Nursing

System Condition: Hypo / hyper kalemia

Basic Concept

Hypokalemia

· Decrease in potassium levels in the blood.

· Ka serum level: < 3.5 mEq/L(3.5 mmol/L)

· Ka moderate serum level: 2.5-3.0 mEq/L

· Severe: serum level <2.5 mEq/L.

Hyperkalemia

· increase in potassium levels in the blood.

· Ka serum level > 5.0-5.5 mEq/L in adults.

· Serum level: > 7 mEq/L can lead to severe complications such as hemodynamic and neurologic consequences.

Pathophysiology

Hypokalemia

· Potassium is obtained through diet.

· Excretion increased by aldosterone, diuretics, and negatively charged ions deposited into the collecting duct.

· Excretion minimized by low serum and urination flow.

Hyperkalemia

· Triggered by minimal glomerular activity.

Risk Factors

Hypokalemia

· Eating disorders

· AIDS

· Alcoholism

· Bariatric surgery

Hyperkalemia

· ARBs or potassium-sparing diuretics.

· Virilization

· Adrenal gland suppression

· Kidney problems

Etiology

Hypokalemia

· Abnormal losses: medications, gastrointestinal losses, renal losses, hypomagnesemia, dialysis

· Transcellular shift: medications, thyrotoxicosis.

· Pseudo hypokalemia: extreme leukocytosis, delayed sample analysis

· Starvation, dementia.

Hyperkalemia

· Pseudo hyperkalemia

· Decreased renal excretion

· Deficiency in insulin, mineral acidosis, cell injury

Pathophysiology with different types

Hypokalemia

· Low levels of potassium will cause rise in sodium levels therefore causing hypernatremia.

Hyperkalemia

· high levels of potassium will cause drops in levels of sodium hence causing hyponatremia.

Clinical Presentation

Hypokalemia

· Asymptomatic when mild (3-3.5 mmol/L)

· Nonspecific symptoms (general weakness, lassitude, constipation) with more severe hypokalemia

· Serum level of < 2.5 mmol/L leading to muscle necrosis

· Serum level of < 2.0 mmol/L leading to ascending paralysis and impairment of respiratory functions.

Hyperkalemia

· Weakness which at times progresses to flaccid paralysis and hypoventilation.

· Metabolic acidosis.

· Altered heart electrical activity.

Diagnostic Test/Procedures

Hypokalemia

· Repeated serum potassium measurements.

· Measurements for magnesium and glucose.

· Measurements for creatine and urine.

· Acid-base balance.

· If initial work-ups fail, perform thyroid and adrenal work-up.

Hyperkalemia

· Clinical history

· Physical examination

· Medications review

· Assessment of cardiac functions

· Assessment of hydration status

· Electrocardiogram

· Comprehensive laboratory workup

Treatment

Hypokalemia

· Potassium tablets or infusion.

· Increase intake of materials containing potassium.

Hyperkalemia

· Calcium chloride.

· Insulin

· Furosemide

· Sodium polystyrene

· Patiromer

Complications

Hypokalemia

· Increases mortality in CKD or CHF

· Symptoms dependent on severity

· Severe hypokalemia may result in heart block.

Hyperkalemia

· Frequently asymptomatic

· Can present irregular heart rhythms

System Condition: Hypo / hyper natremia

Basic Concept

Hyponatremia

· Na+ serum level < 135 mEq/L

· Common imbalance that is mostly seen in isolation

· Mild; serum level 130-134 mmol/L

· Moderate: serum level 125-129 mmol/L

Hypernatremia

· Rise in sodium concentration.

· Level of concentrations exceeds 145 mmol/L

· A water and not sodium problem

Pathophysiology

Hyponatremia

· Water intake depends on thirst mechanism.

· Thirst is stimulated by osmolality increase.

· Hyponatremia occurs only when some conditions impair normal free water excretion.

Hypernatremia

· Cells become dehydrated after hypernatremia of any etiology occurs.

