welcome to unit 1 laboratory values and nursing management so before we really dive into electrolytes I want to discuss a few basic concepts that you should have had in anatomy and physiology these need to be reviewed please take some time make sure these Concepts make sense it will help you make sense of the rest of the content specifically related to electrolytes if it is new to you please don't be afraid to reach out to me and clarify some of these Concepts these are extremely important when understanding both fluid and electrolyte shifts as well as solute shifts as well so if we look at over here on the left you have this little picture that I put together you've got your blood vessel so let's say this is a capillary right here you have your cells and whether it's a heart nerve muscle brain cell whatever I want you to know that this right here so this little Beaker that has a semi-permeable membrane down the center that represents a blood vessel and a cell okay or the interstitial tissue in a Cell so I just want you to know kind of what we're talking about when we're looking at this sort of Beaker and I explain some of these Concepts okay so we need to go through osmosis diffusion and filtration osmosis is the movement of water diffusion is the movement of solutes filtration is the forced movement of water through a membrane and it's not because of a concentration gradient it's because of pressure so if we talk about osmosis up here you can see in these first two beakers so let's say here on the left you have this Beaker where on one side of a beaker that has a semi-permeable membrane meaning some stuff gets through not everything on one side you have a hypertonic or highly concentrated solution it's got a lot of solutes in it all right for the sake of this discussion we'll say it's sodium so if you have your blood vessels let's say this is on the left this is your blood vessels it's highly concentrated and your cells over here are very dilute that fluid that water is going to go down its concentration gradient and it's going to move fluid into that vascular space right so it's movement of fluid from an area of high concentration to an area of low concentration so let's say I have a really high concentration of sodium in my blood what it's going to do is it's going to pull fluid from my cells to make this a bit more equal right because these your body is a system that likes to create equilibrium across all of the membranes and in particular between your blood vessels and your cells that's very simplified but just for the sake of what we're going to talk about just think about the balance between your cells and your blood vessels so moving down here to B this right here is diffusion so this is the movement of solutes so again it's the same kind of setup it's a beaker you've got a semi-permeable membrane but this membrane also allows the movement of solutes as well not only fluid but solutes so you've got diffusion so movement of solutes down their concentration gradient from high area of concentration to low you have movement of fluid from high area of concentration to low and there both can be going in opposite directions so let's say again I have high sodium in my blood it's maybe a bit lower or normal in my cells and if I have if across my membrane I can have both movement of sodium and water which in your cells you typically can you do have little pores that allow Force sodium to passively diffuse you do primarily keep your balance of sodium and potassium through the sodium potassium pump and we'll talk really briefly about that but just for the sake of this discussion right here you do have some movement of sodium through diffusion so you can have both sodium move across the membrane and want to move across the membrane to allow for this balance so keep in mind that as these fluid shifts are occurring it could be that it improves the balance it makes things better and is making the patient better or it's making the patient worse just depending upon what's going on and we're going to talk about that one more thing I do want to mention is filtration here so filtration again is fluid being forced through a membrane say for example in your glomerulus right like you have glomeruli or a little knot of vessels in all of your in each of your nephrons in your kidney and so you have fluid and some solutes that are forced through that glomerulus into the nephron to be excreted through the kidney you can also have filtration because of just excess fluid in your body and so it can cause edema it's being forced into your interstitial space because there's just too much fluid either by pressure sometimes because of a lack of tonicity inside your vessels so filtration is another area of fluid movement you need to be familiar with so I want to talk really briefly about the electrochemical gradient so don't get too deep into this if you haven't had this before basically what I want you to know is that the vast majority of your cells in your body like to have a certain balance of sodium calcium magnesium potassium and a whole bunch of other stuff a very very specific and delicate precise balance across the cellular membrane and so because you have most of your sodium in your excuse me your vascular space and you have calcium primarily in your vascular Space versus the inside of the cell inside of the cell is primarily potassium and magnesium this specific balance in each of their respective concentrations this allows for something called the electrochemical gradient and so um let me actually move to my next slide here so basically what that means is on the inside of the cell It's relatively more negative than the outside of the cell and the only thing I want you to know about this is that the the charge on the inside of the cell and the outside of the cell is slightly different and the way that we maintain that is by making sure potassium magnesium sodium calcium and our fluid are balanced in a very specific in their ratios their respective ratios to make sure the cell can function appropriately so let's go back here to this slide I want you to also be familiar if you're not already with the sodium potassium pump this guy is a little protein he's driven by energy or ATP and this right here is the the key driver in your sodium and potassium balance across the cellular membrane right so it's always pulling in potassium and kicking out sodium to keep sodium and higher concentration in the ECF and potassium and a higher concentration in the ICF or intracellular fluid so this guy gets really important we start talking about certain types of medications and just the overall balance of the cell one thing that's important to know about this resting membrane potential meaning that say