FLUID & ELECTROLYTE IMBALANCE

FLUID & ELECTROLYTE IMBALANCE

1. ADVANCE NURSING PRACTICE PRESENTATION ON FLUID & ELECTROLYTE IMBALANCE Presented by, Ms.Flavia Dass 1 st year MSc.Nursing KIMS, H ubli

2. INTRODUCTION Fluid & electrolyte balance is a dynamic process that is crucial for life . It plays an important role in homeostatis . Imbalance may result from money factors & it is associated with illness Fluid & electrolyte balance is mandatory to maintain the stability of the body.

3. The body contains lots of fluid & electrolyte which are the transporters & catalysts as well as solvents & solution for various reactions in our body. There is a required limit for every fluid type & electrolyte in our body, an increase or a decrease in the total or independent volume or concentration will result in the abnormalities contributing to systemic results.

4. COMPOSITION OF BODY FLUID

5. Intracellular space or compartment Most of the body fluids are in the intra cellular compartment (inside the cells). Electrolyte prevalent are K+ & PO 4 3-  Extracellular space or compartment (fluid outside the cells) Interstitial fluid – fluid between the cells Intravascular fluid – fluid inside blood vessels Transcellular fluid – fluid in CSF, GI tract, pleural space, synovial space etc.

6. ELECTROLYTES Electrolyte are chemicals in the body that have an electric charge Maintain body’s blood chemistry, muscle action & other processes Electrolyte includes sodium, calcium, phosphate, chloride, potassium & magnesium Electrolyte that are positively charged are called cations Electrolyte that are negatively charged are called anions The unit of measure of electrolyte is milliequivalent ( mEq )

7. Edema Edema is an excess accumulation of fluid in the interstitial space. ANASARCA G eneralized edema due to excessive accumulation of fluid in the interstitial space throughout the body & occur as a result of condition such as cardiac, renal or liver failure.

8. REGULATION OF BODY FLUID COMPARTMENTS DIFFUSION - The movement of a substance from an area of high concentration to an area of low concentration

9. FACILITATED DIFFUSION Also known as facilitated transport or passive mediated transport is the process of spontaneous passive transport of molecules or ions across a biological membrane via specific transmembrane integral protein

10. ACTIVE TRANSPORT Movement of molecules across a cell membrane from a region of lower concentration to a region of higher concentration against the concentration gradient

11. OSMOSIS movement of a solvent across a semi permeable membrane towards a higher concentration of solute to lower concentration until the concentrations become equal on either side of the membrane

12. HYDROSTATIC PRESSURE Is the pressure that is exerted by a fluid at equilibrium at a given point within the fluid, due to the force of gravity.

13. ONCOTIC PRESSURE Is a form of osmotic pressure induced by the proteins in a blood vessel’s plasma that displaces water molecules

14. Body F luids E xcretion Daily body fluid excretion occurs by several routes Skin – 400ml/day Lung – 350ml/day GI tract – 150ml/day Kidney – 150ml/day

15. Body Fluids Replacement Fluid enters the body through three sources Orally ingested liquid Water in food Water formed by oxidation of food

16. Maintaining Fluid & Electrolyte Homeostasis is a term that indicates the relative stability of the internal environment of the body. The kidneys play a major role in controlling the fluid & electrolyte balance. Normal kidneys can adjust the amount of water & electrolytes leaving the body

17. The adrenal glands, through the secretion of aldosterone also help in controlling the extra cellular fluid volume by regulating the amount of sodium reabsorbed by the kidneys. Pituitary gland secrets anti diuretics hormone which regulates the osmotic pressure of extracellular fluid by regulating the amount of water reabsorbed by the kidney

18. INTRAVENOUS FLUIDS It is also known as intravenous solution are supplemental fluid used in intravenous therapy to restore or maintain normal fluid volume & electrolyte balance when the oral route is not possible

19. Types of IV Fluids

20. CRYSTALLOIDS Solutions (electrolyte) with small molecules that can diffuse freely throughout the extracellular space.

21. Types of Crystalloids I sotonic crystalloids When the concentration of the particles(solutes) is similar to that of plasma, it doesn’t move into cells & remain within the extra cellular compartment thus increasing intravascular volume.

