Medical Surgical Nursing Preparation for Practice CHAPTER 18

LEARNING OBJECTIVE 1 • Explain the normal composition of fluids and electrolytes in the

Body Fluid Composition • Compartments – ICF § Cell cytoplasm and nucleus – ECF

Functions of Body Fluids • Salivary enzymes • Transport to body tissues: – –

Functions of Body Fluids • Elimination of waste products – Bowel – Bladder •

LEARNING OBJECTIVE 2 • Describe the normal osmolality of the blood and urine. Medical

Osmolality • Number of solutes per kilogram of water – Isotonic – Hypertonic –

Regulation of Body Fluids • Osmosis – Movement of water • Diffusion – Movement

Osmosis & Diffusion Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita

Diffusion • • • Molecule size Electrical charges Pressure gradient Active diffusion Passive diffusion

Filtration • Movement is result of hydrostatic pressure – Pressure of water on surrounding

LEARNING OBJECTIVE 3 • Evaluate fluid status of an adult according to normal fluid

Evaluation of Fluid Status • Osmolality – Normal is 275 – 295 m. Osm/kg

Evaluation of Fluid Status • Normal serum hematocrit – 40 – 50% • Dilute

Distribution of Body Fluids • Overhydration: osmosis shifts water from blood to ICF and

Fluid Accumulation • Can also occur in lung capillaries, alveoli – Crackles heard on

Dehydration • Causes – Excessive urinary water loss – Hyperglycemia – Inadequate fluid intake

Dehydration and the Elderly • Increased risks for dehydration – Decrease in thirst –

Manifestations of Dehydration • • • Thirst; dry mouth and tongue Tenting of skin

LEARNING OBJECTIVE 4 • Define the normal ranges of electrolytes in the body. Medical

Electrolytes • • • Sodium Chloride Potassium Calcium Phosphorus Magnesium Medical Surgical Nursing: Preparation

Sodium • Most abundant cation in ECF • Functions – ECF volume – Acid-base

Sodium Regulation • Aldosterone – Sodium retention • Antidiuretic hormone (ADH) – Water reabsorption

Potassium • Intracellular cation • Normal serum levels: 3. 5 – 5. 0 m.

Potassium • Food sources include bananas, meat, potatoes • Anabolic states – Stored in

Calcium • Cation found in both ICF and ECF but > in ECF. •

Calcium Regulation • Vitamin D – Calcium absorption • Calcitonin – Inhibits resorption in

Magnesium • • • Intracellular Cation Normal serum levels: 1. 4 – 2. 1

Phosphorus • Intracellular anion • Normal serum levels: 1. 5 – 2. 5 mg/d.

Chloride • Primary extracellular anion • Normal serum levels: 95 – 108 m. Eq/L

LEARNING OBJECTIVE 4 • Discuss various circumstances that place the patient at risk for

Causes of Hypernatremia • Deficit of water relative to sodium • Causes – Excessive

Manifestations of Hypernatremia • • Thirst Low grade fever Edema Altered mental status Hypertension

Causes of Hyponatremia • • • Water retention Inadequate sodium intake Loss of sodium-rich

Manifestations of Hyponatremia • Depolarization and repolarization of cells • Neurological symptoms – Lethargy

Manifestations of Hyponatremia • Fluid overload causes dilutional hyponatremia • Symptoms: – Hypertension –

Causes of Hyperkalemia • Increased potassium intake – Inappropriate potassium supplementation • Decreased urinary

Manifestation of Hyperkalemia • • Muscle weakness and cramping ECG changes – peaked T

Hyperkalemia in Cardiac rhythm Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn |

Causes of Hypokalemia • • Sweat, urinary and GI losses Diarrhea Decreased intake Increased

Manifestations of Hypokalemia • • Muscle weakness Cramps Nausea Vomiting Decreased bowel sounds Paresthesias

ECG changes in hypokalemia Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn |

Causes of Hypercalcemia • Primary hyperparathyroidism – Calcium mobilization from bones • Bone malignancy

Manifestations of Hypercalcemia • • • Neuromuscular Renal Gastrointestinal Cardiovascular Musculoskeletal Eye and skin

Causes of Hypocalcemia • • • Reduced calcium intake or absorption Low parathyroid hormone

Manifestations of Hypocalcemia • • • Decreased cardiac contractility Neuromuscular symptoms Mental changes Pathological

Causes and Manifestation of Hypermagnesemia • Causes – Renal failure – Treatment for pregnancy-induced

Causes of Hypomagnesemia • Decrease in GI absorption – Excessive calcium absorption • Malnutrition

Manifestations of Hypomagnesemia • More evident at serum levels <1 mg/d. L – –

Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl

Causes and Manifestations of Hyperphosphatemia • Causes – Decreased renal excretion – Excessive phosphate