· Increased sodium reacts and extracts the water.

Risk Factors

Hyponatremia

· Older age >65

· Use of pain medications

· SSRIs for antidepressant therapy

· Diuretics

· Diets poor in sodium

· Hypothyroidism

Hypernatremia

· Older age >65

· Mental and physical disability

· Hospitalization

· Residence in nursing home

· Inadequate nursing care

· Diabetes insipidus

· Diabetes mellitus

· Diuretic therapy

Etiology

Hyponatremia

· Kidney failure

· Congestive heart failure

· Diuretics

· Pain medication

· Severe vomiting or diarrhea

· Excessive thirst

Hypernatremia

· Diabetes insipidus- Central, Nephrogenic

· Diarrhea, emesis

· Burns, excessive sweating

· Premature infants, radiant warmers, phototherapy

Pathophysiology with different types

Hyponatremia

· Low levels of sodium will cause an increase in potassium levels, thus causing hyperkalemia

Hypernatremia

· Subsequently, high levels of sodium will cause a drop in potassium levels causing hypokalemia.

Clinical Presentation

Hyponatremia

· Headaches, seizures, confusion, coma

· Weakness in muscles

· Vomiting, diarrhea, pain in abdomen

Hypernatremia

· 50 % mortality rate due to encephalopathy

· Coma, weakness, neurologic deficits

Diagnostic Test/Procedures

Hyponatremia

· Physical examination

· History examination

· Radiologic imaging

Hypernatremia

· Thorough physical exam inclusive of volume status, mental status and neurologic assessment.

Treatment

Hyponatremia

· Fluid restriction (0.5- 1 liter/day). Encourage water intake

· Demeclocycline (600- 1200 mg/d). inhibits action of adh

· Urea (30mg/d). osmotic diuresis

· Lithium (up to 900mg/d). inhibits action of adh

Hypernatremia

· Reduce intakes rich in sodium.

· Sodium chloride

· Intravenous dextrose

Complications

Hyponatremia

· Fatigue

· Convulsions

· Feeling weak

· Coma

· Low blood pressure

· Confusion

· Short temper

Hypernatremia

· Intense thirst

· Fever

· Nausea or vomiting

· Intense thirst

· Seizures

· Labored respiration

· Focal neurologic deficits

System Condition: Hypo / hyper calcemia

Basic Concept

Hypocalcemia

· Ca serum level: <8.8 mg/dL

· Hereditary.

Hypercalcemia

· 90% of hypercalcemia cases caused by hyperparathyroidism.

· Mild: Ca 10.5-11.9 mg/dL (2.5-3 mmol/L

· Severe: Ca 14-16 mg/dL (3.5-4 mmol/L)

Pathophysiology

Hypocalcemia

· Cased by numerous conditions: hypoparathyroidism, hungry bone syndrome, medications, infusion of phosphate, and kidney and liver diseases.

Hypercalcemia

· Calcium is crucial in intracellular and extracellular metabolism controlling many processes.

· Ca metabolism regulated by hormones affecting entry into the intercellular space and controls its excretion from the kidneys.

Risk Factors

Hypocalcemia

· Medications

· Rapid citrated blood transfusion

· Infusion of phosphate

· Hungry bone syndrome

· Altered vitamin D metabolism

· hypoparathyroidism

Hypercalcemia

· Vitamin D intoxication

· Vitamin A intoxication

· AIDS

· Drugs

· Lithium

· Thiazide diuretics

· Mild alkali syndrome

· Chronic renal insufficiency

Etiology

Hypocalcemia

· Hypoalbuminemia

· Hypomagnesemia

· Hyperphosphatemia

· Surgical effects

· PTH deficiency or resistance

· Vitamin D deficiency or resistance

· Medication effects

Hypercalcemia

· Hyperthyroidism

· Primary adenoma, hyperplasia, carcinoma

· lithium therapy

· tertiary hyperparathyroidism

· familial hypocalciuric hypercalcemia

Pathophysiology with different types

Hypocalcemia

· low levels of calcium may be caused by low or deficiency of magnesium.