22. TYPES OF ISOTONIC SOLUTION

23. NORMAL SALINE (NS) It contains water, sodium & chloride USES Isotonic solution of choice for expanding ECF volume Infused to correct extracellular fluid volume deficit Used along side administration of blood products Used to replace large sodium losses such as burns injuries CAUTION Should not be used for patients with heart failure, pulmonary edema & renal impairment

24. DEXTROSE 5% IN WATER(D5W) It contains water & glucose USES Initially isotonic & provides free water when dextrose is metabolized Expands the ECF & ICF, helps in rehydrating & excretory purpose Used to treat hypernatremia CAUTION Should not be used for fluid resuscitation because hyperglycemia can result & client at risk for increased intracranial pressure

25. LACTATED RINGER’S SOLUTION 5% DEXTROSE(D5LRS) It contains water, sodium, potassium, calcium, chloride & lactate USES Used to correct dehydration, sodium depletion & replace GI tract fluid losses Also used in fluid losses caused by burns, fistula drainage & trauma Often administered for patient with metabolic acidosis because it is an alkalizing solution CAUTION Should not be given to patients who cannot metabolize lactate Used in caution for patient with heart failure & renal failure

26. RINGER’S SOLUTION(RL) It contains sodium, chloride, lactate, potassium, calcium &water USES Deficit , intra operative fluid loss Severe hypovolemia CAUTION Severe metabolic acidosis Don’t give with blood products (reduces anticoagulant activity)

27. HYPOTONIC SOLUTION A hypotonic solution is one in which the concentration of solutes is greater inside the cell than outside of it

28. TYPES OF HYPOTONIC SOLUTION

29. 0.45% SODIUM CHLORIDE SOLUTION (0.45%Nacl) It contains water, sodium & chloride USES Used for replacing water in patients who have hypovolemia with hypernatremia CAUTION Excessive use may lead to hyponatremia due to the dilution of sodium

30. 0.33% SODIUM CHLORIDE SOLUTION (0.33%Nacl) It contains water, sodium, chloride & glucose USES Used to allow kidneys to retain needed amount of water. Free water helps kidneys eliminates solutes Typically administered with dextrose to increase toxicity CAUTION Used in caution for patients with heart failure & renal insufficiency

31. 0.225% SODIUM CHLORIDE SOLUTION (0.255%Nacl) It contains water, sodium, chloride & glucose USES Used as maintenance fluid for pediatric patients as it is the most hypotonic fluid available Typically administered with dextrose to increase toxicity

32. 2.5% DEXTROSE IN WATER (D2.5W) It contains water & glucose USES Used to treat dehydration & decrease the levels of sodium & potassium CAUTION Should not be administered with blood products as it can cause hemolysis of red blood cells

33. HYPERTONIC SOLUTION A hypertonic solution is one where the concentration of solutes is greater outside the cell than inside it.

34. TYPES OF HYPERTONIC SOLUTION

35. HYPERTENSION SODIUM CHLORIDE SOLUTION 3% Nacl – sodium & chloride 5% Nacl – sodium & chloride USES Used in the acute treatment of severe hyponatremia & should only be used in critical situations to treat hyponatremia Used in patient with cerebral edema Some patients may need diuretic therapy to assist in fluid excretion CAUTION Should be infused at a very low rate to avoid risk of pulmonary edema If administered in large quantities & rapidly, they cause ECF excess & circulatory overload

36. DEXTROSE 10% (D10W) It contains water & glucose USES Used in the treatment of ketosis of starvation & provides calories & free water CAUTION Should be administered using a central line if possible Do not infuse using the same line as blood products as it can cause RBC hemolysis

37. DEXTROSE 20% (D20W) It contains water & glucose USES Used as an osmotic diuretic that causes fluid shifts between various fluid compartments to promote diuresis

38. DEXTROSE 50% (D50W) It contains water & glucose USES Used to treat severe hypoglycemia Administered rapidly via IV bolus

39. FLUID VOLUME DISTURBANCE It is an abnormally decreased or increased fluid volume or rapid shift one compartment of the body fluid to another Hypovolemia Hypovolemia

40. HYPOVOLEMIA Hypovolemia or fluid volume deficit occurs from a loss of fluid into the third space or from a reduced fluid intake CAUSES Inadequate fluid intake Active fluid loss Failure of regulatory mechanism Increased metabolic rate ( chronic illness,fever ) Fluid shifts (edema or effusion)

