The HYPERKALEMIA "Machine" - Causes of Increased Serum K+ M - Medications - ACE inhibitors, NSAIDS A - Acidosis - Metabolic and respiratory C - Cellular

destruction - Burns, traumatic injury H - Hypoaldosteronism, hemolysis I - Intake - Excesssive N - Nephrons, renal failure E - Excretion - Impaired MURDER Signs and Symptoms of Increased Serum K+ M - Muscle weakness U - Urine, oliguria, anuria R- Respiratory distress D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid)

HYPERNATREMIA "You Are Fried" F - Fever (low grade), flushed skin R - Restless (irritable) I - Increased fluid retention and increased BP E - Edema (peripheral and pitting) D - Decreased urinary output, dry mouth Can also use this one: SALT S = Skin flushed A = Agitation L = Low-grade fever T = Thirst "CATS" of "HYPOCALCEMIA" C - Convulsions A- Arrhythmias T - Tetany S - Spasms and stridor chloride

The MAJOR Anion in the ECF Normal range is 95-108 mEq/L

FUNCTIONS 1. major component of gastric juice aside from H+ 2. together with Na+, regulates plasma osmolality 3. participates in the chloride shift 4. acts as chemical buffer The MAJOR Anion in the ICF Normal range is 2.5-4.5 mg/L

FUNCTIONS of PO4 Bicarbonates Present both in ICF and ECF Normal range- 22-26 mEq/L 1. component of bones 2. needed to generate ATP 3. components of DNA and RNA PTH decreases PO4 in blood by renal excretion Calcitonin increases renal excretion of PO4 HYPERPHOSPHATEMIA Serum PO4 more than 4.5 mg/dL Etiology: Tissue trauma, chemotherapy. PO4 containing medications, osteoporosis

FUNCTION 1. regulates acid-base balance 2. component of the bicarbonate-carbonic acid buffer system

Effects of hyponatremia on respiratory system:

shallow, ineffective respiratory movements as a late manifestation r/t skeletal muscle weakness Effects of hyponatremia on neuromusclar system: generalized skeletal muscle weakness that is worse in the extremities Effects of hyponatremia on cerebral function: headache, personality changes Effects of hyponatremia on GI system: a. Increased motility and hyperactive bowel sounds b. Nausea c. Abdominal cramping and diarrhea If the client is taking lithium for hyponatremia, why should you monitor lithium levels? Hyponatremia can cause diminished lithium excretion, resulting in toxicity. What are four conditions that cause decreased sodium excretion can result in hypernatremia? a. Corticosteroids b. Cushing's syndrome c. Renal failure d. Hyperaldosteronism Effects of hypernatremia on neuromuscular system: a. Early: spontaneous muscle twitches; irregular muscle contractions b. Late: skeletal muscle weakness; deep tendon reflexes diminshed or absent Effects of hypernatremia on central nervous system: a. altered cerebral function is the most common manifestation of hypernatremia Effects of hypokalemia on cardiovascular system: a. Thready, weak, irregular pulse b. Peripheral pulses weak c. Orthostatic hypotension d. EKG changes: ST depression; shallow, flat or inverted T wave; and prominent U wave Effects of hypokalemia on respiratory system: a. Shallow, ineffective respirations that result from profound muscle weakness of the skeletal muscles of respiration b. Diminished breath sounds Effects of hypokalemia on neuromuscular system: a. Anxiety, lethary, confusion, coma b. Skeletal muscle weakness; eventual flaccid paralysis c. Loss of tactile discrimination d. Deep tendon hyporeflexia Effects of hypokalemia on GI system: a. Decreased motility, hypoactive to absent bowel sounds b. Nausea, vomiting, constipation, abdominal distention c. Paralytic ileus

The maximun recommended infusion rate is ___ mEq/hr, never to exceed ___ mEq/hr under any

circumstances. 5-10; 20

Effects of hyperkalemia on cardiovascular system: a. Slow, weak, irregular HR b. Decreased BP c. EKG changes: tall peaked T waves; widened QRS complexes; prolonged PR intervals; and flat P waves Effects of hyperkalemia on respiratory system: profound weakness of the skeletal muscles causes respiratory failure Effects of hyperkalemia on system: a. Early: muscle twitches, cramps, paresthesias b. Late: profound weakness, ascending flaccid paralysis in the arms and legs Effects of hyperkalemia on GI system: a. Increased motility, hyperactive bowel sounds b. Diarrhea If renal function is impaired, prepare to administer ___, cation exchange resin that promotes GI sodium absorption and potassium excretion. Kayexalate Effect of hypocalcemia on cardiovascular system: a. Decreased HR b. Hypotension c. Diminished peripheral pulses d. EKG changes: prolonged ST interval; prolonged QT intervals Effect of hypocalcemia on neuromuscular system: a. Irritable skeletal muscles: twitches, cramps, tetany, seizures b. Parasthesias followed by numbness that may affect the lips, nose, and ears in addition to the limbs c. Hyperactive deep tendon reflexes Effect of hypocalcemia on GI system: a. Increased gastric motility; hyperactive bowel sounds