· A drop in calcium levels causes an increase in phosphate levels causing hyperphosphatemia

Hypercalcemia

· Too much calcium in the body will cause a decrease in potassium levels in the blood. Patients with severe hypercalcemia will always be hypokalemic.

· An increase in calcium level in the blood will cause a drop in phosphate levels thus causing hypophosphatemia when hypercalcemia is not severe.

Clinical Presentation

Hypocalcemia

· Paranesthesia around mouth, fingers and toes.

· Muscle cramps

· Tetany

· Seizures

· Latent hypocalcemia

Hypercalcemia

· Diabetes insipidus

· Acute kidney injury

· Hypertension

· Nausea

· Vomiting

· Constipation

· Fatigue

· Coma

Diagnostic Test/Procedures

Hypocalcemia

· Physical examination

· History examination

· Measurement of serum intact parathyroid hormone.

Hypercalcemia

· Blood test for high calcium levels in blood.

· Mammogram

· Chest x-ray

· MRI

· CT scan

Treatment

Hypocalcemia

· Magnesium supplements

· Intravenous IV calcium gluconate for acute hypocalcemia

· Calcium and vitamin D supplements (oral) for chronic hypocalcemia

Hypercalcemia

· IV hydration with isotonic saline

· Salmon calcitonin

· Bisphosphonate

Complications

Hypocalcemia

· Respiratory arrest

· Cardiac arrest

· Tetany

· Seizures

· Laryngospasm

Hypercalcemia

· Kidney stones

· Kidney failure

· Fractures

· Hypertension

· Pancreatitis

· Osteoporosis

System: Condition: Hypo / hyper phosphatemia

Basic Concept

Hypophosphatemia

· Phosphate serum level:< 2.5 mg/dL (0.8 mmol/L) in adults.

· Normal ranges of Phos in neonates are 4.8 – 8.2 mg/dL, 3.8 – 6.5 mg/dL in 1week to 3 years old children, 3.7 – 5.5 mg/dL in 3 to 12 year olds, and 2.9 to 5 mg/dL for adolescents to age 19 years.

· A serum Phos < 2.5 mg/dL considered hypophosphatemia where < 1.5 is severe.

Hyperphosphatemia

· Abnormally high serum phosphate levels.

· A serum Phos from > 4.5 mg/dL considered hyperphosphatemia.

Pathophysiology

Hypophosphatemia

· Mainly caused by low intake of phosphate into the body, high excretion of phosphate.

Hyperphosphatemia

· Most common cause are decreased kidney function, and massive extracellular fluid phosphate loads.

Risk Factors

Hypophosphatemia

· Severe malnutrition

· Alcoholism

· Severe burns

· Fanconi syndrome

· Chronic diarrhea

· Vitamin D deficiency (in children)

· Inherited conditions such as X-linked familial hypophosphatemia (XLH)

Hyperphosphatemia

· Excessive body fat

· Diabetes mellitus

· Hypercalcemia

· Kidney infections

· High cholesterol levels

Etiology

Hypophosphatemia

· Malnutrition

· Hyperparathyroidism

· Starvation

Hyperphosphatemia

· Renal failure

Pathophysiology with different types

Hypophosphatemia

· A drop in phosphate levels will cause a rise in calcium levels in the blood causing hypercalcemia.

Hyperphosphatemia

· A rise in phosphate levels in the blood will always cause a drop in calcium levels leading to hypocalcemia.

Clinical Presentation

Hypophosphatemia

· Weakness in muscles.

· Seizures

· Blood issues

· Getting numb

· Alteration of mental state

· Weakening of bones

Hyperphosphatemia

· Rashes

· Soft bones thus weak

· Pain in joints

· Spasms

· Numbness in the mouth

Diagnostic Test/Procedures

Hypophosphatemia

· Measurement of blood phosphate.

