Professional Documents
Culture Documents
CHAPTER
Fluids and
Electrolytes
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OBJECTIVES
In this chapter, you’ll review:
앫 The key concepts associated with fluid volume excess and fluid volume
deficit.
앫 The causes, signs and symptoms, and treatments of electrolyte
imbalances.
앫 The complications associated with fluid and electrolyte imbalances.
앫 When someone loses too much water, they are dehydrated. Notice I
said “WATER”; this will become important later in the chapter when
we study sodium imbalances.
앫 When more than one-third of the body’s fluid is absent, life-
threatening situations can occur.
앫 Fat has a tiny amount of water; lean tissue (muscle) has heaps of water.
앫 It’s not fair, but babes (females) have more body fat than dudes (males);
therefore, females have less body fluid.
앫 Elderly clients have a decreased amount of body fluid due to less body
fat, which makes them a high risk for dehydration.1,2
Adequate fluids
When major organs aren’t being
A person can have adequate fluids in the body, but for some physiological perfused with adequate fluids they
reason maybe the fluids are not being pumped around to all the vital can die. Vascular collapse—or
organs by the heart like they should. Because of this malfunction, the vital shock—can occur when there are
organs don’t realize the fluids are there, and thus they don’t access them. not enough fluids to keep the
In turn, the body goes into shock because it doesn’t realize that fluids are blood vessels open.
available.
FLUID INTAKE The usual fluid intake per day in a healthy adult looks
something like this:
Ingested fluids 1300 mL
Water in foods 1000 mL
Oxidation 300 mL
2600 mL
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Acceptable fluid intake and loss on a daily basis for a healthy adult is
1500 to 3000 mL.1,2
Table 1-1
Abnormal fluid loss Definition
Emesis Vomiting of fluid
Fistulas Abnormal opening that secretes fluid
Secretions Drainage from wounds or suction tubes
Wound exudates Fluid from surgical drains
Paracentesis A procedure where fluid is extracted from the
abdomen (the peritoneum)
Thoracentesis A procedure where fluid is extracted from the
space between the visceral and parietal pleura
(linings around the lungs)
Diaphoresis Excessive sweating during illness
CASE IN POINT A loss of 20% or more of body fluid can result in death
unless drastic measures to rehydrate the client are taken.1,2 For example,
in a burn client, the damaged vessels cannot hold fluid in, so large
amounts of fluid shift out of the vascular space. This is why fluid
replacement is one of the most important aspects of burn treatment,
especially in the first 24 hours.
✚ Electrolytes
What are electrolytes? Electrolytes are elements that, when dissolved in
water, acquire an electrical charge—positive or negative. Body fluid is
mainly a mixture of water and electrolytes. If either water or electrolytes
get out of whack—causing lack of homeostasis—then your clients may
encounter potentially life-threatening problems.
The following are the vital electrolytes:
앫 Sodium (Na+)
앫 Potassium (K+)
앫 Calcium (Ca2+)
앫 Magnesium (Mg2+)
앫 Chloride (Cl−)
_
앫 Phosphate (HPO42 )1
Raging hormones!
Hormones help keep electrolytes within normal range. Here’s how:
l. Insulin: moves potassium from the blood (vascular space) to the inside
of the cell, causing the serum K⫹ to drop.
2. Parathyroid hormone (PTH): moves calcium from the bone into the
Calcitonin causes serum calcium to
blood when serum calcium levels are low. This causes the serum calcium
decrease.
to increase.
3. Calcitonin: moves calcium into the bones as needed. When the serum
calcium is too high, calcitonin kicks in and moves calcium from the
blood into the bone. This causes serum calcium to decrease.
Calcitonin occurs naturally in the body, but it may be given in drug
form as well.1
Anytime serum calcium increases,
the phosphorus level decreases,
and vice versa. How do we get rid of excess electrolytes?
Excess electrolytes are excreted by:
앫 Urine, feces, and sweat.
앫 Aldosterone: causes sodium and water retention while causing
potassium excretion through the urine.
앫 PTH: increases urine excretion of phosphorus and decreases urine
A severe excess or deficit of
excretion of calcium.1,2
magnesium or potassium can lead
to life-threatening complications:
respiratory arrest, seizures, or life- What causes decreased oral electrolyte intake?
threatening arrhythmias. Table 1-2 explores the causes of decreased oral electrolyte intake and why
this occurs.
