Electrolyte Imbalances

E-lyte Imbalance Causes

Hyponatremia

Hypernatremia

[< 135 mEq/L] • ↑ Na excretion

[> 145 mEq/L] • ↓ Na excretion

: Excessive diaphoresis

: Corticosteroids

Hypokalemia

Hyperkalemia

[< 3.5 mEq/L] • Potentially lifethreatening!

[> 5.1 mEq/L] • Excessive K+ intake : Food

: GI losses (vomiting, diarrhea) : Cushing’s syndrome

• Total body K+ loss

: Diuretics

: Hyperaldosteronism

: ↑ use of meds (diuretics or

: Hypoaldosteronism

: RF

• Inadequate Na intake

• ↑ Na intake

: NPO / low-salt diet

: ↑ oral sodium ingestion

• Dilution of serum Na

• ↓ Water intake

: Vomiting, diarrhea

: K+-sparing diuretics

: ↑ ingestion of hypotonic

: NPO

: Prolonged NG suction

: RF

fluids

• ↑ Water loss

: Renal dis imparing

: Adrenal insufficiency

: RF

: ↑ metabolism

reabsorption of K+

: SIADH (= ↑ ADH activity =

: Fever

• Inadequate K+ intake

= water retention &

: Infection

: NPO

corticosteroids) : Hyperaldosteronism / Cushing’s syndrome

inappropriate urinary excretion : Diarrhea

• Dilution of serum K+

of Na)

: Water intoxication

: Diabetes insipidus

• Movement of K+ from

: Hyperglycemia

the ECF to ICF : Alkalosis

: Meds = potassium chloride or salt substitutes : Rapid infusion of K+containing IV solutions • ↓ K+ excretion

(Addision’s dis)

• Movement of K+ from the ECF to ICF : Tissue damage = trauma, burns, sepsis etc : Acidosis : Hyperuricemia : Hypercatabolism

: Insulin treatment /

Assessment / Sx

• CV

• CV

Hyoerinsulinism • CV

• CV

: Sx vary w/ changes in

: Sx vary w/ changes in

: Thready, weak, irregular

: Slow, weak, irregular HR

pulse

: ↓ BP

vascular vol

vascular vol

: Normovolemic = rapid pulse

• Resp

: Peripheral pulse weak

• ECG changes

: Hypovolemic = Thready,

: Pulm edema if

: Orthostatic hypotension

: Tall peaked T waves

weak, rapid pulse,

hypervolemia

• ECG changes

: Flat P waves

hypotension, flat neck vein

• Neuromuscular

: ST depression

: Widens QRS complexes

: Early = spontaneous muscle

: Shallow, flat or inverted T

: Prolonged PR intervals

: Hypervolemic = Rapid, bouncing pulse • Resp : Shallow, ineffective resp mvmt r/t sk muscle weakness

twitches, irregular muscle contractions : Late = sk muscle weakness, diminished or absent DTR

wave : Prominent U wave • Resp

• Resp : SK muscle weakness leading to resp failure

: Shallow, ineffective resp

• Neuromuscular : Early = muscle twitches,

• Neuromuscular

• CNS

: Diminished breath sounds

: Generalized sk muscle

: Altered cerebral fxn (the

• Neuromuscular

cramps, paresthesias in the hands and feet and mouth

weakness

most common

: Anxiety, lethargy,

: ↓ DTR

manifestation)

confusion, coma

• Cerebral fxn

: Normo-/hypovolemia =

: Sk muscle weakness →

: Late = profound weakness, ascending flaccid paralysis in

: HA

agitation, confusion,

flaccid paralysis

: Personality changes

seizures

: Loss of tactile

• GI

discrimination

: ↑ motility

: ↓ DTR

: Hyperactive bowel sounds : Diarrhea

: Confusion : Seizures → Coma

: Hypervolemia = lethargy, stupor, coma

• GI

• Renal

• ↑GI

: ↑ motility & bowel sounds

: ↓ urinary specific gravity

: ↓motility

: Abd cramping

: ↑ UO

: Hypoactive bowel sounds

: N&V

• Integumentary

: N&V, constipation

• Renal

: Dry skin

: Paralytic ileus

: ↓ urinary specific gravity

• Renal

: ↑ UO

: ↓ urinary specific gravity

the arms and legs

: ↑ UO

• Hypovolemia → IV NS

Tx

infusion (slowely)

* Always monitor CV, resp, neuro, cerebral, renal, and GI status

• Hypervolemia → Osmotic diuretic

• Water restriction for pt w/

• For inadequate renal excretion of sodium, administer diuretics to promote sodium loss

• Oral K+ supplement

• Restrict sodium and fluid

: AEs = abd pain, distention,

intake

normal or excess fluid vol

supplement

: Not take on an empty stomach to ↓ GI effects

N&V, diarrhea, or GI bleeding → d/c supplement

• SIADH → Lithium,

: Liquid K+ = take w/ juice

Demeclocycline

• D/C IV or PO K+

to mask the bad taste

• K+-restricted diet

• K+-excreting diuretics if renal fxn is patent

• If renal fxn is impaired, administer sodium polystyrene sulfonate

• IV K+

(Kayexalate) [= promote GI

* Hyponatremia potentiates

: NEVER given by IV push

Na+ absorption and K+

lithium toxicity → monitor

: Use infusion pump (5-10

excretion]

(Declomycin)

lithium level closely

mEq/hr)