this is say let's say this is a heart cell or nerve cell and it's not being activated right there's no heartbeat currently occurring there's no nervous stimulus occurring that it's at rest nothing's happening that means that it's negative on the inside positive on the outside it's this nice little gradient from the inside to the outside that maintains this this nice balance that cells really like so that's the resting membrane potential that sets up the electrochemical gradient that allows for neurostimulus and conduction of that message down the neuron right to actually communicate with a muscle cell or maybe to release a hormone um with Insight or your cardiac cells your myocytes they communicate with each other right they have that automaticity and so if they're fluid and electrolyte balance is off if they're electrochemical gradient is not just the way it should be they don't communicate the way they should need to do nervous cells or muscle cells so when we talk about these imbalances with these different types of electrolytes be thinking about when these electrolytes when the fluid is off when these concentrations aren't just where they want to be it makes the cell irritable or it makes it unable to respond and that's where all these symptoms that we're going to talk about come from so really quickly a disclaimer and especially for those of us in the accelerated track LPNs and paramedics who have quite a bit of experience when we talk about these labs in this class causes manifestations management is not all-inclusive there's so much more to Labs it's it's mind-boggling but what we're going to focus on in this class is specifically those are generally common things that are you know high stakes like cardiac issues mental status changes things are going to cause a fall stuff like that or maybe a broken bone or they're just highly relevant to this course specifically so the first segment we're going to talk about is a portion of the basic metabolic panel or a b m p so you can also have something called a complete metabolic panel or a CMP that has a lot more o lab values in it it's got like liver and yeah liver enzymes albumin things like that but we're talking about is the more basic metabolic panel and we're only looking at certain elements within that so we're not looking at every single one of them we're just looking at certain elements of that basic metabolic panel or the BMP and the first thing we're going to talk about is electrolytes foreign let's talk about some electrol item balances so let's talk about sodium just this is just some general preview stuff before we really get into hypo and Hyper of all the different electrolytes sodium um you have to know that water and sodium are very closely related water follows salt okay and actually found this little graphic online I thought it was kind of funny but it really is a great just visual to help you remember this that water really does follow salt so if you're losing sodium you're more than likely losing fluid if you have a fluid or sorry a sodium shift you're going to have a fluid shift in your body too and that becomes really important when we talk about the imbalances of sodium specifically so again it has a low concentration inside the cell it's a high concentration outside the cell it is a made sorry major cation in the ECF or extracellular fluid it does highly contribute to that electrochemical gradient right that we talked about that allows for that nice resting membrane potential that makes cells really happy that helps regulate muscle contraction nerve impulses essentially the communication between your cells balance of sodium is highly due to intake or your diet as well as renal excretion uh sodium is highly regulated by the renin Angiotensin aldosterone system or the RAS system and it is also highly regulated by your thirst sensation and one thing that's important to note with thirst since we're going to talk a lot about the elderly in this class too is that as we age we tend to have less of a thirst sensation so that's not as reliable in the elderly potassium overall the key thing with potassium is that it's extremely important to cardiac function now you know really all electrolytes are important to cardiac function but the key thing about potassium is it has a very very narrow range 3.5 to 5. that's it the rest of your electrolytes have a larger range than that and so that potassium because it's also super high concentrations inside the cell versus on the um sorry inside the cell versus outside of the cell just a tiny change in potassium can have a Major Impact so even though magnesium doesn't have as wider range say as like sodium you know calcium is somewhat comparable potassium it overall has a narrower range and it's just that the heart is more sensitive to changes in potassium so when we're thinking about potassium I want you to automatically think about that heart right the heart should be the first thing that pops into your mind when we're concerned about potassium there's other um symptoms but sorry cardiac is the biggest issue so again highly concentrated inside the cell low outside the cell major cation in intracellular fluid just like sodium contributes to that electrochemical gradient very important in cellular communication balances related to diet and another key thing about potassium is it's very important in acid-base balance and that's going to become really important in unit two when we start talking about diabetes and diabetic ketoacidosis so magnesium and calcium I don't want to get into too much depth with these two but they're just really important magnesium is important because you see a lot of Mag Riders given on the floors or a magnesium piggyback and so I want you at least be somewhat familiar with mag because you're going to see it and essentially it's a lot like potassium you really are concerned primarily about the heart with magnesium of course there's you know neuromuscular function is affected too but the heart's a big thing with magnesium and then calcium is also important because it's highly relevant to this course we're going to talk about osteoporosis and just different types of cell metabolism related to the density of Bones and of course that's highly related to calcium of course because bone and teeth are the key reservoirs in the body there's only actually a tiny little bit of calcium in your blood but it does help regulate muscular contraction that will become important in unit three when we talk about um malignant hyperthermia because that relates to calcium regulation and muscle contraction and then lastly you have to monitor calcium of course in any sort of Orthopedic patient whether they're osteoporic and they had a fracture or it's a trauma or