HYPOKALEMIA I. Definition -Below 3.5 mEq/L (3.5mmol/L) serum potassium level. -Indicates an actual deficit in total potassium stores.

II. Etiology 1. GI loss of potassium 2. Medications a. Potassium-losing Diuretics b. Corticosteroids c. Sodium penicillin 3. Vomiting and gastric suction 4. Diarrhea 5. Prolonged intestinal suctioning 6. Recent ileostomy 7. Villous adenoma 8. Hyperaldosteronism 9. Insulin hypersecretion 10.Patients who are unable or unwilling to eat a normal diet for a prolonged period of time a. Debilitated elderly patients b. Alcoholic patients c. Patients with anorexia nervosa 11.Magnesium depletion III. Clinical Manifestations 1. Fatigue 2. Anorexia 3. Nausea 4. Vomiting 5. Muscle weakness 6. Leg cramps IV. Medical Management 7. Decreased bowel motility 8. Paresthesias 9. Dysrhythmias 10.Increased sensitivity to digitalis 11.For prolonged hypokalemia, dilute urine and excessive thirst 12.For severe hypokalemia, cardiac or respiratory arrest then death. d. Carbenicillin e. Amphotericin

1. Increase potassium intake in the daily diet. 2. Oral supplements such as salt substitutes and Oral hydration solutions 3. IV potassium supplements such as KCl, or KPO4 or potassium acetate through an infusion pump. V. Nursing Management 1. Monitor patient for signs and symptoms, assess serum potassium concentration, Monitor ECG for changes and check ABG for elevated bicarbonate and pH levels. 2. Prevention a. Encourage patient to eat foods rich in potassium (when the diet allows) a.1. Fruits bananas, melon, citrus fruits a.2. Fresh and Frozen vegetables a.3. Fresh meats a.4. Milk a.5. Processed foods

b. If the hypokalemia is caused by abuse of laxatives or diuretics, provide patient education. c. Careful monitoring of intake and output. (40mEq/L is lost for every 1L of urine) 3. Correcting Hypokalemia a. Check potassium requirements b. Administer IV potassium 3.b.1 Ensure that adequate urine flow is established. 3.b.2. Administer as per policy standards, but the maximum concentration is 20mEq/100mL at rate no faster than 10-20 mEq/hr. 3.b.c. For concentrations higher than 2omEq/100mL, it should be administered through a central IV catheter using an infusion pump. c. Monitor BUN and creatinine levels, together with serum potassium levels after the IV administration. HYPERKALEMIA I. Definition Greater than 5mmol/L (5mEq/L ) serum potassium levels

II. Etiology 1. Iatrogenic causes 2. Decreased renal excretion of potassium as in Renal Failure 3. Pseudohyperkalemia

a. Use of a tight tourniquet around an exercising extremity while drawing a blood sample b. Hemolysis of blood sample before analysis c. Marked leukocytosis d. Thrombocytosis e. Drawing blood above a site where potassium is infusing f. Familial pseudohyperkalemia 4. At risk are patients with hypoaldosteronism or Addisons disease. 5. Medications as probable contributing factor a. KCl b. Heparin c. Potassium sparing diuretics d. ACE inhibitors e. NSAIDs f. Captopril 6. Occurrence of extensive tissue trauma such as burns, crushing injuries or severe infections, lysis of malignant cells after chemotherapy. III. Clinical Manifestations 1. Skeletal muscle weakness and even paralysis R/T depolarization block in muscle 2. Slow ventricular conduction 3. Ascending muscular weakness leading to flaccid quadriplegia 4. Paralysis of respiratory and speech muscles 5. GI manifestations Nausea, intermittent intestinal colic, and diarrhea IV. Medical Management 1. Immediate and continuous ECG monitoring. 2. Monitor serum potassium levels. 3. In non-acute situations, restriction of dietary potassium and potassium-containing medications. 4. Administration of Cation exchange resins (Kayexalate) for patients with renal impairment and if the patient does not have paralytic ileus. 5. Emergency Pharmacologic Therapy

a. For dangerously elevated serum potassium levels, administer IV calcium gluconate to antagonize the action of hyperkalemia on the heart. b. IV administration of sodium bicarbonate to alkalinize the plasma and cause temporary shift of potassium into the cells. c. IV administration of regular insulin and a hypertonic dextrose solution. d. Loop diuretics increase water excretion by inhibiting reabsorption of K, Na and Cl. e. If the hyperkalemic condition is not transient, Peritoneal dialysis, hemodialysis may be done. V. Nursing Management 1. Closely monitor for signs and symptoms those patients at risk for potassium excess eg.. with renal failure. 2. Serum potassium levels should be monitored periodically. 3. To avoid false positive serum potassium values, a. Avoid prolonged use of a tourniquet while drawing the blood sample. b. Advise patient not to exercise the extremity immediately before blood sample is obtained. c. Deliver the blood sample immediately to the laboratory as soon as possible. 4. Prevention a. For patients at risk, encourage them to stick to prescribed potassium restriction b. Advise patients to take potassium-rich foods in moderation. c. Caution patients to use salt substitutes sparingly if they are taking potassiumsparing diuretics d. Do not administer potassium-sparing diuretics, potassium supplements, salt substitutes to patients with renal dysfunction. HYPOCALCEMIA I. Definition -Lower than 8.6 mmol/L (8.6mEq/L) total serum calcium level. II. Etiology 1. Medications predisposing to hypocalcemia: a. Aluminum-containing antacids b. Aminoglycosides c. Caffeine d. Cisplatin e. Corticosteroids f. Mithramycin g. Phospates

h. Isoniazed

i.