Causes and Manifestations of Hypophosphatemia • Causes – Malabsorption, alcoholism, vitamin D deficiency –

Causes and Manifestations of Hyperchloremia • Causes – Hyperparathyroidism, dehydration – Respiratory acidosis •

Causes and Manifestations of Hypochloremia • Causes – Loss of gastric fluid – Osmotic

LEARNING OBJECTIVE 5 • Identify nursing interventions to restore fluid and electrolyte balance. Medical

Nursing Interventions for Fluid Imbalances • Assessment of fluid imbalances – Dehydration – Overhydration

Nursing Interventions for Hypernatremia • Replace fluids slowly over 48 – 72 hours •

Nursing Interventions for Hyponatremia • Depends on cause – – Limit water intake Provide

Nursing Interventions for Hyperkalemia • Assess for risk factors – Administer potassium-reducing agents –

Nursing Interventions for Hypokalemia • Correction of underlying cause – Oral and IV potassium

Intravenous Potassium Administration • Indicated for low levels and cardiac symptom – – Never

Nursing Interventions for Hypercalcemia • Treatment of underlying causes – – Normal saline to

Nursing Interventions for Hypocalcemia • Correction of hyperphosphatemia – IV calcium replacement § Avoid

Nursing Interventions for Hypermagnesemia • Close assessment – Tendon reflexes – Respiratory status •

Nursing Interventions for Hypomagnesemia • Parenteral magnesium supplements – Close monitoring to prevent overcorrection

Nursing Interventions for Hyperphosphatemia • Phosphorus-binding agents – Decrease phosphate absorption – Increase phosphate

Nursing Interventions for Hypophosphatemia • Treat underlying causes • High-phosphate diet • Milk, eggs,

Nursing Interventions for Hyperchloremia/Hypochloremia • Treat underlying causes and conditions • Asessment – Metabolic

LEARNING OBJECTIVE 6 • Explain discharge teaching implications to assist patients to maintain fluid

Discharge Teaching for Hydration • Maintain adequate hydration • Recognize signs and symptoms •

Discharge Teaching for Electrolyte Imbalances • • Causes Treatment Prevention of recurrences Knowledge of

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Medical Surgical Nursing Preparation for Practice CHAPTER 18 Fluids and Electrolytes Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

LEARNING OBJECTIVE 1 • Explain the normal composition of fluids and electrolytes in the body. Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Body Fluid Composition • Compartments – ICF § Cell cytoplasm and nucleus – ECF § Serum and interstitial fluid § Cerebral spinal fluid § GI fluids Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Functions of Body Fluids • Salivary enzymes • Transport to body tissues: – – – Electrolytes Oxygen Nutrient Hormones Immune Cells Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Functions of Body Fluids • Elimination of waste products – Bowel – Bladder • Movement of electrolytes between ICF/ECF • Temperature regulation – Perspiration – Capillary dilatation Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

LEARNING OBJECTIVE 2 • Describe the normal osmolality of the blood and urine. Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Osmolality • Number of solutes per kilogram of water – Isotonic – Hypertonic – Hypotonic Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Regulation of Body Fluids • Osmosis – Movement of water • Diffusion – Movement of molecules Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Osmosis & Diffusion Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Diffusion • • • Molecule size Electrical charges Pressure gradient Active diffusion Passive diffusion Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Filtration • Movement is result of hydrostatic pressure – Pressure of water on surrounding tissues – Created by heart action – Arterial pressure is greater than venous pressure • Filtration is opposed by oncotic pressure • Plasma proteins produce oncotic pressure Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

LEARNING OBJECTIVE 3 • Evaluate fluid status of an adult according to normal fluid and electrolyte values. Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Evaluation of Fluid Status • Osmolality – Normal is 275 – 295 m. Osm/kg – Water deficit – >295 m. Osm/kg – Water excess – <275 m. Osm/kg – Multiply sodium x 2 Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Evaluation of Fluid Status • Normal serum hematocrit – 40 – 50% • Dilute serum – Low hematocrit and electrolyte levels • Concentrated serum – Elevated hematocrit and electrolyte levels Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Distribution of Body Fluids • Overhydration: osmosis shifts water from blood to ICF and ECF • ECF: lower extremity/sacral edema • ICF: cellular edema • Causes – Decreased renal excretion – Cirrhosis – Congestive heart failure Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Fluid Accumulation • Can also occur in lung capillaries, alveoli – Crackles heard on auscultation – Decrease in gas exchange – Respiratory acidosis • Accumulation in heart atria – S 3 heart sound Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dehydration • Causes – Excessive urinary water loss – Hyperglycemia – Inadequate fluid intake – Diuretic overuse Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dehydration and the Elderly • Increased risks for dehydration – Decrease in thirst – Lack of fluid replacement – Use of diuretic medications for high BP – Susceptibility to contagious diseases Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Dehydration • • • Thirst; dry mouth and tongue Tenting of skin Elevated temperature Orthostatic hypotension Tachycardia and weak pulse Mottled skin Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