41. PATHOPHYSIOLOGY Decreased fluid volume Stimulation of thirst center in hypothalamus Person complains of thirst Increase ADH secretion Increased water resorption Decreased urine output Increased urine specific gravity expect with osmotic diuresis Renin – Angiotension aldosterone system Increased sodium & water resorption

42. CLINICAL MANIFESTATION Acute weight loss Oliguria Low BP Sunken eyes Dizziness Weakness Decreased skin turgor Concentrated urine LABORATORY FINDINGS increased hematocrit Increased serum sodium level & BUN level Increased serum osmolarity

43. MANAGEMENT Fluid management Oral rehydration therapy – solutions containing glucose & electrolytes IV therapy – type of fluid ordered depends on the type of dehydration & the clients cardiovascular status Diet therapy – mild to moderate dehydration, correct with oral fluid replacement.

44. Nursing management Monitor & measure fluid at least every 8 hours & sometimes hourly Monitor daily body weight Monitor vital signs Observe for weak, rapid pulse & orthostatic hypotension Monitor urine concentration Assess degree of oral & mucous membrane moisture

45. HYPERVOLEMIA Hypervolemia or fluid volume excess occurs from an increased total body water and an increase in total body sodium content

46. CAUSES Excessive sodium & fluid intake Sodium & water retention Renal failure Steroid therapy Liver cirrhosis Hormonal disturbance Cardiac failure Fluid shift to intravascular space Administration of hypertonic fluid Administration of plasma protein

47. CLINICAL MANIFESTATION Increased BP Weight Gain Bounding pulse Venous distention Pulmonary edema Dyspnea Orthopnea Crackles on auscultation

48. LABORATORY FINDINGS Decreased hematocrit Decreased serum osmolality Decrease urine specific gravity Decreased BUN level MANAGEMENT Diuretics such as thiazide diuretics & loop diuretics Potassium supplement Correct electrolyte imbalance Mild to moderate fluid restriction Dialysis to remove nitrogenous waste

49. NURSING MANGEMENT I/O chart at regular intervals to identify excessive fluid retention Breath sound are assessed at regular intervals in at risk patient particularly if parenteral fluid are being administered Monitor the degree of edema in most dependent parts of body such as feet & ankles Restrict fluid & sodium intake as prescribed Monitor body weight daily

50. ELECTROLYTE IMBALANCE Electrolyte imbalance is an abnormality in the concentration of electrolyte in the body. It can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte

51. HYPONATREMIA Hyponatremia is an electrolyte disturbance in which the sodium concentration in the serum is lower than normal. Normal serum sodium level 135 – 145mEq/L Hyponatremia – less than 135mEq/L

52. CAUSES Excessive diaphoresis Diuretics Vomiting Diarrhea Renal disease/ failure SIADH (syndrome of inappropriate antidiuretic hormone secretion) Hyperglycemia Congestive heart failure Fresh water drowning

53. PATHOPHYSIOLOGY Sodium loss from the intravascular compartment ↓ Diffusion of water into the interstitial spaces ↓ Sodium in the interstitial space is dilated ↓ Decreased osmolarity of ECF ↓ Water moves into the cell as a result of sodium loss ↓ Extracellular compartment is depleted ↓ Clinical symptoms

54. CLINICAL MANIFESTATION Headache Confusion & altered mental state Seizures Restlessness Diminished deep tendon reflexes Muscle spasm or cramps Nausea Weakness & tiredness LABORATORY FINDINGS Serum sodium level will be greater than 135mEq/L Serum osmolality will be decreased Urine osmolality will be increased Urine sodium level will be elevated

55. MANAGEMENT Restore Na levels to normal & prevent further decreases in Na Drug therapy IV therapy to restore both fluid & Na If severe may see 2-3% saline Administer osmotic diuretic ( mannitol ) to excrete the water rather than the sodium Increased oral sodium intake & restrict oral fluid intake

56. NURSE’S INTERVENTION Strictly monitor fluid intake & output If it is accompanied by a fluid deficit ,IV sodium chloride infusion is administered to restore sodium content & fluid volume as prescribed If the hyponatremia is accompanied by fluid excess, osmotic diuretics are administered to promote the excretion of water Observe for dehydration & also observe fro neuromuscular changes Instruct the patient to increase oral sodium intake & inform the patient about the food to include in the diet If the patient is taking lithium, monitor the lithium level, because hyponatremia can cause diminished lithium excretion, resulting intoxicity

