Transcript Potassium - Shelbye's CSON Notes Blog | A Place to Share

Potassium
• Major electrolyte in intracellular fluid
• Normal serum K+ is 3.5 to 5.0 mEq/L
• Influences both skeletal and cardiac
muscle activity
• 2% is in the ECF is important for
neuromuscular function.
Potassium
• Minor variations are significant
• Imbalances
• Renal system is important in keeping
balanced potassium
• Body does not conserve potassium
– There are no stores. We either have it or we don’t
– Gains K thru foods and meds. Elevated K usually
doesn’t occur unless there is a reduction in renal
function. Renal failure is the #1 cause of
Hyperkalemia. K needs to be adjusted daily and
your best sources are bananas, apricots,
oranges, meats, veggies, potatoes, carrots, dried
fruit
Hypokalemia
• K+ < 3.5 mEq/L
• Cause
– GI suction, vomiting, diarrhea
– TPN or IVF without K+ replacement
– Trauma
– Diabetes – if it’s uncontrolled
– Low oral intake of K+
– Sweat loss
– Medications – diuretics, laxatives, insulin
Renal Loss of K+
• Diuretics
– Make you pee more, chances are you’ll pee
out some K along with the extra pee
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Hyperaldosteronism
High dose Na+ PCNs
Large dose corticosteroids
Greatest risk is in the elderly for
developing this. Think about all the old
bastards you had to give K-lyte to in
clinicals…
S/S Hypokalemia
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Fatigue
Anorexia, N/V, Decrease bowel motility
Muscle weakness & leg cramps
Impaired glucose tolerance
Paresthesias (numbness & tingling in the
extremities)
• Impaired renal concentrating ability
• Diminished deep tendon reflexes
• Flaccid paralysis – late sign! You’re
usually fucked by this time…
S/S Hypokalemia
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Increased sensitivity to digitalis
Dysrhythmias
Severe hypokalemia
Hypokalemia commonly accompanies
alkalosis.
Memory Jogger for
Hypokalemia
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SUCTION
S = Skeletal muscle weakness
U = U wave (on the EKG)
C = Constipation
T = Toxicity of Digoxin
I = Irregular or weak pulse
O = Orthostatic Hypotension
N = Numbness or parasthesia
Hypokalemia & Cardiac
Changes
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 strength of contraction
Myocardium irritability
ST segment depression
K+ < 2.7 mEq/L may result in PACs, PVC's, Vfib or cardiac arrest
– PAC = premature atrial contractions
– PVC = premature ventricular contractions
• K+ < 3.5 assoc. with metabolic alkalosis, high
pH & high HCO3
• Digoxin toxicity
– B/c hypokalemia potentiates the actions of digoxin
Hypokalemia: Lab Results
• K+ deficit < 3.5 mEq/L
• K+ < 3.5mEq/L often assoc. with
metabolic alkalosis, high pH, & high
HCO3
• K+ < 2.7 may result in dangerous
dysrhythmias
•  pH & HCO3
•
Danger signs of low K are dyshrythmias, Cardiac arrest, digoxin toxicity,
muscle paralysis (can lead to respiratory arrest)
Medical Treatment
Hypokalemia
• K+ replacement (PO or IV)
• Increase on a daily basis
– 40-80 mEq/day
• At risk patient
– 50-100 mEq/day
• K+ rich foods
– Green, leafy vegetable and what not
• Treat the underlying cause
• Is the patient’s magnesium low? Cause if it is,
it makes it harder for the kidneys to conserve
K
Oral K+ Supplements
• Minimize GI irritation
– Dilute liquid & effervescent
supplement
– Give tabs & capsules w/ 8 oz. H2O
– Give K+ with food
• Adverse reaction – N/V, diarrhea, GI
bleed (sometimes)
Oral Potassium Supplements
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Avoid overdose (hyperkalemia)
 K+ dose if using K+ salt substitute
Not used with K+ sparing diuretics
K in the IV is VERY irritating to the vein!
Can cause phlebitis very easily.
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Intravenous K+ Supplement
Must be diluted! You will DIE!!!
Do NOT give by direct IVP
Max. dose is 60 mEq at a time
Must use IV pump. No gravity allowed! Must
be on pump 100% of the time!
Monitor renal output
CHS policy – pt on heart monitor (cause K
effects the heart… May not be on monitor if
it’s a very low dose)
Monitor IV site (necrosis! Go slowly!)
