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Fluid and Electrolytes

Fluids
Body weight of adult male 55-60%, female

50-55%, newborn 75-80% Very little in adipose tissues Loss of 20% - fatal Elderly - decreases to 45-50% of body weight R/T decreased muscle mass, smaller fat stores, and decrease in body fluids

Fluid Shifts in Infants


predisposed to serious, rapid fluid

volume deficit limited ability to concentrate urine proportionately greater ratio of surface area to volume higher metabolic rate

Compartments
Intracellular (ICF) Fluid within the cells themselves 2/3 of body fluid Located primarily in skeletal muscle mass

Provide nutrients for metabolism:

High in K, Po4, protein

Moderate levels of Mg, So4


Assists in cellular metabolism

Compartments
Extracellular (ECF)

1/3 of body fluid


Comprised of 3 major components

Intravascular

Plasma Interstitial Fluid in and around tissues Transcellular Over or across the cells

Compartments
Extracellular Nutrients for cell functioning

Na Ca

Cl
Glucose

Fatty acids
Amino Acids

Compartments
Intravascular Component

Plasma

fluid portion of blood


Made of:

water plasma proteins small amount of other substances

Compartments
Interstitial component

Made up of fluid between cells

Surrounds cells

Transport medium for nutrients,

gases, waste products and other substances between blood and body cells Back-up fluid reservoir

Compartments
Transcellular component

1% of ECF
Located in joints, connective tissue,

bones, body cavities, CSF, and other tissues Potential to increase significantly in abnormal conditions

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Regulation of Fluids in Compartments


Osmosis

Movement of water through a

selectively permeable membrane from an area of low solute concentration to a higher concentration until equilibrium occurs Movement occurs until near equal concentration found Passive process

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Regulation of Fluids
Diffusion Movement of solutes from an area of higher

concentration to an area of lower concentration in a solution and/or across a permeable membrane (permeable for that solute) Movement occurs until near equal state Passive process

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Osmosis versus Diffusion


Osmosis

Low to high
Water potential

Diffusion
High to low Movement of particles Both can occur at the same time

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Regulation of Fluids
Active Transport

Allows molecules to move against

concentration and osmotic pressure to areas of higher concentration Active process energy is expended

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Active Transport Na / K pump Exchange of Na ions for K ions More Na ions move out of cell More water pulled into cell ECF / ICF balance is maintained

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Active Transport
Insulin and glucose regulation

CHO consumed
Blood glucose peaks

Pancreas secretes insulin


Blood glucose returns to normal

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Osmolality
Concentration of body fluids affects

movement of fluid by osmosis Reflects hydration status Measured by serum and urine Solutes measured - mainly urea, glucose, and sodium Measured as solute concentration/Kg

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Osmolality
Serum Osm/L = (serum Na x 2) +

BUN/3 + Glucose/18 Normal serum value - 280-300 mOsm/Kg Serum <240 or >320 is critically abnormal Normal urine Osm 250 900 mOsm / kg

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Factors that affect Osmolality


Serum

Increasing Osm

Free water loss Diabetes Insipidus Na overload Hyperglycemia

Uremia

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Factors that affect Osmolality


Serum

Decreasing Osm

SIADH

Renal failure
Diuretic use Adrenal insufficiency

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Factors that affect Osmolality


Urine

Increasing Osm

Fluid volume deficit SIADH Heart Failure Acidosis

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Factors that affect Osmolality


Urine

Decreasing Osm

Diabetes Insipidus Fluid volume excess


Urine specific gravity

Factors affecting urine Osm affect urine

specific gravity identically

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Fluid Volume Shifts


Fluid normally shifts between

intracellular and extracellular compartments to maintain equilibrium between spaces Fluid not lost from body but not available for use in either compartment considered third-space fluid shift (thirdspacing) Enters serous cavities (transcellular)

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Causes of Third-Spacing
Burns

Peritonitis
Bowel obstruction Massive bleeding into joint or cavity Liver or renal failure Lowered plasma proteins

Increased capillary permeability


Lymphatic blockage

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Assessment of Third-Spacing
More difficult fluid sequestered in deeper

structures Signs/Symptoms Decreased urine output with adequate intake Increased HR Decreased BP, CVP Increased weight Pitting edema, ascites

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Phases of Third-Spacing
Loss phase

Lasts 48-72 hours


Symptoms of FVD Reabsorption phase Fluid gradually reabsorbed after problem

subsides FVO possible Monitor VS, I&O, Wt, and breath sounds

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Treatment
Treat underlying cause if possible

Close observation of VS
Monitor I & O more frequently Daily weights Measure abdominal girth in ascites Measure extremities if necessary

