II-3.

Day 3_ Electrolytes Part 2 (Cl, Mg & • particularly involved in the production

PO4) and use of ATP
Chloride (Cl) • necessary for protein and DNA
• major anion of ECF synthesis within the cells
• normal serum levels are 95 to 108 mEq/ • Only about 1% of the body’s
L magnesium is in ECF
• Chloride functions with sodium to • involved in regulating neuromuscular
regulate serum osmolality and blood and cardiac function
volume. • Cereal grains, nuts, dried fruit,
• The concentration of chloride in ECF is legumes, and green leafy vegetables are
regulated secondarily to sodium good sources of magnesium in the diet,
• when sodium is reabsorbed in the as are dairy products, meat, and fish.
kidney, chloride usually follows. Phosphate PO4
• major component of gastric juice as • major anion of intracellular fluids
hydrochloric acid (HCl) • found in ECF, bone, skeletal muscle,
• involved in regulating acid–base and nerve tissue
balance. • Normal serum levels of phospate in
• acts as a buffer in the exchange of adults range from 2.5 to 4.5 mg/dL.
oxygen and carbon dioxide in RBCs • Children have much higher phosphate
• found in the same foods as sodium. levels than adults
Magnesium (Mg++) • involved in many chemical actions of
• primarily found in the skeleton and in the cell;
intracellular fluid. • essential for functioning of muscles,
• It is the second most abundant nerves, and red blood cells.
intracellular cation • involved in the metabolism of protein,
• normal serum levels is 1.5 to 2.5 mEq/L fat, and carbohydrate.
• It is important for intracellular • Phosphate is absorbed from the
metabolism intestine and

 • is found in many foods such as meat, IMBALANCES IN CHLORIDE

fish, poultry, milk products, and 1. HYPOCHLOREMIA
legumes. CAUSES:
3.1 HYPOCHLOREMIA & • Excessive losses through the GI
HYPERCHLOREMIA system- vomiting, diarrhea
CHLORIDE • nasogastric suctioning & irrigation
• Cl – extracellular anion, • Diuresis
• Nornal serum levels = 96-106 mEq/L • Metabolic alkalosis
• binds with Na, H (also K, Ca, etc) • Hyponatremia, prolonged D5W IV
• Most abundant anion in ECF • Excessive water within the body
• exchanges with HCO3 in the kidneys & • over infusion of hypotonic solution
in RBC • excessive water intake
• Cl- is roduces in the stomach as HCl SIGNS & SYMPTOMS:
acid • hypoNa, hypoK, metabolic alkalosis
FUNCTIONS • Hyperactivity of
• helps regulate BP, serum osmolarity muscles,tetany,weakness,dysrhythmias
• Helps balance Na NURSING DIAGNOSIS
• Acid/base balance (exchanges with • Fluid volume excess / deficit
HCO3) • High risk for injury
• Major component of gastric secretions • Impaired physical mobility
• Na & Cl assist in determining osmotic MANAGEMENT:
pressure 1. replace fluids as ordered
• Works with Na+ to maintain serum 2. replace electrolytes
osmolality. 3. monitor serum electrolytes
• Maintains the balance of anions in the 4. increase patient's cl- intake
ICF and ECF 5. Assess for SZ
Sources 6. MIO
• salt, canned food, cheese, milk, eggs, 7. VS
crab, olives 8. ABG

 9. Meds ( KCl or NaCl ) • Monitor ingestion of Cl- from sources

DIET: high chloride food • MIO, VS, ABG
• Advise to avoid salt
2. HYPERCHLOREMIA • Meds : NaHCO3
CAUSES: • Correct DHN
• Metabolic acidosis (terminal cancer, Diet: low Cl (& usually Na)
starvation) 3.2 HYPOMAGNESEMIA &
• Usually noted in hyperNa, hyperK and HYPERMAGNESEMIA
loss of bicarbonate Magnesium [Mg]
• Dehydration • Mg influences carbohydrate
SIGNS & SYMPTOMS: metabolism, secretion of parathyroid
• Deep, rapid respirations, weakness, hormone, sodium/potassium transport
lethargy across the cell membrane, and synthesis
• hyperK, hyperNa of protein and nucleic acid.
• Diminished cognitive ability, • Mg activates adenosine triphosphate
hypertension (ATP) and mediates neural transmission
NURSING DIAGNOSIS within the CNS.
• Fluid volume excess / deficit • Normal serum range is 1.5–2.5 mEq/L
• High risk for injury or 1.8–3.0 mg/dL.
• Impaired physical mobility • Mg – 2nd most abundant intracellular
• Self care deficit cation = 1.5-2.5 meq/L
NURSING MANAGEMENT: • 70% found in bone combined w/PO4 &
• Identify patient at risk Ca, 30% is intracellular or soft tissue
• Treat acidosis • Competes with Ca & PO4 absorption in
• Diuretics monitor V/S, M the GI
• Measure I/O • Inhibits PTH
• Hypotonic solutions, D5W to restore • Daily requirements : 200-300 mg/day
balance • Absorption :45% absorbed via GIT
• Monitor serum electrolytes

