Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology and clinical manifestations of various electrolyte imbalances
- Describe the diagnostics and laboratory values related to various electrolyte imbalances
- Apply nursing concepts and plan associated nursing care for patients with various electrolyte imbalances
- Evaluate the efficacy of nursing care for patients with various electrolyte imbalances
- Describe the medical therapies that apply to the care of those experiencing electrolyte imbalances
Ions dissolved in body fluid are known as electrolytes. They play an important role in most physiological functions and assist in maintaining homeostasis. There is a very narrow target range for normal electrolyte values, and even slight abnormalities can have devastating consequences. For this reason, it is crucial to understand normal ranges for the body’s key electrolytes: potassium, sodium, calcium, magnesium, phosphorus, and chloride. Nurses should also understand the causes and clinical manifestations of electrolyte imbalances and appropriate medical and nursing interventions.
Link to Learning
Explore additional information on normal laboratory values and view a helpful cheat sheet.
Potassium Overview
Potassium is the most abundant electrolyte in the intracellular fluid compartment and is exchanged with sodium back and forth into and out of the cell by the sodium-potassium pump mechanism. Potassium levels normally range from 3.5 to 5.1 mEq/L, with slight range variations between different health care institutions depending on their policies and laboratory equipment. Potassium is obtained through the dietary consumption of foods such as bananas, oranges, and tomatoes, and its excretion is regulated by aldosterone in the kidneys. Recall that aldosterone causes sodium reabsorption and potassium excretion in the distal tubule of the kidneys. In response to potassium levels rising or sodium levels falling in the bloodstream, the adrenal cortex releases aldosterone and targets the kidneys. In response, the kidneys excrete potassium and reabsorb sodium. Potassium is also affected by insulin, which moves potassium back into the cells from the extracellular fluid compartment.
Potassium Imbalances
Potassium is necessary for normal cardiac function, neural function, and muscle contractility, including effective contractility of the cardiac muscles. In a potassium imbalance, there is either too much potassium present in the blood (hyperkalemia) or too little (hypokalemia). Both types require early assessment and intervention to prevent severe adverse effects, including cardiac dysrhythmias or arrest.
A decreased potassium level in the blood is known as hypokalemia. Common causes of hypokalemia include
- excessive vomiting or diarrhea
- use of potassium-wasting diuretics or insulin use
- decreased dietary intake of potassium
An increased potassium level in the blood is known as hyperkalemia. Common causes of hyperkalemia include
- administration of potassium-sparing diuretics or oral potassium supplements
- kidney failure
- metabolic acidosis
Table 10.7 compares the pathophysiology and clinical manifestations of, and diagnostic tests, and treatments for both types of potassium imbalances.
| Hypokalemia | Hyperkalemia | |
|---|---|---|
| Pathophysiology | Increased excretion of potassium (e.g., due to prolonged vomiting or diarrhea, potassium-wasting diuretics) or abnormal movement of potassium into cells from the intravascular space (e.g., resulting from insulin administration) | Decreased renal excretion of potassium (e.g., kidney failure) or abnormal movement of potassium out of cells and into intravascular space (e.g., acidosis, potassium-sparing diuretics) |
| Clinical manifestations |
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| Diagnostic tests |
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| Treatments |
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Nursing Care of Patients with Hypokalemia
Nursing care for patients with hypokalemia should focus on monitoring the patient’s condition and preventing associated complications, especially the development of deadly cardiac dysrhythmias.
Recognizing Cues and Analyzing Cues
In the early stages of hypokalemia, the patient may be asymptomatic. However, when potassium values are less than 3.0 mEq/L, signs and symptoms become more obvious and can develop and progress quickly. It is important that the nurse monitor the patient for signs and symptoms that would indicate the hypokalemia is not improving. Clinical manifestations associated with hypokalemia that should be assessed are listed in Table 10.7.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
First and foremost, because potassium imbalances can result in lethal cardiac dysrhythmias, it is imperative that the nurse ensure the patient’s cardiovascular function is being closely monitored. Patients with hypokalemia should be placed on continuous telemetry monitoring for the early detection of electrocardiogram (ECG) changes that may indicate the development of abnormal rhythms. If the patient is being treated with oral potassium supplements, the nurse should encourage the patient to consume a large glass of water with the medication to help facilitate absorption and prevent gastrointestinal (GI) upset. If the patient has a more severe case of hypokalemia that requires administration of potassium intravenously, the nurse should be aware of the following additional safety concerns:
- Because too much potassium (especially when administered too quickly) can cause life-threatening cardiac dysrhythmias, it should never be administered as an IV push medication. Instead, IV potassium should always be given slowly over several hours via an IV pump.