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Table 1-2
Cause Why
Anorexia Lack of appetite
Feeling weak Lack of energy to take in nutrients
Shortness of breath Some clients need all of their energy to
breathe and will neglect eating in the
process (shortness of breath may ↑ with
eating, so client chooses not to eat)
GI upset When you are nauseated, do you feel like
eating?
Income Not able to afford nutritious foods
Fad dieting (low in potassium) Intentionally limiting oral intake
Table 1-3
Problem Why
Vomiting Causes expulsion of ALL stomach contents, which
contains a lot of electrolytes (especially potassium
and chloride)
Nasogastric (NG) suction Electrolytes are sucked out of the stomach
Intestinal suction Most electrolytes are absorbed in the intestine; if
the intestine is being suctioned then electrolytes
can’t be absorbed properly
Drainage All body fluid contains electrolytes; drainage causes
(from wounds or fistulas) a decrease of body fluid, resulting in a loss of
electrolytes
Paracentesis Removing fluid from the body causes a decrease
in electrolytes
Diarrhea Intestines are rich with magnesium. Diarrhea
causes loss of magnesium and prevents
magnesium from staying in the GI tract long
enough to be absorbed
Diuretics Causes excretion of potassium through the kidneys
(depends on the type of diuretic)
Kidney trauma, illness, Causes loss or retention of electrolytes
disease
Table 1-4
Cause Why
When administering medications,
Kidney trauma, illness, When the kidneys are sick, electrolytes can
make it a habit to check how each
or disease accumulate in the blood; the kidneys aren’t
particular drug can affect elec- able to excrete the excess—especially
trolyte balance. magnesium and potassium
Massive blood transfusions Preservatives in blood can contain a lot of
calcium; the longer blood sits in the blood
bank, cells begin to rupture—or hemolyze.
When cells rupture, potassium is released
from the cell into the bag of blood.
Therefore, several blood transfusions could
If your client has an illness that increase the serum potassium, especially
impairs kidney function, you must if the kidneys aren’t working properly
monitor for potassium retention— (excess potassium is excreted through the
hyperkalemia—which can lead to kidneys)
life-threatening arrhythmias.
Tumors Certain types can cause calcium to leach
from the bone and move into the blood
Crushing injuries Cells rupture, causing potassium and
phosphorus to release into the
bloodstream
Chemotherapy Destroys and ruptures cells, which releases
Alcoholics may have many potassium and phosphorus into the
electrolyte imbalances due to poor bloodstream
nutrition and decreased absorption
of electrolytes. Source: Created by author from Reference #1.
Kidneys
The kidneys (Fig. 1-1):
앫 Maintain sodium and water balance.
앫 Regulate fluid and electrolyte balance by controlling output.
앫 Filter 170 L of plasma per day.
앫 Regulate fluid volume and osmolality (concentration of particles in a
solution). The renin–angiotensin response
kicks in when blood volume is low.
앫 Activate the renin–angiotensin response as needed. This causes retention of sodium
앫 When not taking fluid in by mouth, the urine output will drop. Why? and water in the vascular space to
The kidneys aren’t getting enough perfusion/blood flow to produce replenish lost blood volume.
urine OR the kidneys are trying to compensate by holding on to fluid.
Kidney
Renal pelvis
Renal artery
Renal vein
Medulla
Ureter
Cortex
CASE IN POINT Anytime the kidneys are not perfusing adequately, per-
manent kidney damage can occur. It only takes 20 minutes of poor per-
fusion to promote acute tubular necrosis.1,2 Acute tubular necrosis results
in damage to the renal tubules, usually from ischemia during shock. If
you don’t recognize decreased kidney perfusion, renal failure and possible The renin–angiotensin response . . .
patient death can result. just like Martha Stewart says, “It’s
a good thing.”
Cardiovascular system
앫 Pumps and carries fluids and other good stuff throughout the body, to
the vital organs, especially to the kidneys; a client must have a BP of at
least 90 systolic to maintain adequate organ perfusion.
