E-lyte Hyponatremia Hypernatremia Hypokalemia Hyperkalemia

Imbalance
[< 135 mEq/L] [> 145 mEq/L] [< 3.5 mEq/L] [> 5.1 mEq/L]
Causes • ↑ Na excretion • ↓ Na excretion • Potentially life- • Excessive K+ intake
threatening!
: Excessive diaphoresis : Corticosteroids : Food

: GI losses (vomiting, diarrhea) : Cushing’s syndrome • Total body K+ loss : Meds = potassium chloride

: Diuretics : Hyperaldosteronism : ↑ use of meds (diuretics or or salt substitutes

: Hypoaldosteronism : RF corticosteroids) : Rapid infusion of K+-

• Inadequate Na intake • ↑ Na intake : Hyperaldosteronism / containing IV solutions

: NPO / low-salt diet : ↑ oral sodium ingestion Cushing’s syndrome • ↓ K+ excretion

• 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+ (Addision’s dis)

: SIADH (= ↑ ADH activity = : Fever • Inadequate K+ intake • Movement of K+ from the

= water retention & : Infection : NPO ECF to ICF

inappropriate urinary excretion : Diarrhea • Dilution of serum K+ : Tissue damage = trauma,

of Na) : Diabetes insipidus : Water intoxication burns, sepsis etc

: Hyperglycemia • Movement of K+ from : Acidosis

the ECF to ICF : Hyperuricemia

: Alkalosis : Hypercatabolism

: Insulin treatment /

Hyoerinsulinism
Assessment / • CV • CV • CV • CV
Sx
: Sx vary w/ changes in : Sx vary w/ changes in : Thready, weak, irregular : Slow, weak, irregular HR

vascular vol vascular vol pulse : ↓ BP

: 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

: Hypervolemic = Rapid, : Early = spontaneous muscle : Shallow, flat or inverted T : Prolonged PR intervals

bouncing pulse twitches, irregular muscle wave • Resp

• Resp contractions : Prominent U wave : SK muscle weakness leading

: Shallow, ineffective resp : Late = sk muscle weakness, • Resp to resp failure

mvmt r/t sk muscle weakness diminished or absent DTR : Shallow, ineffective resp • Neuromuscular

• Neuromuscular • CNS : Diminished breath sounds : Early = muscle twitches,

: Generalized sk muscle : Altered cerebral fxn (the • Neuromuscular cramps, paresthesias in the

weakness most common : Anxiety, lethargy, hands and feet and mouth

: ↓ DTR manifestation) confusion, coma : Late = profound weakness,

• Cerebral fxn : Normo-/hypovolemia = : Sk muscle weakness → ascending flaccid paralysis in

 : HA agitation, confusion, flaccid paralysis the arms and legs

: Personality changes seizures : Loss of tactile • GI

: Confusion : Hypervolemia = lethargy, discrimination : ↑ motility

: Seizures → Coma stupor, coma : ↓ DTR : Hyperactive bowel sounds

• GI • Renal • ↑GI : Diarrhea

: ↑ 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

: ↑ UO

Tx • Hypovolemia → IV NS • For inadequate renal • Oral K+ supplement • D/C IV or PO K+

infusion (slowely) excretion of sodium, supplement
administer diuretics to : Not take on an empty
promote sodium loss
* Always • Hypervolemia → Osmotic stomach to ↓ GI effects • K+-restricted diet

monitor CV, diuretic • Restrict sodium and fluid : AEs = abd pain, distention, • K+-excreting diuretics if
resp, neuro, • Water restriction for pt w/ intake N&V, diarrhea, or GI renal fxn is patent

cerebral, normal or excess fluid vol bleeding → d/c supplement • If renal fxn is impaired,
renal, and GI • SIADH → Lithium, : Liquid K+ = take w/ juice administer sodium

status Demeclocycline to mask the bad taste polystyrene sulfonate

(Declomycin) • 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]

lithium level closely mEq/hr) • If severe, dialysis

• ↑ oral sodium intake : Observe sx of phlebitis • IV hypertonic glucose w/

• D/C K+-losing diuretics regular INS to move excess

K+ into the cells

E-lyte Hypocalcemia Hypercalcemia Hypomagnesemia Hypermagnesemia

Imbalance
[ < 8.6 mg/dL] [ > 10.0 mg/dL] [< 1.6 mg/dL] [> 2.6 mg/dL]
Causes • ↓ GI Ca absorption • ↑ Ca absorption • 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 and laxatives

: Malabsorption syndrome D : Malabsorption syndrome : Excessive IV therapy

(Celiac sprue, Crohn’s dis) • ↓ Ca excretion • ↑ Mg secretion • ↓ renal excretion of Mg

: Vit D deficiency : RF : Diuretics : Renal failure

 : 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

: ↓ peripheral pulse cardiac arrest • ECG changes • ECG changes

• 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

muscle tetany or seizures muscle weakness : Trousseau’s and Chvostek’s : Sk muscle weakness

• Neuromuscular • Neuromuscular signs • CNS

: Twitches, cramps, tetany, : Profound muscle weakness : Hyperreflexia : Drowsiness and lethargy

seizures : Diminished or absent DTR : Tetany, seizures : Coma

: Paresthesias f/b numbness : Disorientation, lethargy, • CNS

: Trousseau’s and Chvostek’s coma : Irritability

signs • GI : Confusion

: Hyperactive DTR : ↓ motility, hypoactive bowel • GI

: Anxiety, irritability sounds : ↓ motility

• GI : Anorexia, nausea, abd : Anorexia, nausea, abd

: ↑ gastric motility; hyperactive distention, constipation distention, constipation

bowel sounds • Renal

: Abd cramping, diarrhea : ↑ UO → dehydration

: Low back pain from renal


Tx • Administer Ca via PO or IV
• IV Ca = warm the solution to
the body temp and monitor
* Always for hypercalcemia
monitor CV, • Medications to ↑ Ca
resp, neuro, absorption
cerebral, renal, : Aluminum hydroxide [= ↓
and GI status serum phosphorus levels,
causing the countereffect of ↑
Ca]
: Vit D to aid Ca GI absorption
• ↓ env stimuli
• Initiate seizure precautions
• Monitor for fracture
• Keep 10% Ca gluconate
available
Phosphorus [2.7 – 4.5 mg/dL]: ↓ serum phosphorus = ↑ serum calcium / ↑ serum phosphorus = ↓ serum calcium
calculi (kidney stones)
• D/C IV or PO meds
containing Ca or Vit D
• D/C thiazide diuretics →
replace w/ diuretics that ↑
Ca excretion
• Medications that inhibit Ca
resorption from the bone
: Phosphorus
: Calcitonin (Calcimar)
: Bisphosphonates
: Prostaglandin synthesis
inhibitors (aspirin, NSAIDs)
• Monitor for fracture
• Monitor for flank or abd
pain, and strain the urine to
check for the presence of
urinary stones
• Hypocalcemia freq • Diuretics to ↑ renal
accompanies excretion of Mg
hypomagnesemia →
interventions aim to restore
normal serum Ca levels • IV calcium chloride or
calcium gluconate to
• For severe case, IV reverse the effects of Mg
magnesium sulfate (No IM on cardiac muscle
injection to prevent pain • Restrict dietary intake of
and tissue damage) Mg-containing foods
• Initiate seizure precautions
• Monitor for DTR,
suggesting
hypermagnesiemia during
the administration of Mg
• PO Mg may cause diarrhea
and ↑ Mg loss