ELECTROLYTES

BY:
Kerwin Rico Reyes
Major Electrolytes/Chief Function
❑ Sodium — controls and regulates volume of body fluids
❑ Potassium — chief regulator of cellular enzyme activity and water content
❑ Calcium — nerve impulse, blood clotting, muscle contraction, B12
absorption
❑ Magnesium — metabolism of carbohydrates and proteins, vital actions
involving enzymes
❑ Chloride — maintains osmotic pressure in blood, produces hydrochloric
acid
❑ Bicarbonate — body’s primary buffer system
❑ Phosphate — involved in important chemical reactions in body, cell division
and hereditary traits
Sodium
❑ Normal 135-145 mEq/L
❑ Major cation in ECF
❑ Regulates voltage of action potential; transmission of impulses in
nerve and muscle fibers, one of main factors in determining ECF
volume
❑ Elderly at risk
❑ Helps maintain acid-base balance
 American Heart Association
Recommendation
Healthy American adults should eat less than 2,300 milligrams of
sodium a day. This is about 1 teaspoon of sodium chloride (salt). To
illustrate, the following are sources of sodium in the diet.
❑ 1/4 teaspoon salt = 575 mg sodium
❑ 1/2 teaspoon salt = 1,150 mg sodium
❑ 3/4 teaspoon salt = 1,725 mg sodium
❑ 1 teaspoon salt = 2,300 mg sodium
❑ 1 teaspoon baking soda = 1000 mg sodium
 Sodium Guidelines Set by the FDA

⦿ Sodium-free – less than 5 milligrams of sodium per serving

⦿ Very low-sodium – 35 milligrams or less per serving
⦿ Low-sodium – 140 milligrams or less per serving
⦿ Reduced sodium – usual sodium level is reduced by 25 percent 
⦿ Unsalted, no salt added or without added salt – made without the salt
that's normally used, but still contains the sodium that's a natural part
of the food itself
⦿ The FDA and USDA state that an individual food that has the claim
"healthy" must not exceed 480 mg sodium per reference amount.
"Meal type" products must not exceed 600 mg sodium per labeled
serving size

 Sodium Recommended Daily
Allowance (RDA)
•The current recommendation is to consume less than
2,400 milligrams (mg) of sodium a day. This is about 1
teaspoon of table salt per day. It includes ALL salt and
sodium consumed, including sodium used in cooking
and at the table.
 SODIUM

Na
Na
Na Na

SHRINK

Na Na
SWELL
Na
Na Na
HYPERNATREMIA HYPONATREMIA
Hyponatremia
 Hyponatremia
❑ Results from excess Na loss or water
gain
❑ GI losses, diuretic therapy, severe renal
dysfunction, severe diaphoresis, DKA,
unregulated production of ADH
associated with cerebral trauma,
narcotic use, lung cancer, some drugs
❑ Clinical manifestations
❑ ↓ BP, confusion, headache, lethargy,
seizures, decreased muscle tone,
muscle twitching and tremors, vomiting,
diarrhea, and cramps

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 The imbalance between sodium and water in your
blood may occur in three primary ways:
⦿ Hypovolemic hyponatremia.
⦿ water and sodium levels are both low. This
may occur, for example, when exercising in
the heat without replenishing your fluids or
with marked blood loss.
⦿ Euvolemic hyponatremia.
⦿ Normal water levels combined with low
sodium levels (commonly due to chronic
health conditions, cancer or certain
medications) can lead to euvolemic
hyponatremia.
⦿ Hypervolemic hyponatremia.
⦿ excess water — commonly the result of
kidney failure, heart failure or liver failure —
dilutes the sodium concentration, causing
low sodium levels.
 CAUSES
⦿ Consuming excessive water during exercise.
Because you lose sodium through sweat,
drinking too much water during endurance
activities, such as marathons and triathlons, can
dilute the sodium content of your blood.
⦿ Hormonal changes due to adrenal gland
insufficiency (Addison's disease). Your adrenal
glands produce hormones that help maintain
your body's balance of sodium, potassium and
water.
⦿ Hormonal changes due to an underactive
thyroid (hypothyroidism). Hypothyroidism may
result in a low blood sodium level.
⦿ Diuretics (water pills) — especially thiazide
diuretics. Diuretics work by making your body
excrete more sodium in urine.
 CAUSES
⦿ Syndrome of inappropriate anti-diuretic hormone
(SIADH). In this condition, high levels of the
anti-diuretic hormone (ADH) are produced, causing
your body to retain water instead of excreting it in
your urine.
⦿ Primary polydipsia. In this condition, your thirst
increases significantly, causing increased fluid intake.
⦿ Certain medications. Some medications, such as
some antidepressants and pain medications, can
cause you to urinate or perspire more than normal.
⦿ Chronic, severe vomiting or diarrhea. This causes
your body to lose fluids and electrolytes, such as
sodium.
⦿ Dehydration. In dehydration, your body loses fluids
and electrolytes.
 CAUSES
⦿ Diet. Consuming a low-sodium diet combined
with excessive water intake for prolonged
periods can disturb the proper balance between
sodium and fluids in your blood.
⦿ Cirrhosis. Liver disease can cause fluids to
accumulate in your body.
⦿ Kidney problems. Kidney failure and other
kidney disease may render your body unable to
efficiently remove excess fluids from your body.
⦿ Congestive heart failure. The condition causes
your abdomen and lower extremities to retain
fluids.
CAUSES
 Risk factors
❑ Age.
❑ Low blood sodium is more common in older adults. This is due to age-related changes and
increased prevalence of chronic disease that may impair your body's normal sodium balance.
❑ Sex.
❑ more common in women than in men.
❑ Diet.
❑ increased risk of hyponatremia if you are following a low-sodium diet, especially if combined
with diuretic intake.
❑ Intensive physical activities.
❑ People who take part in marathons, ultramarathons, triathlons and other long-distance,
high-intensity activities are at an increased risk of hyponatremia.
❑ Climate.
❑ Not being acclimated to hot weather can increase the amount of sodium you lose through
sweating during exercise.
❑ Conditions that impair your body's water excretion.
❑ Medical conditions that may increase your risk of hyponatremia include kidney disease,
syndrome of inappropriate anti-diuretic hormone (SIADH) and heart failure, among others.
 Assessment

