Fluid & Electrolytes Calcium & Magnesium Calcium: Normal serum Calcium level = 8.9 10.

10.1 mg/dL Stored in BONES, TEETH, & MUSCLE CELLS List functions of Ca+: BONE STRENGTH & DENSITY, SKELETAL MUSCLE CONTRACTION, CARDIAC MUSCLE CONTRACTION, TRANSMITS NERVE IMPULSES, HELPS WITH CLOTTING Half of all Ca+ is bound to PROTEIN (ALBUMIN) List foods with Ca+: DAIRY PRODUCTS, KELP, NUTS & SEEDS, MOLASSES, BEANS, FIGS, QUINOA, COLLARD GREENS, OKRA, BROCCOLI, ORANGE JUICE, SOYMILK (FORTIFIED) Recommended daily requirements = 800 1000 MG If Ca+ is low, PARATHYROID HORMONE is released to draw Ca+ from the bones into the serum = Ca+ If Ca+ is high, CALCITONIN is released to inhibit Vitamin D activation & increase Ca+ excretion = Ca+ o VITAMIN D is needed to absorb calcium Ca+ has an inverse relationship with PHOSPHORUS Critical level for Ca+ is below 8.1 MG/DL Magnesium: Normal serum magnesium level = 1.5 2.5 mEq/L Absorbed from FOOD, lost in URINE & STOOL (regulated by the kidneys) Stored in BONE, MUSCLE, & SOFT TISSUE List functions of Mg+: CARBOHYDRATE METABOLISM, PRODUCES ATP, MOVES Na+ and K+ ACROSS CELL MEMBRANES, VASODILATION, CARDIAC & SKELETAL MUSCLE CONTRACTILITY (LESS THAN CA+), CLOTTING List foods that contain Mg+: MEATS, NUTS, SEEDS, GREEN VEGGIES, BANANAS, ORANGES, PEANUT BUTTER, CHOCOLATE

ELECTROLYTE IMBALANCE 1. 2.

CAUSES Insufficient intake Hypoparathyroidism (not enough PTH produced to help Ca+) Impaired absorption (laxatives) Chronic renal failure Chronic alcoholism Pancreatitis Multiple blood transfusions 1.

SIGNS & SYMPTOMS Anxiety/confusion/irritabili ty 2. Muscle twitching 3. Parathesia (tingling) in toes, fingers, or face 4. Spasm of abdominal or laryngeal muscles 5. Tetany 6. Arrythmias / ECG changes 7. Altered blood clotting 8. Positive Trousseaus (carpal spasms of hands) 9. Positive Chvosteks sign (facial spasms) 10. Ca+ below 8.9 THINK OVERACTIVE

3. 4. 5. 6. 7.

HYPOCALCEMIA

TREATMENT/INTERVENTION S 1. TREAT THE CAUSE 2. Give Ca+ oral (30 mins prior to food) or IV (calcium gluconate or calcium chloride) GIVE IT SLOWLY BY PUSH 3. Give Vitamin D if needed 4. Encourage dietary intake 5. Avoid laxatives 6. Avoid seizure precautions 7. Injury prevention (weak bones) 8. Monitor: Ca+, albumin, clotting levels 9. MONITOR THE IV SITE extravasation can lead

RESPONSE

to tissue death

1.

2. 3. 4. HYPERCALCEMIA 5. 6. 7.

8. 9. 1. 2.

3. HYPOMAGNESEMIA 4.

5. 6. 7. 8.

Hyperparathyroidis m (too much PTH moving Ca+ into serum) Bone tumors (osteometastisis) Loss of Ca+ from bone into plasma Prolonged immobility (bone mineral loss) Osteoporosis Excess intake (antacids) Renal failure, prolonged use of thiazide diuretics Vitamin D overdose Acidosis Chronic alcoholism Uncontrolled diabetes mellitus (glucose moves into cell & pushes Mg+ out to be excreted) Malabsorption, starvation Acute renal disease (unable to reabsorb Mg) Vomiting, diarrhea, NG suction Pancreatitis Prolonged TPN w/o supplements Diuretics

1. 2.

