Fluid and Electrolyte

Disturbances Nursing Management

Monitor I&O and daily weights, as ordered
Monitor vital signs; WOF for hypotension and tachycardia
Fluid Imbalances Monitor skin and tongue turgor
Encourage small, frequent sips of oral fluids; Consider likes and
dislikes of patient
Regulate IV fluid to prescribed rate
Hypovolemia Administer medications, as prescribed
Hypovolemia occurs when loss of ECF volume exceeds the intake of
fluid.
It occurs when water and electrolytes are lost in the same proportion
as they exist in normal body fluids
Dehydration- loss of water ONLY
Cause/s:

ABNORMAL FLUID LOSS DECRESED INTAKE

THIRD SPACING
Vomiting Nausea
Edema in burns
Diarrhea Lack of access
Ascites in liver
GI suctioning to fluids
dysfunction
Profuse
diaphoresis
Poor skin turgor seen in hypovolemia
Other causes: Diabetes insipidus, adrenal insufficiency, hyperglycemia,
hemorrhage, coma
Clinical Manifestations “FEWCHART”
F - Flat neck veins
E - Eyes sunken
W- Weight loss
C - Concentrated urine (SG> 1.025, oliguria)
H - Hypotension
A - Anxiety Normal tongue appearance Dry tongue
R - Rapid, weak pulse; Respirations increased
T - Temperature elevated
Medical Management
Fluid replacement therapy
Mild- moderate
Hypervolemia
•Increase oral fluids
•Oral rehydration salts (e.g., Hydrite) Hypervolemia refers to an isotonic expansion of the ECF caused by
Severe the abnormal retention of water and sodium in approximately the
•IV Therapy same proportions in which they normally exist in the ECF.
•If with hypotension, give isotonic fluid Fluid overload
•Once normotensive, give hypotonic fluids
Antidiarrheals, if with diarrhea
•Loperamide (Diatabs)
Antiemetics, if with nausea/vomiting
•Metoclopramide (Plasil)
 Hyponatremia develops when:
Causes There is too much water relative to the amount of sodium
Heart failure Too little sodium relative to the amount of water
Kidney injury
Liver cirrhosis
Excessive salt intake
Excessive administration of sodium- containing fluids in patients with
impaired regulatory mechanisms
Clinical Manifestations
Edema
Distended neck veins
Puffy eyelids
Crackles
Weight gain
Hypertension
Bounding pulse Medical Management
Tachypnea, dyspnea Sodium replacement
Increased urine output; dilute urine •Sodium-rich diet for those who can eat and drink
Medical Management •NaCl tablets
Low sodium diet (mild restriction to as low as 250 mg/day) •PLR or PNSS IV infusion, for those who cannot take sodium by
Diuretics mouth
•Thiazide diuretics- mild to moderate hypervolemia Water restriction
•Loop diuretics- severe hypervolemia •Indicated for hyponatremic patients with normal or excess fluid
Potassium supplementation, to prevent hypokalemia while on diuretics volume
Dialysis for severe renal impairment Hypertonic saline solution
•Indicated for severe hyponatremia
Nursing Management Drug Therapy: AVP receptor antagonists “vaptans”
Monitor I&O as ordered MOA: act on AVP receptors in the renal tubules to promote aquaresis
Weigh daily, WOF rapid weight gain (1kg= 1L of fluid) •Conivaptan HCl (Vaprisol) IV- hospitalized patients with moderate to
Monitor breath sounds, especially if with IV therapy severe hyponatremia
Monitor for presence of edema •C/I: seizure, delirium, coma
•Feet and ankles for ambulatory patients •Tolvaptan (Samsca)- oral medication for clinically significant
•Sacral area for bed ridden patients hypervolemic and euvolemic hyponatremia
Encourage bed rest – this favors diuresis Nursing Management
Regulate IVF as prescribed Monitor I&O and daily weights
Place on semi- Fowlers position if with dyspnea Monitor laboratory values
Reposition at regular intervals to prevent pressure ulcers Monitor the progression of manifestations
Emphasize need to read food labels For patients who are able to consume by mouth, encourage foods and
Instruct to avoid foods high in sodium fluids with high sodium content
Encourage use of seasoning substitutes such as lemon juice, onions, •Broth made with one beef cube (900mg)
and garlics •8 oz of tomato juice (700mg)
Administer IV fluids, as prescribed

Electrolyte Imbalances WOF signs of circulatory overload:

