsorption Hypomagnesemia Alkalosis Sepsis Alcohol abuse PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: a. Numbness, tingling of extremities and around the mouth b. Muscle tremors, cramps; if severe, can progress to tetany and convulsions c. Cardiac dysrhythmias; decreased cardiac output d. Positive Trousseaus Sign carpal spasm or contraction of hand and fingers on affected side when inflating a blood pressure cuff on the upper arm to 20 mmHg greater than the systolic pressure, and leaving it in place for 2 to 5 minutes. e. Positive Chvosteks sign facial muscle twitching including eyelids and lips on side of stimulus when tapping over facial nerve about 2cm anterior to tragus of ear. f. Confusion, anxiety, possible psychosis LABORATORY FINDINGS: a. Prolonged QT interval b. Serum calcium level less than 8.5 mg/dl or 4.5 mEq/L c. Elevated phosphate level HYPERCALCEMIA serum calcium levels greater than 10.5 mg/dl. Most often occurs when calcium is mobilized from the bony skeleton. This may be due to malignancy or prolonged immobilization ETIOLOGIC AND RISK FACTORS: a. Prolonged immobilization b. Hyperparathyroidism c. Malignancy of the bone d. Pagets disease e. Excessive calcium intake or administration f. Milk-alkali syndrome PATHOPHYSIOLOGY: CLINCIAL MANIFESTATIONS: a. Lethargy, weakness b. Depressed deep tendon reflexes c. Anorexia, nausea, vomiting d. Constipation e. Polyuria, hypercalciuria f. Flank pain secondary to urinary calculi g. Dysrhythmias, possible heart block LABORATORY FINDINGS:

7.

8.

9.

serum calcium greater than 10.5 mg/dl or 5.5 mEq/L b. shortening of QT interval and bradycardia c. Xray reveals bone cavitations, malignancy and kidney stones HYPOMAGNESEMIA serum magnesium less than 1.5 mEq/L Occurs more frequently than hypermagnesemia. Aggravates the manifestations of alcohol withdrawal, such as delirium tremens. ETIOLOGIC AND RISK FACTORS: a. Excessive loss from the gastrointestinal tract b. Long-term use of drugs (diuretics, aminoglycoside antobiotics) c. Poor nutrition d. Alcoholism most common cause e. Pancreatitis f. Burns PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS: (the same with hypocalcemia) a. Neuromuscular irritability with tremors b. Increased reflexes, tremors, convulsions c. Positive Chvosteks and Trousseaus sign d. Tachycardia e. Elevated blood pressure f. Dysrhythmias g. Disorientation and confusion h. Vertigo LABORATORY FINDINGS: a. Serum magnesium level below 1.5 mEq/L b. ECG reveals flattened T waves, depressed ST segment, widened QRS, prolonged PR and QT intervals HYPERMAGNESEMIA serum magnesium greater than 2.5 mEq/L ETIOLOGIC AND RISK FACTORS: a. Abnormal retention of magnesium Renal failure Adrenal insufficiency b. Treatment with magnesium salts c. Untreated Dm d. Overuse of magnesium containing antacids and laxatives/enemas e. Severe dehydration PATHOPHYSIOLOGY: CLINCIAL MANIFESTATIONS: (the same with hypercalcemia) a. Peripheral vasodilation, flushing b. Nausea, vomiting c. Muscle weakness, paralysis d. Hypotension, bradycardia e. Depressed deep tendon reflexes f. Lethargy, drowsiness g. Respiratory depression, coma h. Respiratory and cardiac arrest if severe LABORATORY FINDINGS: a. Serum magnesium level greater than 2.5 mEq/L b. Prolonged PR, QT and QRS intervals c. AV block may occur PHOSPHATE DEFICIT: HYPOPHOSPHATEMIA Serum phosphate level less than 2.5mg/dL Etiologic factors a. Chronic alcoholism, alcohol withdrawal and intense hyperventilation b. Diabetic ketoacidosis c. Thermal burns d. Hyperparathyroidism e. Excess intake of phosphate binding drugs f. Total parenteral nutritional administration g. Severe dehydration

a.

Assessment a. Irritability b. Muscle weakness and pain c. Seizures and coma d. Hypoxic signs leading to increased respiration e. Respiratory alkalosis related to hyperventilation f. Bruising and bleeding g. Increased susceptibility to infection h. Paresthesias i. Numbness j. Apprehension, confusion k. Fatigue Laboratory findings a. Phosphate serum level below 2.5 mg/dL b. X-ray may show rickets or osteoporosis

a. b. c.

Serum level below 96 mEq/L Sodium is also decreased Metabolic alkalosis

10. PHOSPHATE EXCESS: HYPERPHOSPHATEMIA Serum phosphate levels above 4.5 mg/dL Etiologic factors a. Renal failure b. Chemotherapy for neoplastic disease c. Hypoparathyroidism d. High phosphate intake e. Profound muscle necrosis f. Increased phosphate absorption Assessment a. Tetany due to a high phosphate leading to low calcium b. Muscle weakness c. Hyperreflexia d. Tachycardia e. Soft tissue calcification f. Tingling sensation g. Anorexia, nausea, vomiting Laboratory findings a. Serum PO4 is above 4.5 mg/dL b. Serum calcium is low c. X-ray will show faulty bone development Nursing interventions: 1. Instruct client to avoid phosphorous-rich foods s/a hard cheese, cream, nuts, whole grain cereals, dried fruits & vegetables, kidneys, sardines, sweetbreads and foods made with milk 2. Instruct pt. to avoid phosphate containing substances s/a laxatives and enemas 3. Teach pt. to recognize the signs of impending hypocalcemia 4. Administration of vitamin D preparations s/a calcitol (oral), calcijex (IV) 11. CHLORIDE DEFICT: HYPOCHLOREMIA Serum chloride level ids less than 96 mEq/L Etiologic factors a. Severe vomiting b. GI tube drainage c. Diarrhea Pathophysiology Loss of chloride by the above factorshypochloremiabicarbonate is retained by the kidney acutely to maintain the (-), sodium is also retainedhypochloremic metabolic alkalosis. To compensate, body retains carbon dioxide to bring down the pH Assessment a. Hyperexcitability b. Hyperactive deep tendon reflexes c. Twitching d. Tetany e. Signs/symptoms of hyponatremia f. Nausea and vomiting Laboratory findings

12. CHLORIDE EXCESS: HYPERCHLOREMIA Chloride level above 106 mEq/L Etiologic factors a. Loss of bicarbonate e contain via the kidney b. Increased administration of chloride containing drugs and IVF c. Hypernatremia, metabolic acidosis Pathophysiology Hyperchloremia with hypernatremiacauses increased water retentionhypervolemiasigns of fluid excess Loss of bicarbonate acutelymetabolic acidosiskidney retains chloride acutelyhyperchloremiadeep and rapid respiration to compensate from the acidosis Assessment a. Metabolic acidosis manifestations b. Tachycardia c. Lethargy d. Deep and rapid respirations e. Hypertension Laboratory findings a. Serum chloride level above 109 mEq/L b. Metabolic acidosis c. Hypernatremia d. Normal anion gap