 • Excretion : 60% excretion via feces , • Decrease intake of Mg

40% via kidneys SIGNS & SYMPTOMS
• Inhibits absorption via GIT: • muscle weakness, tremors, athetoid
◦ Excess fat movement(dysphagia),
◦ Increase PO4 • seizures, hyperactive reflexes
◦ Increase Ca (+Chvostek’s and Trousseau’s)
◦ alkalosis • Like hypocalcemia,
FUNCTIONS hypokalemia potentiates digitalis
• important in maintaining intracellular toxicity
activity Predisposing/contributing factors
• affects muscle contraction, & especially • GI losses
relaxation • Protein/calorie malnutrition
• maintains normal heart rhythm • Prolonged IV infusion of magnesium-
• promotes vasodilation of peripheral free solutions
arterioles • multiple transfusions with citrated
• Activates enzymatic activity esp.in the blood products
CHO & CHON metabolism • Chronic alcoholism, alcohol
Sources withdrawal; pancreatitis
• green leafy vegetables, nuts, legumes, • Hyperaldosteronism: Primary or
seafood, whole grains, bananas, secondary (e.g., cirrhosis or HF)
oranges, cocoa, chocolate • Renal losses
IMBALANCES IN MAGNESIUM • Drugs that affect magnesium balance:
1. HYPOMAGNESEMIA (Magnesium Aminoglycosides (gentamicin,
Deficit) tobramycin), antifungals (amphotericin
Cause B); chemotherapy agents (cisplatin);
• Chronic alcoholism (most common) antirejection agents (cyclosporine), and
• Inflammatory bowel disease, small excessive doses of calcium or vitamin
bowel resection, GI cancer, chronic D supplements
pancreatitis (poor absorption)

 • Diabetic ketoacidosis, hypercalcemic • Calcium: May be decreased, unless

states, severe burns, sepsis, there is a hypercalcemic condition
hypothermia; hypoparathyroidism, causing the magnesium deficit.
hypercalcemia, hyperthyroidism • Potassium: Decrease
Patient Assessment • ECG: Prolonged PR and QT intervals,
• Generalized weakness, insomnia widened QRS complex, ST segment
• Ataxia, vertigo depression, T wave inversion.
• Tachycardia, dysrhythmias MANAGEMENT
• Hypotension (vasodilation); occasional • Magnesium sulfate IV slow or infusion
hypertension pump, IM (make sure renal function is
• Anorexia, nausea/vomiting, diarrhea ok)
• Paresthesia (legs, feet) • Oral: Magnesium oxide 300mg/day,
• Vertigo • Diet: high magnesium
• Nystagmus • Monitor urine output
• Musculoskeletal fasciculations/tremors, • Calcium gluconate must be readily
neuromuscular irritability/spasticity, available
• spontaneous carpopedal spasms, NURSING ACTIONS/INTERVENTIONS
hyperactive deep tendon reflexes, Electrolyte Management: Hypomagnesemia
clonus Independent
• Tetany, convulsions; positive 1. Monitor cardiac rate/rhythm
Babinski’s, Chvostek’s, and 2. Monitor for signs of digitalis
Trousseau’s signs intoxication
• Disorientation, apathy, depression, 3. Assess level of consciousness and
irritability, agitation, hallucinations/ neuromuscular status
psychoses, 4. Monitor status of airway and
• coma swallowing.
Diagnostic studies 5. Take seizure/safety precautions
• Serum magnesium: Decreased 6. Provide quiet environment and subdued
lighting.

 7. Encourage ROM exercises as tolerated. • Magnesium treatment for pre-eclampsia

8. Place footboard/cradle on bed. • Renal failure
9. Auscultate bowel sounds. • Excessive use of Mg antacids/laxatives
10. Encourage intake of dairy products, • DKA
whole grains, green leafy vegetables, Signs and symptoms
meat, and fish. **Same like hypercalcemia
11. Instruct patient in proper use of Predisposing/contributing factors
laxatives and diuretics. • Reduced renal function
12. Observe for signs of magnesium • Excessive Mg intake/absorption
toxicity during replacement therapy, • Untreated diabetic ketoacidosis
Collaborative • Hyperparathyroidism, aldosterone
1. Assist with identification/treatment of deficiency, adrenal insufficiency
underlying cause. • Extracellular fluid volume depletion
2. Monitor laboratory studies, e.g., serum (e.g., after diuretic abuse)
magnesium, calcium, and potassium • Salt-water near-drowning, hypothermia,
levels. shock
3. Administer medications as indicated: • Chronic diarrhea; diseases that interfere
4. Magnesium sulfate or magnesium with gastric absorption
chloride IV, monitoring administration Patient Assessment
closely; • Generalized weakness, fatigue,
5. Magnesium sulfate IM, or magnesium somnolence
hydroxide PO (Amphojel, Milk of • Drowsiness, lethargy, stupor, coma
Magnesia); • Hypotension, Pulses weak/irregular,
6. Magnesium-based antacids, e.g., bradycardia, arrhythmia/ cardiac arrest
Mylanta, Maalox, Gelusil, Riopan. (greater than 25 mEq/L)
• Nausea/vomiting
2. HYPERMAGNESEMIA (Magnesium • Hyporeflexia
Excess) • Depressed deep tendon reflexes
Cause progressing to flaccid paralysis