Spontaneous fractures Confusion, personality changes, depression 3. Lethargy, drowsiness, apathy, coma 4. Muscle weakness, slow reflexes 5. Tachycardia -> bradycardia -> heart block 6. Anorexia, N/V/C 7. Polyuria, polydipsia 8. Renal calculi (kidney stones) 9. Hypertension 10. Excessive clotting 11. Ca+ above 10.1 THINK DEPRESSED RESPONSE 1. 2. 3. 4. 5. 6. 7. 8. 9. Irritability, seizures, tetany Parathesias (tingling) Positive Chvosteks sign (facial spasms) Positive Trousseaus sign (carpal spasms) Confusion, delusions, insomnia Dysrhythmias, HTN N/V/C, anorexia Hyperactive reflexes Mg+ less than 1.5 mEq/L

1. 2. 3. 4. 5. 6. 7.

Loop diuretics to excrete extra Ca+ IV NS to replace Na+ lost with loop diuretics WEIGHT BEARING ACTIVITY WATCH FOR FALLS Increase fluid intake to 3000 4000 mL/day Monitor cardiac function (telemetry)

1. 2.

3. 4. 5. 6. 7. 8. 9.

THINK: OVERACTIVE RESPONSE

TREAT THE CAUSE SLOW infusion of MgSO4 watch tissue damage Encourage dietary intake Reduce stimuli MONITOR cardiac (tele) & neuro status Avoid laxatives & antacids ASSESS DTR EVERY HOUR STOP LOOP DIURETICS Ca+ may be low - treat

1.

2. 3. 4. 5.

HYPERMAGNESEMI A

6.

Chronic renal failure (cannot excrete Mg+) Excess intake (Maalox, Milk of Mg) Addisons disease Dehydration Untreated diabetic ketoacidosis (severely high blood sugar & metabolic acidosis) If on TPN with IV Mg replacement

1. 2. 3. 4. 5. 6. 7.

Feeling warmth, sweating, depression (vasodilation) Bradycardia, weak pulse, ECG changes Lethargy, drowsiness, confusion, coma Tremors, muscle weakness, hypoactive reflexes Hypotension Low BP with vasodilation CARDIAC ARREST & RESPIRATORY DEPRESSION Mg above 2.5 mEq/dL

1. 2. 3. 4.

5. 6. 7. 8.

THINK: DEPRESSED REACTION

If renal failure Dialysis If renal normal IV fluids Loop diuretic - excrete Mg Give IV Calcium Gluconate Ca+ reverses effects of excessive Mg+ on cardiac Avoid laxatives & antacids with Mg Encourage fluid intake MONITOR cardiac & respiratory status MONITOR I & Os

FLUID IMBALANCE

FLUID VOLUME DEFECIT = body loses water & electrolytes in the same proportion to normal ratio Serum Electrolyte levels remain NORMAL

CAUSES 1. Vomiting/diarrhea (losses from GI tract) 2. GI suction (again, GI loss) 3. Sweating-excessive 4. Inadequate Fluids At Risk: - Elderly forgetting to drink - Do not feel thirst; or dementia - People who cannot speak for themselves; infants 1. HF Renal failure Cirrhosis, liver failure Excessive ingestion of table salt Over-hydration with sodium containing fluids At Risk: Poorly controlled IV therapy for younger and older patients

SIGNS & SYMPTOMS 1. Weight loss (1 pint of fluid loss = 1 lb of weight loss) 2. Decreased skin turgor 3. Dry/sticky mucous membranes 4. Weak, rapid pulse Elevated hemoglobin and hematocrit - Blood is more concentrated

TREATMENT/INTERVENTIONS ASSESS: - Strict Intake & output - Daily Weights ISOTONIC fluid replacement, preferably orally (less invasive) IV if needed What do you NOT give, but it is easy for us to think we should? - WATER - NOT ISOTONIC (IT IS HYPOTONIC) Administer ordered diuretics (LASIX) Fluid restrictions Strict I& O Sodium restricted diet Na+ attracts water and will hold in body DAILY WEIGHTS K+ serum level monitoring