Monitor lab values


albumin level important

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Evaluation
Stabilized I & O

Stabilized weight
VS within normal range

Resolution of third-spacing

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Fluid volume deficit


Hypovolemia Abnormally low volume of body fluid in

intravascular and/or interstitial compartments Causes Vomiting Diarrhea Fever Excess sweating Burns Diabetes insipidus Uncontrolled diabetes mellitus

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Fluid volume deficit


What happens Output > Intake -> Water extracted from ECF

ECF hypertonic (water moves out of cell ->

cell dehydration) + osmotic pressure increased (stimulates thirst preceptor in hypothalamus) ICF hypotonic with decreased osmotic pressure -> posterior pituitary secretes more ADH Decreased ECF volume -> adrenal glands secrete Aldosterone

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Signs and Symptoms


Acute weight loss Decreased skin turgor Oliguria Concentrated urine Weak, rapid pulse Capillary filling time elongated Decreased BP Increased pulse Sensations of thirst, weakness, dizziness,

muscle cramps

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Significant Points
Dehydration one of most common

disturbances in infants and children


Additional S/S
Sunken eyeballs Depressed fontanels Significant wt loss

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Significant Points
Older Adult

Vein filling better indicator than skin

turgor Have additional health problems Take various medications May intake to prevent incontinence

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Labs
Increased HCT

Increased BUN out of proportion to Cr


High serum osmolality Increased urine osmolality Increased specific gravity Decreased urine volume, dark color

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Interventions
Major goal prevent or correct abnormal fluid

volume status before ARF occurs Encourage fluids IV fluids Isotonic solutions (0.9% NS or LR) until BP back to normal, then hypotonic (0.45% NS) Monitor I & O, urine specific gravity, daily weights

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Interventions
Monitor skin turgor

Monitor VS and mental status


Evaluation

Normal skin turgor, increased UO

with normal specific gravity, normal VS, clear sensorium, good oral intake of fluids, labs WNL

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Fluid Volume Excess (FVE) Hypervolemia Isotonic expansion of ECF caused by abnormal retention of water and sodium Fluid moves out of ECF into cells and cells swell

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Causes
Cardiovascular Heart failure

Urinary Renal failure


Hepatic Liver failure, cirrhosis Other Cancer, thrombus, PVD, drug

therapy (i.e., corticosteriods), high sodium intake, protein malnutrition

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Signs/Symptoms
Physical assessment

Weight gain
Distended neck veins Periorbital edema, pitting edema Adventitious lung sounds (mainly

crackles) Dyspnea Mental status changes Generalized or dependent edema

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Signs / Symptoms
VS

High CVP/PAWP
cardiac output Lab data Hct (dilutional) Low serum osmolality Low specific gravity BUN (dilutional)

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Signs / Sympotms
Radiography

Pulmonary vascular congestion


Pleural effusion

Pericardial effusion
Ascites

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Interventions
Sodium restriction (foods/water high in

sodium) Fluid restriction, if necessary Closely monitor IVF If dyspnea or orthopnea > Semi-Fowlers Strict I & O, lung sounds, daily weight, degree of edema, reposition q 2 hr Promote rest and diuresis

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Sources of Water
Oral liquids- ~1300ml/day

Water in foods ~1000ml/day


Meats and vegetables ~ 60-90%

water Water from oxidation - ~300ml/day 10ml/cal of food metabolized Parenteral fluids Enteral feedings

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Normal Water Loss


Skin

Perspiration 0-1000 ml/day


Lungs - ~300-400 ml/day Increases with increased respiratory rate

or depth or dry climate GI Tract - ~ 100-200 ml/day Kidneys - ~ 1-2 L/day Insensible loss ~ 600 ml/day (evaporation) 1ml/kg of body wt/hr in all ages

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Other Causes of Water Loss Fever Burns Diarrhea Vomiting N-G Suction Fistulas Wound drainage

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Other causes of water loss Mechanical ventilation Increased metabolism Diabetes Insipidus Uncontrolled DM ATN

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IV Fluid Replacement
IV Fluid to manage fluid volume

imbalances Isotonic fluids (approximate normal serum plasma) Rapid ECF expansion needed D5W, NS, LR Hypotonic fluids Treatment of cellular dehydration .45% NS, .2% NS, 2.5% dextrose

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IV Fluid Replacement
Hypertonic

Treatment of water intoxication


D5 NS, D10W, 3% NS Shifts fluids from ICF & ECF to

intravascular component expands blood volume Now can be removed by kidneys

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Sodium
Normal 135-145 mEq/L

Major cation in ECF


Regulates voltage of action potential;

transmission of impulses in nerve and muscle fibers, one of main factors in determining ECF volume Elderly at risk Helps maintain acid-base balance

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Hyponatremia
Results from excess Na loss or water gain GI losses, diuretic therapy, severe renal

dysfunction, severe diaphoresis, DKA, unregulated production of ADH associated with cerebral trauma, narcotic use, lung cancer, some drugs Clinical manifestations BP, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching and tremors, vomiting, diarrhea, and cramps