Neut will neutrilize the K a little bit so the K
doesn’t sting as much in their veins when
they’re getting it IV
Nursing Interventions:
Hypokalemia
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Identify pt at risk – esp. if on Digoxin
Monitor EKG (or ECG) & BP
Monitor serum K+
Pt education – diuretics & laxatives
Administer K+ supplements PO or IV
 dietary K+
Monitor urine output
Hyperkalemia
• Serum K+ > 5.5 mEq/L
• Causes
– Renal failure
– Release of K+ from damaged cells
– Acidosis
– Addison’s Disease
– K+ sparing diuretics
– High K+ intake
– Medications
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S/S Hyperkalemia
Main effects cardiac function
Muscle weakness and paralysis
Ventricular conduction is slowed
Paresthesias & irritability
– Respiratory and speech muscles
• Flaccid muscular paralysis
– Legstrunkarms (including respiratory)
• GI hyperactivity
– N/V, colic, & diarrhea
Hyperkalemia & Cardiac
Changes
• Slows heart rate
• ECG changes
– Tall, peaked T wave, short QT interval
– Longer PR interval, widening QRS
complex
– Risk for Heart Block, A-fib, or, V-fib
• All of these are severe and we need to fix them as
soon as we can, that is, if we can.
• The higher the K is the worse these are. Usually
associated with a K higher than 7
• Severe  K+
– Decreased heart contraction strength
– Dilated & flaccid heart
ECG & Potassium
Hyperkalemia: Lab Data
• Serum potassium > 5.5 mEq/L
• ECG abnormalities
• Arterial blood gases – low pH indicating
acidosis
• Metabolic acidosis is usually
accompanied by hyperkalemia
Hyperkalemia Medical
Treatment
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K+ restricted diet
Stop K containing medications
Monitor for “Digitalis toxicity”
Cation-exchange resins
– Kayexalate – PO or PR (in the rectum)
• Fastest way to lower your potassium. It’s gross.
– 1Gm of resin removes 1 mEq K+
• Dialysis
– If conservative methods not suffice
Emergency Medical Treatment
Hyperkalemia
• Ca Gluconate – IV
– Does NOT  K+
– Antagonizes K+ action on heart (keeps it from letting the
heart get flaccid. Works against the K but doesn’t lower
the K levels! This is a quick thing to give them to prevent
heart problems)
– Monitor ECG
• Hypertonic Glucose & Insulin
– Insulin - facilitates K+ movement into cells
• If you can get things out of the circulating volume and into the
cells, it doesn’t have an effect on the body. Unusable when
it’s in the cells
– Glucose -  insulin release from pancreas
• NaHCO3
– K+ shifts into cells
– May be the best thing to move K into the cells quickly!
On the test make sure to read the question and look for distracters and pick the appropriate
answer
Nursing Interventions
Hyperkalemia
• Be aware of pt at risk
• Monitor for:
– Generalized weakness & dysrythmias
– Irritability & GI symptoms
– Nausea & intestinal colic
– ECG or lab abnormalities
• Prevention of hyperkalemia
• Educate pt: medication & diet
• Do NOT draw blood above K+ infusion site
– Would have a very high rate of K if you do this.
If they have hyperkalemia make sure you know foods
that are high in K. I missed the foods he was saying.
Calcium
• Serum Ca++ level 8.6 – 10.2 mg/dl (total)
• 99% stored in bones (bones & teeth)
• Found in three forms:
- bound: to proteins (less than 50%)
- ionized: found in serum (50% of calcium and is most
important)
- Children have high levels of this for bone growth
- Old people have very low levels of this due to bone loss.