57. HYPERNATREMIA When serum sodium level exceeds 145mEq/L, then the condition is called hypernatremia CAUSES Decreased sodium excretion Corticosteroids Cushing’s syndrome Renal failure Hyperaldosteronism Decreased water intake

58. Increased sodium intake Increased oral intake Administration of sodium containing IV fluids Increased water loss Diabetes insipidus Diarrhea Excessive diaphoresis Fever Hyperventilation burns

59. PATHOPHYSIOLOGY Increased sodium concentration in ECF ↓ Osmolarity rises ↓ Water leaves the cells by osmosis & enters the extracellular compartment ↓ ↓ Dilution of fluids cells are water in ECF depleted ↓ ↓ Suppression of aldosterone → sodium is excreted in the urine Secretion Clinical symptoms

60. CLINICAL MANIFESTATIONS Lethargy Irritability Confusion Altered cerebral function Seizures Spontaneous muscle twitches Absent deep tendon reflexes Increased thirst Decreased urine output Dry skin Edema LABORATORY FINDINGS Serum sodium level will be elevated

61. MANAGEMENT Drug therapy Lowering of serum sodium levels by infusion of hypotonic electrolyte solution Diuretics also may be prescribed to treat sodium gain Desmopression acetate to treat diabetes insipidus if it is cause of hypernatremia Diet therapy Mild-ensure water intake The amount of water necessary to replace existing deficits may be estimated by the following formula free water deficit= dosing factor ×total body weight× [( serumNa +/40)] Dosing factor- 0.6if male , 0.5 if female

62. NURSING INTERVENTION Assess the signs & symptoms Prepare to administer IV infusion if prescribed If the cause is inadequate renal excretion of sodium, administer diuretics that promote sodium loss as prescribed Advice the patient to restrict sodium intake as prescribed

63. HYPOKALEMIA Hypokalemia is a metabolic disorder that occurs when the level of potassium in the blood drops down Potassium is needed for the proper functioning of nerve & muscle cells Normal level of K+ - 3.5 to 6.1mEq/L Hypokalemia –K+ level lower than 3.5mEq/L

64. CAUSES Medications ( diuretics,antibiotics ) Hyperaldosteronism Vomiting & diarrhea Chronic kidney failure Excessive sweating Water intoxication Prolonged nasogastric suction Magnesium deficiency

65. PATHOPHYSIOLOGY Low extracellular K+ ↓ Increased in resting membrane potential ↓ The cell becomes less excitable ↓ Aldosterone is secreted ↓ Sodium is retained in the body thorough resorption By the kidney tubules ↓ Potassium is excreted

66. Use of certain diuretics such as thiazides & furosemide & corticosteroids ↓ Increased urinary output ↓ Loss of potassium in urine

67. CLINICAL FINDINGS Abnormal heart rhythm Constipation Fatigue Muscle weakness or spasms Nausea & vomiting Increased urinary output LABORATORY FINDINGS Serum potassium level decreased Serum magnesium ECG Aldosterone level

68. MANAGEMENT Administration of 40-80mEq/day of potassium is adequate in adult if there are abnormal losses of potassium Dietary intake of potassium in average adult is 50-100meq/day When dietary intake is inadequate for any reason, oral or IV potassium supplement may be prescribed

69. NURSE’S INTERVENTION Monitor the signs & symptoms & place the patient on a cardiac monitor Monitor electrolyte values Administer potassium supplements orally or IV as prescribed Oral potassium supplements should not be given on an empty stomach & advised to take juice or another liquid due to its unpleasant taste

70. When potassium is added to an IV solution, rotate & mix the solution to ensure that the potassium is distributed evenly The maximum recommended infusion rate is 5-10mEq/hour & never to exceed 20mEq/hour If the patient is in diuretics, ensure that they are taking diuretics which are potassium sparing Instruct the patient regarding the food that are rich in potassium

71. HYPERKALEMIA Hyperkalemia is a metabolic disorder in which the potassium level exceeds 5.1mEq/L. CAUSES Renal failure Adrenal insufficiency Excessive use of potassium supplement Potassium sparing diuretics Tissue damage

72. PATHOPHYSIOLOGY Aldosterone signalling defects Receptor antagonism: Spironolactone Parenchymal renal disease ↓ Hyperkalemia ← Aldosterone effect reduction ↑ ↑ Reduced sodium concentration Aldosterone synthesis In distal collector tubules reduction low cardiac output Renal disease with less Diet sodium restriction renin synthesis Drugs(ACE inhibitors, Beta blockers)