Effect of hypercalcemia on cardiovascular system: a. Increased HR in early phase; bradycardia that can lead to cardiac arrest in late phases

b. Increased BP c. Bounding, full peripheral pulses d. EKG changes: shortened ST segment; widened T wave Effect of hypercalcemia on respiratory system: Ineffective respiratory movement as a result of profound skeletal muscle weakness Effect of hypercalcemia on neuromuscular system: a. Profound muscle weakness b. Diminished or absent deep tendon reflexes c. Disorientation, lethary, coma Effect of hypercalcemia on renal system: a. Increased urinary output leading to dehydration b. Anorexia, nausea, abdominal distention, constipation Effect of hypomagnesemia on neuromuscular system: a. Twitches; paresthesias b. Positive Trousseau's and Chvostek's signs hypo-___ frequently accompanies hypomagnesemia. calcemia Effects of hypermagnesemia on neuromuscular system: a. Diminished deep tendon reflexes b. Skeletal muscle weakness Effects of hypermagnesemia on central nervous system: drowsiness and lethargy that progresses to coma A decrease in the serum phosphorus level is accompanied by an increase in the serum ___ level. calcium Effects of hypophospatemia on neuromuscular system: a. Weakness b. Decreased deep tendon reflexes c. Decreased bone density that can cause fractures and alterations in bone shape An increase in the serum phosphorus level is accompanied by a decrease in the serum ___ level. calcium The problems that occur in hyperphosphatemia center on the hypo-___ that results when serum

phosphorus levels increase. calcemia

Types of therapy 1. Maintenance therapy o Provides water, electrolytes, glucose, vitamins, and in some instances protein to meet daily requirements. 2. Restoration of deficits o In addition to maintenance therapy, fluid and electrolytes are added to replace previous losses. 3. Replacement therapy o Infusions to replace current losses in fluid and electrolytes. Types of intravenous fluids 1. Isotonic solutions a. Fluids that approximate the osmolarity (280-300 mOsm/L) of normal blood plasma.

Sodium Chloride (0.9%) - Normal Saline

Indications:

Extracellular fluid replacement when Cl- loss is equal to or greater the Na loss. Treatment of matebolic alkalosis. Na depletion Initiating and terminating blood transfusions.

Possible side effects:

Hypernatremia Acidosis Hypokalemia Circulatory overload.

b. Five percent dextrose in water (D5W).

Provides calories for energy, sparring body protein and preventing ketosis resulting from fat breakdown.

Indications:

Dehydration Hypernatremia Drug administration

Possible side effects:

Hypokalemia Osmotic diuresis dehydration Transient hyperinsulinism Water intoxication.

c. Five percent dextrose in normal saline (D5NS).

Prevents ketone formation and loss of potassium and intracellular water.

Indications:

Hypovolemic shock temporary measure. Burns Acute adrenocortical insufiency.

Possible side effects:

Hypernatremia Acidosis Hypokalemia Circulatory overload

d. Isotonic multiple-electrolyte fluids.

Used for replacement therapy; ionic composition approximates blood plasma.

Types:

a. Plasmanate b. Polysol c. Lactated Ringers

Indications:

Vomiting Diarrhea Excessive diuresis Burns

Possible side effects:

Circulatory overload. Lactated Ringers is contraindicated in severe metabolic acidosis and/or alkalosis and liver disease. Hypernatremia Acidosis Hypokalemia

2. Hypertonic solutions

Fluids with an osmolarity much higher than 310 mOsm (+ 50 mOsm); increase osmotic pressure of blood plasma, thereby drawing fluid from cells.

a. Ten percent dextrose in normal saline

Administered in large vein to dilute and prevent venous trauma.

Indications:

Nutrition Replenish Na and Cl.

Possible side effects:

Hypernatremia (excess Na) Acidosis (excess Cl) Circulatory overload.

b. Sodium Chloride solutions, 3% and 5% Indications:

Slow administration essential to prevent overload (100 mL/hr) Water intoxication Severe sodium depletion

3.