 • Decreased level of consciousness, 4. Monitor RR, depth/rhythm. Encourage

lethargy progressing to coma cough/deep-breathing exercises.
• Slurred speech Elevate head of bed as indicated.
• Hypoventilation progressing to apnea 5. Check patellar reflexes periodically.
(12–15 mEq/L) 6. Encourage increased fluid intake if
• Decreased RR & respiratory appropriate.
paralysis(cardiac arrest) 7. Monitor urinary output and 24-hr fluid
• Skin flushing, sweating balance
Diagnostic studies 8. Promote bedrest, assist with personal
• Serum magnesium: inc care activities as needed.
• ECG: Prolonged PR and QT intervals, 9. Recommend avoidance of magnesium-
wide QRS, elevated T waves, containing anatacids, e.g., Maalox,
development of heart block, cardiac Mylanta, Gelusil, Riopan, in patient
arrest. with renal disease.
MANAGEMENT Collaborative
• Diuretics 1. Assist with identification/treatment of
• Stop Mg-containing antacids & enemas underlying cause.
• IV fluids rehydration 2. Monitor laboratory studies as indicated,
• Calcium gluconate – (antidote, e.g.,: serum magnesium and calcium
antagonizes cardiac & respiratory levels.
effects of Mg) 3. Administer IV fluids and thiazide
NURSING ACTIONS/INTERVENTIONS diuretics as indicated.
Electrolyte Management: Hypermagnesemia 4. Administer 10% calcium chloride or
Independent gluconate IV.
1. Monitor cardiac rate/rhythm. 5. Assist with dialysis as needed.
2. Monitor BP. 3.3 HYPOPHOSPHATEMIA &
3. Assess LOC and neuromuscular status HYPERPHOSPHATEMIA
PHOSPHORUS
• P – primary intracellular anion

 • Normal serum ranges at 5-4.5 mg/dL • Aluminum & Mg-containing antacids

• part of ATP – energy (bind P)
• 85% bound with Ca in teeth/bones, • Severe vomiting & diarrhea
skeletal muscle • Malnourished, alcohol withdrawal,
• reciprocal balance with Ca DKA
• absorption affected by Vit D, SIGNS & SYMPTOMS
• regulation affected by PTH (lowers P • Anemia, bruising (weak blood cell
level) membrane)
FUNCTIONS • ATP deficiency
• bone/teeth formation & strength • Seizures, coma, irritability, fatigue,
• Essential to the function of muscle & confusion
RBC • Muscle weakness, paresthesias
• part of ATP • Constipation, hypoactive bowel sounds
• Involved in structure of genetic • Tissue anoxia or hypoxia
material DNA and RNA • *Like hypercalcemia
• Maintenance of acid-base balance MANAGEMENT & NURSING ACTIONS
• Metabolism of carbo,protein,& fat • Sodium phosphate or potassium
• Contituent of all body tissues phosphate IV (give slowly, not faster
Sources than 10 mEq/hr)
• Red & organ meats (brain, liver, • Sodium & potassium phosphate orally
kidney),poultry,fish,eggs,milk,legumes, (Neutra-Phos, K-Phos) – give with
grains,nuts,soda meals to prevent gastric irritation
IMBALANCES IN PHOSPHORUS / • Avoid P-binding antacids
PHOSPHATE • Monitor joint stiffness, arthralgia,
1. HYPOPHOSPHATEMIA fractures, bleeding
Cause • Goal of Care: prevention and maintain
• Decreased Vit D absorption, low PO4 within normal
Ca(osteomalacia) • Diet: high Mg, milk
• Hyperparathyroidism (increased PTH)

 2. HYPERPHOSPHATEMIA
Causes
• Acidosis (P moves out of cell)
• Cytotoxic agents/chemotherapy in
cancer
• Renal failure
• Hypocalcemia
• Massive BT (P leaks out of cells during
storage of blood)
• Hyperthyroidism
SIGNS & SYMPTOMS
• Tetany
• Tachycardia
• Anorexia
• N/V
• Muscle weakness
• S/Sx of hypocalcemia
MANAGEMENT & NURSING ACTIONS
• Aluminum antacids as phosphate
binders: Al carbonate (Basaljel), Al
hydroxide (Amphojel)
• Ca carbonate for hypocalcemia
• Avoid phosphate laxatives/enemas
• Increase fluid intake
Diet: low P, no carbonated drinks