73. CLINICAL MANIFESTATION Abnormal heart rhythm ECG changes – Tall peaked – T waves Flat P waves Widened QRS complex Prolonged PR intervals Muscles fatigue & weakness Nausea Paralysis Increased motility & diarrhea LABORATORY FINDINGS Serum potassium increased ECG Other electrolyte levels

74. MANAGEMENT In non acute situations, restriction of dietary potassium & potassium containing medication may correct the imbalance Administration either orally or by retention enema of cation exchange resins Emergency pharmacologic therapy If serum potassium level are dangerously elevated, it may be necessary to administration IV calcium gluconate Monitor blood pressure

75. NURSES INTERVENTION Patient at risk for potassium excess need to be identified & closely monitored for signs of hyperkalemia Nurse should monitor I/O & observe for signs of muscle weakness & dysrythmias Serum potassium level as well as BUN, creatinine, glucose & arterial blood gas values are monitored for patient at risk for developing hyperkalemia

76. HYPOCALCEMIA Hypocalcemia is a condition in which the blood calcium level becomes normally low. Calcium is the salt that help the heart & muscles work Normal calcium level → 8.6 to 10mg/dl hypocalcemia → less 8.6mg/dl

77. CAUSES Decrease absorption of calcium from the gastrointestinal tract eg.vitamin D deficiency hypoparathyroidism magnesium depletion severe hypermagnesemia Increased calcium excretion e.g. Renal failure Diarrhea Acute pancreatitis Malignancy(prostate & breast cancer) Other causes Sepsis Surgery chemotherapy

78. PATHOPHYSIOLOGY Decrease in extracellular Ca +2 ↓ The membrane potential on the outside becomes less negative ↓ Less amount of depolarisation is required to initiate action potential ↓ Increased excitability of muscles & nerve tissue

79. CLINICAL MANIFESTATION Decreased heart rate ECG- prolonged ST segment prolonged QT segment Seizures Muscle cramps Painful muscle spasms in the calf or foot during periods of inactivity Positive Trousseau’s & chvostek’s sign Anxiety , irritability Hyperactive deep tendon reflexes Diarrhea

80. Trausseau’s sign Eliciting carpal spasm by inflating the blood pressure cuff & maintaining the cuff pressure above systolic

81. Chovstek’s sign Tapping of the inferior portion of the zygoma will produce facial spasms

82. LABORATORY FINDINGS Serum calcium level & ionized calcium levels decreased Parathyroid hormone levels Vitamin D levels Other electrolyte levels ECG MANAGEMENT Drug therapy calcium supplements vitamin D

83. Diet therapy High calcium diet Prevention of injury Seizure precautions Severe hypocalcemia Administer calcium supplements IV (10ml of Ca gluconate in of 5% dextrose in water to be administered over 5-10minutes) Treat the cause of hypocalcemia

84. NURSES INTERVENTION Monitor signs & symptoms of hypocalcemia Administer calcium supplements orally or IV as prescribed While administering calcium IV be cautions & monitor for hypercalcemia Administer medication that increase calcium absorption e.. Vitamin D, Aluminum hydroxide Initiate seizure precautions Instruct the patient to consume food high in calcium

85. HYPERCALCEMIA Hypercalcemia occurs when the serum calcium level is more than 10mg/dl. It is a dangerous imbalance when severe in fact, hypercalcemic crisis has a mortality rate as high as 50% if not treated promptly.

86. CAUSES Hyperparathyroidism Adrenal gland failure Hyperthyroidism Renal failure Hypervitaminosis D (vitamin D excess) Cancerous tumors (e.g. lung, breast cancer) Calcium excess in diet Being bed bound for a long period of time Certain medications such as thiazides diurectics

87. CLINICAL MANIFESTATION Abnormal heart rhythm Muscle twitches Constipation Bone pain & fracture Nausea & vomiting Poor appetite Abdominal pain Dementia Frequent thirst Depression Frequent urination Memory loss Curving of the spine & loss of height LABORATORY FINDINGS Serum calcium levels increased Urine calcium PTH levels Vitamin D levels X-ray ECG

88. MANAGEMENT Primary hyperparathyroidism- surgical removal of abnormal parathyroid gland cure the hypercalcemic Severe hypercalcemia that causes symptoms is treated in a hospital setup with the following calcitonin Diuretics drugs that stop bone breakdown e.g. pamidronate etidronate IV fluids Glucocorticoids Hemodialysis Cardiac monitoring

89. NURSES INTERVENTION Increasing patient mobility & encouraging fluids Encourage to drink 2.8 to3.8 L of fluid daily Adequate fiber in diet is encouraged Safety precautions are implemented.