•Cough, dyspnea, puffy eyelids, dependent edema, excessive weight
gain in 24 hours, crackles)
Institute safety precautions:
•Keep side rails up
Sodium •Supervised ambulation
Most abundant electrolyte in the ECF Causes: “MODEL”
ECF concentration: 135- 145 mEq/L M - Medications, meals
Functions: O - Osmotic diuretics
•Controls body water distribution D - Diabetes insipidus
•Establishes the electrochemical state necessary for muscle E - Excessive water loss
contraction and nerve impulse transmission L - Low water intake
Hyponatremia
Serum sodium level < 135 mEq/L
Causes:
Vomiting, diarrhea, gastric suctioning
Medications: diuretics, lithium, cisplatin, heparin, and NSAIDs
Decreased aldosterone (Addison’s disease)
Water intoxication
CHF
Chronic renal failure
Clinical Manifestations
Extreme thirst- first sign Potassium
Dry, sticky mucous membranes
Oliguria Neuromuscular irritability
Firm, rubbery turgor
Red, dry, swollen tongue
Restlessness, tachycardia, fatigue In hypokalemia, “everything is low and slow”
Disorientation, hallucination
Medical Management Clinical Manifestations
Lethargy- drowsy and fatigued (early sign)
Safety Alert! Low, shallow respirations
•Serum sodium correction should be done gradually Lethal cardiac dysrhythmias (ST depression, shallow T wave,
prominent U wave)
•Too rapid reduction in sodium level renders the plasma temporarily Lots of urine (frequency and volume)
hypo-osmotic to the brain tissue Leg cramps
Limp muscles
Treat underlying cause Low blood pressure (severe)
Sodium correction Medical Management
•Hypotonic electrolyte solution- first line Potassium-rich diet:
•IV of choice: 0.3% NaCl
•Isotonic non saline solution- second line
•D5 W- indicated when water needs to be replaced without sodium
Medical Management
Provide oral fluids at regular intervals
Restrict sodium in diet, as prescribed
Monitor behavioral changes
Promote safety
Monitor intake and output
Potassium
Most abundant electrolyte in the ICF
Normal serum concentration: 3.5 to 5 mEq/L
Has an inverse relationship with sodium; direct relationship with
magnesium Potassium chloride (KCl)
Functions: Oral supplementation for mild to moderate hypokalemia
•Maintains ICF volume •S/E: small bowel lesions
•Neuromuscular excitability •Assess for abdominal distention, pain or GI bleeding
•Regulates contraction and rhythm of heart IV route for severe hypokalemia (K+ of 2 mEq/L)
•Incorporate in IV bottle, as ordered
•Never give by IV push or direct IV- this causes fatal dysrhythmias
and cardiac arrest
Hypokalemia
Serum Potassium Level <3.5 mEq/L
IV Potassium Chloride
Causes: “SAD BITCH”
S - Starvation Potassium is excreted via kidneys
A - Alkalosis (promotes the transcellular shift of K+) Should be given ONLY after adequate UO has been established
D - Drugs (Furosemide, Hydrocortisone, laxatives) A decrease in UO to less than 20 mL per hour for 2 consecutive
B - Bulimia nervosa hours is an indication to stop potassium infusion
I - inadequate intake of K+ Use an infusion pump as much as possible
T - Too much insulin Monitor patient by continuous ECG while infusion is going on
C - Cushing’s syndrome (causes kidneys to excrete K+) Apply warm compress to IV site
H - Heavy fluid loss
Nursing Management Nursing Management
Monitor for early presence in at-risk patients Monitor I&O and closely monitor signs of muscle weakness and
Encourage to consume potassium- rich foods dysrhythmias
Educate on proper use of laxative and/or diuretics Monitor vital signs, use apical pulse
Monitor I&O – 1L of urine output = 40mEq/L K+ loss Administer medications, as prescribed
Administer potassium replacement, as ordered and using the Encourage patient to strictly adhere to potassium restriction.
recommended method of administration Avoid fruits and vegetables, legumes, whole-grain breads, lean meat,
milk, eggs, coffee, tea, and cocoa
Caution patients to use salt substitutes sparingly if they are taking

Hyperkalemia other supplementary forms of potassium or potassium- sparing

diuretics
Calcium
Located primarily in the bones and teeth; the rest can be found
Serum potassium level > 5 mEq/L circulating in the serum
Less common than hypokalemia Functions:
More life-threatening because cardiac arrest is more frequently •Bone mineralization
associated with its occurrence •Stabilizes the resting membrane potential of neurons thereby
Causes: “CARED” preventing their spontaneous activation
•Regulation of muscle contraction – causes actin and myosin
C - Cellular movement of K+ from ICF to ECF filaments to slide into each other
A - Addison’s disease (hypoaldosteronism) •Cardiac contractility and conduction
R - Renal failure
E - Excessive K+ intake •Types of Calcium:
D - Drugs (Spironolactone, ACE inhibitors, NSAIDs) Ionized calcium
Protein-bound calcium
Calcium complexed to anions
Potassium Normal Values:
Neuromuscular irritability Ionized calcium: 4.5 to 5.1 mg/dL
Total calcium: 8.5 to 10.5 mg/dL
In hyperkalemia, “everything is high and fast”