❑Labs
❑ Increased HCT, K
❑ Decreased Na, Cl, Bicarbonate, Urine Output with low Na and Cl
concentration
❑ Urine specific gravity ↓ 1.010

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 Treatment
❑Interventions
❑Mild
❑ Water restriction if water retention problem
❑ Increase Na in foods if loss of Na
❑Moderate
❑ IV 0.9% NS, 0.45% NS, LR
❑Severe
❑ 3% NS – short-term therapy in ICU setting

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 NURSING MANAGEMENT
❑ Watch cardiac, respiratory, neuro, renal, and GI status
❑ Hypovolemic Hyponatremia: give IV sodium chloride infusion to restore sodium and
fluids (3% Saline hypertonic solution….harsh on the veins…given in ICU usually
through central line very slowly…must watch for fluid overload)
❑ Hypervolemic Hyponatremia: Restrict fluid intake and in some cases administer
diuretics to excretion the extra water rather than sodium to help concentrate the
sodium. If the patient has renal impairment they may need dialysis.
❑ Caused by SIADH or antidiuretic hormone problems: fluid restriction or treated
with an antidiuretic hormone antagonists called Declomycin which is part of the
tetracycline family (don’t give with food especially dairy or antacids…bind to
cations and this affect absorption).
❑ If patient takes Lithium remember to monitor drug levels because lithium excretion
will be diminished and this can cause lithium toxicity.
❑ Instruct to increase oral sodium intake and some physicians may prescribe sodium
tablets. Food rich in sodium include: bacon, butter canned food, cheese, hot dogs,
lunch meat, processed food, table salt
HYP HYP
ERN ERN
ATR ATR
EMI EMI
A A
 Hypernatremia

❑Gain of Na in excess of water or loss

of water in excess of Na
❑Causes
❑ Deprivation of water; hypertonic tube
feedings without water supplements,
watery diarrhea, greatly increased
insensible water loss, renal failure,
inadequate blood circulation to
kidneys, use of large doses of adrenal
corticoids, excess sodium intake
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 Signs/Symptoms
❑Early: Generalized muscle weakness,
faintness, muscle fatigue, HA
❑Moderate: Confusion, thirst
❑Late: Edema, restlessness, thirst,
hyperreflexia, muscle twitching,
irritability, seizures, possible coma
❑Severe: Permanent brain damage,
hypertension, tachycardia, N & V

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LABORATORY

❑Increased serum Na
❑ Increased serum
osmolality
❑ Increased urine specific
gravity

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 Treatment
❑ Free water to replace ECF volume
❑ Gradual lowering with hypotonic
saline
❑ Decrease by no more than 2 mEq/L/hr
❑ Offer fluids at regular intervals
❑ Supplement tube feedings with free
water
❑ Teach about foods, medications high
in Na
❑ Treat underlying problem

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 Evaluation

❑Normal serum NA levels

❑Resolution of symptoms
❑A client who has resolved this crisis will see a return to
normal Na levels, and resolution of their neurological
symptoms. The attempt of the medical management
is to move the Na level until symptoms are resolved,
and then allow for correction through oral feedings.

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NURSING MANAGEMENT
❑ Restrict sodium intake! Know foods high in salt such
as bacon, butter, canned food, cheese, hot dogs, lunch
meat, processed food, and table salt.
❑ Keep patient safe because they will be confused and
agitated.
❑ Doctor may order to give isotonic or hypotonic solutions
such as 0.45% NS (which is hypotonic and most commonly
used). Give hypotonic fluids slowly because brain tissue is
at risk due to the shifting of fluids back into the cell
(remember the cell is dehydrated with hypernatremia) and
the patient is at risk for cerebral edema. In other words,
the cell can lyse if fluids are administered too quickly.
❑ Educate patient and family about sign and symptoms of
high sodium level and proper foods to eat.

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POTASSIUM
 Potassium
❑ Normal 3.5-5.5 mEq/L
❑ Major ICF cation
❑ Vital in maintaining normal cardiac and neuromuscular function
❑ influences nerve impulse conduction,
❑ important in CHO metabolism,
❑ helps maintain acid-base balance,
❑ control fluid movement in and out of cells by osmosis

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 3.5-5
mmol/L
POTASSIUM
K K
3.5-5
mmol/L
K 3.5-5
mmol/L

150
K K
3.5-5 3.5-5
mmol/L mmol/L
 POTASSIUM RICH FOODS
⦿ VEGETABLE ⦿ FRUITS
◼ AVOCADO ◼ DRIED FRUITS(RAISINS)
◼ RAW CARROT ◼ BANANA
◼ BAKED POTATO ◼ APRICOT
◼ RAW TOMATO ◼ CANTALOUPE
◼ SPINACH ◼ ORANGE
⦿ MEATS AND FISH ⦿ BEVERAGE
◼ BEEF ◼ MILK
◼ PORK ◼ ORANGE JUICE
◼ VEAL ◼ APRICOT NECTAR
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 Hypokalemia
❑ Serum potassium level
below 3.5 mEq/L
❑ Causes
❑ Loss of GI secretions
❑ Excessive renal excretion of
K
❑ Movement of K into the
cells (DKA)
❑ Prolonged fluid
administration without K
supplementation
❑ Diuretics (some)

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 Signs/Symptoms
❑ Skeletal muscle weakness, ↓ smooth muscle
function, ↓ DTR’s
❑ ↓ BP, EKG changes, possible cardiac arrest
❑ N/V, paralytic ileus, diarrhea
❑ Metabolic alkalosis
❑ Mental depression and confusion