90. HYPOMAGNESEMIA Hypomagnesemia is serum magnesium level lower than 1.6 mg/dl Normal value – 1.6mg/dl to 2.6mg/dl

91. CAUSES Malnutrition & starvation Malabsorption syndrome Celiac syndrome Crohn’s disease Medication such as diuretics sepsis

92. PATHOPHYSIOLOGY Low serum magnesium level ↓ Increased acetylcholine release ↓ Increased neuromuscular irritability ↓ Increased sensitivity to acetylcholine at the myoneural juction ↓ ↓ Diminished threshold of Enchancement of myofibril Excitation for the motor contraction nerve

93. CLINICAL MANIFESTATION Tachycardia Hypertension Constipation Anorexia Abdominal distension muscle twitches Paresthesias Hyper reflexia Tetany , seizures Irritability Confusion Positive Trousseau's & Chvostek’s sign

94. LABORATORY FINDINGS Serum magnesium levels decreased Other electrolytes especially serum calcium ECG MANAGEMENT Mild cases – only dietary management Severe cases – IV administration of magnesiumsulfate Initiate seizure precautions Increase food containing magnesium in diet

95. NURSE’S INTERVENTIONS Monitor for signs & symptoms of hypomagnesemia Place the patient on a cardiac monitor Hypocalcemia always accompanies hypomagnesemia. Interventions should aim to restore normal serum calcium levels Administer magnesium sulfate IV in severe cases as prescribed Monitor serum magnesium levels frequently & monitor for reduced deep tendon reflexes which is a feature of hypermagnesemia Instruct the patient to increase the intake of magnesium rich foods

96. HYPERMAGNESEMIA Hypermagnesemia is serum magnesium level that is greater than 2.6mg/dl It is a rare electrolyte abnormality because kidney efficiently excrete magnesium.

97. CAUSES Hemolysis Renal insufficiency Increased intake of magnesium as magnesium containing antacid & laxatives

98. PATHOPHYSIOLOGY Renal failure, excessive IV infusion of magnesium, increased GI eliminination and/or absorption etc ↓ accumulation of Mg in the body ↓ Mg levels rises ↓ Altered electrical conduction ↓ ↓ Diminishing of reflexes slowed heart rate & Drowsiness lethargy AV block ↓ ↓ Severe respiratory peripheral vasodilation depression ↓ ↓ hypotension, flushing & Respiratory arrest may ↑sed skin warmth occur

99. CLINICAL MANIFESTATION Bradycardia Dysrhythmia Hypotension Respiratory insufficiency Absent or decreased deep tendon reflexes Skeletal muscle weakness Hypercalcemia Drowsiness & lethargy LABORATORY FINDINGS Serum magnesium level increased

100. MANAGEMENT IV calcium gluconate in severe cases- calcium antagonizes the action of magnesium IV diuretics to increase the excretion of magnesium in the presence of normal renal function Dialysis in case of renal insufficiency

101. NURSES INTERVENTION Monitor for sign & symptoms of hypermagnesemia Diuretics are administered as prescribed IV calcium gluconate may be administered as prescribed to reverse the effects of magnesium on cardiac muscles Instruct the patient to restrict dietary intake of magnesium containing foods Instruct the patient to avoid use of laxative & antacids containing magnesium

102. HYPOPHOSPHATEMIA This is an electrolyte disturbance in which the serum phosphorus is abnormally low Normal value – 2.7 to 4.5mg/dl Hypophosphatemia – less than 2.7mg/dl

103. CAUSES Malnutrition & starvation Alcoholism, less vitamin D Increased phosphorus excretion Hyperparathyroidism Malignancy Use of magnesium based antacid Intracellular shift Respiratory alkalosis CLINICAL MANIFESTATION Muscle dysfunction & weakness Decreased cardiac output