LEARNING OBJECTIVE 4 • Define the normal ranges of electrolytes in the body. Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Electrolytes • • • Sodium Chloride Potassium Calcium Phosphorus Magnesium Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Sodium • Most abundant cation in ECF • Functions – ECF volume – Acid-base balance – Nerve impulse control • Normal serum values – 135 -145 m. Eq/L Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Sodium Regulation • Aldosterone – Sodium retention • Antidiuretic hormone (ADH) – Water reabsorption • Atrial natriuretic peptide (ANP) – Sodium excretion Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Potassium • Intracellular cation • Normal serum levels: 3. 5 – 5. 0 m. Eq/L • Functions – Cellular integrity – Neuromuscular impulse transmission – Acid-base balance – Conversion of carbohydrate to energy – Formation of proteins Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Potassium • Food sources include bananas, meat, potatoes • Anabolic states – Stored in cells • Catabolic states – Moves into blood • Excreted via kidney and GI tract Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Calcium • Cation found in both ICF and ECF but > in ECF. • Normal serum levels: 8. 5 – 10. 5 mg/d. L • Neuromuscular transmission; muscle contraction • Blood clotting; cell membrane function • Found mainly in bones and teeth • Exists in ionized and non-ionized forms – Acidosis and alkalosis Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Calcium Regulation • Vitamin D – Calcium absorption • Calcitonin – Inhibits resorption in bone – Inhibits renal excretion • Parathyroid hormone – Mobilizes calcium from bone – Increases kidney reabsorption Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Magnesium • • • Intracellular Cation Normal serum levels: 1. 4 – 2. 1 mg/d. L Co-factor of enzymatic reactions Neuromuscular interactions Cardiac contractility Food sources Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Phosphorus • Intracellular anion • Normal serum levels: 1. 5 – 2. 5 mg/d. L • Needed for metabolism, nerve and muscle function • Part of energy units • Component of phospholipids • Regulated by calcitonin, parathyroid hormone and Vitamin D Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Chloride • Primary extracellular anion • Normal serum levels: 95 – 108 m. Eq/L • Creates electrical neutrality when combined with sodium • Hydrochloric acid • Buffers carbonic acid • Anion gap - calculated AG = (Na + K) – (Cl + HC 03 (metabolic acidosis) Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

LEARNING OBJECTIVE 4 • Discuss various circumstances that place the patient at risk for fluid and electrolyte imbalances. Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes of Hypernatremia • Deficit of water relative to sodium • Causes – Excessive water losses § Sweating § Diabetes insipidus – Sodium retention § Cushing's syndrome Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Hypernatremia • • Thirst Low grade fever Edema Altered mental status Hypertension Weight gain Coma and seizures Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes of Hyponatremia • • • Water retention Inadequate sodium intake Loss of sodium-rich fluid Excess use of 5% dextrose solution Syndrome of Inappropriate Anti-diuretic Hormone (SIADH) Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Hyponatremia • Depolarization and repolarization of cells • Neurological symptoms – Lethargy – Headache – Personality changes – Seizures • Permanent brain damage below 115 m. Eq/L Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Hyponatremia • Fluid overload causes dilutional hyponatremia • Symptoms: – Hypertension – Bounding pulse – Fluid retention – Weight gain Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes of Hyperkalemia • Increased potassium intake – Inappropriate potassium supplementation • Decreased urinary excretion of potassium – Acute and chronic renal failure – Potassium-sparing diuretic • Cellular release of potassium Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestation of Hyperkalemia • • Muscle weakness and cramping ECG changes – peaked T waves Irregular pulse Irritability Abdominal distention and cramping Muscle weakness Paresthesia Diarrhea Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Hyperkalemia in Cardiac rhythm Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes of Hypokalemia • • Sweat, urinary and GI losses Diarrhea Decreased intake Increased insulin levels Cushing’s disease Stress Hypomagnesemia Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Hypokalemia • • Muscle weakness Cramps Nausea Vomiting Decreased bowel sounds Paresthesias ECG changes Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