- It’s important in muscle contraction, conduction of nerve
impulses, cardiac contractility, and helps in the formation of
prothrombin
- complexed: combined with nonprotein anions:
phosphate, citrate, and carbonate
Calcium and Phosphorus
• Ca and phosphorus have a reciprocal
relationship
– If the Ca is low, the phosphorus is high
– If the phosphorus is low, the Ca will be high
Ionized Calcium
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Activate body chemical rxn
Muscle contractions and relaxation
Promote transmission of nerve impulse
Cardiac contractility & automaticity
Formation of prothrombin
Calcium Regulators
• Parathyroid Hormone (PTH) pulls
– Releases Ca from the bone
– Increases Ca absorption from GI
– Increases Ca absorption from renal
tubules
– When serum Ionized Ca is low, the
parathyroid gland releases PTH. Pulls Ca
from the bone and promotes movement
of Ca (with phosphorus) into the plasma
Calcium Regulators
• Calcitonin – secreted by thyroid (keeps)
– Antagonist of PTH
– Secretion stimulated by high serum Ca++
– Inhibits Ca reabsorption from bone
– When Ca levels are too high, the body
releases calcitonin which keeps the Ca in the
bone which causes a decrease in the Ca
levels in your blood
Calcium Regulators
• Phosphate
–Reciprocal relationship with Ca
– Ca =  Phos
• Vitamin D
–Necessary for absorption &
utilization of Ca
–We get Vitamin D from the
sunshine
Hypocalcemia
• Serum Ca++ < 8.5 mg/dl
• Causes include:
- hypoparathyroidism & surgical
hypoparathyroidism
- malabsorption syndrome
- vitamin D deficiency
- prolonged admin. of Ca free IVF
- acute pancreatitis (Affects PTH secretion, so
you’re not able to absorb your Ca)
Ca absorption occurs primarily in the Small
intestine. If you have Celiacs Disease or
something like that, where you can’t absorb stuff,
you’ll have low levels of Ca. Lack of Vit D
decreases the absorption of Ca
Causes Hypocalcemia
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Excessive admin. of citrated blood
Alkalosis
Hyperphosphatemia
Hypomagnesemia
Thyroid cancer
- Causes excessive calcitonin secretion
- Low serum albumin
- Cimetidine (Tagamet)
- Interferes with the PTH function
- Alcohol Abuse
- Medications
S/S Hypocalcemia
• Tetany (# 1 sign)
– Condition characterized by cramps, convulsions,
twitching of the muscles, and sharp flexion of the
wrists and ankle joints. Think of tetanus. Tetanus
is “Lock Jaw.” Your muscles get stiff and spastic.
• Vary with severity, duration & rate of
development
• Numbness & tingling
• Spasms of muscles of extremities & face
• Pain
S/S Hypocalcemia
• Hyperactive deep tendon reflexes
• Abdominal muscle spasms
• Respiratory effects
• Altered mood & memory
• Convulsion/Seizures
– Seizures may occur b/c the hypocalemia
increases the irritability of the Central
Nervous System
S/S Hypocalcemia
• Laryngeal spasm
• + Trousseau’s
• + Chvostek’s
• Remember these bitches
+ Trousseau’s Sign
• Carpopedal
spasm of hand
when
– Blood supply

– Pressure on
nerve
• Occurs several
minutes after BP
cuff inflated >
systolic BP
•
Ischemia Indicates tetany and a
good sign of hypocalcemia and
hypomagnesium
+ Chvostek’s Sign
• Spasm of muscles
innervated by
facial nerve
• Tap facial nerve
anterior to ear
lobe below
zygomatic
process
• They close their
eyes and their
muscles kind of
twitch
Hypocalcemia Cardiac
Effects
• Prolonged QT interval
• Prolonged ST segment
•  cardiac contractility
•  sensitivity to Digoxin
Hypocalcemia: Lab Data
• Serum calcium levels < 8.5 mg/dl
• Albumin/protein levels can give incorrect
levels of Ca
• Ionized (serum) levels of Ca should be
obtained for accurate results (more
important physiologically)
• PTH levels can effect Ca
• Magnesium and phosphorus levels should
also be obtained
• Remember:
– A low Magnesium is equal to a low Ca
– A high phosphorus is equal to a low Ca
– A high pH is equal to a low Ca
Hypocalcemia Medical
Treatment
• Acute symptomatic  Ca is emergency.
– Requires prompt adm. of IV Calcium
• 10% Ca-Gluconate
– For severe symptoms
• Has to be given IV and slowly! Never give IM!
• Ca-Chloride
– Never give IM
• Oral Ca or Vitamin D
Nursing Interventions
Hypocalcemia
• Identify pt at risk
– Hx, labs, etc…
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Seizure precautions if severe  Ca levels
Monitor airway
Monitor ECG
Educate pt: Ca loss & risks & Ca rich foods
– Ca rich foods are milk products, green leafy
veggies, canned salmon, sardines, and fresh
oysters
Hypercalcemia
• Calcium > 10.5 mg/dl
• If severe – dangerous with  mortality
• Causes include:
– Hyperparathyroidism (most common cause of
hypercalcemia!)
