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Course: Medical Surgical Nursing

Topic: Electrolyte Imbalance I

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Module Goals

Learners will be able to:

Define the term “electrolytes.”
Correlate laboratory data and clinical manifestations related to disorders in sodium imbalance, potassium imbalance, and calcium imbalance.
Discuss the causes of these electrolyte imbalances.
Identify the signs/symptoms of electrolyte imbalance in the body.
Discuss the nursing implications in treating clients with electrolyte imbalances (including considerations for the elderly).

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Electrolytes

Minerals in the body that have an electric charge
Found in blood, urine, tissues, and other body fluids.
Essential for basic life functioning
Maintain electrical neutrality
Generate and conduct action potentials

Healthline, 2018

MedlinePlus, 2016

Shrimanker & Bhattarai, 2021

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Electrolytes (Continued)

Imbalances (high or low levels) disrupt normal bodily functions and can lead to life-threatening complications.

These six electrolytes are the most important for bodily functions: sodium, potassium, chloride, bicarbonate, calcium, and phosphate.

Healthline, 2018

MedlinePlus, 2016

Shrimanker & Bhattarai, 2021

Contact info: info@nursesinternational.org

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Significance of Electrolytes

Functions:

Balance the amount of water in the body
Balance the body's acid/base (pH) level
Move nutrients into the cells
Move wastes out of the cells
Assure that the nerves, muscles, heart, and brain work the way they should.

MedlinePlus, 2016

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Key Terms

Hyper: High
Hypo: Low
Ion: An atom that has an electrical charge
Cations: Ions with a positive charge
Anions: Ions with a negative charge
pH: A scale that measures acidity or base
Neutral: pH of 7.36-7.44
Acidic: pH of less than 7
Basic/alkaline: pH of more than 7.44

Cleveland Clinic, 2021

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Major Electrolytes: Normal Values

Sodium (Na): 136 - 144 mmol/L.
Potassium (K): 3.7 - 5.1 mmol/L.
Calcium (Ca): In adults, 8.5 - 10.2 mg/dL.
Chloride (Cl⁻): 97 - 105 mmol/L.
Magnesium (Mg): 1.7 - 2.2 mg/dL.
Phosphate (PO₄³⁻): 2.5 - 4.8 mg/dL.
Bicarbonate (HCO3-): 22 - 30 mmol/L.

Cleveland Clinic, 2022

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Critical Thinking Question

Which statement by the new nurse regarding electrolytes indicates the need for additional teaching?

Electrolytes balance the amount of water in the body.
Electrolytes balance the pH level of blood in the body.
Electrolytes are negatively charged ions found in the body.
Electrolytes move nutrients in and waste out of the cells.

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Sodium

Serum sodium levels range from 136 -145 mEq/L.

Most abundant electrolyte in the extracellular fluid (ECF)
Maintained by the sodium-potassium pump
Diet sources:

Salt
Bread and rolls
Pizza
Sandwiches
Cold cuts and cured meats
Savory snacks
Chicken
Cheese
Eggs

Ernstmeyer & Christman, 2021

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Sodium: Hypernatremia

Serum sodium levels are greater than 145 mmol/L.
Causes

Dehydration from:

Vomiting
Diarrhea
Diabetes
Excessive perspiration

Ernstmeyer & Christman, 2021

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Sodium: Hypernatremia (Continued)

Symptoms

Severe thirst (major symptom)
Dry mucous membrane
Tachypnea
Sleeping difficulty
Restlessness

Treatment

Decrease sodium intake
Increase oral water intake
Rehydrate with a hypotonic IV solution

(45 NS ( ½ NS)

Ernstmeyer & Christman, 2021

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Nursing Intervention

Identify the risk of hypernatremia
Identify the signs of hypernatremia
Assess fluid losses and intake and output
Monitor vital signs and weight
Monitor the severity of symptoms
Send lab work as needed
Nutritional consult
Encourage increasing fluid intake and decreasing sodium intake
Promote awareness, prevention, recognition, and treatment of hypernatremia.

King Saud University College of Nursing, n.d.

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Sodium: Hyponatremia

Serum sodium level < 135 mmol/L
Symptoms

Headache
Confusion
Nausea
Delirium
Seizure
Coma

Ernstmeyer & Christman, 2021

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Sodium: Hyponatremia (Continued)

Treatment:

Address the cause

Limit water intake
Discontinue administration of hypotonic IV fluids

If severe hyponatremia, a hypertonic IV saline solution may be prescribed (10% Dextrose in water)

*Nursing consideration: Rapid sodium corrections can have serious consequences, such as cerebral edema and osmotic demyelination syndrome.

Ernstmeyer & Christman, 2021

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MedlinePlus (2022),

Osmotic Demyelination syndrome:

Osmotic demyelination syndrome (ODS) leads to brain cell dysfunction. It is caused by the destruction of the layer (myelin sheath) covering nerve cells in the middle of the brainstem (pons).