104. Diminished peripheral pulses Shallow respirations Decreased deep tendons reflexes Decreased bone density Irritability seizures White cell dysfunction confusion

105. LABORATORY FINDING Serum phosphorus level decreased X-ray may show skeletal changes of rickets MANAGEMENT Treat underlying cause Oral replacement with vitamin D IV phosphorus ( serve case) Serum phosphorus level should be closely monitored Diet therapy – food high in oral phosphate

106. NURSE’S INTERVENTION Monitor the signs & symptoms Administer oral phosphorus & vitamin D supplements as prescribed IV administered of phosphorus when serum phosphorus level falls below 1mg/dl Monitor for signs of hyperphosphatemia while giving IV phosphorus Assess the renal function before administrating phosphorus Instruct the patient to increase phosphorus containing foods in diet

107. HYPERPHOSPHATEMIA Hyperphosphatemia is an abnormal increase in serum phosphorus level (<4.5mg/dl) CAUSES Decreased renal excretion Tumor lysis syndrome Increased intake of phosphorus Hypoparathyroidism

108. CLINICAL MANIFESTATIONS Tetany Tachycardia Anorexia Nausea & vomiting Muscle weakness Hyperactive reflexes LABORATORY FINDINGS Serum phosphorus level increased Serum calcium level decreased

109. MANAGEMENT Administration of vitamin D such as calcitriol which is available both oral (Rocaltrol) & parenteral (calajex, paricalcitol forms) Calcium binding antacids Administration of amphojel with meals Restriction of dietary phosphate, forced diuresis with loop diuretics volume replacement with saline Surgery may be be indicated for removal of large calcium & phosphorus deposits Dialysis may also lower phosphorus

110. NURSE’S INTERVENTIONS Interventions of hypocalcemia Administer phosphate binding medication as prescribed Instruct to avoid phosphate containing medications & phosphorus rich food Instruct in medication administration phosphate binding medications should be taken with meals or immediately after meals

111. HYPOCHLOREMIA Hypochloremia is a serum chloride level below 97mEq/L Normal value – 95 to 105mEq/L

112. CAUSES Nasogastric suction Vomiting Kidney disease Heart failure CLINICAL MANIFESTATION Irritability Tremors Muscle cramps Hyperactive deep tendon reflexes Slow shallow respiration Coma seizures

113. LABORATORY FINDINGS Serum chloride level ↓sed Serum sodium level ↓sed Serum potassium level ↓sed If acid base imbalance is suspected, ABG is evaluated MANAGEMENT Correcting the cause of hypochloremia & contributing electrolytes & acid base imbalance Normal saline (0.9%Nacl) or half strength saline(0.45%Nacl) solution is administered by IV to replace the chloride

114. NURSE’S INTERVENTION Monitor the patients I/O, ABG values & serum electrolyte levels Changes in patients level of consciousness, muscle strength & movement & reported to the physician promptly Vital signs are monitored & respiratory assessment is carried out frequently Educate the patient about food with high chloride content which include tomato juice, banana, eggs, cheese etc

115. HYPERCHLOREMIA Hyperchloremia is a serum chloride level above 105mEq/L (105mmol/L) Normal value – 95 to 105mEq/L

116. CAUSES Severe dehydration Kidney failure Hemodialysis Traumatic brain injury Aldosteronism can also cause Hyperchloremia Drugs such as Boric acid & ammonium chloride IV infusion of Nacl resulting in Hyperchloremic metabolic acidosis

117. CLINICAL MANIFESTATION Weakness Headache Nausea Tachypnea Lethargy Hypertension If untreated leads to decreased cardiac output , dysrythmias & coma

118. LABORATORY FINDINGS Serum chloride level increased Serum sodium level greater than 145mEq/L Serum PH is more than 7.35 Serum bicarbonate level is < 22mEq/L Urine chloride excretion increase MANAGEMENT Correcting the underlying cause of hyperchloremia & restoring electrolyte fluid & acid base balance is essential Hypotonic IV solution may be administered to restore balance Lactated ringers solution may be prescribed to convert lacatate to bicarbonate in liver

119. Diuretics may be administered to eliminate chloride as well Sodium chloride & fluid are restricted NURSE’S INTERVENTION Monitoring vital signs, ABG values & I/O chart is important to assess the patient status & the effectiveness of treatment Assess finding related to respiratory, neurological & cardiac system are documented & changes are discussed with physician Educate about diet