• Causes increased bone release of Ca and increased
absorption of Ca from the intestines and kidneys
– malignant neoplastic disease and
chemotherapies
• 2nd major cause of Hypercalcemia
– thiazide diuretics
– prolonged immobilization
• Causes and increase in loss of Ca from the bone,
moves it into the circulatory system
– large doses Vit. D & Vit. A
S/S Hypercalcemia
• Decreased neuromuscular excitability:
Muscle weakness and incoordination
•  GI motility: anorexia, N/V,
constipation
S/S Hypercalcemia
• Altered memory, confusion, slurred
speech, lethargy, acute psychotic
behavior, & coma
• Depressed deep tendon reflexes
S/S Hypercalcemia
• Bone pain & abdominal pain
• Hypercalcemic crisis: severe polyuria &
polydipsia, intractable nausea (you have this
all the time and it won’t go away), abdominal
cramps, lethargy, coma and cardiac arrest
• Can cause kidney stones
– Increased urinary calcium concentrations
decreases the kidneys ability to concentrate urine.
This leads to polyuria and volume depletion
Hypercalcemia Cardiac
Changes
• Calcium: inotropic effect on heart &
reduces heart rate
– Effects the contractility of the heart, it’s
ability to squeeze down. Because the heart
and conduction system are effected by Ca
you’ll get dysrhythmias and bradycardia
which can lead to cardiac arrest
• Shorten ST segment & QT interval
• Prolonged PR interval
• Potentiate digoxin toxicity
Hypercalcemia: Lab Data
• Serum calcium > 10.2 mg/dl
• ECG-dysrythmias
• PTH- increased (which will throw all the
Ca into the blood stream)
• X-ray-reveal osteoporosis (cause Ca is
being tossed out from the bones into the
blood)
• Urine (will be high in Ca)
Hypercalcemia Medical
Treatment
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Treat underlying cause
Dilute serum Ca++ with NS
Lasix/furosemide
IV phosphate
– Reciprical thing. Phosphate will pull the Ca down
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Calcitonin
Glucocorticoids
Hemodialysis or CAPD
You want to hydrate the pt cause this
encourages peeing and excreting the Ca out of
your pee
Nursing Interventions
Hypercalcemia
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Monitor for pt risk
 activity & fluids if possible
 Ca++ intake
Safety measures for confusion
Monitor ECG, I&O, breath sounds
Monitor for Digoxin toxicity
Prevent Ca++ renal stones
– Whenever they get a kidney stone they usually
analyze them to see what they’re made of
Magnesium
• Normal 1.3 – 2.3 mEq/L
• Second most important Ion in the ICF next to K
• Mg is important for neuromuscular function
• Activator for enzymes
• Carbohydrate & protein metabolism
• Vasodilation in peripheral arteries
• Found in bone and tissue
• Eliminated by kidneys
• The GI and urinary systems are the best regulator
systems for Magnesium
Hypomagnesemia
• Mg < 1.3 mEq/L
• 1/3 Mg is bound to protein, 2/3 remains as free
cation
• Causes include:
• GI loss
-Alcoholism: decrease dietary intake, impairs
renal conservation, intestinal malabsorption,
intermittent diarrhea and vomiting
Kidney is the primary route of Mg excretion.
Chronic alcoholism is the most common cause
due to poor dietary intake of magnesium
Causes Hypomagnesemia
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Intestinal malabsorption syndromes
Diarrhea
Diuretics
Prolonged admin. Mg free IVF/TPN
NG Suction
Renal or liver disease
Diabetic ketoacidosis
S/S Hypomagnesemia
• Usually occur Mg < 1.0 mEq/L
• Most are neuromuscular: hyperexcitability
with muscle weakness, tremors & athetoid
movements (slow involuntary twisting
motion, kind of constantly in motion and
they don’t even know they are doing it. It’s
reversible once you get the levels up)
• Tetany
• + Trouseau’s and Chvostek’s
S/S Hypomagnesemia
• Seizures
• Laryngeal stridor
– You make a sound when you breathe. Like a high
pitched squeek thing
• Signs of low hypocalcemia r/t low PTH
• Alterations in mood: apathy, depression,
agitation, dizziness, insomnia, audio or visual
hallucinations, psychoses, laryngeal strider
(you make a sound when you breathe. Like a
high pitched squeek thing…)
• Digoxin Toxicity
Memory Jogger for
hypomagnesemia
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STARVED
S = Seizures
T = Tetany
A = Anorexia
R = Rapid Heart Rate
V = Vomiting
E = Emotional labillity (your emotions are
all fucking crazy)
• D = Deep tendon reflexes increased
Hypomagnesemia Cardiac
Changes
• Predisposes to dysrhythmias
– PVC or V-fib
•  risk for digoxin toxicity
• ECG:
– Prolonged PR & QT intervals
– Widening QRS complex
– depressed ST segment
– Flattened T waves
– Prominent U waves
– Don’t need to know these guys
Hypomagnesemia: Lab Data
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Mg < 1.3 mEq/L
Potassium
Calcium
ECG
Urine Mg. level
Hypomagnesemia Medical
Treatment
• Diet
– Can be used alone for mild  Mg
– Green vegetables, meat, seafood,
nuts, seeds, legumes, whole grains,
peanut butter, cocoa, and Spinach
(probably one of the best sources)
Hypomagnasemia
Medical Treatment (Cont)
• Mg replacement
– Assess renal function – route of Mg
elimination
– PO Slow-Mag
• Diarrhea possible side effect
– IV or IM
• Because the kidneys are main route of excretion,
make sure to watch BUN and Creatinine levels.