앫 Cardiac output is the amount of fluid the left ventricle is pumping
out. Consistent and adequate cardiac output leads to adequate tissue
Clients with renal failure cannot
perfusion. excrete excess volume as they
앫 Blood vessels can constrict in response to decreased volume. When blood need to, which can result in serious
pressure drops below 90 systolic, blood vessel constriction may occur. conditions such as pulmonary
앫 When blood vessels constrict, BP increases. When blood vessels dilate, edema or heart failure.
BP decreases. This compensatory response helps maintain tissue per-
fusion and fluid and electrolyte homeostasis.1,2
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Table 1-5
Cause Why
Myocardial infarction (MI) Damaged cardiac muscle can’t pump effectively,
causing cardiac output to drop
Bradycardia When pulse is decreased the heart is unable to
pump as much blood out so cardiac output
decreases
Excessive tachycardia The ventricles of the heart do not have time to
completely fill with blood when the heart is
beating fast, so less blood is pumped out
Low fluid volume Not enough volume exists to fill the heart
chambers, resulting in decreased cardiac
output
Arrhythmias Some arrhythmias decrease cardiac output
because the heart does not pump effectively
due to a glitch in the cardiac electrical system.
Arrhythmias are no big deal until they affect
cardiac output
High blood pressure If the heart is having to pump blood out
against a high pressure, not as much blood can
set out to the body. Therefore, cardiac output
decreases
Drugs Can affect heart contractions, thus impacting
heart rate and cardiac output
Lungs
Short and sweet: The lungs regulate fluid by releasing water as vapor
with every exhalation. Every time you exhale, water is lost.
Clients who experience rapid
breathing either due to a high
ventilator setting or anxiety may Adrenal glands
need increased fluids to maintain The adrenal glands (Fig. 1-2) secrete aldosterone. Aldosterone:
homeostasis. 앫 Retains sodium and water.
앫 Excretes potassium at the same time.
앫 Builds up vascular volume, which makes the BP go up (because
sodium and water are being retained in vascular space).
Remember, more vascular volume means more blood pressure.
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Adrenal glands
Pituitary gland
Retention of sodium and water
The pituitary gland (Fig. 1-3) stores antidiuretic hormone (ADH), causes potassium excretion,
which causes retention of water. As water is retained in the vascular because sodium and potassium
space, vascular volume and blood pressure increase. have an inverse relationship.
Thyroid gland
The thyroid gland (Fig. 1-5) releases thyroid hormones. These hormones
increase blood flow in the body by:
When you eat the entire industrial- 앫 Providing energy
size bag of salty chips all by your-
self, you become thirsty because
your serum sodium goes up. You 앫 Increasing 앫 Increasing
are able to respond to your thirst pulse rate cardiac output
mechanism by preparing yourself
a lovely beverage to quench your 앫 Increasing renal 앫 Increasing
thirst. (A patient may not be able perfusion diuresis
to quench their thirst without your
help)
앫 Ridding of excess fluid1,2
Thyroid
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Hypothalamus
The amount of fluid the body desires is monitored by the thirst response,
which is controlled by the hypothalamus (Fig. 1-6).
앫 Most adults can respond to their thirst mechanism. Clients who are As Kramer on the television show
elderly, confused, unconscious, or very young (infants) may not be Seinfeld said, “These pretzels are
making me thirsty!” Remember
able to respond to their thirst mechanism.1,2
that?
Hypothalamus
Pituitary gland
Small intestine
The small intestine absorbs 85% to 95% of fluid from ingested food and
delivers it into the vascular system.1,2
As serum sodium increases, so
Lymphatic system does thirst.
The lymphatic system moves water and protein back into the vascular
space.
Plasma protein
Plasma protein holds on to fluid in the vascular space. There are several
types of plasma proteins, but the most abundant is albumin.
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Glucose
The vascular space likes the particle-to-water ratio to be equal. In this case the
particle is glucose. The body doesn’t like it when the balance gets out of whack.
CASE IN POINT When the blood sugar is very high, as in diabetics, the blood
has too many glucose particles compared to water in the vascular space. This
causes particle-induced diuresis (PID), sometimes called osmotic diuresis.
The kidneys monitor the blood for fluid, electrolyte, and particle imbalances.
