Nursing implementation

Nursing implementation 150 150 Tony Guo
  • Nursing implementation
    • Treat cause
    • Oral or IV calcium supplements
    • Rebreathe into paper bag
    • Treat pain and anxiety to prevent hyperventilation-induced respiratory alkalosis

 

Calcium Imbalances: Causes and Manifestations
Hypercalcemia (Ca2+ >10.2 mg/dL [2.55 mmol/L]) Hypocalcemia (Ca2+ <8.6 mg/dL [2.15 mmol/L])
Cause
  • Increased Total Calcium 
  • Decreased Total Calcium
  • Hyperparathyroidism
  • Primary hypoparathyroidism
  • Hematologic malignancy
  • Renal insufficiency
  • Malignancies with bone metastasis
  • Acute pancreatitis
  • Prolonged immobilization
  • Elevated phosphorus
  • Vitamin A or D overdose
  • Vitamin D deficiency, malnutrition
  • Paget’s disease
  • Magnesium deficiency
  • Adrenal insufficiency
  • Bisphosphonates
  • Thyrotoxicosis
  • Tumor lysis syndrome
  • Thiazide diuretics
  • Loop diuretics
  • Milk-alkali syndrome
  • Chronic alcoholism
  • Calcium-containing antacids
  • Diarrhea
  • Mycobacterium infection
  • Decreased Serum albumin
Increased Ionized Calcium Decreased Ionized Calcium
  • Acidosis
  • Alkalosis
  • Excess administration of citrated blood 
ECG changes
  • Shortened ST segment
  • Elongation of ST segment
  • Shortened QT interval
  • Prolonged QT interval
  • Ventricular dysrhythmias
  • Ventricular tachycardia
  • Increased digitalis effect

 

Phosphate

  • Primary anion in ICF
    • Essential to function of muscle, red blood cells, and nervous system
    • Involved in acid-base buffering system, ATP production, cellular uptake of glucose, and metabolism of carbohydrates, proteins, and fats
    • Serum levels controlled by parathyroid hormone
    • Maintenance requires adequate renal functioning
    • Reciprocal relationship with calcium
  • Hyperphosphatemia
    • High serum PO43- caused by 
      • Acute kidney injury or chronic kidney disease
      • Chemotherapy
      • Excess intake of phosphate or vitamin D
      • Hypoparathyroidism
    • Manifestations 
      • Neuromuscular irritability and tetany (hypocalcemia)
      • Calcified deposits in soft tissue like, arteries, skin, kidneys, and corneas (can cause organ dysfunction)
      • Numbness and tingling in extremities and region around mouth
      • Hyperreflexia, muscle cramps
      • Tetany, seizures
    • Management
      • Identify and treat underlying cause
      • Restrict foods and fluids containing phosphorus
      • Oral phosphate-binding agents
      • Volume expansion and forced diuresis
      • Correct any hypocalcemia
      • Hemodialysis
  • Hypophosphatemia
    • Low serum PO43- caused by
      • Malnourishment/malabsorption/diarrhea
      • Use of phosphate-binding antacids
      • Inadequate replacement during parenteral nutrition
    • Manifestations
      • CNS depression
      • Muscle weakness and pain
      • Respiratory and heart failure
      • Rickets and osteomalacia
      • Cardiac problems (dysrhythmias, heart failure)
      • Osteomalacia, rickets
      • Rhabdomyolysis
    • Management
      • Oral supplementation
      • Ingestion of foods high in phosphorus
      • IV administration of sodium or potassium phosphate
Phosphate Imbalances: Causes and Manifestations
Hyperphosphatemia (PO43− >4.4 mg/dL [1.42 mmol/L]) Hypophosphatemia (PO43− <2.4 mg/dL [0.78 mmol/L])
Cause
  • Renal failure
  • Malabsorption syndromes
  • Phosphate enemas (e.g., Fleet Enema)
  • Chronic diarrhea
  • Excessive ingestion (e.g., phosphate-containing laxatives)
  • Malnutrition, vitamin D deficiency
  • Rhabdomyolysis
  • Parenteral nutrition
  • Tumor lysis syndrome
  • Chronic alcoholism
  • Thyrotoxicosis
  • Phosphate-binding antacids
  • Hypoparathyroidism
  • Diabetic ketoacidosis
  • Sickle cell anemia, hemolytic anemia
  • Hyperparathyroidism
  • Hyperthermia
  • Refeeding syndrome
  • Respiratory alkalosis

 

