Medical Surgical Nursing

Topic: Electrolytes

Electrolytes Hyponatremia
• Electrolytes are charged particles (ions) that • Refers to the serum sodium concentration
are dissolved in body fluids less than 135 mEq/L
• Electrolytes (dissolved ions) • Common with thiazide diuretic use, but may
also be seen with loop and potassium-
Major Positive Ions (Cations)
sparing diuretics as well
• Na+ - Sodium Ion
• Occurs with marked sodium restriction,
• K+ - Potassium Ion
vomiting and diarrhea, SIADH, etc. The
• Ca2+ - Calcium Ion
etiology may be mulfactorial
• Mg2+ - Magnesium Ion
• May also occur postop due to temporary
Major Negative Ions (Anions) alteration in hypothalamic function, loss of GI
• Cl – Chloride Ion fluids by vomiting or suction, or hydration
• HC0-3 – Bicarbonate Ion with nonelectrolyte solutions
• HPO4 2- & H2PO4- - Phosphate Ions • Postoperative hyponatremia is a more
Normal Values serious complication in premenopausal
women. The reasons behind this is unknown
• Therefore, monitoring serum levels is critical
Cations Anions
and careful assessment for symptoms of
Na – 135-145 mEq/L HCO3 -22-26 mEq/L
K – 3.5 mEq/L Cl – 96-106 mEq/L hyponatremia is important for all
Ca – 4.5-5.5 mEq/L PO4 - 1.2 – 3.0 mEq/L postoperative patients
Mg – 1.5-2.5 mEq/L

What do electrolytes do?

• Promote neuromuscular irritability
• Maintain body fluid volume and osmolarity
• Distribute body water between fluid
compartments
• Regulate acid-base balance

Sodium (Na+)
• Controls and regulates volume of body fluids
• Its concentration is the major determinant of
• Is the chief electrolyte of ECF
• Influence ICF volume
• Participates in the generation and
transmission of nerve impulses
• Is an essential electrolyte in the sodium-
potassium pump
• RDA: not know precisely. 500 mg
• Eliminated primarily by the kidneys, smaller
in feces and perspiration
• Salt intake affects sodium concentrations
• Sodium is conserved through reabsorption in
the kidneys, a process stimulated by
aldosterone
• Normal value: 135-145 mEq/L
Medical Surgical Nursing
Topic: Electrolytes