Loop diuretics

2. Elderly people with osteoporosis have an increased risk because bed rest increases bone resorption. 3. Occurs and is common in patients with pancreatitis due to increased secretion of glucagon which results to increased secretion of calcitonin. 4. Hyperphosphatemia 5. Inadequate Vit D consumption 6. Magnesium deficiency 7. Medullary thyroid carcinoma 8. Low serum albumin levels 9. Alkalosis 10.Alcohol abuse III. Clinical Manifestations 1. Tetany entire symptom complex induced by increased neural excitability. a. Sensations of tingling in the tips of the fingers, around the mouth and in the feet. b. Spasms of the muscles of face and extremities 2. Trousseaus sign by inflating a BP cuff on the upper arm 20 mmHg above systolic pressure, within 2-5 mins. An adducted thumb, flexed wrist and metacarpopharyngeal joints, extended interphalangeal joints with fingers together. 3. Chvosteks sign- twitching of muscles supplied by the facial nerve when the nerve is tapped 2 cm anterior to the earlobe, just below the zygomatc arch. 4. Seizures 5. Mental changes such as a. Depression b. Impaired memory c. Confusion d. Delirium e. Hallucinations 6. Respiratory effects a. Dyspnea b. Laryngospasm 7. Chronic hypocalcemia

a. Hyperactive bowel sounds b. Dry and brittle hair and nails c. Abnormal clotting Medical Management 1. IV calcium administration (Calcium Chloride ) 2. Vitamin D therapy 3. Aluminum hydroxide, calcium acetate or calcium carbonate may be given to decrease elevated phosphorous levels in patients with CRF. Nursing Management 1. Observe patients at risk for signs and symptoms 2. Safety precautions are taken if the condition is severe 3. Take adequate dietary calcium 4. Advise patient to consider calcium supplements but must be taken in divided doses with meals. 5. Encourage patient to do weight-bearing exercises in decreasing bone loss. 6. Emphasize that alcohol and caffeine inhibit calcium absorption and moderate cigarette smoking increases urinary calcium excretion. 7. Caution patients using laxatives and antacids that contain phosphorus because they decrease calcium absorption.

V.

V.

HYPERCALCEMIA Definition -excess of calcium in the plasma, is a dangerous imbalance when severe; hypercalcemic cases has a mortality rate as high as 50% if not treated promptly. Etiology 1. Malignancies and Hyperparathyroidism 2. Bone mineral loss during immobilization causing elevated total calcium in the bloodstream. 3. Thiazide diuretics 4. Vitamin A and Vitamin D intoxication, and use of lithium Clinical Manifestations 1. Muscle weakness

2. Incoordination 3. Anorexia 4. Constipation 5. Vomiting 6. Abdominal and bone pain 7. Excessive urination 8. Excessive thirst secondary to polyuria 9. Slurred speech 10. Acute psychotic behavior 11. Hypercalcemic crisis acute rise of serum calcium level to 17 mg/dL: a. Peptic ulcer symptoms b. Lethargy c. Confusion d. Abdominal cramps e. Coma IV.Medical Management 1. General measures include administering fluids to dilute serum calcium and promote its excretion by the kidneys, mobilize the patient, and restricting dietary calcium intake. 2. IV administration of 0.9% NaCl solution. 3. IV administration of phosphate can cause reciprocal drop in serum calcium. 4. Furosemide increases calcium excretion. 5. Calcitonin to lower serum calcium level for patient with renal failure or heart disease. 6. Corticosteroids may be used for patients with sarcoidosis, myeloma, lumphomas and leukemia. 7. Biphosphonates Pamidronate (Aredia) and Etidronate (Didronel) inhibit osteoclast activity. Nursing Management 1. Monitor patients who are at risk. 2. Increase patient mobility and ambulation. 3. Encourage patient to drink fluids containing sodium unless contraindicated.

4. Encourage patient to drink 3 to 4 quarts of fluid daily. 5. Adequate fiber should be provided in the diet. 6. Provide patient safety as necessary when mental symptoms are present. 7. Assess patient for signs and symptoms of digitalis toxicity. 8. Monitor ECG changes (premature ventricular contractions, paroxysmal atrial tachycardia, heart block) for abnormalities.