Electrolytes

1. Electrolytes

2. Objectives • Electrolytes – Cations & Anions • Functions – Electrolytes • Electrolyte Imbalances – You See & You Do

3. Electrolytes • Charged particles in solution • Cations (+) • Anions (-) • Integral part of metabolic and cellular processes

4. Composition of Body FluidsComposition of Body Fluids

5. Major Cations • EXTRACELLULAR – SODIUM (Na+) • INTRACELLULAR – POTASSIUM (K+)

6. What do Electrolytes - Do? • Promotes neuromuscular impulses. • Maintain body fluid volume & Osmolarity. • Distribute body water between fluid compartments. • Regulate acid base balance.

7. Electrolyte Imbalances • Hyponatremia/ Hypernatremia • Hypokalemia/ Hyperkalemia • Hypomagnesemia/ Hypermagnesemia • Hypocalcemia/ Hypercalcemia • Hypophosphatemia/ Hyperphosphatemia • Hypochloremia/ Hyperchloremia

8. Hyponatremia • Serum Na+ level < 135 mEq/L • Deficiency in Na+ related to amount of body fluid • Several types – Dilutional – Depletional – Hypovolemic – Hypervolemic – Isovolemic

9. Surgical Causes - Hyponatremia • Intestinal obstruction • Intestinal fistulas – biliary / duodenal / gastric / pancreatic • GOO – severe vomiting • Ryle’s tube aspiration • Severe diarrhoea – Colitis / colerectal polyps • After surgery & trauma – occurs

10. What Do You See ? • Sunken eyes, Dry coated tongue, poor skin turgor • Headache, N/V, muscle twitching, altered mental status • Irritability, neurological symptoms, convulsions , coma

11. What Do We Do? • MILD / CHRONIC CASE – Na < 115 mEq/ L – Restrict fluid intake for hyper/isovolemic hyponatremia – IV fluids and/or increased Na+ intake for hypovolemic hyponatremia • SEVERE / ACUTE CASE – Na < 100 mEq/L – Infuse hypertonic NaCl solution (3% or 5% NaCl) – Frusemide to remove excess fluid – Monitor client in ICU

12. Hypernatremia • Excess Na+ relative to body water • Occurs less often than hyponatremia • Na > 150 mEq / L • When hypernatremia occurs, fluid shifts outside the cells • May be caused by water deficit or over- ingestion of Na+ - Renal dysfuction • Also may result from diabetes insipidus, Cardiac failure, Drug – NSAID / Steroids

13. What Do You See ? • Think S-A-L-T Skin flushed Agitation Low grade fever Thirst • Neurological symptoms • Signs of hypovolemia Firm,

14. What Do We Do? • Correct underlying disorder • Restrict saline & sodium • Gradual / Slow fluid replacement • Monitor for s/s of cerebral edema • Monitor serum Na+ level • Seizure precautions

15. Potassium • Major intracellular cation • Untreated changes in K+ levels can lead to serious neuromuscular and cardiac problems • Normal K+ levels = 3.5 - 5 mEq/L

16. Balancing Potassium • Most K+ ingested is excreted by the kidneys • Three other influential factors in K+ balance : – Na+/K+ pump – Renal regulation – pH level

17. Hypokalemia • Serum K+ < 3.5 mEq/L • Caused by – • SUDDEN = Pts in Diabetic coma • GRADUAL – Diarrhoea – Villous+UC – PS + GOO – Duodenal fistula – Ileostomy / USD – Poisoning – Beta agonists

18. What Do You See? • Think S-U-C-T-I-O-N – Skeletal muscle weakness / Slurred speech – U wave (ECG changes) - Arrythmias – Constipation, ileus – Tone – Hypotonia = Sign – I rregular, weak pulse – O rthostatic hypotension – N umbness (paresthesias)

19. HypokalemiaHypokalemia

20. What Do We Do? • Increase dietary K+ • Oral KCl supplements • IV K+ replacement • Change to K+-sparing diuretic • Monitor ECG changes

21. IV K+ Replacement • Mix well when adding to an IV solution bag • Concentrations should not exceed 40-60 mEq/L • Rates usually 10- 20 mEq/hr NEVER GIVE IVNEVER GIVE IV PUSHPUSH POTASSIUMPOTASSIUM

22. Hyperkalemia • Serum K+ > 6 mEq/L • Less common than hypokalemia • Caused by altered kidney function, increased intake (salt substitutes), blood transfusions, meds (K+-sparing diuretics), cell death (trauma)

23. What Do You See? • Irritability • Paresthesia • Muscle weakness (especially legs) • ECG changes (tented / peak T wave) • Irregular pulse • Hypotension • Nausea, abdominal cramps, diarrohea

