FLUID & ELECTROLYTE IMBALANCE

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

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
Total body fluid 60% of body weight
Intracellular
fluids
Extracellular
fluids
Interstitial
Fluid
( 15% of body wt)
Transcellular
Fluid
(plasma)
Intravascular
Fluid
(CSF)

5.  Intracellular space or compartment
Most of the body fluids are in the intra cellular
compartment (inside the cells). Electrolyte
prevalent are K+ & PO4
3-
 Extracellular space or compartment
(fluid outside the cells)
a) Interstitial fluid – fluid between the cells
b) Intravascular fluid – fluid inside blood vessels
c) 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
Generalized 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 Fluids Excretion
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
IV FLUIDS
Crystalloids
Isotonic
Hypertonic
Hypertonic
Colloids Blood products

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

21. Types of Crystalloids
 Isotonic 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
o If serum potassium level are dangerously
elevated, it may be necessary to
administration IV calcium gluconate
o 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