When the kidneys sense the increased number of glucose particles, they
By the time you get an acutely ill want to help the blood rid the excess. But think about this: Have you ever
diabetic client who is in diabetic excreted just a sugar particle? No! You would have remembered that! The
ketoacidosis (DKA) into the inten- glucose is excreted out of the body through the urine, which is made up of
sive care unit, he may have zero many substances including water and electrolytes. Polyuria occurs as the
output! This is an emergency that kidneys excrete the excess sugar. The kidneys continue to filter the blood to
needs immediate attention or the decrease the serum glucose, resulting in fluid loss from the vascular space.
kidneys could die forever!
If this goes on long enough, hypovolemia and shock can result. Once
shock occurs, polyuria ceases. Oliguria results, which could lead to anuria.
Now the kidneys feel used and are really ticked off! The kidneys tried to
help the blood get rid of the glucose particles, and as a result vascular
volume dropped. The kidneys say, “Look what you’ve done to me! I was
trying to help you, blood, and now you are trying to kill me!” Why are
When a client goes into DKA, the the kidneys so emotional? Because they are the first organs to die when
urine output will go through 3 there is inadequate fluid in the body. Remember, it only takes 20 minutes
phases: polyuria, oliguria, and then of poor kidney perfusion for acute tubular necrosis to occur.
anuria. IV fluids must be started
prior to the anuria stage to prevent DEFINE TIME
kidney failure! 앫 Oliguria is urine output < 400 mL/day.
앫 Anuria is the absence of urine output.1,2
What is it?
In FVD, sodium and water are lost in equal amounts from the vascular
space. FVD is:
앫 Also called hypovolemia or isotonic dehydration. Dehydration is when water is lost
and sodium is retained.
앫 Not the same as dehydration.
Table 1-6
Cause Why
Vomiting Stomach loses electrolytes and fluid
Diarrhea Loss of fluid and electrolytes from the “other end”
GI suction Mechanical removal of fluid and electrolytes with an
NG tube
Diuretics Excessive excretion of fluid and electrolytes through
the kidneys
Impaired swallowing Decreased oral intake of fluids and electrolytes
Tube feedings Contain nutrients needed to survive EXCEPT water
Fever Causes fluid loss (sweating)
Laxatives Excessive use causes fluid and electrolyte loss
Hemorrhage Loss of blood volume at a fast rate
Third spacing Blood volume drops when fluid leaves the vascular
space
Table 1-7
Signs and symptoms Why
Acute weight loss Water weighs about 8 lbs/gallon; l liter weight is
2.2 lbs or 1 kg. Weight loss may mean water loss
(not fat)
Decreased skin turgor Decreased skin elasticity caused by decreased
(tenting occurs) tissue perfusion
Postural hypotension Fluid deficit causes BP drop from supine or sitting
(orthostatic hypotension) position to upright position
Increased urine What little urine that is being excreted will be
specific gravity concentrated as not much fluid is present in the
body
Weak, rapid pulse Heart pumps faster to move fluid
Cool extremities Peripheral vasoconstriction shunts blood to vital
organs and away from extremities
Dry mucous membranes Decreased fluids causes membrane dryness
Decreased BP Less vascular volume leads to lower blood pressure
Decreased peripheral Blood shunted away from extremities; poor
pulses tissue perfusion
Oliguria Body holding on to what fluid is available
Decreased vascularity in Not enough fluid to keep vasculature open
the neck and hands
Decreased central venous Less vascular volume leads to lower central
pressure (CVP) venous pressure
Increased respiratory rate Maintain oxygen distribution throughout the body
What is it?
Fluid volume excess is:
앫 Excessive retention of water and sodium in the extracellular fluid (ECF).
The heart moves fluid forward;
앫 Also called hypervolemia or isotonic overhydration.
otherwise, the fluid backs up into
the lungs causing pulmonary
What causes it and why edema.
Table 1-8 demonstrates the causes of FVE and why it occurs.