- Intravenous administration of potassium can be irritating to the veins, so the patient may require co-administration of fluids to dilute the potassium or the placement of a central line in a bigger vein.
Evaluation of Nursing Care of the Patient with Hypokalemia
After diagnosis of and initiation of treatment for hypokalemia, it is important for the nurse to evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, the nurse should monitor the patient for signs indicating the potassium imbalance has been corrected. Signs that would indicate an improvement in condition include
- constipation
- improved muscle weakness, cramps, and paresthesia
- normal bowel movement(s)
- normal ECG findings
- normal reflexes
- normalized serum potassium level (3.5–5.1 mEq/L)
Nursing Care of Patients with Hyperkalemia
Nursing care for patients with hyperkalemia is like that of those with hypokalemia in that care should focus on monitoring the patient’s condition and preventing associated complications, especially the development of lethal cardiac dysrhythmias.
Recognizing and Analyzing Cues
Though patients with hyperkalemia may be asymptomatic initially, because of internal compensatory mechanisms, clinical manifestations can develop quickly as potassium levels increase. A serum potassium level of greater than 6.0 mEq/L warrants prompt intervention and appropriate treatment to prevent serious complications.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Just as with hypokalemia, one of the most important nursing interventions is to closely monitor the patient’s cardiovascular function, typically with the use of continuous telemetry monitoring. If the patient is being treated with medications such as sodium polystyrene sulfonate (Kayexalate), it is important for the nurse to monitor the patient’s bowel movements. These kinds of medications promote the excretion of potassium in the stool, so the patient will likely have multiple loose stools soon after the medication is administered. If so, the nurse should monitor the patient closely for skin breakdown and ensure they are clean and dry between bowel movements to promote an optimal level of skin integrity.
If the patient is receiving therapy with IV diuretics, it is important for the nurse to monitor the patient’s serum electrolyte levels closely. Occasionally, diuretics may result in the loss of too many electrolytes and can cause hypokalemia. For this reason, it is often necessary to provide potassium supplements when administering loop and thiazide diuretics, because potassium is excreted from the kidneys along with water. People taking diuretics will urinate more frequently, so the nurse should ensure the patient can ambulate safely to the bathroom on their own or that they have a call light within reach so they can call for assistance to prevent falls.
Evaluation of Nursing Care of the Patient with Hyperkalemia
After diagnosis of and initiation of treatment for hyperkalemia, it is important that the nurse evaluates patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, the nurse should monitor the patient for signs indicating the potassium imbalance has been corrected. Signs that would indicate an improvement in condition include
- improved muscle weakness, cramps, and paresthesia
- normal ECG findings
- normal reflexes
- normalized serum potassium level (3.5–5.1 mEq/ L)
Sodium Overview
Sodium is the most abundant electrolyte in the extracellular fluid compartment. Sodium levels in the blood typically range from 136 to 145 mEq/L, depending on the health care institution’s normal reference range, and sodium levels are maintained by the sodium-potassium pump mechanism. Sodium plays an important role in maintaining adequate fluid balance in the intravascular and interstitial spaces; it also contributes to normal nerve and muscle function.
Recall from previous sections that sodium is regulated by the RAAS in the kidneys as well as by the release of ADH by the pituitary gland. Additionally, it is important to remember that wherever sodium travels, water follows.
Sodium Imbalances
In sodium imbalances, there is either too much sodium present in the blood (hypernatremia) or too little (hyponatremia). Both types are common and require early assessment and intervention to prevent severe adverse effects.
