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I. POTASSIUM IMBALANCES
main intracellular ion; involved in cardiac rhythm, nerve transmission (normal level 3.55.0 mEq/ L)
Hypokalemia (< 3.5 mEq/ L)
Causes:
a. Vomiting
b. Gastric suction
c. Prolonged diarrhea
d. Diuretics and steroidse. Inadequate intake
Signs and symptoms:
a. Anorexia, nausea, vomiting
b. Weak peripheral pulses
c. Muscle weakness, paresthesias; decreased deep tendon
reflexes
d. Impaired urine concentration
e. Ventricular dysrhythmias
f. Potential for digitalis toxicity
g. Shallow respirations
Nursing management:
a. Administration of oral potassium supplementsdilute
in juice and give with meals to avoid gastric irritation
b. Increase dietary intakeraisins, bananas, apricots,
oranges, beans, potatoes, carrots, celery
c. IV supplements2040 mEq/ L usual concentration;
cannot give concentration greater than 1 mEq/ 10mL into
peripheral IV, or without cardiac monitor; do not exceed
20 mEq/ h infusion rate; stop solution immediately if
burning occurs
d. Assess renal function prior to administratione. Risk for digitalis toxicity
Hyperkalemia (> 5.0 mEq/ L)
Causes:
a. Renal failure
b. Use of potassium supplements
c. Burns
d. Crushing injuriese. Severe infection
f. Potassium-sparing diuretics
g. ACE inhibitors
Signs and symptoms
a. EKG changespeaked T waves, wide QRS complexes
b. Dysrhythmias, ventricular fibrillation, heart block
c. Cardiac arrest
d. Muscle twitching and weakness
e. Numbness in hands and feet and around mouth
f. Nausea
g. Diarrhea
Nursing management
a. Restrict dietary potassium and potassium-containing
medications or IV solutions
b. Sodium polystyrene sulfonate (Kayexalate)cation-
exchange resin (causes diarrhea)
1) Orallydilute to make more palatable
2) Rectallygive in conjunction with sorbitol to avoid
fecal impaction
c. In emergency situation
1) Calcium gluconate given IV2) Sodium bicarbonate given IV
d. IV administration of regular insulin and dextrose shifts
potassium into the cells
e. Peritoneal or hemodialysis f. Diuretics
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II. SODIUM IMBALANCES
main extracellular ion; responsible for water balance (normal: 135145 mEq/ L)
Hyponatremia (< 135 mEq/ L)
Causes:
a. Vomiting
b. Diuretics
c. Excessive administration of dextrose and water IVs
d. Burns, wound drainagee. Excessive water intake
f. Syndrome of inappropriate antidiuretic hormone
secretion (SIADH)
g. Elderlykidneys unable to excrete free water
Signs and symptoms:
a. Nausea
b. Muscle cramps
c. Confusion
d. Muscular twitching, coma
e. Seizures
f. Headache
g. Delirium in older adults
Nursing management:
a. Oral administration of sodium-rich foodsbeef broth,
tomato juice
b. IV lactated Ringers or high concentrations of NaCl
(0.9%)
c. Water restriction (safer method)
d. I and O
e. Daily weight
Hypernatremia (> 145 mEq/ L)
Causes:
a. Hypertonic tube feedings without water supplements
b. Hyperventilation
c. Diabetes insipidus
d. Ingestion of OTC drugs such as Alka-Seltzere. Inhaling large amounts of saltwater (near drowning)
f. Inadequate water ingestion
Signs and symptoms:
a. Elevated temperature
b. Weakness
c. Disorientation
d. Irritability and restlessness
e. Thirst
f. Dry, swollen tongue
g. Sticky mucous membranes
h. Postural hypotension with ECF Hypertension with
normal or ECF
i. Tachycardia
j. Elderlymental status changes, coma
Nursing management:
a. IV administration of hypotonic solution0.3% NaCl or
0.45% NaCl; 5% dextrose in water
b. Offer fluids at regular intervals
c. Decrease sodium in diet
d. Daily weight