whatever anytime you have a broken bone it's either caused by an imbalance in calcium could be caused by an imbalance or it's causing an imbalance so the overall electrolytes we're going to talk about are sodium na plus so 135 to 145 mil equivalents per liter we've got potassium or K plus 3.5 to 5 Milli equivalents per liter we're also going to talk about magnesium 1.3 to 2.3 milligrams per deciliter and we also have calcium CA plus plus 8.6 to 10.2 milligrams per deciliter the reason I had that asterisk by magnesium is because I just don't want you guys to get too down deep into Mac I just want to briefly discuss it because you're going to see it in clinical so the first one we're going to talk about is sodium imbalances so a key thing with sodium is your fluid volume considerations so let's first talk about just overall hyponatremia and hypernatremia so hypo or low natremia is loss of both water and sodium right so you can have that you're just losing both you don't have enough of either or it could be caused by excess water gain or something that we call hemodilusion which we'll talk about in more detail later on in this presentation let's also talk a little bit about hypernatremia so that could be loss of water alone uh dehydration or something called hemoconcentration which we'll also talk more about or it could be caused by excess intake of sodium so the key thing with sodium whether high or low it's highly dependent on fluid status and really in reality all electrolytes are but it's most important to look at your fluid balance in relation to sodium because water follows salt and water follows specifically sodium technically potassium is also a salt you've got calcium salts and stuff too but when we say that a key thing we're talking about is sodium sodium and water just really like each other so they tend to follow each other so anytime you're thinking about a sodium imbalance you need to also be thinking about okay so they've got low sodium or high sodium but what's their fluid status doing because that's going to tell me a lot more about what's going on with my patient so first we're going to talk about hypo or low sodium and just to make sure we're clear so hyponatremia hypo of course means low nature is like sodium anemia is in the blood and so this is a serum or blood sodium when we say serum we mean blood that would be in comparison to say like a urine sodium or like a any kind of other body fluid lab whether it's you know lung Pleural fluid or CSF or something like that Serum is specifically in the blood and we're talking about low sodium specifically in the blood and that'll be anything less than 135 ml equivalents per liter so causes can be because of a fluid volume deficit GI losses vomiting um or induced whether it's through bulimia or just illness you can have diarrhea anything like that suctioning but some kind of GI loss diuretics also the ones that are not or sorry well things like Lasik stuff like that that can really flush out a system excessive sweating so maybe a lot of working out if you're losing both sodium and fluid a key hormonal imbalance there are lots of hormonal imbalances that can cause problems with electrolytes and namely sodium but the key one I want you to know about is hyperglycemia so hyperglycemia is caused by an imbalance of insulin which is a hormone and so when we talk about hyperglycemia in unit two hyperglycemia causes osmotic diuresis which basically means there's so much sugar in the blood that it's forcing the kidneys to just waste a bunch of fluid and as we know fluid and salt really like each other so if you're losing fluid you're also losing salt and namely potassium or um sorry sodium just not taking it enough for various reasons sometimes people diagnosed with hypertension don't take it enough because they think well low sodium is good no sodium is better well that's wrong right we have to have some for that balance that resting membrane potential maybe they just can't get to it maybe they're an invalid maybe they're mobile maybe they're just elderly maybe they're weak you know there's so many different reasons why they may not have good intake and of course malabsorption and a key reason we want to talk about that is because in unit five you can end up with a lot of nutrient related imbalances just because of certain GI diseases and medications associated with those diseases as well you can also have hyponatremia because you just have too much fluid so sometimes we cause it because we just give too much IV fluid um either too fast or we're just not monitoring it like we should if they're taking in too much po fluid intake you can see that in athletes who aren't appropriately replacing electrolytes there's also an instance where a lady died they had it was like a we for a wee or some kind of Radio contest where it was a water drinking contest to get a Nintendo Wii some lady she drank the most water she won she got her Wii but she went home she actually her brain herniated and she died because she had diluted herself so much um so renal and heart failure um so you can also cause dilutional hyponatremia because you're just not moving fluid around like you shouldn't it can't get to your kidneys or and or um your kidneys just can't um excrete enough fluid so you're delusional or you have a dilutional hyponatremia so what are these clinical manifestations of hyponatremia what is your patient going to look like well there's a lot with these signs and symptoms and so don't let them overwhelm you a key thing with all of these different electrolyte imbalances we're going to talk about is trying to figure out what is the key differentiating factor that's going to say that's going to tell you whether or not your patient has a potassium magnesium a calcium or a sodium imbalance so even with hyponatremia it's not so much cardiac irritation but you might have changes in blood pressure and heart rate and that's really going to be more related to fluid status right if you have a decrease in um in fluid and sodium you're going to have decreased blood pressure you might have orthostatic blood pressures and an increase in the heart rate because your heart's trying to work super hard um to to get that lack of blood moving right your low blood volume moving around um so central nervous system central nervous system changes altered mental status is key I'm going to repeat that central nervous system changes altered mental status is key to sodium okay any kind of sodium imbalance so you might see dizziness mental status changes headache is key to low sodium lethargy confusion seizures they might even end up with increased ICP or intracranial pressure because it's maybe a dilutional hyponatremia which can cause papilledema or basically