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Treatment

❑Hydrate if low Urine

Output
❑Oral replacement through
high K diet
❑IV supplementation
❑No more than 10 mEq/hr;
for child 2-4 mEq/kg/24 h
❑No more than 40 mEq/L
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Treatment
❑Hypertonic glucose solution
❑Monitor
❑I & O
❑ Bowel sounds
❑ VS, cardiac rhythm
❑ Muscle strength
❑ Digoxin level if necessary

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NURSING MANAGEMENT
❑ Assess heart rhythm (place on cardiac monitor…most are already on
telemetry), respiratory status, neuro, GI, urinary output and renal
status (BUN and creatinine levels)
❑ Assess other electrolytes like Magnesium (will also decrease…hard to
get K+ to increase if Mag is low), watch glucose, sodium, and calcium
all go hand-in-hand and play a role in cell transport
❑ Administer oral Supplements for potassium with doctor’s order:
usually for levels 2.5-3.5…give with food can cause GI upset
❑ IV Potassium for levels less 2.5 (NEVER EVER GIVE POTASSIUM via IV
push or by IM or subq routes)
NURSING MANAGEMENT
❑ -Give according to the bag instruction don’t increase the rate…has to be
given slow…patients given more than 10-20 meq/hr should be on a cardiac
monitor and monitored for EKG changes
❑ -Cause phlebitis or infiltrations
❑ Don’t give LASIX, demadex , or thiazides (waste more Potassium) or
Digoxin (cause digoxin toxicity) if Potassium level low…notify md for
further orders)
❑ Physician will switch patient to a potassium sparing diuretic
Spironolactone (Aldactone), Dyazide, Maxide, Triamterene
NURSING MANAGEMENT
❑ -Give according to the bag instruction don’t increase the rate…has to be
given slow…patients given more than 10-20 meq/hr should be on a cardiac
monitor and monitored for EKG changes
❑ -Cause phlebitis or infiltrations
❑ Don’t give LASIX, demadex , or thiazides (waste more Potassium) or
Digoxin (cause digoxin toxicity) if Potassium level low…notify md for
further orders)
❑ Physician will switch patient to a potassium sparing diuretic
Spironolactone (Aldactone), Dyazide, Maxide, Triamterene
NURSING MANAGEMENT
Instruct patient to eat Potassium rich foods (Remember POTASSIUM)
❑ Potatoes, pork ❑ Spinach
❑ Oranges ❑ fIsh
❑ Tomatoes ❑ mUshrooms
❑ Avocados ❑ Musk melons: cantaloupe
❑ Strawberries, ❑ Also included are: (carrots,
raisins, bananas)
Hyperkalemia
 THREE TYPES OF REGULATORY PROCESSES
❑First, various cells and organs act to prevent hyperkalemia by
taking up potassium from the blood.
❑Prevented by the action of the kidneys, which excrete
potassium into the urine.
❑Protective mechanism is vomiting. Consumption of a large
dose of potassium ions, such as potassium chloride, induces
a vomiting reflex to expel most of the potassium before it can
be absorbed.
 Hyperkalemia
❑Serum potassium
level above 5.3 mEq/L
❑Causes
❑Excessive K intake (IV
or PO) especially in
renal failure
❑Tissue trauma
❑Acidosis
❑Catabolic state
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 Hyperkalemia
❑Serum potassium level
above 5.3 mEq/L
❑Causes
❑Excessive K intake (IV or
PO) especially in renal
failure
❑Tissue trauma
❑Acidosis
❑Catabolic state
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Signs/Symptoms
❑ ECG changes – tachycardia to
bradycardia to possible cardiac
arrest
❑ Tall, tented T waves
❑ Cardiac arrhythmias
❑ Muscle weakness, paralysis,
paresthesia of tongue, face,
hands, and feet, N/V, cramping,
diarrhea, metabolic acidosis

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Treatment
❑ 10% Calcium gluconate
❑ Sodium bicarbonate
❑ 50% glucose solution
❑ Kayexalate PO or PR
❑ Stop K supplements and avoid K
in foods, fluids, salt substitutes

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 TREATMENT
C
“See” Calcium: Calcium gluconate (10%) 10 mL IV over 10 min . Calcium is a – cardiac stabilizer.
Beta agonists: Salbutamol 10 – 20 mg in 4 mL normal saline nebulized over 10 min
OR
– Bicarbonate: sodium bicarbonate 8.4% (50 mEq) 1 ampoule IV over 5 minutes – Both of these
B agents cause temporary intracellular shift.
I insulin: Short acting insulin 10 units IV push followed by … (see next box!)
Glucose: D50W 1 ampoule IV over 5 minute given with insulin. Insulin causes– temporary intracellular
G shift and glucose is given to maintain blood glucose levels.
Kayexalate: Sodium polystyrene sulfonate 15-30 g in 15-30 mL (70% sorbitol) PO. Kayexalate may
K facilitate– gastrointestinal removal.
D Diuretics: Furosemide 40-80 mg IV push. This facilitates – renal removal.
ROP
“Renal unit
for dialysis
Of Patient” Dialysis achieves extracorporeal removal.
 Nursing management
❑Monitor ins and outs
❑Check serum potassium levels
❑Follow ECG closely to look for peaked T waves
❑Educate patient on hyperkalemia
❑Administer diuretics as ordered
❑Administer insulin to lower potassium as ordered
 Nursing management
❑Check blood glucose when administering insulin
❑Check BUN and creatinine levels
❑Educate patient on a low potassium diet
❑Encourage patient to follow closely with the clinician
❑Educate patient on renal dysfunction and hyperkalemia
❑Ensure patient is on no medications that can cause
hyperkalemia or renal dysfunction
 Evaluation

❑Normal serum K values

❑Resolution of symptoms
❑Treat underlying cause if possible

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CALCIUM
Hypocalcemia
Hypercalcemia
 Calcium
❑ Normal 8.6-10.3 mg/dL
❑ Normal ionized calcium is generally accepted as between 4.5 – 5.5
mg/dL
❑ 99% of Ca in bones, other 1% in ECF and soft tissues
❑ Total Calcium – bound to protein – levels influenced by nutritional
state
❑ Ionized Calcium – used in physiologic activities – crucial for
neuromuscular activity