Magnesium

  • Roles of Magnesium
    • Coenzyme in metabolism of carbohydrates 
    • Required for DNA and protein synthesis
    • Blood glucose control
    • BP regulation
    • Necessary for ATP production
    • Acts directly on myoneural junction 
    • Important for normal cardiac function
    • 50% to 60% contained in bone
    • Absorbed in GI tract
    • Excreted by kidneys
  • Hypermagnesemia
    • High serum Mg caused by
      • Increased intake or ingestion of products containing magnesium when renal insufficiency or failure is present 
      • Excess IV magnesium administration
    • Manifestations
      • Lethargy 
      • Nausea and vomiting
      • Impaired reflexes
      • Muscle paralysis 
      • Respiratory and cardiac arrest
      • Urinary retention
      • Flushed, warm skin, especially facial
      • Decreased Pulse, Decreased BP
    • Management
      • Prevention first—restrict magnesium intake in high-risk patients
      • IV CaCl or calcium gluconate if symptomatic
      • Fluids and IV furosemide to promote urinary excretion
      • Dialysis
  • Hypomagnesemia
    • Low serum Mg caused by
      • Prolonged fasting or starvation
      • Chronic alcoholism
      • Fluid loss from gastrointestinal tract
      • Prolonged parenteral nutrition without supplementation
      • Diuretics
      • Hyperglycemic osmotic diuresis
    • Manifestations
      • Hyperactive deep tendon reflexes
      • Muscle cramps
      • Tremors
      • Seizures and confusion
      • Cardiac dysrhythmias 
      • Corresponding hypocalcemia and hypokalemia
      • Chvostek’s and Trousseau’s signs
      • Increased Pulse, Increased BP, dysrhythmias
    • Management
      • Treat underlying cause
      • Oral supplements
      • Increase dietary intake
      • Parenteral IV or IM magnesium when severe
Magnesium Imbalances: Causes and Manifestations
Hypermagnesemia (Mg+ >2.5 mEq/L [1.25 mmol/L]) Hypomagnesemia (Mg+ <1.5 mEq/L [0.75 mmol/L])
Cause
  • Renal failure
  • GI tract fluid losses (e.g., diarrhea, NG suction)
  • IV administration of magnesium, especially for treatment of eclampsia
  • Chronic alcoholism
  • Tumor lysis syndrome
  • Malabsorption syndromes
  • Hypothyroidism
  • Prolonged malnutrition
  • Metastatic bone disease
  • Increased Urine output
  • Adrenal insufficiency
  • Hyperglycemia
  • Antacids, laxatives
  • Proton pump inhibitor therapy

 

Oral Fluid Replacement

  • Used to correct mild fluid and electrolyte deficits
    • Water
    • Glucose
    • Potassium
    • Sodium

IV Fluids

  • Purposes
    • Maintenance
      • When oral intake is not adequate
    • Replacement
      • When losses have occurred 
  • Types of fluids categorized by tonicity
    • Hypotonic
      • More water than electrolytes
      • Pure water lyses RBCs
      • Water moves from ECF to ICF by osmosis
      • Usually maintenance fluids
      • Monitor for changes in mentation
    • Isotonic
      • Expands only ECF
      • No net loss or gain from ICF
      • Ideal to replace ECF volume deficit
  • D5W
  • 5% Dextrose (sugar) in Water
  • Free water without electrolytes
  • Provides 170 cal/L
  • Used to replace water losses, treat hypernatremia, prevent ketosis
  • Normal Saline (NS or NSS)
  • More NaCl than ECF
  • No free water, calories or electrolytes
  • Expands IV volume
  • Preferred fluid for immediate response
  • Compatible with most medications
  • Only solution used with blood
  • Lactated Ringer’s Solution
  • Similar in composition to plasma  except contains no magnesium
  • Expands ECF—treat burns and GI losses
  • Contraindicated with hyperkalemia and lactic acidosis
  • No free water or calories
  • Hypertonic
    • Initially expands and raises the osmolality of ECF
    • Require frequent monitoring of 
      • Blood pressure
      • Lung sounds
      • Serum sodium levels

 

  • D5 12NS
    • 5% Dextrose and 0.45% Sodium Chloride Injection
    • Common maintenance fluid
    • Replaces fluid loss
    • KCl added for maintenance or replacement
  • D10W
    • Dextrose 10 % in Water
    • Provides 340 kcal/L
    • Provides free water but no electrolytes
    • Limit of dextrose concentration may be infused peripherally
  • Colloids
    • Stay in vascular space and increase osmotic pressure 
    • Include:
      • Human plasma products (albumin, fresh frozen plasma, blood) 
      • Semisynthetics (dextran and starches, [Hespan])

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