A decreased sodium level in the blood is known as hyponatremia. Hyponatremia can be caused by excess water intake or excessive administration of hypotonic IV solutions. For example, a marathon runner who rehydrates only with water rather than fluids containing solutes, like sports drinks, can develop hyponatremia due to dilution. Altered sodium levels often cause neurological signs and symptoms due to the movement of water into brain cells, which causes them to swell.
An elevated sodium level in the blood is known as hypernatremia. Typically, hypernatremia is caused by excess water loss due to lack of fluid intake, vomiting, or diarrhea. Elevated sodium levels in the blood cause the osmotic movement of water out of the cells to dilute the blood. This causes the body’s cells to shrink, which is referred to as cellular dehydration. This fluid shift can have a significant impact on various organs of the body and, as with hyponatremia, is especially notable in the patient’s neurological function.
Table 10.8 compares the pathophysiology and clinical manifestations of, and diagnostic tests and treatments for both types of sodium imbalances.
| Hyponatremia | Hypernatremia | |
|---|---|---|
| Pathophysiology | Increased excretion of sodium (e.g., due to prolonged vomiting or diarrhea, diuretics) or dilution of sodium (e.g., due to increased water intake without electrolyte replenishment; overuse of hypotonic fluid replacement) | Excessive sodium intake (e.g., a high-sodium diet) or decreased fluid volume (e.g., due to prolonged vomiting or diarrhea; hypovolemia) |
| Clinical manifestations |
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| Diagnostic tests |
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| Treatments |
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Nursing Care of Patients with Hyponatremia
Nursing care for patients with hyponatremia should be focused on monitoring the patient’s condition and preventing associated complications, especially the development of neurological complications.
Recognizing and Analyzing Cues
In the early stages of hyponatremia, the patient may be asymptomatic. However, as sodium levels continue to fall, signs and symptoms can begin quite suddenly and cause adverse neurological effects. With more acute declines in sodium levels—typically when the level drops to about 115 mEq/L—symptoms occur quickly and are more severe. Clinical manifestations associated with hyponatremia that should be assessed are listed in Table 10.8. Remember, where sodium goes, water follows. In cases of hyponatremia, the sodium level inside the vessel is low, indicating that the sodium has moved elsewhere, often the brain tissue. If that is the case, water will follow the sodium to the brain, resulting in signs and symptoms such as confusion and decreased level of consciousness.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
For patients who can eat and drink, nurses should promote the intake of sodium through salty food and drink options such as broth salt tablets or sports drinks. For patients unable to eat or drink, the main treatment is IV sodium replacement. This is typically done by administering isotonic fluids such as normal saline or lactated Ringer’s, because both contain sodium. If the nurse is administering IV fluids with a goal of correcting sodium balance, it is important to avoid giving the fluids too quickly. If sodium levels increase too fast (>0.5 mEq/L/h), severe neurologic damage may occur due to the movement of fluid out of brain cells, resulting in cellular shrinkage. This condition is called osmotic demyelination syndrome.
Evaluation of Nursing Care for Patients with Hyponatremia
After diagnosis of and initiation of treatment for hyponatremia, it is important that the nurse evaluates patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, the nurse should monitor the patient for signs indicating that the sodium imbalance has been corrected. Signs that would indicate an improvement in condition include
- improved mentation and level of consciousness
- normal reflexes
- normalized serum sodium level (135–146 mEq/L)
Nursing Care of Patients with Hypernatremia
As with hyponatremia, nursing care for patients with hypernatremia focuses on monitoring the patient’s condition and preventing associated neurological complications.
Recognizing and Analyzing Cues
In the early stages of hypernatremia, one of the only symptoms the patient may exhibit is thirst. As sodium levels increase, water moves out of cells, resulting in brain-cell shrinkage and signs such as confusion or seizures. Clinical manifestations associated with hyponatremia that should be assessed are listed in Table 10.8.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The main nursing intervention for patients with hypernatremia is monitoring accurate intake and output of fluid to prevent excessive gains or losses. Additionally, the nurse should encourage the patient to consume more water to dilute the excess sodium. If the patient is unable to drink fluids orally, fluid replacement with hypotonic solutions may be necessary. Just as with hyponatremia, fluid replacement should be performed slowly and cautiously. If sodium levels are decreased too quickly, water may move into brain cells and cause cerebral edema, which can quickly become life-threatening.
