Chronic renal failure Congestive heart failure Excessive corticosteroid therapy Syndrome of inappropriate secretion of ADH (SIADH
Potent diuretic therapy Diabetes insipidus Fluid losses from GI tract Excessive sweating
weakness Distended neck veins Full, bounding pulse Elevated BP Slow-emptying peripheral veins Effusions into third spaces
Since a fluid volume deficit decreases blood flow to kidneys, treatment must begin promptly to prevent damage to kidneys. If fluids cannot be ingested, isotonic IV fluids (.9% NaCL and D5W) are given initially. Electrolytes are added to IV solution if adequate renal function is present (Lactated Ringer=s solution) Although a fluid volume deficit usually takes days to develop, a severe deficit may occur within hours and may lead to circulatory collapse (hypovolemic shock)
Diabetes insipidus Renal concentrating disorders Watery diarrhea Profuse diaphoresis without fluid replacement
Excessive administration of sodiumfree IV fluids (D5W) Excessive tap water enemas Stimulation of antidiuretic hormone (ADH) Psychogenic polydipsia
Inability to respond to thirst mechanism Difficulty swallowing fluids Hypertonic tube feedings without adequate water supplements Excessive administration of hypertonic NaCl or NaHCO3 Adrenal hyperfunction B
Hyperaldosteronism
Use of hypotonic irrigating solutions (distilled water) Excessive use of thiazide or loop diuretics Sodium-losing renal disease Replacement of water, but not electrolytes lost in massive burns, diaphoresis, vomiting, diarrhea, NG suction
Adrenal insufficiency
To prevent hyponatremia:
Administer water between hypertonic tube feedings Teach elderly patients to drink fluids regularly, as thirst sensation often decreases with aging Offer fluid frequently to patients at risk
Use normal saline instead of distilled water for irrigations Avoid tap water enemas in bowel management Teach patients to replace body fluid losses with fruit juice or bouillon rather than water
To correct hypernatremia:
To correct hyponatremia:
Monitor replacement of water loss as prescribed Diuretics to remove excess Na+ may also be prescribed Monitor specific gravity of urine
Help patient comply with prescribed fluid restriction Administer hypertonic IV solutions when prescribed, with great caution
Decreased K+ intake:
Rapid IV administration of K+ Anorexia nervosa Administration of aged blood Gastrointestinal K+ loss: Increased oral intake causes hyperkalemia only if Vomiting, gastric suction accompanied by decreased K+ Diarrhea, laxative abuse, recent excretion ileostomy Excessive use of salt substitutes + B (K Cl )
Large sweat loss without K+ replacement Increased renal excretion of K+:
Acute and chronic renal failure Decreased production of Aldosterone Adrenal insufficiency (Addison=s
disease)
Excessive use of K+ conserving diuretics: Spironolactone Entry of K+ into cells: (Aldactone) and Amiloride (Moduretic) Alkalosis B increased pH with
Use of K+ losing diuretics without K+ replacement Ex.: Furosemide (Lasix), Bumetanide (Bumex), and HCTZ Hyperaldosteronism
Tissue injury (burns, major surgery, or crush injury) Acidosis B decreased pH with
Hypersecretion of insulin
Potassium (K+)
excess H+ in ECF (compensation causes K+ to shift from cells to ECF)
Mental confusion GI hyperactivity (N&V, abdominal cramping and diarrhea) Cardiotoxicity EKG changes (K+ > 6 mEq/L: o Peaked T waves and prolonged
o o o
Cardiac arrhythmias B
bradycardia and heart block
Cardiac arrest
Muscle weakness/paralysis, flaccid muscles (lack tone) Decreased bowel motility (intestinal ileus, nausea and vomiting) Polyuria EKG changes (serum K+ < 3 mEq/L): o ST segment depression, T wave flattening, prominent U waves o Cardiac arrhythmias B
PACs or PVCs
o
Respiratory failure B K+
<1.5 mEq/L
To prevent hypokalemia:
Monitor IV infusions of K+ carefully Evaluate renal function before administering K+ intravenously Avoid use of salt substitutes for patients with renal problems Teach patients, particularly those with renal failure, about foods/fluids which are high in K+
Teach patients which foods have high K+ content Teach patients about their diuretics
Give fluids to increase urinary output IV NaHCO3 a base, shifts K+ into cells in exchange for H+.