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Assessment
Labs Increased HCT, K Decreased Na, Cl, Bicarbonate, UOP

with low Na and Cl concentration Urine specific gravity 1.010

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Treatment
Interventions Mild

Water restriction if water retention problem Increase Na in foods if loss of Na


Moderate

IV 0.9% NS, 0.45% NS, LR


Severe

3% NS short-term therapy in ICU setting

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Gain of Na in excess of water or loss of

Hypernatremia

water in excess of Na Causes Deprivation of water; hypertonic tube feedings without water supplements, watery diarrhea, greatly increased insensible water loss, renal failure, inadequate blood circulation to kidneys, use of large doses of adrenal corticoids, excess sodium intake

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Signs/Symptoms
Early: Generalized muscle weakness,

faintness, muscle fatigue, HA Moderate: Confusion, thirst Late: Edema, restlessness, thirst, hyperreflexia, muscle twitching, irritability, seizures, possible coma Severe: Permanent brain damage, hypertension, tachycardia, N & V

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Labs
Increased serum Na Increased serum osmolality Increased urine specific gravity

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Treatment
Free water to replace ECF volume

Gradual lowering with hypotonic saline


Decrease by no more than 2 mEq/L/hr Offer fluids at regular intervals Supplement tube feedings with free water Teach about foods, medications high in Na Treat underlying problem

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Evaluation
Normal serum NA levels Resolution of symptoms

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Potassium
Normal 3.5-5.5 mEq/L Major ICF cation Vital in maintaining normal cardiac and

neuromuscular function, influences nerve impulse conduction, important in CHO metabolism, helps maintain acidbase balance, control fluid movement in and out of cells by osmosis

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Hypokalemia
Serum potassium level below 3.5 mEq/L

Causes
Loss of GI secretions

Excessive renal excretion of K


Movement of K into the cells (DKA) Prolonged fluid administration without K

supplementation Diuretics (some)

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Signs/Symptoms
Skeletal muscle weakness, smooth

muscle function, DTRs BP, EKG changes, possible cardiac arrest N/V, paralytic ileus, diarrhea Metabolic alkalosis Mental depression and confusion

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Treatment Hydrate if low UOP Oral replacement through high K diet IV supplementation No more than 10 mEq/hr; for child 24 mEq/kg/24 h No more than 40 mEq/L

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Treatment
Hypertonic glucose solution Monitor I & O

Bowel sounds
VS, cardiac rhythm

Muscle strength
Digoxin level if necessary

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Hyperkalemia
Serum potassium level above 5.3

mEq/L Causes Excessive K intake (IV or PO) especially in renal failure Tissue trauma Acidosis Catabolic state

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Signs/Symptoms
ECG changes tachycardia to

bradycardia to possible cardiac arrest Tall, tented T waves Cardiac arrhythmias Muscle weakness, paralysis, paresthesia of tongue, face, hands, and feet, N/V, cramping, diarrhea, metabolic acidosis

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Treatment
10% Calcium gluconate Sodium bicarbonate 50% glucose solution

Kayexalate PO or PR
Stop K supplements and avoid K in

foods, fluids, salt substitutes

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Evaluation
Normal serum K values Resolution of symptoms Treat underlying cause if possible

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Calcium
Normal 4.5-5.5 mEq/L 99% of Ca in bones, other 1% in ECF

and soft tissues Total Calcium bound to protein levels influenced by nutritional state Ionized Calcium used in physiologic activities crucial for neuromuscular activity

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Calcium
Required for blood coagulation,

neuromuscular contraction, enzymatic activity, and strength and durability of bones and teeth Nerve cell membranes less excitable with enough calcium Ca absorption and concentration influenced by Vit D, calcitriol (active form of Vitamin D), PTH, calcitonin, serum concentration of Ca and Phos

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Causes of Hypocalcemia
Most common depressed function or

surgical removal of the parathyroid gland Hypomagnesemia Hyperphosphatemia Administration of large quantities of stored blood (preserved with citrate) Renal insufficiency absorption of Vitamin D from intestines

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Signs/Symptoms
Abdominal and/or extremity cramping

Tingling and numbness


Positive Chvostek or Trousseau signs Tetany; hyperactive reflexes Irritability, reduced cognitive ability,

seizures Prolonged QT on ECG, hypotension, decreased myocardial contractility Abnormal clotting

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Treatment
High calcium diet or oral calcium salts

(mild) - formulas for calcium content IV calcium as 10% calcium chloride or 10% calcium gluconate give with caution Close monitoring of serum Ca and digitalis levels Phosphorus levels Magnesium levels Vitamin D therapy

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Hypercalcemia
Causes Mobilization of Ca from bone Malignancy