When the myelin sheath that covers nerve cells is destroyed, signals from one nerve to another aren't properly transmitted. Although the brainstem is mainly affected, other areas of the brain can also be involved.

The most common cause of ODS is a quick change in the body's blood sodium levels. This most often occurs when someone is being treated for low blood sodium (hyponatremia), and the sodium is replaced too fast. Sometimes, it occurs when a high level of sodium in the body (hypernatremia) is corrected too quickly.

ODS does not usually occur on its own. Most often, it's a complication of treatment for other problems or from the other problems themselves.

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Nursing Interventions in Hyponatremia

Identify the risk for hyponatremia
Assess fluid intake and output
Assess for the signs and symptoms of hyponatremia
Monitor vital signs, intake, and output
Monitor the severity of symptoms
Restrict fluid intake
Administer isotonic I.V. fluids as prescribed

King Saud University College of Nursing, n.d.

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Critical Thinking Question

A client’s lab report shows a sodium level of 175 mmol/L. Which clinical manifestation would the nurse expect to see in the client? (Select all that apply).

Extreme thirst
Delirium
Peaked T wave
Dry mucous membranes

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Potassium

Serum levels: 3.5 to 5.1 mEq/L

Most abundant electrolyte in intracellular fluid and maintained by the sodium-potassium pump
Regulated by aldosterone in the kidneys
Obtained in the diet through the consumption of bananas, oranges, and tomatoes.
Impacted by the hormone insulin
Necessary for normal cardiac function, neural function, and muscle contractility.

Ernstmeyer & Christman, 2021

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Hyperkalemia (Increased Serum Potassium)

Serum Potassium > 5.1 mEq/L

Causes:

Kidney failure
Metabolic acidosis
Administration of potassium-sparing diuretics
Oral/intravenous potassium supplements

Ernstmeyer & Christman, 2021

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Hyperkalemia: Signs and Symptoms

Generally of cardiac nature
Irritability
Cramping
Diarrhea
Electrocardiogram (ECG) abnormalities
Cardiac dysrhythmias and cardiac arrest as the severity increases

Ernstmeyer & Christman, 2021

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Hyperkalemia: Treatment

Depends on the severity of the symptoms
For mild symptoms

Decrease potassium intake in the diet
Adjust medications that contribute to increased potassium levels

For severe symptoms

Sodium polystyrene sulfonate orally or rectally
Insulin
IV calcium gluconate
Temporary hemodialysis for severe symptomatic hyperkalemia

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Treatment for hyperkalemia depends on the severity of the hyperkalemia symptoms. For mild symptoms, decreased potassium intake in the diet is helpful. Adjustment to the medications contributing to increased levels of potassium may be indicated. For severe symptoms, the administration of sodium polystyrene sulfonate (Kayexalate) orally or rectally helps bind excess potassium so it is excreted through the GI tract. Insulin may be administered to push potassium into cells and decrease serum potassium levels. It is important to monitor blood glucose levels closely, often hourly, per agency policy when administering an insulin infusion. The client often requires supplemental IV dextrose to prevent low blood sugar levels when insulin is used for potassium reduction. IV calcium gluconate may also be given to prevent excess potassium from affecting cardiac muscle. This temporary measure wears off quickly but allows time for other treatments to take effect and lower potassium levels before cardiac arrest develops. For severe symptomatic hyperkalemia, temporary hemodialysis may also be used to quickly decrease potassium levels.

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Hyperkalemia: Nursing Interventions

Monitor

Intake and Output
Serum potassium levels, BUN, and creatinine levels.
ECG for peaked T waves
Blood glucose when administering insulin therapy

Administer diuretics and insulin as prescribed
Discontinue medications that can cause hyperkalemia or renal dysfunction
Client education about hyperkalemia, low potassium diet, and its effect on renal function.

Simon et al., 2022

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Hypokalemia - Decreased Serum Potassium

Serum levels < 3.5 mEq/L

Causes

GI-Excessive vomiting, diarrhea
Medication-Potassium-wasting diuretics and insulin use
Nutrition-Lack of potassium in the diet

Signs and symptoms

Weakness
Arrhythmias
Lethargy
Thready pulse

Ernstmeyer & Christman, 2021

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Treatment: Hypokalemia

Increase oral intake of potassium in the diet
Oral potassium supplementation
Intravenous potassium supplementation

*Note: Administering IV potassium too quickly may cause cardiac arrest.

Ernstmeyer & Christman, 2021

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Nursing Interventions for Hypokalemia

Identify clients at risk for hypokalemia.
Assess for signs and symptoms of hypokalemia.
Address the client’s diet; increase potassium-rich foods.
Monitor vital signs, ECG changes, serum potassium levels.
Monitor for complications and severity.
Administer potassium replacements as indicated.
Prepare for medical emergencies like cardiopulmonary resuscitation and cardiac defibrillation.

King Saud University College of Nursing, n.d.

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Critical Thinking Question

A nurse reviews the lab reports of several clients. Which of the following clients would the nurse suspect is at risk for hyperkalemia?