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 Daily Calcium Needs

It is also important to understand how much calcium

kids actually need. The Food and Nutrition Board of the
National Academy of Sciences recommends:
❑500 mg a day for kids who are 1 to 3 years old
❑800 mg a day for kids who are 4 to 8 years old
❑1,300 mg a day for kids who are 9 to 18 years old
CALCIUM Ca-
8.5-10mg/
DL

Ca-2.1-2.6
mmol/L ICF Ca-2.1-2.6
mmol/L

Ca-
8.5-10mg/
DL
 Calcium
❑Required for blood coagulation,
neuromuscular contraction,
enzymatic activity, and strength and
durability of bones and teeth
❑Nerve cell membranes less excitable
with enough calcium
❑Ca absorption and concentration
influenced by Vit D, calcitriol (active
form of Vitamin D), PTH, calcitonin,
serum concentration of Ca and Phos

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HYPOCALCEMIA
Hypocalcemia
❑ total serum calcium
concentration < 8.8 mg/dL
(< 2.20 mmol/L) in the
presence of normal plasma
protein concentrations
❑ serum ionized calcium
concentration < 4.7 mg/dL (<
1.17 mmol/L).
❑ Reference ranges for serum
calcium vary by age and sex;
Causes of Hypocalcemia
❑Most common – depressed function or surgical removal of the
parathyroid gland
❑Hypomagnesemia
❑Hyperphosphatemia
❑Administration of large quantities of stored blood (preserved
with citrate)
❑Renal insufficiency
❑↓ absorption of Vitamin D from intestines
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 Causes of Hypocalcemia (low calcium)
❑ Low parathyroid hormone due. This is due to the destruction or removal parathyroid
gland (any surgeries of the neck ex: thyroidectomy you want to check the calcium
level) Professors love to ask this on an exam.
❑ Oral intake inadequate (alcoholism, bulimia etc.)
❑ Wound drainage (especially GI System because this is where calcium is absorbed)
❑ Celiac’s & Crohn’s Disease cause malabsorption of calcium in the GI track
❑ Acute Pancreatitis
❑ Low Vitamin D levels (allows for calcium to be reabsorbed)
❑ Chronic kidney issues (excessive excretion of calcium by the kidneys)
❑ Increased phosphorus levels in the blood (phosphorus and calcium do the opposite of
each other)
❑ Using medications such as magnesium supplements, laxatives, loop diuretics, calcium
binder drugs
❑ Mobility issues
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 Signs/Symptoms
❑ Abdominal and/or extremity
cramping
❑ Tingling and numbness
❑ Positive Chvostek or Trousseau signs
❑ Tetany; hyperactive reflexes
❑ Irritability, reduced cognitive ability,
seizures
❑ Prolonged QT on ECG, hypotension,
decreased myocardial contractility
❑ Abnormal clotting

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 Signs/Symptoms
Remember “CRAMPS”
❑ Confusion
❑ Reflexes hyperactive
❑ Arrhythmias (prolonged QT interval and
ST interval) Note: definitely remember
prolonged QT interval…another major
test question
❑ Muscle spasms in calves or feet, tetany,
seizures
❑ Positive Trousseau’s! You will see this
before Chvostek’s sign or before tetany.
This sign may be positive before other
manifestations of hypocalcemia such as
hyperactive reflexes.

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 Treatment
• High calcium diet or oral calcium salts (mild) - √ formulas for calcium
content
• IV calcium as 10% calcium chloride or 10% calcium gluconate – give
with caution
• Close monitoring of serum Ca and digitalis levels
• ↓ Phosphorus levels ↑ Magnesium levels
• Vitamin D therapy

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 NURSING MANAGEMENT
❑ Safety (prevent falls because patient is at
risk for bone fractures, seizures
precautions, and watch for laryngeal
spasms)
❑ Administer IV calcium as ordered (ex:
10% calcium gluconate)….give slowly as
ordered (be on cardiac monitor and
watch for cardiac dysrhythmias). Assess
for infiltration or phlebitis because it can
cause tissue sloughing (best to give via a
central line). Also, watch if patient is on
Digoxin cause this can cause Digoxin
toxicity.
 NURSING MANAGEMENT
❑ Administer oral calcium with Vitamin D
supplements (given after meals or at
bedtime with a full glass of water)
❑ If phosphorus level is high (remember
phosphorus and calcium do the
opposite) the doctor may order
aluminum hydroxide antacids (Tums) to
decrease phosphorus level which in turn
would increase calcium levels.
 NURSING MANAGEMENT
❑ Encourage intake of foods high in
calcium:
Young Sally’s calcium serum continues to
randomly mess-up.
❑ Yogurt
❑ Sardines
❑ Cheese
❑ Spinach
❑ Collard greens
❑ Tofu
❑ Rhubarb
❑ Milk
HYPERCALCEMIA
 Hypercalcemia
❑ Causes
❑ Mobilization of Ca from bone
❑ Malignancy
❑ Hyperparathyroidism
❑ Immobilization – causes bone loss
❑ Thiazide diuretics
❑ Thyrotoxicosis
❑ Excessive ingestion of Ca or Vit D

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 Signs/Symptoms
• Anorexia, constipation
• Generalized muscle weakness,
lethargy, loss of muscle tone, ataxia
• Depression, fatigue, confusion, coma
• Dysrhythmias and heart block
• Deep bone pain and
demineralization
• Polyuria & predisposes to renal
calculi
• Pathologic bone fractures

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 Hypercalcemic Crisis

❑Emergency – level of 8-9

mEq/L
❑Intractable nausea,
dehydration, stupor, coma,
azotemia, hypokalemia,
hypomagnesemia,
hypernatremia
❑High mortality rate from
cardiac arrest
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 Hypercalcemic Crisis