Hyperparathyroidism
Immobilization causes bone loss

Thiazide diuretics
Thyrotoxicosis

Excessive ingestion of Ca or Vit D

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Signs/Symptoms
Anorexia, constipation Generalized muscle weakness,

lethargy, loss of muscle tone, ataxia Depression, fatigue, confusion, coma Dysrhythmias and heart block Deep bone pain and demineralization Polyuria & predisposes to renal calculi Pathologic bone fractures

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Hypercalcemic Crisis
Emergency level of 8-9 mEq/L Intractable nausea, dehydration,

stupor, coma, azotemia, hypokalemia, hypomagnesemia, hypernatremia High mortality rate from cardiac arrest

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Treatment
NS IV match infusion rate to amount of

UOP I&O hourly Loop diuretics Corticosteroids and Mithramycin in cancer clients Phosphorus and/or calcitonin Encourage fluids Keep urine acid

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Evaluation
Normal serum calcium levels Improvement of signs and symptoms

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Magnesium
Normal 1.5 to 2.5 mEq/L Ensures K and Na transport across cell

membrane Important in CHO and protein metabolism Plays significant role in nerve cell conduction Important in transmitting CNS messages and maintaining neuromuscular activity

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Magnesium
Causes vasodilatation Decreases peripheral vascular

resistance Balance - closely related to K and Ca balance Intracellular compartment electrolyte Hypomagnesemia - < 1.5 mEq/L Hypermagnesemia - > 2.5 mEq/L

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Hypomagnesemia
Causes

Decreased intake or decreased

absorption or excessive loss through urinary or bowel elimination Acute pancreatitis, starvation, malabsorption syndrome, chronic alcoholism, burns, prolonged hyperalimentation without adequate Mg Hypoparathyroidism with hypocalcemia Diuretic therapy

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Signs/Symptoms
Tremors, tetany, reflexes, paresthesias

of feet and legs, convulsions Positive Babinski, Chvostek and Trousseau signs Personality changes with agitation, depression or confusion, hallucinations ECG changes (PVCS, V-tach and V-fib)

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Treatment
Mild

Diet Best sources are unprocessed

cereal grains, nuts, legumes, green leafy vegetables, dairy products, dried fruits, meat, fish Magnesium salts More severe MgSO4 IM MgSO4 IV slowly

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Treatment
Monitor Mg q 12 hr Monitor VS, knee reflexes Precautions for seizures/confusion

Check swallow reflex

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Hypermagnesemia
Most common cause is renal failure,

especially if taking large amounts of Mg-containing antacids or cathartics; DKA with severe water loss Signs and symptoms Hypotension, drowsiness, absent DTRs, respiratory depression, coma, cardiac arrest ECG Bradycardia, CHB, cardiac arrest, tall T waves

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Treatment
Withhold Mg-containing products Calcium chloride or gluconate IV for

acute symptoms IV hydration and diuretics Monitor VS, LOC Check patellar reflexes

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Evaluation
Serum magnesium levels WNL Improvement of symptoms

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Phosphorous
Normal 2.5-4.5 mg/dL Intracellular mineral Essential to tissue oxygenation, normal

CNS function and movement of glucose into cells, assists in regulation of Ca and maintenance of acid-base balance Influenced by parathyroid hormone and has inverse relationship to Calcium

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Hypophosphotemia
Causes Malnutrition Hyperparathyroidism

Certain renal tubular defects


Metabolic acidosis (esp. DKA)

Disorders causing hypercalcemia

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Signs/Symptoms
Impaired cardiac function Poor tissue oxygenation Muscle fatigue and weakness

N/V, anorexia
Disorientation, seizures, coma

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Treatment
Closely monitor and correct imbalances

Adequate amounts of Phos


Recommended dietary allowance for formula-

fed infants 300 mg Phos/day for 1st 6 mos. and 500 mg per day for latter of first year 1:1 ratio Phos and Ca recommended dietary allowance. Exception is infants, whose Ca requirements is 400 mg/day for 1st 6 mos and 500 mg/day for next 6 months

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Treatment
Treatment of moderate to severe

deficiency Oral or IV phosphate (do not exceed rate of 10 mEq/h) Identify clients at risk for disorder and monitor Prevent infections Monitor levels during treatment

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Hyperphosphatemia
Causes Chronic renal failure (most common) Hyperthyroidism, hypoparathyroidism

Severe catabolic states


Conditions causing hypocalcemia

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Signs/Symptoms
Muscle cramping and weakness HR Diarrhea, abdominal cramping,

and nausea

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Treatment
Prevention is the goal Restrict phosphate-containing foods Administer phosphate-binding agents

Diuretics
Treat cause

Treatment may need to focus on

correcting calcium levels

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Evaluation
Lab values within normal limits Improvement of symptoms

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