smushing of the optic cup in the back of the eye it can cause seizures and ultimately coma and Death and All of that's related to cerebral swelling because of the low sodium and it's more than likely related to um in excess of fluid of course GI symptoms that almost every single electrolyte imbalance has GI system or sorry uh symptoms so you're going to feel pukey nauseated you don't want to eat you may have you know abdominal cramping so these are pretty generic and typical for most electrolyte imbalances so don't um don't hang your clinical judgment on GI symptoms of electrolyte imbalance because there really are generally I mean they almost all affect the GI system musculoskeletal the same it's pretty um similar similar keyword similar across all the different electrolyte imbalances so cramping twitching weakness fatigue and of course your integument depending upon fluid status you may have poor skin Target dry mucosa degree salivation because you have low volume or maybe it's because it's dilutional hyponatremia and your identities and you have too much fluid so thinking about all these different symptoms signs and symptoms all of these are caused by well with sodium partially your fluid status so be thinking about fluid status but also remember that resting membrane potential and the fact that cells love to have that balance and that's how they can communicate with each other with the right fluid and the right electrochemical balance so if we don't have something that's in the right balance our brain like mental status changes the brain cells are not going to communicate our GI cells are not going to work well like they should right they might either you know slow down or speed up or whatever whatever musculoskeletal the your your nerves are not going to be able to communicate to your muscles like they should be able to your muscle cells will be able to contract like they should and so on and so forth so when we when we talk about a lot of these signs and symptoms it's going to get really repetitious be thinking about that upset and that nice little balance that the cell really likes of that electrical chemical gradient as well as fluid balance so how do we manage hyponatremia well there's a lot of nursing assessments and if you know what's going on or what's uh being what symptoms are being caused by hyponatremia the assessments just make sense and so do the interventions so eyes and O's right daily weights how much we got going in how much we got going out fluid sodium Vital Signs because we are concerned about their fluid status edema turgor mucous membranes again fluid status CNS changes optic cup visualization because we know they might have seizures headache papilledema we're assessing for strength because we know they might be weak we're looking at their assessing their GI tract are they still vomiting right maybe that's maybe there have been in tremic and they're puking right that's causing hyponatremia and then it's actually causing worsening hyponatremia because they're puking um you're going to want to watch their serum sodium levels and then also look to see are there some kind of medication that they're on that's aggravating on this issue like diuretics are we are we dumping all their sodium out um same thing with maybe a lithium level lithium is one of those drugs um that the body and this is a very simplified explanation but lithium and sodium the body gets them confused so when sodium is low the body thinks that lithium is sodium and uses more lithium and you actually become lithium toxic not because you have too much lithium in your body but because your sodium is low your body just gets them confused so thinking about these clinical manifestations and assessments what are we supposed to do as nurses well of course increase monitoring and assessments increase our safety and seizure or just Implement safety precautions and we already have some safety but if they're weak if they're confused we need to increase safety precautions we can manage whatever kind of medications we have ordered do we need to hold something do we need to hold that diuretic because yeah their blood pressure maybe it stinks a little bit but you know what there are sodiums in the toilet so I'm not giving them a diuretic I'm going to wash them out or maybe you need to give them a PRN sodium tap because they tend to struggle with hyponatremia and you've got something PRN you can give it to them um and then lastly of course a little bit less you know invasive of course than a medication or holding or giving something would just be to encourage maybe some dietary sodium um and then monitor maybe restrict sorry fluid intake if fluid overload is an issue and we're going to talk about medical interventions on all of these uh imbalances because I just want you to have a good idea of what is medicine what's the role of medicine right or an APRN um and then of course what's the role of the nurse so medical for all of these they need to be treating that underlying condition what is causing the hyponatremia right don't just give them more sodium or reduce their fluid and hope for the best why are they like that in the first place like what's causing it what are they doing that's making that an issue and then treat that so we don't end up with the same problem all over again um supplementation fluid restrictions so um nurses can do that to some degree but you may have ordered supplementation or an ordered specific like two liter 1.5 liter one liter whatever fluid restriction the patient's gonna have to abide by because maybe they've got harder renal failure and then lastly for sodium they you might have low sodium you might have IV administration of just normal saline if it's mild or hypertonic Solutions such as three percent or five percent or LR because LR does also contain sodium slowly and with a pump key thing with um replacing um sodium really all electrolytes the key thing with sodium is you go super slow because if you rapidly correct a sodium imbalance you can cause brain damage because it will disrupt the myelination of the brain neurons and it can cause permanent damage all right so moving on to hypernatremia so hypernatremia is serum sodium of greater than 145 mil equivalents per liter and again that's in the blood so causes again dependent on fluent status usually with hypertremia it's going to be because of a fluid volume deficit either we just can't get enough fluid in right it's not sodium deficit it's fluid deficit now because you're very young they just can't get to it very old maybe disabled um maybe they have some losses so excessive sweating sometimes you see this with athletes especially if they're taking in salt tabs right combination of losing fluid and taking