Renal failure clients have problems with high
Magnesium
Admin. Of Mg Sulfate IV
• Monitor rate closely
– Too rapid: risk cardiac arrest
– Dose: based on severity
– Rate not to exceed 150 mg/min or 67 mEq
over 8 hours (severe)
• Contraindicated in heart block
– You DO NOT want to give Mg Sulfate to a person
with heart block!!!
• Monitor renal something and look at deep
tendon reflexes before you give them the med.
If they are absent, don’t give them the drug!
The med could have caused them to go hyper
mg and you don’t want to give them more!
Admin. Of Mg Sulfate IV
• Monitor urinary output
– 100 ml q 4 hr
• Assess patellar reflexes
• Monitor respiratory status
– Risk respiratory arrest
Nursing Interventions
Hypomagnesemia
• Identify & monitor pt at risk
• Asses of digoxin toxicity
• Seizure precautions
• Monitor airway
• Safety for confusion / psychosis
– These guys you put them in bed and head
down the hall and before you get to the nurses
station they’ve passed you on the way to the
elevator trying to escape!
Nursing Interventions
Hypomagnesemia
• Pt education: diuretics & laxative use
• Pt education: diet
Hypermagnesemia
• Mg > 2.5 mEq/L (this abnormality is very rare)
• Causes
– Hemolyzed blood samples
• May show that you have hyper when you don’t. You’re
blood sample is fucked up and they look at it and it says
you have this when you really don’t
– Renal failure
• Most common reason for mypermagnesium
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Addison’s Disease
Excessive use antacids and laxatives
Untreated ketoacidosis
Excessive infusion
Hypothermia
Lithium toxicity
S/S Hypermagnesemia
• Acute elevations: depression of the CNS
• Mild increases: (cause these things below)
-low blood pressure
-N/V
-facial flushing
-sensations warmth
Primary symptoms occur as a result of
peripheral and central nervous symptom
depression
S/S Hypermagnesemia
• Higher increases:
-lethargy
-dysarthria (Difficult or poorly articulated speech
caused by damage to central or peripheral motor
nerves)
-drowsiness
-loss of deep tendon reflexes
-muscle weakness and paralysis
-depressed respirations
-coma
Hypermagnesemia Cardiac
Changes
• Sinus Bradycardia
• Prolonged PR, & QT intervals
• Tall T waves
• Widened QRS
• Heart Block
• Cardiac arrest in diastole
Hypermagnesemia: Lab Data
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Mg > 2.5 mEq/L
ECG
K+ increased
Ca- increased
Creatinine clearance decreases to
less than 3.0 ml/min.
Hypermagnesemia Medical
Treatment
• Prevention is key!
• Avoid administration of Mg in renal failure
• Hemodialysis (sometimes this is
necessary to get the Mg level down)
Hypermagnesemia Medical
Treatment
• Emergency treatment if respiratory or
cardiac problems develop
– Ventilator support
– Calcium Gluconate
• Direct antagonist to Magnesium
• 5 – 10 mEq may reverse cardiac or
respiratory problems
• Lasix
• NaCL or LR
Nursing Interventions
Hypermagnesemia
• Monitor pt at risk
• Monitor vital signs
– Low BP
– Shallow resp. with progressive apnea
• Assess patellar reflexes
– Absent reflexes implies Mg > 7.0
– When you go to hit the knee you get absolutely
nothing. This means it’s above 7.0
• Monitor LOC
– Drowsy, lethargy, coma
• When you have periods of low BP and signs of
apnea and lowered reflexes you need to call the
dr. Have all your information ready before you call
cause they’ll yell at you.