Table 1-8
Causes Why
Renal failure Kidneys aren’t able to remove fluid
CHF Decreased kidney perfusion due to decreased cardiac output leads to
excessive fluid retention
Cushing syndrome Excess steroids associated with the disease cause fluid retention
Excessive sodium: from IV normal saline Causes fluid retention in the vascular space
or lactated ringers or foods
Blood product administration Blood products go directly into the vascular space expanding the volume
Increased ADH ADH tells the body to retain water in the vascular space
Medications For example, steroids cause fluid retention
Liver disease Excess production of aldosterone, which causes sodium and water retention
Hyperaldosteronism Sodium and water retention in the vascular spaces
Burn treatment After 24 hours postburn, the damaged vessels start to repair and hold fluid.
Rapid hydration therapy can cause fluid overload. After 24 hours, fluid begins
to shift from the interstitial space to the vascular space
Albumin infusion Causes fluid retention (albumin/protein holds fluid into the vascular space)
Table 1-9
Signs and symptoms Why
Jugular vein distension ( JVD) Vascular space is full, causes distension of
jugular veins
Bounding pulse, tachycardia Heart pumps hard and fast to keep the fluid
moving forward
Abnormal breath sounds Excess fluid collects in the lungs; lungs
sound wet
Polyuria Kidneys excrete the excess fluid
Decreased urine specific gravity Kidneys are trying to get rid of excess fluid
which causes urine to be diluted
Dyspnea and tachypnea Excess fluid in the lungs impairs respiratory
efforts
Increased BP More vascular volume leads to increased
blood pressure
Increased central venous More vascular volume leads to increased
pressure (CVP) central venous pressure
Edema Vascular spaces leak fluid into the tissues
Productive cough Fluid collects in the lungs causing a
productive cough; the body is trying to rid
of the excess fluid through mucous
Weight gain Fluid retention causes weight gain
✚ Sodium imbalances
The following apply to the electrolyte sodium:
앫 Chief electrolyte in ECF.
앫 Assists with generation and transmission of nerve impulses.
앫 An essential electrolyte of the sodium–potassium pump in the cell
membrane.
앫 Food sources: bacon, ham, sausage, catsup, mustard, relishes,
processed cheese, canned vegetables, bread, cereals, snack foods.
앫 Excess sodium is excreted by kidneys.
앫 Excretion of sodium retains potassium.
앫 Normal adult sodium level is 135 to 145 mEq/L.
앫 Helps maintain the volume of body fluids. Sodium is the only electrolyte that
is affected by water. Sodium level
decreases when there is too much
Renin–angiotensin system water in the body. Conversely,
ECF (vascular volume) decreased → Renin produced by sodium level increases with less
kidneys → Angiotensin I converted to angiotensin II → Aldosterone water in the body.
secreted → Sodium and water retained.
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Table 1-10
Causes Why
Excessive administration of D5W Water dilutes the sodium level
Diuretics May cause excessive loss of sodium
Wound drainage Loss of sodium
Psychogenic polydypsia Excessive, rapid oral intake of fluids dilutes the blood
Decreased aldosterone Sodium and water are excreted while potassium is retained
Low-sodium diet Not enough sodium in the diet, which causes decreased blood levels
of sodium
Syndrome of inappropriate Large amount of water is retained in the vascular space, causing
antidiuretic hormone (SIADH) dilution of blood; blood dilution causes decreased serum sodium
because the sodium is measured in relation to the water in the blood
Vomiting and sweating Loss of fluids and sodium (probably losing more sodium than water)
Replacing fluids with water only Sodium is not replenished, leading to low blood levels
Table 1-11
Signs and symptoms Why
Lethargy and confusion Decreased excitability of cell membranes; brain does not function well with
low levels of sodium
Muscle weakness Decreased excitability of cell membranes
Decreased deep tendon reflexes (DTRs) Decreased excitability of cell membranes
Diarrhea GI tract motility increases
Respiratory problems Late symptom; respiratory muscles become weak and can’t function
properly
Table 1-12
Causes Why
Administration of IV normal saline without Too much sodium, not enough water
proper water replacement
Hyperventilation Exhalation causes water loss, which causes sodium level to
appear increased
Watery diarrhea Fluid loss from the GI tract; water loss causes increased sodium
concentration
Hyperaldosteronism Retention of large amount of sodium
Renal failure Kidneys not able to excrete excess sodium
Heat stroke Water loss exceeds sodium loss causing increased sodium
concentration in the blood
NPO status Decreased intake causing hemoconcentration and increased
sodium
Infection Fever associated with infection causes loss of water and
concentration of sodium
Diabetes insipidus Excess water loss resulting in sodium concentration
✚ Potassium imbalances
The following are true regarding potassium:
앫 Makes skeletal and cardiac muscle work correctly.