in too many salt tabs watery diarrhea because if you're just losing a lot of fluids it might cause more concentration of diarrhea and of course Burns or hyperventilation so anything that's causing fluid loss that doesn't also encourage um this equivocal sodium loss so poor renal excretion right so just not excreting sodium or excessive intake um just Americans have a very very high sodium diet so watching your just general intake of of sodium supplementation there might be some kind of supplement you're taking that has a sodium salt in it and people don't even know it um there's certain kinds of medications that have sodium in them or encourage sodium retention so any kind of IV administration of any sort of saline whether it's normal hypotonic um that may be because it's something we're doing to our patient and then lastly just as an example so drinking seawater or drowning in the ocean any kind of ingestion of a hypertonic saline solution Um this can cause some pretty nasty issues and absolutely can be fatal um too much sodium in your body is absolutely fatal so what does this look like and we're not going to go through all of this in extreme detail like we did with hyponatremia we're going to kind of just kind of walk through it a little bit so again cardiovascular dependent on fluid status what's going on with the blood pressure and the heart rate CNS changes again for sodium CNS changes that altered mental status that's really key but with hypernatremia they're probably also thirsty because what what really when you're younger anyway um activates your thirst sensation is high sodium that's why after you eat really salty popcorn or a salty meal it's not that you've lost a lot of fluid it's that your sodium's gone up and your body's saying oh this is really high sodium I need to dilute this out a little bit so I don't get into trouble um they might have a slight increase in temperature and that could also be related to dehydration but again seizures irritability restlessness you might also see some irritation in the peripheral nervous system so hyperreflexio so when you do that patellar deep tendon reflex their leg might fly up super fast because it's hyper responsive it's irritated of course GI feeling terrible not wanting to eat muscle weakness twitching again and then also your integument more than likely with hypernatremia it's just going to be that if you have a dehydration issue so look at that trigger be assessing their mucosa and also just decrease elevation might be another manifestation so again hypernatremia is highly dependent on fluid status a lot of these assessments look the same eyes and O's daily weight Vital Signs CNS changes CNS changes CNS changes um skin turgor mucous membranes assessing for thirst um again dtrs their strength that they're having muscle weakness GI serum sodium levels sources of sodium intake that maybe we're not thinking about some kind of medication or maybe a supplement they think is innocuous but it's got a bunch of sodium in it so nursing interventions are extremely similar in hypernatremia so increase your monitoring and assessments we're increasing safety uh seizure we're implementing seizure precautions managing our meds as appropriate and encouraging now dietary restriction and maybe encouraging fluid intake so it's the opposite of hyponatremia depending upon their fluid status so medical interventions of course treating that underlying condition maybe even diuretics depending upon their fluid status if they can tolerate that if they can't tolerate a diuretic because they're hypernatremic because they're dehydrated um they may have to have an infusion of a hypotonic electrolyte solution such as half normal or 0.45 normal saline and again rapid correction may result in Rapid or sorry yeah rapid cerebral edema which basically again blows that myelination which is your nervous uh system like electrical tape your conduction it just blows it right off and it causes permanent brain damage so that's why a lot of your hypotonic hype specifically hypertonic Solutions those are administered in um lowered nurse to Patient ratio areas like the unit things like that all right so moving on to potassium so potassium hypokalemia is serum potassium less than 3.5 ml equivalents per liter GI losses similar to sodium prolonged intestinal suctioning is a big one racist ileostomy diarrhea so lower GI is a big issue GI losses if you maybe abuse laxatives maybe you can calculate too much because kayexalate can actually bind potassium sometimes calculate you can actually use that to treat hyperkalemia um just not taking in enough hormonal imbalances again that hyperglyce hyperglycemia sorry it causes osmotic diuresis just like hyponatremia and just pulls that potassium right out of the bloodstream alkalosis or a high pH can cause low potassium so acid pH balance and potassium are always opposites right so if you've got a high pH it's going to be low potassium if it's low or high potassium you're going to have a low PH that'll become important in Med search or I'm sorry unit two certain medications a big one is simultaneous administration of insulin and glucose or if you're just giving insulin to a patient who's hyperglycemic insulin or sorry potassium follows insulin into the cell and so if you are administering insulin to a hyperglycemic patient or you're giving insulin glucose that potassium will go down so you have to make sure that that potassium is adequate before um for those are administered or at least be sure you're monitoring that potassium so what does it look like so cardiovascular ECG changes dysrhythmias Cardiac Arrest okay so cardiac cardiac cardiac with potassium it's so so important because of that narrow range you might also have a peripheral nervous system changes so numbness and tingling that's what that paresthesia means so stigia means feeling para means like like Paranormal like not quite normal or to the side of normal so it's like weird Sensations like tingling and just weird feelings like fingers and toes kind of stuff um hypoactive reflexes so those deep tendon reflexes you're not going to get much of a response GI everything kind of slows down um decreased motility which will lead to distension and potentially even an Ilias if it's really bad and of course anorexia and then muscular weakness as well leg cramps and fatigue so what are we watching on patients with hypokalemia very similar eyes and O's daily weights dtr's strength or deep tendon reflexes they're GI but we're really looking at the sodium or I'm sorry the serum potassium levels pH levels becomes important in potassium as well a big thing is those cardiac changes you've got to watch the heart um taking an apical or apical pulse medications such as