Evaluation of Nursing Care for Patients with Hyponatremia
After diagnosis of and initiation of treatment for hypernatremia, the nurse should evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, the nurse should monitor the patient for signs and symptoms indicating that the sodium imbalance has been corrected. Signs and symptoms that would indicate an improvement in condition include
- improved mentation and level of consciousness
- normalized serum sodium level (135–146 mEq/L)
- normal thirst level
Interdisciplinary Plan of Care
Interdisciplinary Care of a Patient with Electrolyte Imbalances
Care of the patient with electrolyte imbalances requires collaboration within an interdisciplinary team. Team members may play different roles, depending on the patient’s needs. These may include
- dietitian: counsels patient about foods high and low in sodium and ensures patient has adequate education to make informed decisions about diet at home
- laboratory technician and/or phlebotomist: collects blood and/or urine specimens, and obtains or conducts testing, and provides the results
- nurse: implements care at patient’s bedside
- ordering provider: oversees care plan and makes decisions about care goals
- pharmacist: oversees prescription medications and IV fluid orders to determine correct medication, dose, route, and so forth
- physical therapist: may show patient how to move to improve circulation and blood flow and urinary output
- social worker: connects patient with necessary resources outside of hospital
Calcium Overview
Calcium levels in the body normally range from 8.6 to 10.2 mg/dL, though this may vary depending on the institution’s specific protocol. Calcium circulates in the bloodstream, but the majority is stored in bones. Calcium is important for maintaining bone and teeth structure, as well as in nerve transmission and muscle contraction. Calcium excretion and reabsorption are regulated by the parathyroid hormone (PTH), which is secreted from the parathyroid glands near the thyroid. As PTH is secreted in response to low calcium levels in the blood, calcium is reabsorbed in both the kidneys and the intestine and released from the bones to increase serum calcium levels. Calcium is also affected by dietary intake and physical activity. Physical activity causes calcium to move into bones, whereas immobility causes the release of calcium from bones, making them weaker.
Calcium Imbalances
In calcium imbalances, there is either too much calcium present in the blood (hypercalcemia) or too little (hypocalcemia). Both types require early assessment and intervention to prevent associated adverse effects.
A decreased calcium level in the blood is known as hypocalcemia. This imbalance can be caused by hypoparathyroidism, in which not enough PTH is excreted; as a result, the reabsorption of calcium and its release from the bones both decrease. Hypocalcemia is also caused by vitamin D deficiency and renal disease. Because phosphorus is inversely related to calcium, an abnormally high phosphorus level, as seen with renal failure, can also result in hypocalcemia.
An increased calcium level in the blood is known as hypercalcemia. It can be caused by prolonged immobilization that allows calcium to seep out of the bones and into the serum. Additionally, many types of cancers may cause excessive calcium release from bones. And because both hyperparathyroidism and parathyroid tumors can increase PTH secretion, they can also cause hypercalcemia, because too much calcium is reabsorbed in the kidneys and intestines and released from bone.
Table 10.9 compares the clinical manifestations of and diagnostic tests and treatments for both types of calcium imbalance.
| Hypocalcemia | Hypercalcemia | |
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| Pathophysiology |
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| Clinical manifestations |
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| Diagnostic tests |
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| Treatments |
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Nursing Care of Patients with Hypocalcemia
Nursing care for patients with hypocalcemia should focus on monitoring the patient’s condition and preventing associated complications, especially the development of seizures.