앫 Major electrolyte in the intracellular fluid.
앫 Potassium and sodium are inversely related (when one is up, the other
is down).
앫 Plays a vital role in the transmission of electrical impulses.
앫 Food sources: peaches, bananas, figs, dates, apricots, oranges, melons,
raisins, prunes, broccoli, potatoes, meat, dairy products.
앫 Excreted by the kidneys.
앫 Stomach contains large amount of potassium.
앫 Normal potassium level: 3.5 mEq/L to 5.0 mEq/L.1
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When we think about hypokalemia Source: Created by author from Reference #1.
usually we think about muscle
cramps first. However, don’t forget
the client can have muscle
Signs and symptoms and why
weakness too! The signs and symptoms and corresponding rationales for hypokalemia
are given in Table 1-15.
Table 1-15
Signs and symptoms Why
Muscular weakness, cramps, flaccid Potassium is needed for skeletal and smooth muscle contraction, nerve impulse
paralysis conduction, acid–base balance, enzyme action, and cell membrane function
Hyporeflexia Muscle cells require potassium for cell membrane excitability
Life–threatening arrhythmias Heart cells require potassium for nerve impulse transmission and smooth
muscle contraction
Slow or difficult respirations Respiratory muscles are weakened
Weak, irregular pulse Cardiac muscles are weakened
Decreased bowel sounds Hypomotility of GI tract
EKG changes: ST segment depression; Potassium needed for nerve impulse conduction
flat T-wave; inverted T-wave
Decreased LOC Potassium needed for excitability of brain cell membranes
Table 1-16
Cause Why
Renal failure Kidneys aren’t able to excrete potassium
IV potassium chloride overload Too much potassium in the IV fluid
Burns or crushing injuries Potassium is released when cells rupture
Tight tourniquets Red blood cells rupture and release potassium when the tourniquet has
been placed too tightly
Hemolysis of blood sample Damaged cells in the sample result in a false high reading (damaged cells
release potassium)
Incorrect blood draws Drawing blood above on IV site where potassium is infusing will cause a
false high reading
Salt substitutes Usually made from potassium chloride
Potassium-sparing diuretics Cause potassium retention
Blood transfusions Deliver elevated levels of potassium in the transfused blood. Blood trans-
fusions may have increased K⫹ levels. As blood sits over a period of time,
cells rupture and release K into blood that is going to be given to the patient
ACE inhibitors Retain potassium
Tissue damage Destroys cells releasing potassium into the bloodstream
Acidosis Causes serum potassium to increase
Adrenal insufficiency (Addison’s disease) Causes sodium and water loss and potassium retention
Chemotherapy Destroys cells releasing potassium into the bloodstream
Table 1-17
Signs and symptoms Why
Begins with muscle twitching associated with tingling Excess potassium interferes with skeletal and smooth muscle
and burning; progresses to numbness, especially around contraction, nerve impulse conduction, acid–base balance,
mouth; proceeds to weakness and flaccid paralysis enzyme action, and cell membrane function
Diarrhea Smooth muscles of the intestines hypercontract, resulting in
increased motility
Cardiac arrhythmia; bradycardia; EKG changes: peaked Dysfunctional nerve impulse conduction and smooth muscle
T-wave, flat or no P-wave, wide QRS complex; contraction
ectopic beats on EKG leading to complete heart block,
asystole, ventricular tachycardia, or ventricular fibrillation
✚ Calcium imbalances
The following points pertain to calcium:
앫 Acts like a sedative on muscles.
앫 Most abundant electrolyte in the body.
앫 Has an inverse relationship to phosphorus.
앫 Necessary for nerve impulse transmission, blood clotting, muscle
contraction, and relaxation.
앫 Needed for vitamin B12 absorption.
앫 Promotes strong bones and teeth.
앫 Who needs extra calcium? Children, pregnant women, lactating women.
앫 Food sources: milk, cheese, dried beans.