❑Emergency – level of 8-9

mEq/L
❑Intractable nausea,
dehydration, stupor, coma,
azotemia, hypokalemia,
hypomagnesemia,
hypernatremia
❑High mortality rate from
cardiac arrest
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 Treatment
❑ NS IV – match infusion
rate to amount of UOP
❑ I&O hourly
❑ Loop diuretics
❑ Corticosteroids and
Mithramycin in cancer
clients
❑ Phosphorus and/or
calcitonin
❑ Encourage fluids
❑ Keep urine acid
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Agent Mode of action Indication in Cautions
hypercalcemia

Normal saline 2 to 4 L Enhances filtration and Severe↑Ca++ > 14 mg May exacerbate heart
IV daily for 1 to 3 days excretion of Ca++ per dL (3.5 mmol per L) failure in elderly patients
Moderate↑Ca++ with Lowers Ca++ by 1 to 3
symptoms mg per dL (0.25 to 0.75
mmol per L)

Furosemide (Lasix) 10 Inhibits calcium Following aggressive ↓K+, dehydration if used

to 20 mg IV as resorption in the distal rehydration before intravascular
necessary renal tubule volume is restored

Bisphosphonates Inhibits osteoclast Hypercalcemia of Nephrotoxicity, ↓Ca++,

Pamidronate (Aredia), action and bone malignancy ↓PO4, rebound↑Ca++ in
60 to 90 mg IV over 4 resorption hyperparathyroidism
hours Zoledronic acid Maximal effects at 72
(Zometa), 4 mg IV over hours
15 minutes
Agent Mode of action Indication in Cautions
hypercalcemia

Calcitonin (Calcimar or Inhibits bone resorption, Initial treatment (after Rebound↑Ca++ after 24
Miacalcin) 4 to 8 IU per augments Ca++ rehydration) in hours, vomiting,
kg IM or SQ every 6 excretion severe/Ca++ cramps, flushing
hours for 24 hours Rapid↑Ca++ within 2 to
6 hours
Glucocorticoids Inhibits vitamin D Vitamin D intoxication, Immune suppression,
Hydrocortisone, 200 mg conversion to calcitriol hematologic myopathy
IV daily for 3 days malignancies,
granulomatous disease
Plicamycin (Mithracin), Cytotoxic to osteoclasts Rarely used in Marrow, hepatic, renal
25 mcg per kg per day severe↑Ca++ toxicity
IV over 6 hours for 3 to
8 doses
Gallium nitrate (Ganite) Inhibits osteoclast Rarely used in Renal and marrow
100 to 200 mg per m2 action severe↑Ca++ toxicity
IV over 24 hours for 5
 NURSING MANAGEMENT
Mild cases of Hypercalcemia
❑Keep patient hydrated (decrease chance of renal stone
formation)
❑Keep patient safe from falls or injury
❑Monitor cardiac, GI, renal, neuro status
❑Assess for complaints of flank or abdominal pain & strain urine
to look for stone formation
❑Decrease calcium rich foods and intake of calcium-preserving
drugs like thiazides, supplements, Vitamin D
NURSING MANAGEMENT
Moderate cases of Hypercalcemia
❑Administer calcium reabsorption
inhibitors: Calcitonin, Bisphosphonates, prostaglandin
synthesis inhibitors (ASA, NSAIDS)
Severe cases of Hypercalcemia
❑Prepare patient for dialysis
 Evaluation
BASIC HYPERCALCEMIA LAB PANEL
❑Complete electrolytes (including Ca/Mg/Phos)
❑ Hypophosphatemia suggests: hyperparathyroidism or humoral
hypercalcemia of malignancy (due to PTH-related peptide)
❑ Hyperphosphatemia suggests: everything else (myriad disorders in
which endogenous PTH is suppressed)
❑Ionized calcium level.
❑Parathyroid hormone (PTH).
❑ Elevated or inappropriately normal in primary or tertiary
hyperparathyroidism
❑ Low in all other causes of hypercalcemia.
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 Evaluation
ADDITIONAL LABS WHICH MAY BE CONSIDERED:
❑Thyroid Stimulating Hormone (TSH).
❑25-OH vitamin D & 1,25-OH vitamin D.
❑Malignancy-related tests:
❑PTH-related peptide (PTH-rp).
❑Serum protein electrophoresis (SPEP).
❑Prostate specific antigen.
❑Skeletal survey.
❑Alkaline phosphatase (may be elevated in malignancy with
bony metastases, without abnormality of other liver function
tests).
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MAGNESIUM
MAGNESIUM Mg- 1.3-2.5
mEq/L

Mg 40
Mg- Mg-
0.65-1.25m 0.65-1.25m
mol/L mol/L

Mg- 1.3-2.5
mEq/L
 Magnesium
❑Normal 1.3-2.3 mEq/L
❑Ensures K and Na transport across cell
membrane
❑Important in CHO and protein metabolism
❑Plays significant role in nerve cell conduction
❑Important in transmitting CNS messages and
maintaining neuromuscular activity
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 Recommended Daily Requirements of
Magnesium:
❑ Children
❑ 1-3 years old: 80 milligrams
❑ 4-8 years old: 130 milligrams
❑ 9-13 years old: 240 milligrams
❑ 14-18 years old (boys): 410 milligrams
❑ 14-18 years old (girls): 360 milligrams
❑ Adult females: 310 milligrams
❑ Pregnancy: 360-400 milligrams
❑ Breastfeeding women: 320-360 milligrams
❑ Adult males: 400 milligram
FOOD AND DRUG ADMINISTRATION

❑to help consumers determine if a food contains a

lot or a little of a specific nutrient. The Daily
Value for magnesium is 400 milligrams (mg).
 Magnesium

❑Causes vasodilatation
❑Decreases peripheral vascular resistance
❑Balance - closely related to K and Ca balance
❑Intracellular compartment electrolyte
❑Hypomagnesemia - < 1.5 mEq/L
❑Hypermagnesemia - > 2.5 mEq/L