digoxin diuretics diuretics wash you out digoxin just like lithium and sodium so digoxin and potassium the body confuses those two as well if you have hypokalemia um your digoxin your body is going to grab onto ditch and you'll become ditch toxic not because you have too much ditch in your body but because your potassium's low so watch that so what are we supposed to do about or for these patients applied Telemetry increase monitoring and assessments increase safety precautions because they're weak right they may have a wonky Rhythm and just pass out so definitely increase safety precautions managing those medications holding something giving something as as needed and maybe even increasing dietary potassium if that's indicated and again medical always treating that underlying condition prescribed supplementation and maybe even an order for IV potassium for severe deficit key thing IV potassium unless like Miss Shepard says you're in the Department of Corrections or if you're doing cardiac surgery you never ever ever ever ever ever ever push potassium IV push because it can kill a patient it basically induces cardiac arrest so like I actually saw that in a cardiac surgery when I was in school and I got to watch I think it was a cabbage and they actually stopped the heart with an IV push of potassium it was the craziest thing and then I put the patient on the heart and lung pump so um so if you're administering IV potassium only after urine output has been established so you don't over correct and give them hyper but it's always given slowly and it's always on a pump always always always so hyperkalemia greater than five mil equivalents per liter so just taking in too much uh potassium a big area where people do that is they take in too much potassium because of potassium chloride salt substitutes they think well sodium is an issue so I'm just going to do potassium well potassium if you're taking too much can also cause problems as well obviously hyperkalemia so sometimes supplements um patients will maybe hold their diuretic but keep taking their potassium supplements because they don't quite understand how they work together if we have impaired renal function your kidneys are just not excreting it they're retaining it certain medications can promote retention of potassium so of course your potassium sparing diuretics ACE inhibitors they specifically act on that sodium potassium pump ACE inhibitors Force the body to excrete more sodium and of course fluid follows that but in exchange it maintains or retains potassium tissue trauma or Crush injuries whenever the cell is literally smushed and broken open you're going to have a lot of potassium dumping out because the potato or the cell is full of potassium also when blood Administration is not um it will administer through the filter correctly so that's why we have to provide that cushion on top of that filter so if you've already had blood Administration check off you know what I'm talking about if you haven't yet and you're going to have this in 110 there's a very specific way to Prime that filter to make sure those blood cells don't burst open on impact falling into that filter because they're full of potassium too they're so so if they break open in that filter you can actually give your patient hyperkalemia by not priming your blood tubing correctly and of course acidosis like I said they're always opposite so a low PH can will cause high potassium because in acidosis or alkalosis your body uses um potassium as sort of an exchange so your cells are like exchanging hydrogen which is an acid with potassium in an effort to balance your pH so it's a compensatory mechanism and we're going to talk more about that in unit two so what does this look like well ECG changes dysrhythmias Cardiac Arrest focus on cardiac you might have some CNS changes not nearly the same as you would with sodium maybe a little anxious a little irritable you're going to have some paresthesia so that's really similar with low um potassium as well GI issues cramps distension not wanting to eat anything and again weakness and or paralysis so what do we do for these patients we're assessing eyes and nose and daily weights we're assessing their mood we're assessing their GI system their serum K levels um oh I'm sorry that should say pH where it says acid-base balance forgive me so pH levels um cardiac changes of course biblical pulse um maybe getting rid of or holding or assessing to see what kind of medications are they on is it a medication issue so just like low potassium we're putting Telemetry on these patients increasing monitoring and assessment increasing their safety precautions um any kind of medication management and then of course dietary restriction and any kind of education that would be appropriate so medical treatment of course treating the underlying condition like I said before you might get an order for kayexalate that could also be like a PRN Med you could give to your patient usually though that's not for um it's not PRN for potassium management um you usually have to call and get an order for that uh just giving IV regular insulin with glucose again slowly with a pump and then also dialysis sometimes it's so high we just and that's usually well not usually but commonly they're hyperkalemic hypernatremic hyper everything because they just need dialysis so sometimes that's the best way to treat them all right so hypomagnesemia and hypermagnesemia I'm not again not going to go into Super um deep detail with this we're going to kind of blow through it but I just want you to be familiar with it primarily for clinical so a low serum magnesium is less than 1.3 milligrams per deciliter causes of GI losses primarily diarrhea so it's you know similar to potassium just not taking it in malnutrition while absorption a GI problem alcoholism is really common cause of hypomagnesemia it causes malnutrition and also causes malabsorption it irritates the GI tract and medications just like diuretics like we've talked about already so what does this look like you can also have ECG changes dysrhythmias with magnesium so a really important intervention with lomag is application of telemetry okay so watching that heart rhythm they may also have some pretty serious mood changes so confusion and psychosis and agitation so a way to differentiate this from say hyponatremia again is they're going to have cardiac issues right like you don't really have that with sodium but CNS changes in hypomagnesemia is Extreme agitation so a way to think about calcium and magnesium is when they're low they're narrative um when they're super high they're almost like a sedative so with hypomagnesemia you're going to have extreme agitation hypertension um one thing you