ECG changes in hypokalemia Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes of Hypercalcemia • Primary hyperparathyroidism – Calcium mobilization from bones • Bone malignancy – Calcium liberation from bones • Drug toxicity – Thiazide diuretics – Vitamin A and D Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Hypercalcemia • • • Neuromuscular Renal Gastrointestinal Cardiovascular Musculoskeletal Eye and skin Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes of Hypocalcemia • • • Reduced calcium intake or absorption Low parathyroid hormone Increased phosphorus Decreased magnesium Hypoalbuminemia Alkalosis Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Hypocalcemia • • • Decreased cardiac contractility Neuromuscular symptoms Mental changes Pathological fractures Trousseau’s sign Chvostek sign https: //www. youtube. com/watch? v=ep 6 IEqnyx. JU https: //www. youtube. com/watch? v=H 13 yn 9 Awt. PY&feature=relmfu Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes and Manifestation of Hypermagnesemia • Causes – Renal failure – Treatment for pregnancy-induced HTN • Manifestations – Decreased neuromuscular activity – Respiratory depression and cardiac arrest – Nausea, vomiting, drowsiness Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes of Hypomagnesemia • Decrease in GI absorption – Excessive calcium absorption • Malnutrition – Intake of phytates, oxalates and fat • Increased kidney excretion – Diuresis – Alcoholism Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Manifestations of Hypomagnesemia • More evident at serum levels <1 mg/d. L – – – Confusion Lethargy Nausea and vomiting Seizures and hyperactive reflexes Cardiac symptoms – Torsades de Pointes Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes and Manifestations of Hyperphosphatemia • Causes – Decreased renal excretion – Excessive phosphate replacement – Extracellular shifts – Cellular destruction • Manifestations – Calcium phosphate deposits – Hypocalcemia Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes and Manifestations of Hypophosphatemia • Causes – Malabsorption, alcoholism, vitamin D deficiency – Excessive use of phosphate-binding agents • Manifestations – Impaired neurological function – Hypoxia – Dysrhythmias Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes and Manifestations of Hyperchloremia • Causes – Hyperparathyroidism, dehydration – Respiratory acidosis • Manifestations – Lethargy, disorientation – Increased rate and depth of respirations Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Causes and Manifestations of Hypochloremia • Causes – Loss of gastric fluid – Osmotic diuresis • Manifestations – Reflects alkalosis – Paresthesias, muscle spasms, slow respirations – Dehydration Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

LEARNING OBJECTIVE 5 • Identify nursing interventions to restore fluid and electrolyte balance. Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Fluid Imbalances • Assessment of fluid imbalances – Dehydration – Overhydration • Monitor weight, intake and output • Monitor bowel patterns • Collaboration with dietician Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hypernatremia • Replace fluids slowly over 48 – 72 hours • Sodium decrease no more than 0. 5 – 1 m. Eq/L per hour • Nursing interventions: – Close monitoring of BP, pulse, temperature, and sodium level – Assessment of level of consciousness, lethargy, headache, nausea and vomiting Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hyponatremia • Depends on cause – – Limit water intake Provide sodium-replacing foods Correct other electrolytes as needed Hypertonic IV solutions used only in severe cases, only enough to correct symptoms Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hyperkalemia • Assess for risk factors – Administer potassium-reducing agents – If these are insufficient, dialysis may be needed Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hypokalemia • Correction of underlying cause – Oral and IV potassium replacement – Potassium-rich foods Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Intravenous Potassium Administration • Indicated for low levels and cardiac symptom – – Never administer IV push Avoid rapid infusion Diluted in normal saline Determine urine output is adequate Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hypercalcemia • Treatment of underlying causes – – Normal saline to promote excretion Bisphonates Monitor fluid overload Avoid potential pathological fractures Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hypocalcemia • Correction of hyperphosphatemia – IV calcium replacement § Avoid rapid administration § Determine if digitalis is taken – Magnesium supplementation – Calcium and vitamin D supplements Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hypermagnesemia • Close assessment – Tendon reflexes – Respiratory status • Discontinue products containing magnesium • Normal saline and diuretics • Calcium gluconate for levels above 8 – 10 mg/d. L Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hypomagnesemia • Parenteral magnesium supplements – Close monitoring to prevent overcorrection • Oral magnesium supplements – Magnesium salts – Antacids – Food sources Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hyperphosphatemia • Phosphorus-binding agents – Decrease phosphate absorption – Increase phosphate excretion • Treatment of hypocalcemia Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hypophosphatemia • Treat underlying causes • High-phosphate diet • Milk, eggs, beans, nuts, whole grains – Oral phosphorus supplements • IV phosphate replacement only in severe cases or non-functioning bowel Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Nursing Interventions for Hyperchloremia/Hypochloremia • Treat underlying causes and conditions • Asessment – Metabolic acidosis – Metabolic alkalosis – Compensation of acid-base imbalances Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

LEARNING OBJECTIVE 6 • Explain discharge teaching implications to assist patients to maintain fluid and electrolyte balance. Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Discharge Teaching for Hydration • Maintain adequate hydration • Recognize signs and symptoms • Daily self-monitoring – Weight – Fluid intake – Urine output • Signs and symptoms to report Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Discharge Teaching for Electrolyte Imbalances • • Causes Treatment Prevention of recurrences Knowledge of food sources Medical Surgical Nursing: Preparation for Practice Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.