An older person who has been taking Furosemide every 4 hours for the last 3 days.
A client who is admitted with polycystic kidney disease.
A client who has been diagnosed with cirrhosis of the liver.
An older person who has a fasting blood sugar level of 250 mg/dL.

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Calcium

Normal serum range: 8.6-10.2 mg/dL

Circulates in the bloodstream, but the majority is stored in bones
Important for bone and tooth structure, nerve transmission, and muscle contraction.
Regulated by the parathyroid hormone
Affected by dietary intake and physical activity
Dietary sources of calcium include:

Dairy products
Green leafy vegetables
Sardines
Whole grains

Ernstmeyer & Christman, 2021

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Hypercalcemia - Increased Serum Calcium

Serum Levels > 10.2 mg/dL

Causes

Prolonged immobilization
Cancers
Hyperparathyroidism and parathyroid tumors

Ernstmeyer & Christman, 2021

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Hypercalcemia - Signs and Symptoms

Often impacts the gastrointestinal and musculoskeletal systems

Nausea
Vomiting
Constipation
Increased thirst and/or urination
Skeletal muscle weakness

Treatment

Decrease dietary calcium
Phosphate supplementation
Hemodialysis
Surgical removal of the parathyroid gland
Weight-bearing exercises as tolerated

Ernstmeyer & Christman, 2021

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Hypercalcemia: Nursing Interventions

Assess the severity of signs and symptoms
Administer medications as indicated (phosphate, loop diuretics)
Ensure hydration
Physical therapy for mobility
Prevent fractures
Reduce dietary calcium
Hospice, palliative care, and pain referral if metastatic disease associated with hypercalcemia.
Education about bisphosphonates

Sadiq et al., 2021

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Hypocalcemia - Decreased Serum Calcium

Serum calcium level < 8.5 mg/dL

Causes

Hypoparathyroidism
Vitamin D deficiency
Renal disease

Ernstmeyer & Christman, 2021

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Hypocalcemia

Signs and Symptoms

Impacts the musculoskeletal and nervous systems
Paresthesias of the lips, tongue, hands and feet.
Muscle cramps and tetany
Classic signs: Chvostek’s sign and Trousseau’s sign

Treatment:

Increase oral intake of dietary calcium and vitamin D
Oral or IV calcium supplementation
Decrease elevated phosphorus levels

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Hypocalcemia: Nursing Interventions

Assess for signs and symptoms
Note changes in cardiovascular and neurologic status
Monitor vital signs
Monitor calcium levels
Administer I.V. calcium gluconate as prescribed
Administer a phosphate-binding antacid as prescribed
Prepare for emergency, seizure or cardiac emergencies
Education:

Encourage intake of calcium and vitamin D-rich foods
Avoid hyperventilation

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

A 14-year-old female who was treated for a serum calcium level of 7.4 mg/dl is being discharged. Which foods should the nurse advise the client and caregiver to include in the diet? (Select all that apply).

Green leafy vegetables and sardines
Whole grains
Pork and chicken
Dried cranberries

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Considerations for the Elderly Population

The kidney is one of the major organs in which specific structural and functional phenotypic changes occur with aging.

Senescent kidney: The structural and functional kidney changes associated with aging.

This may occur without obvious kidney disease.

Glomerular filtration rate (GFR) and renal plasma flow (RPF) decline in elderly individuals.

Schlanger, et al., 2010

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Red Flags

Leg cramps
Arrhythmias
ECG changes
Hypo/hypertension
Drastic weight gain
Edema

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in healthcare decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be acceptable in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Cleveland Clinic. (2021, September 24). Electrolytes. https://my.clevelandclinic.org/health/diagnostics/21790-electrolytes

Cleveland Clinic. (2022, February 07). Electrolyte Panel. https://my.clevelandclinic.org/health/diagnostics/22358-electrolyte-panel

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingfundamentals/

Healthline. (2018a, October 24). Electrolytes: Definition, Functions, Imbalance and Sources. https://www.healthline.com/nutrition/electrolytes

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References

King Saud University College of Nursing. (n.d.). Application of Adult Health Nursing Skills ( NUR 317 : Care for patients with fluid and electrolytes imbalance. https://faculty.ksu.edu.sa/sites/default/files/fluid_imbalance_2.pdf

MedlinePlus. (2016, June 20). Fluid and Electrolyte Balance. https://medlineplus.gov/fluidandelectrolytebalance.html

Sadiq N. M, Naganathan, S., Badireddy, M. (2021, November 26). Hypercalcemia. In: StatPearls StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430714/

Schlanger, L. et al., (2010). Electrolytes in the Aging. Advances Chronic Kidney Diseases. 17(4): 308–319. https://doi.org/10.1053/j.ackd.2010.03.008.

Shrimanker I, Bhattarai S. (2021, Jul 26). Electrolytes. In: StatPearls [Internet] StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK541123/

Simon L. V., et al (2022, Feb 16). Hyperkalemia (Nursing) In: StatPearls [Internet]. StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK568741/

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