• ↑ oral sodium intake

: Observe sx of phlebitis • D/C K+-losing diuretics

• If severe, dialysis • IV hypertonic glucose w/ regular INS to move excess K+ into the cells

E-lyte Imbalance Causes

Hypocalcemia

Hypercalcemia

Hypomagnesemia

[ < 8.6 mg/dL] • ↓ GI Ca absorption

[ > 10.0 mg/dL] • ↑ Ca absorption

[< 1.6 mg/dL] • Inadequate Mg intake

• ↑ Mg intake

: Inadequate oral intake of Ca

: Excessive oral intake of Ca

: Malnutrition

: Mg-containing antacids

: Lactose intolerance

: Excessive oral intake of Vit

: Vomiting or diarrhea

: Malabsorption syndrome

D

: Malabsorption syndrome

: Excessive IV therapy

• ↓ Ca excretion

• ↑ Mg secretion

• ↓ renal excretion of Mg

: RF

: Diuretics

: Renal failure

(Celiac sprue, Crohn’s dis) : Vit D deficiency

Hypermagnesemia [> 2.6 mg/dL]

and laxatives

: ESRD

: Use of thiazide diuretics

: Chronic alcoholism

• ↑ Ca excretion

• ↑ bone resorption of Ca

• Intracellular mvmt of Mg

: RF, polyuric phase

: Hyperparathyroidism

: Hyperglycemia

: Diarrhea

: Hyperthyroidism

: INS administration

: Wound drainage, esp GI

: Malignancy (bone

: Sepsis

• ↓ the ionized fraction of Ca

destruction from metastatic

: Medications (calcium

tumors)

chelators or binders)

: Immobility

: Acute pancreatitis

: Use of glucocorticoids

: Hyperphosphatemia

• Hemoconcentration

: Immobility / bed rest

: Dehydration

: Removal or destruction of the : Use of lithium parathyroid glands (=

: Adrenal insufficiency

Hypoparathyroidism)

Assessment / Sx • CV

• CV

• CV

• CV

: ↓ HR

: Early = ↑ HR

: Tachycardia

: Bradycardia, dysrhythmias

: Hypotension

: Late = bradycardia →

: HTN

: Hypotension

• ECG changes

• ECG changes

: ↓ peripheral pulse

cardiac arrest

• ECG changes

: ↑ BP

: Tall T waves

: Prolonged PR interval

: Prolonged ST interval

• ECG changes

: Depressed ST segments

: Widened QRS complexes

: Prolonged QT interval

: Shortened ST segment

• Resp

• Resp

• Resp

: Widened T wave

: Shallow resp

: Resp insufficiency

: Not directly affected

• Resp

• Neuromuscular

• Neuromuscular

: Possible resp failure d/t

: Ineffective resp mvmt d/t sk

: Twitches, paresthesias

: Diminished or absent DTR

: Trousseau’s and Chvostek’s

: Sk muscle weakness

muscle tetany or seizures

muscle weakness

• Neuromuscular

• Neuromuscular

: Twitches, cramps, tetany,

: Profound muscle weakness

: Hyperreflexia

: Drowsiness and lethargy

: Diminished or absent DTR

: Tetany, seizures

: Coma

: Paresthesias f/b numbness

: Disorientation, lethargy,

• CNS

: Trousseau’s and Chvostek’s

coma

: Irritability

• GI

: Confusion

: Hyperactive DTR

: ↓ motility, hypoactive bowel

• GI

: Anxiety, irritability

sounds

: ↓ motility

• GI

: Anorexia, nausea, abd

: Anorexia, nausea, abd

seizures

signs

: ↑ gastric motility; hyperactive bowel sounds : Abd cramping, diarrhea

distention, constipation • Renal : ↑ UO → dehydration : Low back pain from renal

signs

distention, constipation

• CNS

calculi (kidney stones)

Tx

• Administer Ca via PO or IV

• D/C IV or PO meds

containing Ca or Vit D

• IV Ca = warm the solution to the body temp and monitor

* Always monitor CV, resp, neuro,

for hypercalcemia • Medications to ↑ Ca absorption

• D/C thiazide diuretics →

• Hypocalcemia freq accompanies hypomagnesemia → interventions aim to restore normal serum Ca levels

replace w/ diuretics that ↑ Ca excretion • Medications that inhibit Ca

• For severe case, IV magnesium sulfate (No IM

: Aluminum hydroxide [= ↓

and GI status

serum phosphorus levels,

: Phosphorus

causing the countereffect of ↑

: Calcitonin (Calcimar)

• Initiate seizure precautions

Ca]

: Bisphosphonates

• Monitor for DTR,

: Vit D to aid Ca GI absorption

: Prostaglandin synthesis

• ↓ env stimuli

inhibitors (aspirin, NSAIDs)

• Initiate seizure precautions

• Monitor for fracture

• Monitor for fracture

• Monitor for flank or abd

• Keep 10% Ca gluconate available

pain, and strain the urine to

• IV calcium chloride or calcium gluconate to

cerebral, renal,

resorption from the bone

• Diuretics to ↑ renal excretion of Mg

injection to prevent pain and tissue damage)

suggesting hypermagnesiemia during the administration of Mg • PO Mg may cause diarrhea and ↑ Mg loss

check for the presence of urinary stones

Phosphorus [2.7 – 4.5 mg/dL]: ↓ serum phosphorus = ↑ serum calcium / ↑ serum phosphorus = ↓ serum calcium

reverse the effects of Mg on cardiac muscle • Restrict dietary intake of Mg-containing foods