can think about um if you are have been around OB if you've had a child maybe if you've had preeclampsia um you're going to learn about this in OB but a way that they treat um preeclampsia which is like a hypertensive condition in pregnant women is to give magnesium sulfate because it actually does the opposite it causes the sedative condition so that's an easy way to remember that hypo hypomagnesemia causes a lot of agitation and hypertension it also causes irritation so hyperreflexia you're going to have some really responsive um dtr's or deep tendon reflexes you'll also see some tetany tetany is muscular contraction caused by neuromuscular excitability so you can have a positive trousseau and trustex sign and so true so is when you put the blood pressure cuff on and they're again their wrist and their fingers kind of curl in really tight um sort of oh not really immediately well I guess it is medially when you think about it from an anatomical position or you could have Chivas deck sign where the the cheek is tapped and that side of their face will contract because their their nerves are so irritated it causes muscular contraction again GI just feel terrible pukey and muscular weakness muscular irritability right so they may have Ataxia even though things are irritated their muscles aren't working like they should so they may be weak they may be have really poor coordination so assessments uh hopefully this is looking very very similar uh there's a lot of repetition here um so eyes and O's are they losing magnesium because of diuretics what are their Vital Signs doing are they dangerously hypertensive um are they maybe losing magnesium through GI losses because they feel terrible because they're pukey or maybe they've got some diarrhea going on dtr's strength because of muscle weakness and Hyper reflex hyperreflexia of course there's cerium mag levels serum sorry mag levels any kind of cardiac changes CNS changes they could even have seizures uh what kind of medications are they on and then of course Tech assessments or signs so we're applying Telemetry just like potassium increasing monitoring and assessments increasing safety implementing seizure precautions managing those meds and of course teaching or supplementing mag and the medical interventions treating an underlying condition maybe what they need is treatment for alcoholism um and then of course you can treat with uh just IV magnesium sulfate slowly with a pump because again it's very similar to potassium in that it can cause cardiac issues so it's not as um magnesium doesn't irritate the heart as easily as changes in potassium but it still can so we still want to be aware of that and again make sure you've got adequate urine output so we don't cause hyper magnesemia by giving them IV mag so hypermagnesemia greater than three milligrams per deciliter of course retention acute kidney injury is a common cause for hypermagnesemia renal disease we're just not excreting it we have excessive admin of Mag whether it's from an acid milk of magnesia um I know there's a laxative maybe that is the laxative I can't remember off the top of my head um other types of medications that include magnesium um and then of course extensive soft tissue injury so again it's a it's a um one of the key intracellular um cations and so when you have a crush injury and those cells are literally exploded and squished you're going to have a bunch of both potassium and magnesium being dumped into the bloodstream so again what does this look like cardiac cardiac cardiac again that is sensitive um as a potassium imbalance but still a problem and so you'll notice like I said lomag irritation High mag sedation so here you're seeing well still high or low you're going to make that heart mad but now we have hypotension so I went the opposite direction now instead of irritability and seizures we're drowsy we're becoming comatose we have hypo reactive or non-reactive reflexes um decreased bowel motility everything's really slowing down another thing you might see is Flushing and diaphoresis so that kind of bright red flush of the skin and excess sweating so what are we doing for those patients Eyes Nose Vital Signs serum mag levels watching that heart watching the respiratory rate too because if we get too drowsy we may not be breathing appropriately so again it's kind of like a sedative we're looking at dtrs and strength because we're expecting a weakness with hypermagnesemia GI mood CNS changes so that one is more specifically drowsiness going in the opposite direction skin color moisture changes and assessing for any medications that are contributing to hypermagnesemia so nursing interventions putting that teleon basically in doubt put on telly almost any um electrolyte concern with the exception of sodium for the most part uh just put Telly on that patient right better safe than sorry and and more specifically with potassium but with any of them um so increasing your monitoring and assessment safety precautions manage the meds and of course dietary restriction and education yeah so medical treatment underlying condition IV calcium gluconate you're thinking okay why am I giving calcium for hypermagnesemia well the short and sweet of it is basically the calcium gluconate antagonizes or blocks the action of mag and that neuromuscular Junction so it basically blocks the activity of magnesium and it just inhibits its ability to cause irritation essentially it's kind of a Band-Aid right it doesn't treat the mag problem but it can block the effects of Mag if it's a crisis of course slowly with a pump sometimes dialysis if everything's high sodium potassium calcium Mac probably what they need is dialysis I've had a few patients come in like on mentally and they're everything's high and everything's a critical and they miss dialysis and so they're admitted because they just need dialysis and of course Loop Diuretics plus normal saline and LR to help promote excretion of Mag all right so our last electrolyte hypocalcemia so serum calcium is less than 8.5 milligrams per deciliter causes vitamin D deficiency so vitamin D is critical to calcium absorption if you don't have vitamin D you can't absorb calcium so you can take in all the cheese and all the milk and all the Tums and everything else you can think of but if you don't have vitamin D your body can't absorb it you can't get it into your bloodstream so if you don't have enough vitamin D that can cause hypo calcemia or low calcium in the blood um osteoporosis now that's kind of a question of you know chicken for the egg kind of thing but so low calcium can cause Osteo osteoporosis but osteoporosis can be contributed to low calcium so basically it's more of it that's a relationship than a cause