Clinical Manifestations “MURDER”

M – Muscle weakness (late sign)
U – Unable to calm down (irritability, anxiety)
Hypocalcemia
R – Respiratory failure (sec. to muscle weakness)
→
D – Decreasing cardiac contractility (tachycardia bradycardia)
E – Early sign: muscle twitch/cramps
Serum calcium level < 8.5 mg/dL
Causes:
R – Rhythm abnormalities: Tall, peaked T waves and prolonged PR Primary Hypoparathyroidism
interval (most dangerous) Surgical hypoparathyroidism
Radical neck dissection
Medical Management Massive administration of citrated blood
Obtain ECG to detect changes Pancreatitis
Potassium restriction (diet and meds) Kidney injury
Calcium gluconate IV Prolonged bed rest/bed ridden patients
•Emergency management for extremely high K+ levels
•MOA: calcium antagonizes the action of hyperkalemia on the heart
but does not lower serum K+ level Extracellular Calcium
•S/E: hypotension, bradycardia
Sodium polystyrene sulfonate (Kayexalate)
•Cation exchange resin Increased cell membrane permeability
•Administer via PO or retention enema to sodium
•MOA: Increases fecal potassium excretion through binding of
potassium in the lumen of the gastrointestinal tract.
•C/I: paralytic ileus Increased neuromuscular irritability
Hyperkalemia protocol:
•Regular insulin (IV) + D50W: causes temporary shift of potassium
into the cells
•Beta-2 agonist (Salbutamol) “Everything is high and fast”
•Nebulized
•MOA: moves potassium into cells
•S/E: tachycardia, chest discomfort
Dialysis
 Clinical Manifestations: Monitor and maintain airway patency
Tetany: general muscle hypertonia, with tremor and spasmodic or Institute seizure precautions
uncoordinated contractions occurring with or without efforts to make •Reduce environmental stimulation
voluntary movement •Identify and modify triggers
Latent Tetany: •Padded side rails
Numbness, tingling, and cramps in the extremities •Bed in lowest position
Stiffness of hands and feet •Oxygen and suction readily available
Overt Tetany:
•Bronchospasm
Laryngospasm
(+) Trousseau’s sign: carpopedal spasm resulting from occlusion of the
blood flow to the arm for 3 minutes
Hypocalcemia
(+) Chvostek’s sign: sharp tapping over the facial nerve causes spasm
or twitching of mouth, nose, eye Serum Calcium Level > 10.5 mg/dL
Seizures Causes:
Dysrhythmias - torsades de pointes Malignancies
Photophobia Hyperparathyroidism
Thiazide diuretics
Vitamin A and D toxicity
Chronic lithium use
Chvostek sign: a contraction of the Theophylline toxicity
facial muscles elicited in response to
light tap over the facial nerve in Extracellular Calcium
front of the ear