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Magnesium

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HYPOMAGNESEMIA
Hypomagnesemia
❑ Causes
❑ Decreased intake or
decreased absorption or
excessive loss through urinary
or bowel elimination
❑ Acute pancreatitis, starvation,
malabsorption syndrome,
chronic alcoholism, burns,
prolonged hyperalimentation
without adequate Mg
❑ Hypoparathyroidism with
hypocalcemia
❑ Diuretic therapy

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Hypomagnesemia
❑ Causes
❑ Decreased intake or
decreased absorption or
excessive loss through urinary
or bowel elimination
❑ Acute pancreatitis, starvation,
malabsorption syndrome,
chronic alcoholism, burns,
prolonged hyperalimentation
without adequate Mg
❑ Hypoparathyroidism with
hypocalcemia
❑ Diuretic therapy

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 Signs/Symptoms
❑ Tremors, tetany, ↑ reflexes,
paresthesias of feet and legs,
convulsions
❑ Positive Babinski, Chvostek and
Trousseau signs
❑ Personality changes with agitation,
depression or confusion,
hallucinations
❑ ECG changes (PVC’S, V-tach and V-fib)

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PHYSIOLOGY
 Treatment
❑ Mild
❑ Diet – Best sources are unprocessed cereal grains, nuts, legumes, green leafy
vegetables, dairy products, dried fruits, meat, fish
❑ Magnesium salts
❑ More severe
❑ MgSO4 IM
❑ MgSO4 IV slowly
❑ Monitor Mg q 12 hr
❑ Monitor VS, knee reflexes
❑ Precautions for seizures/confusion
❑ Check swallow reflex
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 Treatment
TREAT CO-EXISTING ELECTROLYTE ABNORMALITIES

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 Treatment
❑ Treat hypokalemia
❑ Hypomagnesemia causes hypokalemia.
❑ It is often the combination of these two abnormalities that causes
arrhythmia. Thus, prompt treatment of both abnormalities may rapidly
reduce the risk of arrhythmia rapidly.
❑ Treat hypocalcemia
❑ Magnesium sulfate may complex with calcium, decreasing the calcium level
further.
❑ Treat hypercalcemia or hyperphosphatemia (which may cause
hypomagnesemia)

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 Treatment
GENERAL PRINCIPLES OF MAGNESIUM TREATMENT
❑Magnesium is generally extremely safe, with the following
exceptions:
❑ Patients with myasthenia gravis may be at increased risk of muscle
weakness.
❑ Renal failure (e.g. GFR < 30 ml/min) may cause magnesium
accumulation. These patients may be treated with a normal
“loading” dose of magnesium up-front, but care is needed with
repeated dosing.

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 Treatment
GENERAL PRINCIPLES OF MAGNESIUM TREATMENT
❑Magnesium repletion can be difficult:
❑ Oral magnesium is poorly absorbed and causes diarrhea.
❑ IV magnesium boluses will cause transient elevation in the serum
magnesium level, causing magnesium secretion by the kidneys.
Most of the administered magnesium may be excreted in the
urine.
❑ Most of the body's magnesium is intracellular. The goal is really to
get magnesium into the cells, but cellular uptake occurs slowly.

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 Treatment
MILD HYPOMAGNESEMIA (e.g. ~1.5-2 mg/dL or ~0.6-0.8 mM)
• Oral magnesium may be used if:
❑ Patient is taking oral medications
❑ There is no interaction with other medications (e.g. tetracyclines and calcium
channel blockers)
❑ Dosing of oral magnesium:
❑ Magnesium oxide, 400 mg PO BID
❑ Or milk of magnesia (magnesium hydroxide), 15 ml daily
❑ If unable to give oral magnesium, may give 2 grams IV magnesium
sulfate.

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 Treatment
MODERATE HYPOMAGNESEMIA (e.g. ~1.2-1.5 mg/dL or ~0.5-0.6 mM)
❑ Intermittent administration of 2-4 grams magnesium sulfate IV.
❑ Higher doses may be preferred if renal function is normal and
hypomagnesemia is more severe.
❑ Infusing the dose over a longer time period may improve intracellular
absorption and could also be safer.

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 Treatment
SEVERE ASYMPTOMATIC HYPOMAGNESEMIA (e.g. <1.2 mg/dL or <0.5 mM)
❑ Severe hypomagnesemia generally reflects a low total body magnesium
content.
❑ There are roughly two ways to do this (depending largely on logistics)
❑ Multiple scheduled doses of IV magnesium (e.g. 2 grams IV magnesium sulfate
q6hr-q8hr).
❑ Continuous infusion of IV magnesium (e.g. 4-8 grams of IV magnesium sulfate over
24 hours)
❑ Follow extended electrolyte panel (electrolytes plus Ca/Mg/Phos) daily.
Draw labs several hours after completion of the infusion, to allow for
distribution of the magnesium.
❑ For patients with normal renal function, electrolytes may be followed ~daily.
❑ For patients with renal insufficiency, electrolytes should be followed more
carefully (greater risk of hypermagnesemia).

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 Treatment
MANAGEMENT OF LIFE-THREATENING HYPOMAGNESEMIA (e.g. Torsade de Pointes,
seizures)
❑ Initial loading dose of four grams
❑ 2 grams IV magnesium sulfate over 5-15 minutes.
❑ 2 additional grams IV over 30-60 min.
❑ Maintenance dose
❑ GFR > 30 ml/min: magnesium infusion using the protocol shown below. This protocol was
initially designed for use in atrial fibrillation, but it is safe and can be used in a variety of
situations where aggressive magnesium loading is desired. When the magnesium infusion
protocol is being used, this should be pasted into the chart (electronically or physically) so
that everyone is on the same page.
❑ GFR < 30 ml/min: follow magnesium levels and re-dose based on level.
❑ Potential complications from intravenous magnesium:
❑ Hypermagnesemia may occur, resulting in AV block or muscular weakness.
❑ Magnesium sulfate can reduce calcium levels. This is generally minor, but may exacerbate
pre-existing hypocalcemia.