Recognizing and Analyzing Cues
In the early stages of hypocalcemia, the patient may be asymptomatic, especially if the drop in calcium levels is gradual. More acute or severe cases of hypocalcemia result in a state of increased neuromuscular excitability; thus, some of the first signs the nurse might notice are hyperactive reflexes and involuntary muscle contractions, or tetany. These include Chvostek’s sign, an involuntary twitching of facial muscles when the facial nerve is tapped, and Trousseau’s sign, a hand spasm caused by inflating a blood pressure cuff to a level above systolic pressure for 3 minutes. Figure 10.11 illustrates both these signs. Other clinical manifestations associated with hypocalcemia that should be assessed are listed in Table 10.9.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The main nursing intervention for a patient with hypocalcemia is the implementation of seizure precautions. Seizures are one of the most common serious effects of a low calcium level, so prophylactic prevention of injury from seizures is important. This includes padding the side rails of the patient’s bed with seizure pads and ensuring that suction equipment is located within arm’s reach of the bedside, per hospital protocol. Additionally, the nurse should educate the patient about foods they can consume in their diet to increase calcium levels (e.g., dairy products, green leafy vegetables, whole grains).
Evaluation of Nursing Care for Patients with Hypocalcemia
After diagnosis of and initiation of treatment for hypocalcemia, it is important for the nurse to evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment for hypocalcemia, the nurse should monitor the patient for signs indicating that calcium imbalance has been corrected. Signs that would indicate an improvement in condition include
- normal reflexes
- no seizure activity noted
- normal serum calcium level (8.6–10.2 mg/dL)
Nursing Care of the Patient with Hypercalcemia
Nursing care for patients with hypercalcemia should focus on monitoring the patient’s condition and preventing associated complications.
Recognizing and Analyzing Cues
In the early stages of hypercalcemia, the patient may be asymptomatic, especially if the increase in calcium levels is gradual. More acute or severe cases of hypocalcemia result mostly in adverse GI signs and symptoms such as nausea and vomiting. Other clinical manifestations associated with hypercalcemia that should be assessed are listed in Table 10.9.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
One of the main nursing interventions for patients with hypercalcemia includes educating the patient about ways to decrease the intake of calcium in their diet and ensuring they consume enough phosphorus. Additionally, because prolonged immobilization is a major cause of hypercalcemia, it is important that the nurse encourages the patient to ambulate as frequently as possible to prevent the release of even more calcium from the bones.
Evaluation of Nursing Care for Patients with Hypercalcemia
After diagnosis of and initiation of treatment for hypercalcemia, it is important for the nurse to evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment for hypercalcemia, the nurse should monitor the patient for signs indicating the calcium imbalance has been corrected. Signs that would indicate an improvement in condition include
- improved muscle weakness
- lack of GI symptoms
- normal serum calcium level (8.6–10.2 mg/dL)
Magnesium Overview
Magnesium is essential for normal cardiac, nerve, muscle, and immune system functioning. Magnesium levels typically range from 1.5 to 2.4 mEq/L; about half of the body’s supply is stored in the bones. Dietary sources of magnesium include green leafy vegetables, citrus, peanut butter, almonds, legumes, and chocolate.
Magnesium Imbalances
In magnesium imbalances, there is either too much magnesium present in the blood (hypermagnesemia) or too little (hypomagnesemia). Both types require early assessment and intervention to prevent severe adverse effects, including cardiac dysrhythmias or arrest.
A decreased magnesium level in the blood is referred to as hypomagnesemia. It typically results from inadequate magnesium in the diet or from the use of loop diuretics that result in excretion of magnesium in urine. Additionally, patients with alcohol use disorder often have hypomagnesemia due to concurrent poor diet and impaired nutrient absorption that occurs with alcohol consumption. Chronic use of a proton pump inhibitor can also cause hypomagnesemia, due to impaired nutrient absorption.
An elevated magnesium level in the blood is known as hypermagnesemia. It is usually the result of renal failure, excess magnesium replacement, or the use of magnesium-containing laxatives or antacids. Table 10.10 compares the pathophysiology and clinical manifestations of, and diagnostic tests and treatments for both types of imbalances.
| Hypomagnesemia | Hypermagnesemia | |
|---|---|---|
| Pathophysiology | Increased excretion of magnesium (e.g., with use of diuretics; cases of chronic alcohol use, laxative abuse, cancer, acute pancreatitis, malnutrition) | Decreased renal excretion of magnesium (e.g., as in kidney failure), excessive intake or replacement of magnesium (e.g., overuse of laxatives or antacids containing magnesium) |
| Clinical manifestations |
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| Diagnostic tests |
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| Treatments |
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Nursing Care of Patients with Hypomagnesemia
Nursing care for patients with hypomagnesemia should focus on monitoring the patient’s condition and preventing associated complications, especially the development of deadly cardiac dysrhythmias.