Watch for signs of digitalis toxicity in patients receiving digitalis preparations Administer K+ supplements as ordered
Potassium (K+) Hypertonic glucose infusion stimulates release of insulin which promotes cellular uptake of K+ (5-15 units regular insulin with 50 ml of D50W or 250-500 ml of D10W). Administer K+ depleting diuretics as ordered. Administer Kayexalate (cation exchange resin), if ordered Withhold drugs (e.g., K+ PCN-G) that contain large amounts of K+ Decrease dietary sources of K+
Administer IV K+ (KCl) in diluted concentration. (Usual concentration 20-40 mEq/L/1000cc. Maximum is 80mEq/1000cc.) Never administer potassium solutions by IV push; doing so will very likely cause cardiac arrest
Vitamin D deficiency Chronic insufficient dietary intake of Ca++ Acute pancreatitis Overuse of antacids Malabsorption Syndromes
Calcium (Ca++) Nausea and vomiting Constipation Muscle weakness/flaccidity Depressed deep tendon reflexes Confusion, lethargy, CNS depression (coma) Polyuria Pathological fractures (chronic) Renal calculi EKG changes:
Shortened QT interval
Muscle cramps Confusion, irritability, anxiety Tetany Paresthesias of fingers and circumoral region Neuromuscular irritability:
Positive Chvostek=s sign B muscle spasm at cheek and corner of mouth in response to tap over facial nerve in front of ear. Positive Trousseau=s sign B carpal spasms after occlusion of blood flow to hand with BP cuff for three minutes.
Hyperactive deep tendon reflexes Convulsions EKG changes: Prolonged QT interval Cardiac arrest
Cardiac arrest
To prevent hypocalcemia:
Teach patients careful management of antacids and laxatives Teach patients dietary sources of calcium and vitamin D
as ordered Keep 10 ml of 10% IV calcium gluconate available for emergency use after thyroid surgery. Administer
slowly, not exceeding 2 ml/min.
Ensure adequate hydration to decrease possibility of renal calculi formation Maintain an acid urine Handle patient gently when transferring or repositioning to prevent pathological fractures
Magnesium (Mg++)
Overuse of antacids containing Mg++ (Maalox, Chronic diarrhea Gelusil, Riopan) Chronic malnutrition Overuse of laxatives containing Mg++ (Milk of Magnesia) Malabsorption syndrome B Steatorrhea
Impaired Mg++ excretion:
Small bowel resection Chronic alcoholism Prolonged IV administration without Mg+ + supplementation
Gastrointestinal Mg++ loss:
Prolonged excessive diuretic therapy 4. What are the signs and symptoms? Hypoactive deep tendon reflexes Drowsiness, lethargy Mild hypotension Nausea and vomiting Respiratory depression (serum Mg++ > 15 mEq/L) Hyperactive deep tendon reflexes Coarse tremors Tetany Positive Chvostek=s and Trousseau=s
sign
Intense confusion
Cardiac arrhythmias (bradycardia, heart block) Cardiac arrhythmias (PVC, SVT) Cardiac arrest (serum Mg++ > 25 mEq/L) Convulsions Coma 5. What is appropriate clinical nursing care?
To prevent hypermagnesemia: To prevent hypomagnesemia:
Teach patients careful management of Mg++ containing antacids and laxatives Teach patients with renal problems to avoid preparations containing Mg++
To prevent complications and correct hypomagnesemia safely:
Evaluate renal function before Give fluids to increase urinary output - patients administering Mg++ replacement
with impaired renal function will require dialysis
Withhold preparations containing large amounts of Mg++ Keep 10% calcium gluconate, a magnesium antagonist, available for emergency use