Collaborative Care Management

• General goal: correct sodium imbalance and
restore normal fluid and electrolyte
homeostasis
• Recognition of people at risk for
hyponatremia is essential for its prevention:
athletes, persons working in hot
environments
• Salt is always replaced along with water
• Management includes educating vulnerable
people to recognize signs and symptoms of
sodium depletion and maintaining sufficient
sodium and water intake to replace skin and
insensible fluid loss
• Generally, an increased sodium and water
intake provides adequate treatment
• Education as the importance of sodium and
fluid balance and the rationale for
prescription medications to ensure
compliance
• Daily weight. MIO
• Monitoring of sodium levels to determine
extent of replacement Collaborative Care Management
• Generally, PNSS or PLRS is prescribed • Recognition of risk factors: bedridden and
• Too rapid restoration of sodium balance, debilitated patients, diabetes insipidus, fluid
hypertonic sodium solutions may provoke deprivation, the elderly and the very young
brain injury • A careful and accurate record of MIO permits
quick recognition of negative fluid balance
Hypernatremia • People with kidney failure, CHF, or increased
• A serum sodium level above 145 mEq/L is
aldosterone production may require dietary
termed hypernatremia
sodium intake restriction
• May occur as a result of fluid deficit or sodium
• Usually, osmolar balance can be restored
excess
with oral fluids. If not, the parenteral route
• Frequently occurs with fluid imbalance
may be necessary
• Develops when an excess of sodium occurs
• Fluid resuscitation must be undertaken with
without a proportional increase in body fluid
particular caution in patients with
or when water loss occurs without
compromised cardiac or renal function
proportional loss of sodium
• The nurse should closely monitor the patient’s
• Risk Factors: excess dietary or parenteral
response to fluids and be alert to symptoms
sodium intake, watery diarrhea, diabetes
of fluid overload
insipidus, damage to thirst center, those with
physical or mental status compromise, and
people with hypothalamic dysfunction
Medical Surgical Nursing
Topic: Electrolytes
Potassium (K+)
• Major cation of the ICF. Chief regulator of
cellular enzyme activity and cellular water
content
• The more K, the less Na. The less K, the more
Na
• Plays a vital role in such processes such as
transmission of electrical impulses,
particularly in nerve, heart, skeletal, intestinal
and lung tissue; CHON and CHO metabolism;
and cellular building; and maintenance of
cellular metabolism and excitation
• Assists in regulation of acid-base balance by
cellular exchange with H
• RDA: not known precisely. 50-100 mEq
• Sources: bananas, peaches, kiwi, figs, dates,
apricots, oranges, prunes, melons, raisins,
broccoli, and potatoes, meat, dairy products
• Excreted primarily by the kidneys. No
effective conserving mechanism
• Conserved by sodium pump and kidneys
when levels are low
• Aldosterone triggers K excretion in urine
• Normal value: 3.5 – 5 mEq/L
Collaborative Care Management
• Being alert to the conditions that cause
potassium depletion such as vomiting,
diarrhea and diuretics, by monitoring the
patient for early warning signs •
• No more than 3 enemas without consulting a
physician
• Education about the importance of adequate
dietary intake of potassium
• In severe hypokalemia, a patient may die
unless potassium is administered promptly
• The safest way to administer K is orally. When
K is given IV, the rate of flow must be
monitored closely and should be diluted.
Should not exceed 20 mEq/hr
• If PO, taken with at least glass of water
• Cardiac monitoring is useful
• Potassium sparing diuretics such as
triamterene, spironolactone, etc.
• Symptoms of K depletion: muscle weakness,
anorexia, nausea and vomiting = appropriate
referral
Medical Surgical Nursing
Topic: Electrolytes

teeth and thickness and strength of cell

membranes
• RDA: 1g for adults. Higher for children and
pregnant and lactating women according
to body weight, older people, esp. post-
menopausal
• Found in milk, cheese, and dried beans;
some in meat and vegetables
• Use is stimulated by Vitamin D. Excreted
Collaborative Care Management in urine, feces, bile, digestive secretions,
• Patients at risk should be identified: impaired and perspiration
renal function to avoid OTC, esp. NSAIDS • Normal value 8.5 – 10.5 mg/dl
which provoke hyperkalemia; and salt
substitutes that are high in potassium
• Severity guides therapy
- Mild: Withholding provoking agent (i.e., K
supp)
- Severe - >6 mEq/L: 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; Continuous cardiac
monitoring
Pathophysiology of Hypocalcemia
• Bowel function must be maintained if
• Calcium ions are thought to line the pores of
Kayexalate therapy is to be effective
cell membranes, especially neurons
• Potassium-wasting diuretics may be
• Calcium and Sodium repel each other
prescribed to promote further potassium
• When serum calcium levels are low, this
loss. Dialysis for patients with renal failure to
blocking effect is minimized
eliminate excess potassium
• When Sodium moves more easily into the cell,
• Intravenous Ca Gluconate may be prescribed
depolarization takes place more easily
to counteract the cardiac effects of
• This results in increased excitability of the
hyperkalemia
nervous system leading to muscle spasm,
• Insulin infusions and IV NaCO3 may be used
tingling sensations, and if severe, convulsions
to promote intracellular uptake of K
and tetany
Calcium (Ca2+) • Skeletal, smooth, and cardiac muscle
• Most abundant electrolyte in the body. functions are all affected by overstimulation
99% in bones and teeth
• Close link between calcium and
phosphorus. High PO4, Low Ca
• Necessary for nerve impulse transmission
and blood clotting and is also a catalyst
for muscle contraction and other cellular
activities
• Needed for Vitamin B12 absorption and
use • Necessary for strong bones and
Medical Surgical Nursing
Topic: Electrolytes