Decreased cell membrane permeability

to sodium

Decreased neuromuscular irritability

Trousseau sign: a carpopedal spasm
induced by inflating a blood pressure
cuff above systolic blood pressure.
“Everything is low and slow”
Clinical Manifestations:
Hypotension
ECG Changes: prolonged QT interval and lengthened ST segment Clinical Manifestations: “BACK ME UP”
Labs: hypomagnesemia B - Bone pain
Medical Management A - Arrhythmias (heart blocks, shortened QT interval and ST segment
C - Cardiac arrest (MOST DANGEROUS), constipation
Calcium salts IV K - Kidney stones
•Calcium gluconate (4.5mEq) M - Muscle weakness
•Calcium chloride (13.5mEq) E - Excessive urination
Vitamin D - increases calcium absorption from the GI tract U - Uhaw (thirst)
Calcium supplements (to be taken with meals) P - Pathologic fractures
High calcium diet
•Milk products Medical Management
•Green, leafy vegetables 0.9% NaCl solution
•Canned salmon Temporarily dilutes serum calcium and increases urinary calcium
•Canned sardines excretion
•Fresh oysters Furosemide (Lasix)
Nursing Management: Used in conjunction with PNSS
Promotes diuresis and enhances calcium excretion
Administer via slow IV/slow IV infusion Calcitonin IM
Assess IV site for evidence of infiltration Lowers calcium level by increasing calcium and phosphorous deposition
Do not use PNSS as it increases renal calcium loss; use D5W instead into bones
to dilute solution Useful for patients with heart disease or kidney injury
Do not use concurrently with solutions containing phosphates or Corticosteroids
bicarbonate Decrease bone turn over and tubular reabsorption for patients with
Encourage intake of calcium-rich foods sarcoidosis, myelomas, lymphomas, and leukemia
Advise to quit smoking and consume alcohol and caffeine in
moderation
Advise to avoid overuse of laxatives and antacids that contain
phosphorus
(oncologic origin)​ Clinical Manifestations:
a. Pamidronate disodium (Aredia) Cramps, spasticity
Biphosphonate (+) Trousseau and Chvostek sign
Inhibits osteoclastic activity Insomnia
S/E: fever, transient leukopenia Mood changes
b. Mithramycin Anorexia, vomiting
Cytotoxic antibiotic Increased tendon reflexes
Inhibits bone resorption and thus lowering serum calcium level Hypertension
Nursing Management Similar to hypocalcemia
Encourage early and frequent ambulation ECG changes:
Encourage oral fluids up to 3-4 L/day •Depressed ST segment
Encourage high fiber diet •Prolonged QRS
Implement safety precautions, as necessary •Dysrhythmias
Assess for signs of digitalis toxicity, especially in patients taking •PVCs
digoxin (Calcium enhances effects of digoxin) •SVT
Monitor heart rate and rhythms •Torsades de pointed
•Ventricular fibrillation
Magnesium Medical Management
High-magnesium diet for mild deficiencies
Intracellular cation
Has a direct relationship with potassium and calcium Green leafy vegetables
Normal Serum Mg++: 1.3-2.3 mg/dL Nuts
•1/3 is protein-bound Seeds
•2/3 are free cations – the active component Legumes
Absorbed in the small intestine Whole grains
Functions Seafoods
Activator of IC enzyme systems Peanut butter
Plays a role in CHO and CHON metabolism Cocoa
Affects neuromuscular irritability and contractility Magnesium supplements
Has a sedative effect- inhibits release of ACh Magnesium sulfate IV
Vasodilator and decreases peripheral resistance •For patients with overt manifestations of hypomagnesemia
•Administered using an infusion pump at a controlled rate
Nursing responsibilities:

Hypomagnesemia Magnesium sulfate IV

Monitor vital signs
Monitor urine output; (refer if U/O<100mL over 4 hours)
Calcium gluconate at bedside
Serum Mg++ level < 1.3 mg/dL Nursing Management
Frequently associated with hypokalemia and hypocalcemia Monitor at risk patients for signs and symptoms
Hypoalbuminemia= Hypomagnesemia Institute seizure precautions (severe hypomagnesemia)
Causes: “FAT GUM” Implement safety precautions if with confusion
F - Fistulas Educate on major sources of magnesium-rich foods
A - Alcohol withdrawal
T - Tube feedings/TPN (magnesium def)
G - Gastric suctioning prolonged
U - Uncontrolled BM (diarrhea)
M - Malabsorption disorders (small intestine)
Hypermagnesemia
Serum Magnesium Serum Mg++ >2.3 mg/dL
Rare electrolyte abnormality
Falsely elevated Mg++ may result from:
Hemolyzed blood specimen
Increased ACh release Blood drawn from an extremity with a torniquet that was applied too
tightly
Causes:
Kidney injury
Increased neuromuscular irritability Excessive intake of magnesium- containing antacids
DKA

“Everything is high and fast”

 Serum Magnesium

Decreased ACh release

Decreased neuromuscular irritability

“Everything is low and slow”

Clinical Manifestations
Flushing
Hypotension
Muscle weakness
Drowsiness
Hypoactive reflexes
Respiratory depression
Cardiac arrest
Coma
Diaphoresis
Medical Management
Avoid giving magnesium to patients with kidney injury
Discontinue all sources of magnesium if with severe hypermagnesemia
Calcium gluconate IV - Calcium antagonizes magnesium
Ventilatory support, if with respiratory depression
Hemodialysis
If with adequate renal function:
•Furosemide (Lasix)
•PLR or PNSS
Nursing Management
Monitor vital signs, noting hypotension and shallow respirations
Assess deep tendon reflexes Increased Blood Calcium
Assess level of consciousness level
Caution on use of OTC medications

Decreased neuromuscular
excitability
Increased Calcium
excretion by kidneys

Precipitate formation

Cognitive GI Musculoskeletal Cardiac

dysfunction Disturbance symptoms symptoms
Nephrolithiasis