앫 Must have vitamin D present to utilize calcium.
앫 If blood levels of calcium decrease, the body takes calcium from the
bones and teeth. (to build the blood level back up)
앫 Parathyroid hormone (PTH) increases serum calcium by pulling it
from the bones and putting it in the blood.
앫 Calcitonin decreases serum calcium by driving the blood calcium back
into the bones.
앫 Normal calcium: 9.0 to 10.5 mg/dL.1
Table 1-18
Cause Why
Decreased calcium intake Causes calcium levels in the blood to decrease
Kidney illness Causes excessive calcium excretion
Decreased vitamin D Vitamin D is needed to absorb and utilize
calcium properly
Diarrhea Increased excretion of calcium
Pancreatitis Pancreatic cells retain calcium. Pancreatitis
causes the pancreas to lose calcium
Hyperphosphatemia Increased serum phosphorus causes decreased
serum calcium
Thyroidectomy If the parathyroids are accidentally removed
during a thyroidectomy, PTH levels decrease.
PTH causes an increase in serum calcium;
without it, serum calcium will decrease
Medications (calcium binders) Decrease serum calcium
be SCARED if the QRS starts to widen because it can widen all the
way out to a flat line (asystole)! I didn’t have to go to nursing school to
know a flat line is BAD!
앫 Vitamin D therapy (this vitamin helps the body utilize the calcium
that is present).
앫 Increase dietary calcium (helps increase the serum calcium).
Table 1-20
Cause Why
Hyperparathyroidism Excessive PTH that causes the serum calcium
to increase
Immobilization Calcium leaves the bones and moves into the
bloodstream
Increased calcium intake Increases serum calcium
Increased vitamin D intake Increases serum calcium
Thiazide diuretics Causes calcium retention
Kidney illness Can cause retention of calcium
✚ Phosphorus imbalances
Phosphorus:
앫 Promotes the function of muscle, red blood cells (RBCs), and the
nervous system.
앫 Assists with carbohydrate, protein, and fat metabolism.
앫 Food sources: beef, pork, dried peas/beans, instant pudding.
앫 Has an inverse relationship with calcium.
앫 Regulated by the parathyroid hormone.
앫 Normal phosphorus is 3.0 to 4.5 mg/dL.1
Tests:
앫 X-ray (may be done to assess for any skeletal changes. May have an
unusual amount of calcium being deposited into the bone. Remember,
if the phosphorus level is high, the calcium level is low. The calcium is
being pushed into the bone).
Treatment:
앫 The underlying cause of the hyperphosphatemia must be treated.
앫 Administration of vitamin D preparations such as calcitrol (rocaltrol):
remember, the serum calcium will be low with this condition; vitamin D
helps the body utilize whatever calcium is present.
앫 Administration of phosphate-binding gels (this drug will bind phos-
phorus and therefore lower the serum phosphorus level; however, this
will also make the serum calcium go up).
앫 Restriction of dietary phosphorus (to help decrease serum phosphorus).
앫 Possibly dialysis (to remove the excess phosphorus).
✚ Magnesium imbalances
Magnesium:
앫 Present in heart, bone, nerves, and muscle tissues.
앫 Second most important intracellular ion.
앫 Assists with metabolism of carbohydrates and proteins.
앫 Helps maintain electrical activity in nerves and muscle.
앫 Also acts like a sedative on muscle.
앫 Food sources: vegetables, nuts, fish, whole grains, peas, beans.