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Treatment

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Treatment

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 Treatment
BALANCED NEPHRON DIURETIC STRATEGY
❑ For patients requiring large volume diuresis, loop diuretics may cause
magnesium wasting.
❑ Potassium-sparing diuretics (e.g. amiloride or trimaterene) may have
a magnesium-sparing effect.
❑ A combination diuretic regimen (e.g. loop diuretic, thiazide diuretic,
and potassium-sparing diuretic) may cause the fewest electrolytic
derangements.

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 NURSING MANAGEMENT
❑ Monitor cardiac, GI, respiratory, neuro status. Place on a cardiac monitor (watching for
any EKG changes prolonging of PR interval and widening QRS complex)
❑ May administer potassium supplements due to hypokalemia (hard to get magnesium
level up if potassium level is down)
❑ Administering calcium supplements (oral calcium supplements w/ Vitamin-D or 10%
Calcium Gluconate)
❑ Administer Magnesium Sulfate IV route. Monitor Mg+ level closely because patient
can become magnesium toxic (***Watch for depressed or loss of deep tendon
reflexes)
❑ Place patient in seizure precautions
❑ Oral forms of Magnesium may cause diarrhea which can increase magnesium loss so
watch out for this
❑ Watch other electrolyte levels like calcium and potassium
❑ Encourage foods rich in Magnesium:
NURSING MANAGEMENT
Magnesium foods rich:
“Always Get Plenty Of Foods Containing Large Numbers of Magnesium”
❑ Avocado ❑ Cauliflower, chocolate (dark)
❑ Green leafy vegetables ❑ Legumes
❑ Peanut Butter, potatoes, pork ❑ Nuts
❑ Oatmeal ❑ Oranges
❑ Fish (canned white ❑ Milk
tuna/mackerel)
HYPERMAGNESEMIA
 Hypermagnesemia
Most common cause is
❑ renal failure, especially if taking
large amounts of Mg-containing
antacids or cathartics;
❑ DKA with severe water loss

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 Hypermagnesemia
❑ Signs and symptoms
❑ Hypotension,
❑ drowsiness,
❑ absent DTRs,
❑ respiratory depression,
❑ coma,
❑ cardiac arrest
❑ ECG –
❑ Bradycardia,
❑ Complete Heart Block,
❑ cardiac arrest,
❑ tall T waves

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PHYSIOLOGY
 Treatment
❑ Withhold Mg-containing
products
❑ Calcium chloride or gluconate IV
for acute symptoms
❑ IV hydration and diuretics
❑ Monitor VS, LOC
❑ Check patellar reflexes

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NURSING MANAGEMENT
❑ Monitor cardiac, respiratory, neuro system, renal status. Put patient
on cardiac monitor (watch for EKG changes)
❑ Ensure safety due to lethargic/drowsiness
❑ Prevention:
❑ Avoid giving Magnesium containing antacids/laxative to patients with renal
failure
❑ Assess for hypermagnesemia during IV infusions of magnesium sulfate for
hypomagnesemia (sign and symptom would be diminished/absent deep
tendon reflexes)
❑ Withhold foods high in magnesium, such as:
NURSING MANAGEMENT
❑ Monitor cardiac, respiratory, neuro system, renal status. Put patient
on cardiac monitor (watch for EKG changes)
❑ Ensure safety due to lethargic/drowsiness
❑ Prevention:
❑ Avoid giving Magnesium containing antacids/laxative to patients with renal
failure
❑ Assess for hypermagnesemia during IV infusions of magnesium sulfate for
hypomagnesemia (sign and symptom would be diminished/absent deep
tendon reflexes)
❑ Withhold foods high in magnesium
NURSING MANAGEMENT
FOODS HIGH IN MAGNESIUM:
“Always Get Plenty Of Foods Containing Large Numbers of Magnesium”
❑ Avocado ❑ Nuts
❑ Oranges
❑ Green leafy vegetables
❑ Milk
❑ Peanut Butter, potatoes, pork ❑ Administer diuretics that waste
❑ Oatmeal magnesium (if patient is not in renal
failure) such as Loop and Thiazide
❑ Fish (canned white diuretics
tuna/mackerel) ❑ Patient in renal failure patient prep for
dialysis
❑ Cauliflower, chocolate (dark) ❑ IV calcium may be order to reverse
❑ Legumes side effects of Magnesium (watch IV
for infiltration…prefer central line)
 Evaluation
❑ Serum magnesium levels WNL
❑ Improvement of symptoms

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PHOSPHOROUS
PHOSPHORUS

HPO4 HPO 4 HPO4

2 150 2
 Phosphorous
❑Normal 2.5-4.5 mg/dL
❑Intracellular mineral
❑Essential to tissue oxygenation, normal CNS function
and movement of glucose into cells, assists in
regulation of Ca and maintenance of acid-base balance
❑Influenced by parathyroid hormone and has inverse
relationship to Calcium

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PHOSPHORUS INTAKE

❑There is no recommended intake for

phosphorus in Australia.
❑In the U.S.A. the allowance for adults is 900
milligrams per day. Pregnant and lactating
women, and children during years of rapid
growth (10 to 18 years) should have a higher
intake of 1200 milligrams per day.
 Phosphorus Sources - Rich food in phosphorus

❑The most important food sources of phosphorus are

whole grain cereals, milk, and fish.
❑Vegetables such as carrots, and leafy vegetables; fruits
like black currants, raspberries, raisins, and apricots
are fairly good sources.
❑Other sources of this mineral are soya beans, lentils,
and other pulses and legumes.
HYPOPHOSPHATEMIA
 Hypophosphatemia
Causes
❑ Malnutrition
❑ Hyperparathyroidism
❑ Certain renal tubular defects
❑ Metabolic acidosis (esp. DKA)
❑ Disorders causing hypercalcemia