necessarily um but it all depends on um you know what's really um causing the low calcium because when we talk about osteoporosis we'll talk about the imbalance in cellular metabolism and activity and how that kind of goes together so of course malabsorption so not just a vitamin D deficiency but certain medications antacids they can block the absorption of certain types of um electrolytes like calcium you can also have prevention of absorption by a proton pump inhibitor because a lot of medications require that hydrochloride that acidic environment to absorb medications and again GI diseases like we'll talk about in unit five and then lastly we won't talk about you know thyroid or anything like that until you get to med surg 3 but a a prominent reason for hypocalcemia is thyroidectomy because your thyroid contains also your parathyroid glands on the back which release parathyroid hormone and then your thyroid releases calcitonin and those are incredibly important to your calcium your calcium balance all right so what does this look like well more cardiac changes um so guess what we're putting on our patient Telemetry should say cardiac sorry Cardiac Arrest decrease BP um impaired clotting time so um calcium is integral to um the clotting Cascade so if you don't have calcium you're not going to have clots so you might see some excess bleeding with these patients which then can contribute to low volume and decrease BP and all that kind of stuff and of course you know weird rhythms can also cause decreased BP and that's true for all any of the electrolyte imbalances that cause cardiac irritation so CNS um again it's low right so hypocalcemia as well as hypomagnesemia they're both irritants so just like hypomagnesemia hypocalcemia causes anxiety irritability seizures confusion um you're going to have hyperactive reflexes you'll also have tetany positive trastek and trusso signs as well just like we talked about before and you may also have some diarrhea and that'll become important when we talk about hypercalcemia and how those are different so you might have some diarrhea assessments eyes and O's serum calcium level PTINR now PTINR if you're not familiar we're going to go into a lot more depth on that uh in unit three and so that right there is a clotting time um assessment or lab and so PT is prothrombin and calcium in particular affects prothrombin and PTINR are related so we'll get to that unit three of course cardiac changes deep tendon reflexes you're going to see some hyperreflexia any kind of medications that waste or block the absorption of calcium and of course your true Stone shavas deck signs so put some Telly on that patient increase them some more or increase them some more increase their monitoring sorry and their assessments more increase their safety precautions you may have to implement seizure and or bleeding or both or all of these um manage those medications and of course any kind of dietary restriction and education so medical interventions of course treating the underlying condition and then of course administration of IV calcium makes sense so gluconate or chloride and again slowly with a pump because you can cause irritation of The myocardium with hypercalcemia foreign calcium less than 10.5 or sorry greater than 10.5 is hyper calcemia medications just the the opposite of hypocalcemia vitamin D intoxication so too much of it uh too much of a good thing right if you're taking too much supplementation um just your body's absorbing too much alkaline and acids so antacids that contain calcium any kind of calcium supplements sometimes those are one of the same thing you can take Tums for an acid or um indigestion you can also just take it for a calcium supplement bone trauma because the bones are broken and they're dumping calcium into the bloodstream and then of course cancer and that's a mechanism that I don't understand and it's way above my head if somebody does understand it which I'm sure some oncologist does but it's just something about cancer that causes hypercalcemia so again cardiac changes cardiac arrest so it's it's a sedative right for the most part it's not a Perfect Analogy but it's for the most part you might see some hypertension with hypercalcemia but you're going to see some lethargy confusion coma um hypoactive reflexes so decreased motility constipation versus diarrhea right so diarrhea with hypocalcemia constipation with hypercalcemia anorexia nausea vomiting weakness musculoskeletal wise bone pain and maybe even a pathological fracture um so uh you might also have some renal issues because calcium is one of the key pieces of kidney stones so you might have a kidney stone which of course then will cause flank pain so we're watching eyes and O's Vital Signs um watching ECGs tele serum calcium levels dtrs and looking for any kind of medication that might contain calcium or promote absorption of course strength and GI assessments as well shocking we're putting Telly on this patient uh we're increasing our monitoring our assessment increasing safety precautions um because they are so they can become so drowsy um medication management dietary restriction and education and then also Mobility um a cause of hypocalcemia can be bed rest or immobility so that's another reason to get your patients up and moving so medical interventions treating the underlying condition I see IV calcitona no that does not say calcium that's calcitonin right so that will cause movement of calcium from the bloodstream into the bones or phosphate and again slowly with a pump or diuresis right maybe just or dialysis either one just getting rid of it making the body shed that that high level of calcium and maybe it's just cancer treatment maybe if we can excise that tumor or you know maybe have through successful chemo radiation we can reduce that body's the body's response so this concludes the lecture portion on electrolytes so when you're thinking about trying to make sense of these think about what I stressed what I repeated on a lot of these also you have a tool in your resources link on the website that will help you compare and contrast these differing um you know the different presentations of all these different electrolyte imbalances and I will tell you that some some of these specifically and sodium potassium the high and the low have the same type of symptoms some are very distinguishing and when you get into magnesiumin calcium the high and the low are much more distinguishable than sodium and potassium so put that together compare and contrast you're going to do that a lot sorry and 107 is comparing and contrasting making sure you can really parse out those small differences so as you work through that don't be afraid to reach out and ask questions