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III. CALCIUM IMBALANCES
need for blood clotting, skeletal muscle contraction (normal ionized serum calcium level: 4.55.2 mg/ dL;
normal total serum calcium level: 8.510.5 mg/ dL);regulated by the parathyroid hormone and vitamin D,
which facilitates reabsorption of calcium from bone and enhances reabsorption from the GI tract
Hypocalcemia (< 4.5 mg/ dL [ionized serum calcium] or 5.2 mg/ dL [ionized serum calcium] or >
10.5 mg/ dL [total serum calcium])
Causes:
a. Malignant neoplastic diseases
b. Hyperparathyroidism
c. Prolonged immobilization
d. Excessive intake
e. Immobility
f. Excessive intake of calcium carbonate antacids
Signs and symptoms:
a. Lack of coordination
b. Anorexia, nausea, and vomiting
c. Confusion, decreased level of consciousness
d. Personality changes
e. Dysrhythmias, heart block, cardiac arrest
Nursing management:
a. IV administration of 0.45% NaCl or 0.9% NaCl
b. Encourage fluids
c. Lasix
d. Calcitonindecreases calcium level
e. Mobilizing the patient
f. Dietary calcium restriction
g. Prevent development of renal calculi
1) Increase fluid intake
2) Maintain acidic urine3) Prevent urinary tract infection
h. Injury prevention
i. Limit intake of calcium carbonate antacids
j. Surgical intervention may be indicated in
hyperparathyroidism (cause of hypercalcemia)
1) Preoperativelydirected toward preventing
dangerously high serum calcium levels
2) Postoperatively
a) Observe for signs of hypocalcemia (reverse of
preop)
b) Due to calcium drop postop, large quantities of
calcium salts may be required
c) Encourage early ambulation to aid in
recalcification of bones
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IV. MAGNESIUM IMBALANCE
interdependent with calcium (normal: 1.53.0 mEq/ L)
Hypomagnesemia (< 1.5 mEq/ L)
Causes:
a. Alcoholism
b. GI suction
c. Diarrhea
d. Intestinal fistulase. Poorly controlled diabetes mellitus
f. Malabsorption syndrome
Signs and symptoms:
a. Increased neuromuscular irritability
b. Tremors
c. Tetany
d. Hyperactive deep tendon reflexes
e. Seizures
f. Dysrhythmias especially if hypokalemia present
g. Disorientation
h. Confusion
Nursing management:
a. Increased intake of dietary Mggreen vegetables, nuts,
bananas, oranges, peanut butter, chocolate
b. Parenteral administration of supplementsmagnesium
sulfate
1) Monitor cardiac rhythm and reflexes to detect
depressive effects of magnesium
2) Keep self-inflating breathing bag, airways, and
oxygen at bedside in case of respiratory emergency
3) Calcium preparations may be given to counteractthe potential danger of myocardial dysfunction that
may result from magnesium intoxication secondary to
rapid infusions
c. Orallong-term maintenance with oral magnesium
d. IVassess renal function
e. Monitor for digitalis toxicity
f. Seizure precautions
g. Safety measures for confusion
h. Test ability to swallow before PO fluids/ food because of
dysphagia
Hypermagnesemia (> 2.5 mEq/ L)potent vasodilator
Causes:
a. Renal failure
b. Excessive magnesium administration (antacids,
cathartics)
Signs and symptoms:
a. Depresses the CNS
b. Depresses cardiac impulse transmission
c. Cardiac arrest
d. Facial flushing
e. Muscle weakness
f. Absent deep tendon reflexes
g. Paralysis
h. Shallow respirations
Nursing management:
a. Discontinue oral and IV Mg
b. Emergency
1) Support ventilation
2) IV calcium gluconate
c. Hemodialysis
d. Monitor reflexes
e. Teach regarding over-the-counter drugs containing Mg
f. Monitor respiratory status
g. Monitor cardiac rhythm; have calcium preparations
available to antagonize cardiac depressant