Hypotonic solutions

Fluids whose osmolarity is significantly less than that of blood plasma (-50 mOsm); these fluids lower plasma osmotic pressure, causing fluid to enter cells.

a. 0.45% sodium chloride

Used for replacement when requirement for Na use is questionable.

b. 2.5% dextrose in 0.45% saline, also 5% in 0.2 % NaCl

Common rehydrating solution.

Indications:

Fluid replacement when some Na replacement is also necessary. Encourage diuresis in clients who are dehydrated. Evaluate kidney status before instituting electrolyte infusions.

Possible side effects:

Hypernatremia Circulatory overload Used with caution in clients who are edematous, appropriate electrolytes should be given to avoid hypokalemia.

Table of Commonly Used IV Solutions

Name of Solution Type of Solution Hypotonic pH 5.6 Shorthand Notation: NS 0.9% Sodium Chloride Ingredients in 1-Liter 77 mEq Sodium 77 mEq Chloride Uses Complications

0.45% Sodium Chloride

hypotonic hydration; replace sodium and chloride; hyperosmolar diabetes

if too much is mixed with blood cells during transfusions, the cells will pull water into them and rupture

Isotonic pH 5.7

154 mEq Sodium 154 mEq Chloride

isotonic hydration; replace sodium and chloride; alkalosis; blood transfusions (will not hemolyze blood cells)

None known

Shorthand Notation: NS

3% Sodium Chloride

Hypertonic pH 5.0

513 mEq Sodium 513 mEq Chloride symptomatic hyponatremia due to excessive sweating, vomiting, renal impairment, and excessive water intake rapid or continuous infusion can result in hypernatremia or hyperchloremia

5% Sodium Chloride

Hypertonic pH 5.8

855 mEq Sodium 855 mEq Chloride

5% Dextrose in Water

Isotonic pH 5.0

5 grams dextrose (170 calories/liter)

isotonic hydration; provides some calories

Shorthand Notation: D5W water intoxication and dilution of bodys electrolytes with long, continuous infusions Hypertonic pH 4.3 Shorthand Notation: D10W 10 grams dextrose (340 calories/liter) may be infused peripherally; hypertonic hydration; provides some calories

10% Dextrose in Water

5% Dextrose in 1/4 Strength (or 0.25%) Saline

Hypertonic pH 4.4

5 grams Dextrose 34 mEq Sodium 34 mEq Chloride

fluid replacement; replacement of sodium, chloride and some calories

Shorthand Notation: D5NS

5% Dextrose in 0.45 Sodium Chloride

Hypertonic pH 4.4

5 grams Dextrose 77 mEq Sodium 77 mEq Chloride

hypertonic fluid replacement; replace sodium, chloride, and some calories

vein irritation because of acidic pH, causes agglomeration (clustering) if used with blood transfusions; hyperglycemia with rapid infusion leading to osmotic diuresis

Shorthand Notation: D5NS

5% Dextrose in Normal Saline

Hypertonic pH 4.4

5 grams Dextrose 154 mEq Sodium 154 mEq Chloride

hypertonic fluid replacement; replace sodium, chloride and some calories

Shorthand Notation: D5NS

Ringers Injection, U.S.P.

Isotonic pH 5.8

147 mEq Sodium 4 mEq Potassium 4 mEq Calcium

electrolyte replacement; hydration; often used to replace extracellular fluid losses

rapid administration leads to excessive introduction of electrolytes and leads to fluid overload and congestive conditions; provides no calories and is not an adequate maintenance solution if

155 mEq Chloride

abnormal fluid losses are present

Lactated Ringers

Isotonic pH 6.6

130 mEq Sodium 4 mEq Potassium 3 mEq Calcium 109 mEq Chloride 28 mEq Sodium Lactate (provides 9 calories/liter)

isotonic hydration; replace electrolytes and extracellular fluid losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis)

Shorthand Notation: LR

not enough electrolytes for maintenance; patients with hepatic disease have trouble metabolizing the lactate; do not use if lactic acidosis is present 5% Dextrose in Lactated Ringers Injection Hypertonic pH 4.9 5 grams Dextrose (170 calories/liter) 130 mEq Sodium Shorthand Notation: D5LR 4 mEq Potassium 3 mEq Calcium 109 mEq Chloride 28 mEq Sodium Lactate (provides 9 calories/liter) hypertonic hydration; provides some calories; replace electrolytes and extracellular fluid losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis), the dextrose minimizes glycogen depletion