Recognizing and Analyzing Cues
When there is a low level of magnesium in the blood, there are often also low levels of calcium and potassium. Because of this, the nurse should monitor for clinical manifestations of hypomagnesemia and those of hypocalcemia and hypokalemia. Alterations in magnesium can cause cardiac dysrhythmias; therefore, it is important that the nurse monitors for subtle changes in the ECG that may indicate a worsening condition.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The nurse should place patients with hypomagnesemia on continuous telemetry monitoring to catch any changes that may indicate the development of severe cardiac dysrhythmias. Other main nursing interventions for this imbalance include monitoring intake and output, administering oral or IV magnesium supplements, and regularly monitoring all electrolyte values, because they tend to influence one another.
Evaluation of Nursing Care for Patients with Hypomagnesemia
After diagnosis of and initiation of treatment for hypomagnesemia, it is important for the nurse to evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, the nurse should monitor the patient for signs indicating magnesium imbalance has been corrected. Signs that would indicate an improvement in condition include
- no reported adverse GI symptoms
- normal ECG
- normal reflexes
Nursing Care of Patients with Hypermagnesemia
Like nursing care for patients with hypomagnesemia, care of patients with hypermagnesemia should focus on monitoring the patient’s condition and preventing associated complications.
Recognizing and Analyzing Cues
Symptoms of hypermagnesemia can be nonspecific and vague, making it difficult to diagnose without checking serum electrolyte levels. Some of the first signs of this imbalance include muscle weakness and decreased reflexes. Other signs to monitor for are listed in Table 10.10.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The nurse should place patients with hypermagnesemia on continuous telemetry monitoring to catch any changes that may indicate the development of severe cardiac dysrhythmias, especially complete heart block. Other nursing interventions for this imbalance include monitoring intake and output, encouraging oral fluid intake, and educating the patient about stopping medications that contain high levels of magnesium.
Evaluation of Nursing Care for Patients with Hypermagnesemia
After diagnosis of and initiation of treatment for hypermagnesemia, it is important for the nurse to evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, the nurse should monitor the patient for signs indicating the magnesium imbalance has been corrected. Signs that would indicate an improvement in condition include
- improved muscle weakness
- normal ECG
- normal reflexes
Phosphorous Overview
Phosphorus is important in energy metabolism, RNA and DNA formation, nerve function, muscle contraction, and the building and repair of bone, teeth, and membranes. Phosphorus levels typically range from 2.5 to 4.0 mg/dL. The electrolyte is stored in the bones, excreted by the kidneys, absorbed by the intestines, and predominantly found in the intraocular fluid compartment.
Phosphorus Imbalances
In phosphorus imbalances, there is either too much phosphorus present in the blood (hyperphosphatemia) or too little (hypophosphatemia).
A decreased phosphorus level in the blood is referred to as hypophosphatemia. Acute hypophosphatemia can be caused by acute alcohol abuse, burns, diuretic use, respiratory alkalosis, and starvation. Chronic hypophosphatemia can be caused by hyperparathyroidism, vitamin D deficiency, prolonged use of phosphate binders, and hypomagnesemia or hypokalemia.
An increased phosphorus level in the blood is known as hyperphosphatemia. It can be caused by kidney disease, crush injuries, or overuse of phosphate-containing enemas. Table 10.11 compares the clinical manifestations of and diagnostic tests and treatments for both types of phosphorus imbalances.
| Hypophosphatemia | Hyperphosphatemia | |
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| Pathophysiology |
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| Clinical manifestations |
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| Diagnostic tests |
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| Treatments |
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Nursing Care of the Patient with Phosphorus Imbalances
Phosphorus imbalances are difficult to diagnose without obtaining a serum electrolyte level, because patients with phosphorus imbalance are often asymptomatic. For that reason, it is important for the nurse to be mindful of the patient’s baseline status and investigate any small deviations that may indicate an electrolyte imbalance.