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 Signs/Symptoms
❑ Impaired cardiac
function
❑ Poor tissue
oxygenation
❑ Muscle fatigue and
weakness
❑ N/V, anorexia
❑ Disorientation,
seizures, coma

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PHY
SIOL
OGY
 Treatment

❑Closely monitor and correct imbalances

❑Adequate amounts of Phos
❑Recommended dietary allowance for formula-fed infants
300 mg Phos/day for 1st 6 mos. and 500 mg per day for
latter ½ of first year
❑1:1 ratio Phos and Ca recommended dietary allowance.
Exception is infants, whose Ca requirements is 400
mg/day for 1st 6 mos and 500 mg/day for next 6 months

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 Treatment

❑Treatment of moderate to severe deficiency

❑Oral or IV phosphate (do not exceed rate of 10
mEq/h)
❑Identify clients at risk for disorder and monitor
❑Prevent infections
❑Monitor levels during treatment

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Treatment

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 NURSING MANAGEMENT
❑ **Administer oral phosphorus with Vitamin-D supplement (remember vitamin-d
helps with absorbing phosphate)
❑ If patient is receiving TPN watch for patient complaints of muscle pain or
weakness (may be due to rhabdomyolysis or refeeding syndrome)
❑ Ensure patient safety due to risk of bone fractures
❑ Encourage foods high is phosphate but low in calcium:
❑ **Foods high in phosphate are fish, organ meats, nuts, pork, beef, chicken, whole grains
❑ If phosphate levels less than 1mg/dL, the doctor may order IV phosphorous
which affects calcium levels causing hypocalcemia or increase phosphate levels
(Hyperphosphatemia).
❑ ***Also, assess renal status (BUN/creatintine normal) before administering phosphorous
because if the kidneys are failing the patient won’t be able to clear phosphate). Place on
cardiac monitor and watch for EKG changes.
HYPERPHOSPHATEMIA
 Hyperphosphatemia

❑Causes
❑Chronic renal failure (most
common)
❑Hyperthyroidism,
hypoparathyroidism
❑Severe catabolic states
❑Conditions causing
hypocalcemia

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 Signs/Symptoms
❑ Muscle cramping and weakness
❑ ↑ Heart Rate
❑ Diarrhea, abdominal cramping, and
nausea

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 Signs/Symptoms
NEUROLOGIC
❑ Seizures, paresthesias, tremor
❑ Confusion, dysarthria, stupor, coma
❑ May promote the development of central pontine myelinolysis
CARDIAC
❑ Impaired contractility, heart failure
❑ Arrhythmia (supraventricular and ventricular tachycardia)

MUSCULAR
❑ Rhabdomyolysis
❑ Rare; May mask diagnosis of hypophosphatemia by release of phosphate from
muscle! research and prepared by BATMAN 153
PHYSIOLOGY
PHYSIOLOGY
 Treatment
❑ Prevention is the goal
❑ Restrict
phosphate-containing
foods
❑ Administer
phosphate-binding agents
❑ Diuretics
❑ Treat cause
❑ Treatment may need to
focus on correcting
calcium levels
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NURSING MANAGEMENT
❑**Administer phosphate-binding drugs (PhosLo) which
works on the GI system and causes phosphorus to be
excreted through the stool.*** NCLEX: Give with a meals
or right after eating meal
❑Avoid using phosphate medication such as laxatives and
enema
❑Restrict foods high is phosphate ***eat, poultry, fish,
dairy, nuts, sodas, oatmeal
❑Prepare patient for dialysis if patient in renal failure
 Evaluation
❑ Lab values within normal limits
❑ Improvement of symptoms

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SUMMARY OF SIGN AND SYMPTOMS
“ASKING IS ONE WAY OF SHOWING
YOUR ENTHUSIASM IN LEARNING.”

BY: Kerwin Rico L. Reyes

THE END

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 QUESTIONS
1. OBESE PEOPLE HAVE LESS FLUID THAN THIN PEOPLE? TRUE
2. THE ECF IS FURTHER DIVIED INTO 4?FALSE
3. CATIONS IS THE NEGATIVE CHARGE PARTICLES? FALSE
4. ANIONS CARRIES NEGATIVE CHARGE? True
5. SODIUM IN EXTRACELLULAR SPACES IS THE MAJOR CATIONS?TRUE
6. OSMOSIS IS THE MOVEMENT OF SUBSTANCE FROM HIGHER CONCENTRATION
TO LOWER CONCENTRATION? FALSE
7. IN A NORMAL ADULT URINE OUTPUT IS 1 ml/kg/hr? TRUE
8. HYPOTHALAMUS MANUFACTURES ADH? TRUE
9. HEMATOCRIT MEASURES THE VOLUME PERCENTAGE OF WHITE BLOOD CELLS?
FALSE
10. CREATININE IS THE END PRODUCT OF MUSCLE METABOLISM? TRUE
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 1. What are the contributing factors of fluid volume deficit(9)
2. This is common to hypocalcemia when tapping the facial muscle it will
cause the muscle to go into spasm(1)
3. In Hypernatrimia it is expected that the patient’s urine sodium is
decrease? True or false(1)
4. Calcium affects the contraction of the heart?true or false
5. Where will you assess for the skin turgor of a geriatrics?(2)
Identify the following :
6. If the sodium is 170mEq/L
7. if the potassium is more than 3.5 but less than 5 it is consider as?
8. If the magnesium is less than 10 but more than 3 it is consider as?
9. If there is an increase in the number of Na ecf what will happen to the
cell
10. If there is an increase in the number of Na icf what will happen to the cell
11. What is the meaning of BUN
12. Normal sodium value
13. Normal potassium value
14. Hypokalemia and hyperkalemia is possible electrolyte imbalance in fluid
volume deficit
15. Fluid volume deficit is the same as dehydration
16. Lactated ringer’s solution contains Mg
17. D5w without NaCl can cause water intoxication
18. PNSS is the only fluid that can be administered with blood
19. Lactated ringer solution does not contain mg
20. Pnss is the only is the only fluid that can be administered with blood