FLUID VOLUME EXCESS = body retains water & electrolytes at the same proportion Serum Electrolyte levels remain NORMAL

Peripheral edema Increased, BOUNDING pulse Elevated BP (fluid volume) Distended neck and hand veins Dyspnea MOIST CRACKLES HEARD WHEN LUNGS AUSCULTATED Frothy sputum Hemoglobin and hematocrit are DECREASED - Blood is diluted

ARTERIAL BLOOD GASES (work a bunch of these right before exam!) 1. Normal levels a. pH based on percentage of hydrogen ions (H+) in the blood i. Normal range = 7.35 to 7.45 ii. Below 7.35 acidosis iii. Above 7.45 alkalosis b. PaCO2 35 to 45 mmHg c. HCO3 (bicarb buffer) 22 to 26 mEq/L 2. General rules a. Anything that causes you to not blow off CO2 will lower your pH (respiratory) b. Adjustment to pH by kidneys can take hours/days c. Compensation occurs when one system tries to adjust for the other to regulate pH d. Chemoreceptors vary the rate and depth of breathing to compensate for pH changes 3. Respiratory acidosis a. pH is low, PaCO2 is high b. Causes i. Hypoventilation ii. Neuromuscular problems iii. Depression of the respiratory center in the brain iv. Lung disease v. Airway obstruction c. S/S i. Restlessness, pain, hypoxia ii. Shallow, rapid respirations but will cycle and slow down d. Who is at risk i. Children ii. Mechanical ventilation iii. Post-op patients iv. Anyone on analgesics or sedatives e. Serum electrolytes i. High K+ because it is moving out of the cells d/t H+ moving in f. Treatment i. Maintain patent airway ii. Bronchodilators iii. O2 as needed iv. Drug therapy to treat hyperkalemia v. Antibiotics if there is an infection vi. Chest PT 4. Respiratory Alkalosis a. pH is high, PaCO2 is low b. Causes

i. Hyperventilation d/t anxiety ii. Hypermetabolic states (fever and sepsis) iii. Liver failure iv. Conditions that affect the brains respiratory control center v. Hypoxia (high altitude, PE, hypotension) vi. Elevated progesterone levels (pregnancy) vii. Nicotine, salicylates, catecholamines c. Labs i. Low Na+, low Ca+ ii. ECG possible arrhythmias d. Treatment i. Undisturbed rest periods ii. Correct underlying disorder iii. Relaxation techniques iv. Monitor VS, ABG, electrolytes v. Report changes in cardiac, neuro, or neuromuscular function (can have seizures) 5. Metabolic acidosis a. pH is low, PaCO3 is low b. Causes i. Overproduction of ketone bodies (esp. diabetes) ii. Impaired kidney function (hyperkalemia) iii. GI losses (severe diarrhea, malabsorption) iv. Poisoning / drug toxicity c. S/S i. Rapid, deep respirations (Kussmauls) ii. Fruity breath odor iii. Skin dry, becomes cool and clammy iv. LOC deterioration d. Treatment i. HCO3 by IV ii. Antibiotics, antidiarrheal if needed iii. Rapid-acting insulin, if diabetic; dialysis if also renal failure iv. Ventilation if needed v. Safety and seizure precautions 6. Metabolic alkalosis a. pH is high, PaCO3 is high b. Causes i. Hypokalemia ii. Acid loss from GI tract (vomiting, pyloric stenosis, NG tube suctioning, GI surgeries) iii. Diuretics iv. Kidney disease (renal artery stenosis) v. Transfusions / drugs (antacids that contain bicarb) c. Labs i. Low K+, Ca2+, Cl- (d/t polyuria) ii. Possible ECG changes

d. Treatment i. Stop diuretics and NG suctioning ii. Antiemetics (if underlying cause is NV) iii. Diamox may be given (makes kidneys dump bicarb) iv. IV ammonium chloride in severe cases v. O2 vi. Seizure precautions if necessary vii. Irrigate NG with NS (aids electrolyte balance)