Phosphorus
• Normal 2.5-4.5 mg/dl (adult)
• Essential for fxn of muscle & RBCs
• Essential to nervous system
• Essential to metabolism of:
– Carbohydrate
– Protein
– Fats
– Crucial to cell membrane activity.
Phospholipids make up the cell membrane.
Phosphorus
• Aids in the formation of ATP and 2,3
diphosphoglycerate
• Maintenance in acid-base balance
• 85% is located in bones and teeth
• 14% located in soft tissue
• 1% in ECF
• Critical to nerve and muscle function
Hypophosphatemia
• Phosphorus < 2.5 mg/dl
• Causes
– Severe protein –
• calorie malnutrition
• Anorexia
• Alcoholism
Hypophosphatemia
• Overfeeding with simple carbohydrates
• Elderly debilated & unable to eat
• Hepatic encelopathy (can result in
hypophosphatemia)
Hypophosphatemia
• Prolonged intense hyperventilation
– Alcohol withdrawal
– Diabetic ketoacidosis
• You get Osmotic Diruesis and the insulin causes Ph to move
into cells
– Major thermal burns
• Extensive diruesis of salt and water which typically occurs w/i
first couple of days or something like that. I missed it.
– Hyperventilation causes respiratory alkalosis which
makes phoshporus move into cells (along with K)
S/S Hypophosphatemia
• Most signs & symptoms 2nd to deficiency
– Impaired cellular energy resources
(ATP) Contractility of heart is
decreased due to low amounts of ATP
– Impaired oxygen delivery to tissues
(2,3Diph) DPG
S/S Hypophosphatemia
• Neurological
– Irritability, Apprehension, weakness,
– Numbness, confusion
– Seizure, fatigue, parasthesia, coma
– Without Ph the body can’t make enough
ATP which is necessary for energy
metabolism
• Hyperglycemia
– 2nd to predisposed insulin resistance
S/S Hypophosphatemia
• Muscle damage
– 2nd to  ATP level in muscle tissue
– Muscle weakness & pain
– Acute rhabdomyolysis
• Disintegration of striated muscle
• Skeletal muscle destruction that occurs
due to altered cell activity
– Impaired ventilation
• 2nd to weakened respiratory muscles
Hypophophatemia: Lab Data
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Phos < 2.5 mg/dl
Glucose/insulin admin.
PTH
Alkaline phosphatase
X-ray
Medical Treatment
Hypophosphatemia
• Prevention
• TPN & TF should have adequate Phos.
• Phosphorus – PO
– Aluminum Phosphate (Phosphojel)
• Phosphorus < 1.0 mg/dl (severe)
– K-Phosphate or Na-Phosphate
• 0.2 mMol /kg/hr is max. rate
• Risk of hypocalcemia & tetany (when you’re
trying to correct this)
• Foods rich in Ph: eggs, nuts, whole
grains, meat, fish, poultry and milk
products.
Nursing Interventions
Hypophosphatemia
• Identify & monitor pt at risk
• Gradual introduction of TPN & TF
– Avoid rapid shift of phosphorus
• Prevent infection
• Monitor serum phosphate levels
• Administer meds safely
• Teach about diet
Hyperphosphatemia
• Phosphorus > 4.5 mg/dl
• Causes
– Renal failure (most common cause)
•  Excretion of phosphorus
– Chemotherapy for neoplastic disease
• Causes significant cell destruction, which
releases the Ph into your blood stream
–  Phosphorus intake
– Profound muscle necrosis
– Hypoparathyroidism
S/S Hyperphosphatemia
• Similar to S/S of hypocalcemia (similar to
hypocalcemia)
• Tetany
– Tingling then numbness – fingertips & around
mouth
– Spreads proximally to limbs & face  severity
• Muscle spasm & pain
• Progressive renal impairment
• Remember the inverse relationship with Ph and
Ca. When Ph is high, Ca is low and visa versa.