24. What Do We Do? • Mild – Loop diuretics (Lasix) – Dietary restriction • Moderate – Cation-exchange resin such as Kayexalate (act by exchanging the cations in the resin for the potassium in the intestine) potassium is then excreted in the stool • Emergency – 10% calcium gluconate for cardiac effects – Sodium bicarbonate for acidosis

25. Calcium • 99% in bones, 1% in serum and soft tissue (measured by serum Ca++) • Works with phosphorus to form bones and teeth • Role in cell membrane permeability • Affects cardiac muscle contraction • Participates in blood clotting • Normal value 8.5 – 10.5 mg/dl

26. Hypocalcemia • Serum calcium < 8.9 mg/dl • Caused by inadequate intake, malabsorption, pancreatitis, thyroid or parathyroid surgery, loop diuretics, low magnesium levels

27. What Do You See? • Neuromuscular – Anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers, toes), tetany, carpopedal spasms • Fractures • Diarrohea • Diminished response to digoxin • EKG changes

28. TESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCYTESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCY

29. What Do We Do? • Calcium gluconate for postop thyroid or parathyroid client • Cardiac monitoring • Oral or IV calcium replacement

30. Hypercalcemia • Serum calcium > 10.1 mg/dl • Two major causes – Cancer – Hyperparathyroidism

31. What Do You See? • Fatigue, confusion, lethargy, coma • Muscle weakness, hyporeflexia • Bradycardia ⇒ cardiac arrest • Anorexia, nausea/vomiting, decreased bowel sounds, constipation • Polyuria, renal calculi, renal failure

32. CLINICAL MANIFESTATIONS OF HYPERCALCEMIACLINICAL MANIFESTATIONS OF HYPERCALCEMIA Decreased GIDecreased GI MotilityMotility Cardiac DysrhythmiasCardiac Dysrhythmias ConstipationConstipation NauseaNausea Mental status changes:Mental status changes: lethargy, confusion,lethargy, confusion, memory lossmemory loss

33. CLINICAL MANIFESTATIONS OF HYPERCALCEMIACLINICAL MANIFESTATIONS OF HYPERCALCEMIA ImmobilizationImmobilization BoneBone DemineralizationDemineralization CalciumCalcium accumulates inaccumulates in the ECF andthe ECF and passes throughpasses through the kidneysthe kidneys Ca PrecipitationCa PrecipitationCalcium StonesCalcium Stones

34. What Do We Do? • If asymptomatic, treat underlying cause • Hydrate the patient to encourage diuresis • Loop diuretics • Corticosteroids

35. Magnesium • Cofactor for many enzymes – ATP utilisation in muscle fiber • Role in protein synthesis & carbohydrate metabolism • Helps cardiovascular system function (vasodilation) • Regulates muscle contractions

36. Hypomagnesemia • Serum Mg++ level < 1.5 mEq/L • Caused by poor dietary intake, poor GI absorption, excessive GI/urinary losses • High risk clients – Chronic alcoholism – Malabsorption – GI/urinary system disorders – Sepsis – Burns – Wounds needing debridement

37. What Do You See? • CNS –Altered LOC –Confusion –Hallucinations • Neuromuscular – Muscle weakness – Leg/foot cramps – Hyper DTRs – Tetany

38. CLINICAL MANIFESTATIONS OF HYPOMAGNESEMIACLINICAL MANIFESTATIONS OF HYPOMAGNESEMIA CONFUSIONCONFUSION DEPRESSIONDEPRESSION CRAMPSCRAMPS TETANYTETANY CONVULSIONSCONVULSIONS

39. What Do You See? • Cardiovascular –Tachycardia –Hypertension –ECG changes • Gastrointestinal –Dysphagia –Anorexia –Nausea/vomiting

40. What Do We Do? • Mild – Dietary replacement • Severe – IV or IM magnesium sulfate • Monitor – Neuro status – Cardiac status – Safety

41. Mag Sulfate Infusion • Use infusion pump - no faster than 150 mg/min • Monitor vital signs for hypotension and respiratory distress • Monitor serum Mg++ level q6h • Cardiac monitoring • Calcium gluconate as an antidote for overdosage

42. Hypermagnesemia • Serum Mg++ level > 2.5 mEq/L • Not common • Renal dysfunction is most common cause – Renal failure – Addison’s disease – Adrenocortical insufficiency – Untreated DKA

43. What Do You See? • Decreased neuromuscular activity • Hypoactive DTRs • Generalized weakness • Occasionally nausea/vomiting

44. What Do We Do? • Increased fluids if renal function normal • Loop diuretic if no response to fluids • Calcium gluconate for toxicity • Mechanical ventilation for respiratory depression • Hemodialysis (Mg++-free dialysate)

Electrolytes

Uthamalingam Murali

Electrolytes