Recognizing and Analyzing Clues
Because phosphorus has an inverse relationship with calcium, the nurse may also want to monitor for associated signs and symptoms that may indicate the presence of another imbalance. For example, a patient with hypophosphatemia may be asymptomatic for a decreased level of phosphorus but may have signs or symptoms of hypercalcemia.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The main nursing interventions when caring for patients with phosphorus imbalances include monitoring serum electrolyte levels regularly, recording accurate intake and output, and treating each disorder appropriately. These patients will need education about dietary choices to ensure they are getting enough (or decreasing the amount of) phosphorus in their diet.
Evaluation of Nursing Care for Patients with a Phosphorus Imbalance
After diagnosis of and initiation of treatment for a phosphorus imbalance, it is important for the nurse to evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, the nurse should monitor the patient for signs indicating the patient is improving. Signs that would indicate an improvement in condition include normalized serum phosphorus level (2.5–4.0 mg/dL) and normal vital signs.
Chloride Overview
Chloride is one of the main electrolytes in the extracellular fluid compartment; the normal range in blood samples is 97–107 mEq/L. Chloride is a major contributor to the osmotic pressure gradient between the intracellular and extracellular fluid compartments. Chloride is also important for maintaining proper hydration and acid-base balance in the body. Because chloride is an anion, meaning it is negatively charged, it is attracted to sodium, a positively charged cation. Consequently, these two electrolytes have a direct relationship: if sodium levels are low, chloride levels probably are as well. Chloride has an inverse relationship with bicarbonate, meaning that an increase in bicarbonate levels in the body results in a decrease in chloride levels.
Chloride Imbalances
With chloride imbalances, there is either too much chloride present in the blood (hyperchloremia) or too little (hypochloremia). Both types require early assessment and intervention to prevent severe adverse effects.
A decreased chloride level in the blood is known as hypochloremia. Common causes of hypochloremia include
- diuretic use
- fluid overload (e.g., from congestive heart failure)
- GI loss of chloride, such as with prolonged vomiting or diarrhea
- low dietary sodium intake
- metabolic alkalosis
An increased chloride level in the blood is known as hyperchloremia. Common causes of hyperchloremia include
- corticosteroid use
- fluid loss (e.g., vomiting, frequent urination)
- high intake of sodium in the diet or excessive administration of normal saline
- metabolic acidosis
Table 10.12 compares the pathophysiology and clinical manifestations of and diagnostic tests and treatments for both types of chloride imbalances.
| Hypochloremia | Hyperchloremia | |
|---|---|---|
| Pathophysiology | Increased excretion of chloride (e.g., with prolonged vomiting or diarrhea, use of diuretics), dilution (e.g., with fluid overload), or increased bicarbonate levels (e.g., in metabolic alkalosis) | Increased sodium levels or hemoconcentration (related to fluid loss such as with vomiting or excessive urination) |
| Clinical manifestations |
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| Diagnostic tests |
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| Treatments |
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Nursing Care of Patients with Chloride Imbalances
Nursing care for patients with chloride imbalances should focus on monitoring the patient’s condition and preventing associated complications, especially the development of severe acid-base imbalances.
Recognizing and Analyzing Cues
It is important for the nurse to understand the relationship between chloride and other electrolytes. Specifically, if a patient is experiencing a sodium imbalance, the nurse should investigate the patient’s chloride balance as well, because the two electrolytes have a direct relationship. Because of this relationship, clinical manifestations between hyponatremia and hypochloremia may be similar, because they often occur at the same time. This is also true of hypernatremia and hyperchloremia.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The main nursing interventions for patients with chloride imbalances include
- closely monitoring respiratory and neurological status for deviations from baseline that would indicate worsening of the imbalance
- monitoring and recording accurate intake and output
- monitoring and treating acid-base imbalances
- monitoring vital signs
Evaluation of Nursing Care for Patients with Chloride Imbalances
After diagnosis of and initiation of treatment for a chloride imbalance, it is important for the nurse to evaluate patient outcomes to determine whether treatment was effective and if further intervention is necessary. After treatment, signs that would indicate the patient’s condition is improving include
- improved mental status
- normal reflexes
- normal serum chloride level (97–107 mEq/L)