· Additional tests may also be done to determine underlying cause of disorder

Hyperphosphatemia

· Measurement of blood phosphate

· Other tests to check to reason behind rise of phosphate.

Treatment

Hypophosphatemia

· Phosphate supplements, orally.

· Active vitamin D

· Treatment for related disorders: cinacalcet, calcitonin, or dipyridamole, but in future.

Hyperphosphatemia

· Reduction of phosphate in diet.

· Removal of extra phosphate with dialysis.

· Lower amount of phosphate intestines absorbs using medication

Complications

Hypophosphatemia

· Acute hypocalcemia

· Tetany

· Renal failure

Hyperphosphatemia

· Cardiac arrest

· Valve calcification (heart)

· Elevated PO4 due to lack of adequate binders.

· Elevation of PO4 can still be caused by diets high in phosphorus.

System: Condition: Hypo / hyper magnesemia

Basic Concept

Hypomagnesemia

· An electrolyte disturbance caused by low levels of serum magnesium.

· While in low levels:< 1.46 mg/dL in the blood

Hypermagnesemia

· Serum concentration: Mg >2.6 mg/dL (> 1.05 mmol/L)

Pathophysiology

Hypomagnesemia

· Magnesium is essential for biochemical reactions.

· Affects sodium, calcium and potassium, mostly while is in low levels.

· Magnesium homeostasis involves the kidney.

· Hypomagnesemia occurs when something changes or interferes with magnesium homeostasis.

· Deficiency in magnesium can cause other conditions such as hypocalcemia.

Hypermagnesemia

· Occurs mostly due to chronic kidney disease

Risk Factors

Hypomagnesemia

· Diabetes mellitus

· Poor nutrition

· Heart failure

· Potassium deficiency

· Calcium deficiency

Hypermagnesemia

· Decreased renal function

· Lithium therapy

· Low thyroid activity

· Diseases such as Addison’s

· Syndromes such as milk-alkali

· Drugs containing magnesium

· Familial hypocalciuric hypercalcemia

Etiology

Hypomagnesemia

· Mainly caused by starvation, alcoholism, and critical illness.

· Can be secondary to medications such as proton pump inhibitors, digitalis, chemotherapeutic drugs, amphotericin, aminoglycoside antibiotics, loop and thiazide diuretics.

Hypermagnesemia

· Renal failure.

· Low renal excretion caused by depletion of salt.

· Drug abuse (antacids and laxatives)

· Rhabdomyolysis

· Endocrinopathies

Pathophysiology with different types

Hypomagnesemia

· When magnesium levels in the blood are low (hypomagnesemia) the patient will suffer from hypocalcemia and hypokalemia.

Hypermagnesemia

· Having too much magnesium in the blood is uncommon.

Clinical Presentation

Hypomagnesemia

· Hypocalcemia, prolonged QT and QU interval, tremors, weakness in muscles.

Hypermagnesemia

· Confusion, weakness in muscles, paralysis in the bladder, lethargy

Diagnostic/Test Procedures

Hypomagnesemia

· Physical exam

· Symptoms

· Medical history

· Blood test

Hypermagnesemia

· Blood test

Treatment

Hypomagnesemia

· Supplements for magnesium (oral)

· Increased intake of foods containing magnesium

· Magnesium intravenously for severe cases

Hypermagnesemia

· First identify and stop the production of extra magnesium.

· To reduce symptoms, administer intravenous (IV) calcium.

· Diuretics

· Water pills

· Dialysis for patients with kidney failure or if other medications are failing.

Complications

Hypomagnesemia

· Seizures

· Sudden death

· Cardiac arrhythmias

· Coronary artery vasospasm

Hypermagnesemia

· Hypotension

· Cardiac arrhythmia

· Confusion

· Lethargy

· Coma

· Cardiac arrest