• If PTH or Vit D Deficiency is the cause:

aluminum hydroxide gel is used because
when serum phosphate level rises, calcium
level falls
• Complication: Bone demineralization
• Therefore, careful ambulation should be
encouraged to minimize bone resorption

Collaborative Care Management

• Identify risk factors: Inadequate calcium
intake, excess calcium loss, Vitamin D
deficiency, patients with poor diets
• Education about the importance of adequate
calcium and Vitamin D intake
• Patients undergoing thyroid, parathyroid,
and radical neck surgery are particularly
vulnerable to hypocalcemia secondary to
parathyroid hormone deficit
• Monitoring of serum calcium levels and
correction of deficits
• Citrate is added to store blood to prevent
coagulation.
• Citrate + Transfusion = Citrate + Calcium
• Normally, Liver + Citrate = Quick metabolism
• Preexisting calcium deficit/hepatic
dysfunction/large amounts of BT very rapidly
= hypocalcemia Collaborative Care Management
• With acute hypocalcemia, Ca Gluconate is • Mild hypercalcemia: hydration and
used + Continuous cardiac monitoring education about avoiding foods high in
• Mild Hypocalcemia: High calcium diet or oral calcium or medications that promote calcium
calcium salts elevation
Medical Surgical Nursing
Topic: Electrolytes

• Ambulation as appropriate; weight-bearing

exercises as tolerated
• Trapeze, resistance devices
• Marked hypercalcemia: prevention of
pathologic fractures, individualized plan of
care
• Prevention of renal calculi: encourage oral
fluids to prevent concentrated urine: 3000 to
4000 mL/day unless contraindicated
• Acid-ash fruit juices: cranberry juice and
prune juice
• Severe hypercalcemia: medical emergency:
continuous cardiac monitoring, hydration, IV
furosemide, Calcitonin and/or plicamycin
(mithramycin), q2 serum and urinary
electrolytes

Magnesium (Mg2+)
• Mostly found within body cells: heart, bone,
nerve, and muscle tissues
• Second most important cation in the ICF, 2nd
to K+
• Functions: Metabolism of CHO and CHON,
protein and DNA synthesis, DNA and RNA
transcription, and translation of RNA,
maintains normal intracellular levels of
potassium, helps maintain electric activity in
nervous tissue membranes and muscle
membranes
• RDA: about 18-30 mEq; children require
larger amounts
• Sources: vegetables, nuts, fish, whole grains,
peas, and beans
• Absorbed in the intestines and excreted by
the kidneys
• Plasma concentrations of magnesium range
from 1.5 – 2.5 mEq/L, with about one third of
that amount bound to plasma proteins
Medical Surgical Nursing
Topic: Electrolytes

Collaborative Care Management

• Identification of patients at risk: those with
impaired renal function to avoid OTC that
contain magnesium such as Milk of Magnesia
and some Mg-containing antacids
• Any patient receiving parenteral magnesium
therapy should be assessed frequently for
signs of hypermagnesemia
• Mild hypermagnesemia: withholding
magnesium-containing medications may
suffice
Collaborative Care Management • Renal failure: dialysis
• Recognition of people at risk: people taking • Severe: may require treatment with calcium
loop diuretics and digoxin should be gluconate (10-20 mL of 10% Ca Gluconate
encouraged to eat foods rich in magnesium, administered over 10 minutes)
such as fruits, vegetables, cereals, and milk • If cardiorespiratory collapse is imminent, the
• Recognition of signs and symptoms of patient may require temporary pacemaker
magnesium deficiency and ventilator support
• Magnesium is essential for potassium
resorption, so if hypokalemia does not
respond to potassium replacement,
hypomagnesemia should be suspected
• Treatment of the underlying cause is the first
consideration in hypomagnesemia
• Severe: parenteral magnesium replacement
is indicated
• IV therapy: continuous cardiac monitoring
• Safety measures for patients with mental
status changes

Hypermagnesemia
• Serum Mg level 2.5 mEq/L
• May occur as a result of Mg replacement
• May occur when MgSO4 is administered to
prevent seizures resulting from eclampsia
• Careful monitoring is imperative