Hyperphosphatemia: Lab Data
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Phos > 4.5 mg/dl
Calcium
X-ray
PTH
Bun and creatinine (any time there is
kidney involvement you are going to be
checking these guys)
Medical Treatment
Hyperphosphatemia
• Treat underlying disorder
• If 2nd to tumor cell lysis
– Allopurinol – prevent urate nephropathy
• If 2nd to renal failure
– Phosphate binding gels
–  phosphate diet
– Dialysis
Medical Treatment
Hyperphosphatemia
• Acute hyperphosphatemia
– NS – IVF
• Promotes renal excretion
– Hypertonic dextrose & regular insulin
• Drive phosphorus into cells
– Hemodialysis or Peritoneal dialysis
– Surgery
Nursing Interventions
Hyperphosphatemia
• Identify & monitor pt at risk
• Monitor lab results
• Pt education: Avoid meds with Phos.
– Laxatives & enemas
• Change in urine output
Nursing Interventions
Hyperphosphatemia
• Pt education: Avoid  Phos. Foods
– Dried fruit & vegetables
– sardines
– Hard cheeses,
– Whole grain cereal
– Nuts
– All these are high in Ph
Chloride
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Normal: 97 – 107 mEq/L
Major anion in ECF along with Na
Chloride in ISF & lymph > in IVF
Assists in maintaining serum osmolality & osmotic
pressure
• Component in gastric fluid , pancreatic fluid,
& in sweat
• Inverse relationship to bicarbonate
–  Cl =  HCO3
Hypochloremia
• Cl < 96 mEq/L
• Causes
– Prolonged vomiting
– Prolonged NG suctioning
– Prolonged diarrhea
– GI drainage
– Salt restricted diet
– Diuretics (can cause loss via the kidneys,
you pee it out. No shit. Thanks Durbin, for
that wonderful tidbit)
S/S Hypochloremia
•  Bicarbonate level
•  Na level
• Hyperexcitability of muscles
– Tetany, twitching, weakness
• Hyperactive deep tendon reflexes
• Cardiac dysrhythmia
• Water excess
Hypochloremia: Lab Data
•
•
•
•
Cl < 96 mEq/L
Sodium (low)
Potassium (low)
Arterial Blood Gases: reveals metabolic
alkalosis
• Urine chloride level (low)
Medical Treatment
Hypochloremia
• Correct the cause
• IV therapy: NS or ½NS
• Ammonium chloride (to treat metabolic
alkalosis)
– Dose calculated on chloride deficit
– 100mEq / 500ml NS – give slowly
• You don’t want by gravity b/c the entire
amount could go in too quickly which could
add to their problems (would add fluid
overload)
– Foods high in chloride
Nursing Interventions
Hypochloremia
• Monitor I&O
• Monitor bicarbonate & sodium level
• Assess LOC, muscle strength & movement
Avoid bottled water (doesn’t have any electrolytes,
so large amts of chloride could be excreted in the
kidneys. The water makes you pee, and in this
case, peeing a lot is bad)
• Pt education: food  in chloride
– Tomato juice
– canned vegetables
– broth, fruit, processed meat
Hyperchloremia
• Cl > 107 mEq/L
• Causes:
– Loss of bicarbonate
• Kidney
• GI tract
• Remember Ch and bicarbonate inverse
relationship, if you pee off Ch you will
increase your bicarbonate levels…
S/S Hyperchloremia
• S/S same as those of metabolic acidosis,
hypervolemia and hypernatremia.
• Hyperchloremia rarely produces symptoms
on it’s own. Major symptoms are usually
due to metabolic acidosis!
•  Na level
• Fluid retention
• Tachypnea
• Weakness
• Lethargy
S/S Hyperchloremia
•  Cognitive ability
• HTN
• If Untreated
–  Cardiac output
– Dysrhythmias
– Coma
Medical Treatment
Hyperchloremia
• IV fluid
– Lactated Ringer’s – slowly
– LR may be used to convert the lactate to
Bicarbonate, which increases the pH of your
body, which in this case is good
• Diuretics
• Restrict –
– Sodium
– Chloride
– Fluids other than LR until Cl level 
Hyperchloremia: Lab Data
•
•
•
•
•
Cl > 108 mEq/L
Sodium >145
pH <7.35
Serum bicarbonate <22
Urine chloride increased
Nursing Interventions
Hyperchloremia
• Monitor for those pt at risk
• Monitor vital signs
• Monitor I&O
• Fluid restriction other than LR
• Monitor ABG
• Pt education: diet restrictions
• Remember, IV fluid for Hyperchloremia is
LR. And also remember, do this slowly!
Questions
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