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Table 1-22
Cause Why
Diarrhea Intestines store large amounts of magnesium; diarrhea
depletes these stores
Diuretics Excretion of magnesium in urine
Decreased intake Depletes magnesium stores and does not replenish
them
Chronic alcoholism Alcoholics are malnourished, which leads to decreased
magnesium
Medications Some drugs cause increased excretion of magnesium
Table 1-23
Signs and symptoms Why
Increased neuromuscular irritability Decreased levels of magnesium can
cause neuromuscular irritability
Seizure Decreased levels of magnesium can
cause neuromuscular hyperactivity
Hyperactive DTRs Decreased levels of magnesium can
cause neuromuscular hyperactivity
Laryngeal stridor The larynx is smooth muscle; if there is
not enough magnesium to sedate it,
spasms will occur
Positive Chvostek’s Decreased levels of magnesium can
and Trousseau’s signs cause muscular spasms
Cardiac changes: arrhythmias; The heart is a smooth muscle. If there
peaked T-waves; depressed ST is not enough magnesium to sedate it,
segment; ventricular tachycardia; impaired nerve conduction and muscle
ventricular fibrillation; irregular spasms can occur
heartbeat
(Continued)
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Table 1-24
Cause Why
Renal failure Kidneys are unable to excrete magnesium
Increased oral or IV intake Body cannot process excessive magnesium
Antacids Many antacids contain a large amount of magnesium, which can build up in the blood,
making it difficult for the kidneys to excrete the excess in a timely manner
Table 1-25
Signs and symptoms Why
BP decreases Magnesium causes vasodilation, which decreases BP
Facial warmth and flushing Excess magnesium dilates the capillary beds
Drowsiness to comatose state depending on Excess magnesium acts like a sedative
severity of imbalance
Decreased DTRs Excess magnesium reduces electrical conduction in the muscles,
making them sluggish
Generalized weakness Excess magnesium reduces electrical conduction in the muscles,
making them sluggish
Decreased respirations to respiratory arrest Hypoactive respiratory muscles
depending on severity of imbalance
Cardiac changes: decreased pulse, prolonged PR, Central nervous depression and smooth muscle relaxation
wide QRS, cardiac arrest
SUMMARY
A client’s condition can change rapidly if she develops a fluid and elec-
trolyte imbalance. You must be able to recognize signs and symptoms of
fluid and electrolyte imbalances, prevent possible complications due to
these imbalances, evaluate lab work critically, and implement appropriate
nursing interventions. If you would like to hear Aunt Marlene discuss fluids
and electrolytes, call her office e 601-833-1961 and order her CDs. You’ll
love F and E . . . believe it or not and your med-surg scores will soar! J
Hurst_Pathophysiology-CH01.qxd 2/19/08 11:33 AM Page 39
PRACTICE QUESTIONS
1. The client at the highest risk for fluid volume deficit is a:
1. 36-year-old client with the flu.
2. 4-month-old client with diarrhea.
3. Healthy 80-year-old client with a fractured wrist.
4. 26-year-old pregnant client with nausea and vomiting.
Correct answer: 2. The adult clients in answer choices 1, 3, and 4 can
communicate their needs and independently replace their fluids. A
baby cannot communicate his needs, such as thirst, or independently
replace his fluids. Also, the younger and older populations are always
more prone to dehydration.
9. The nurse knows that when caring for the client on a telemetry unit,
an elevated U-wave seen on an EKG is specific to which electrolyte
imbalance?
1. Hypomagnesemia.
2. Hypermagnesemia.
3. Hyperkalemia.
4. Hypokalemia.
Correct answer: 4. Hypokalemia is the only electrolyte imbalance
that could possibly cause a U-wave on an EKG.
10. A client is being discharged from the hospital after being treated for a
decreased potassium level. In order for the client to maintain an
appropriate potassium level, the nurse suggests which food when pro-
viding discharge teaching?
1. Baked potatoes.
2. Peas.
3. Fowl.
4. Nuts.
Correct answer: 1. Of the foods listed, baked potatoes are highest in
potassium.
References
1. Hurst M. Finally Understanding Fluids and Electrolytes [audio CD-ROM].
Ambler, PA: Lippincott Williams & Wilkins; 2004.
2. Chernecky C. Real-World Nursing Survival Guide: Fluids and Electrolytes.
Philadelphia: Saunders; 2002.
3. Allen KD, Boucher MA, Cain JE, et al. Manual of Nursing Practice
Pocket Guides: Medical-Surgical Nursing. Ambler, PA: Lippincott
Williams & Wilkins; 2007.
Bibliography
Hurst Review Services. www.hurstreview.com.
Kee JL, Paulanka BJ. Fluids and Electrolytes with Clinical Applications: A
Programmed Approach. 6th ed. Albany, NY: Delmar Publishers; 2000.
Springhouse Editors. Nurse’s Quick Check: Fluids and Electrolytes. Ambler,
PA: Lippincott Williams & Wilkins; 2005.
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