FLUID & ELECTROLYTE

BALANCE/IMBALANCES & THERAPY

NCM 112 DCLC FACULTY

BODY Weight 100%

 Water 60% (100)
o Intracellular space 40% (60)
o Extracellular space 20% (40)
 Interstitial space 15% (75)
 Intravascular space 5% (25)
 Tissue 40 %

Terms
Solvent
Fluid. Solvent dissolves solutes.
Water is the universal solvent.

Solute
Solutes are particles dissolved in solvent.
Electrolytes & Non-electrolytes.

BODY Fluid Compartments

1. Intracellular Compartment – All fluids inside the cell.
2. Extracellular Compartment – All fluids outside the cell.
a. Intravascular Compartment All fluids inside a blood vessel
b. Interstitial Compartment All fluids in between tissues.
3. Third Spacing – Trapped extracellular fluid.
4. Edema
a. Localized Edema: Fluid accumulated in the interstitial space. Result of traumatic injury from burns,
inflammation, surgery.
b. Generalized Edema: Anasarca. An accumulation of fluid in interstitial space throughout the body.

NORMAL BODY WATER

DISTRIBUTION
1. Intracellular water (ICF): 40% body wt
2. Extracellular water (ECF): 20% body wt (plasma water + interstitial water)
 Interstitial water: 15 % of body weight (Blood) Plasma water: 5 % of body weight
Note:
Blood volume (BV): 9 % of body weight
BV = plasma water + RBC & WBC

FUNCTIONS of FLUIDS in the body

1. Transports nutrients to cells & collects wastes from cells (cell metabolism & cells’ chemical functioning)
2. Transports hormones, enzymes, blood platelets, RBC & WBC
3. Acts as a SOLVENT for electrolytes and non-electrolytes
4. Helps maintain normal body temperature (thru perspiration)
5. Facilitates digestion & promotes elimination
6. Acts as a tissue lubricant

FLUIDS in the body

Loss 2500ml Intake2500ml
Kidneys: 1500ml OFI: 1,500ml
Skin: Food: 750ml
Diffusion: 400ml Metabolism: 250ml
Perspiration: 100ml
Lungs: 350ml
Feces: 150ml

Purposes Of FLUID THERAPY

1. Replace insensible fluid losses (evaporation, diffusion).
2. Replace sensible fluid losses (blood loss, sweating).
3. Maintain an adequate and effective blood volume. Maintain cardiac output and tissue perfusion.
4. Maintain IV route of drug administration.

Solutes:

IONS
When some compounds are placed in water, they breakdown (or decompose) into ions or ionize. The result is an ion:
an atom bearing an electrical charge.
 Cations: ions with a positive charge. (+)
 Anions: ions with a negative charge. (-)

 Electrolytes:
o Produce electrical charges (+ or -) Na+, K+, Mg+
o Cl-, HCO3-, PO4-
 Non-Electrolytes:
o Do not produce electrical charges.
 Ions the ECF are:
Na+ Sodium
Cl – Chloride
HCO3- Bicarbonate
Other ions
 The major ions in the ICF are:
K+ Potassium
PO4- Phosphate
Mg+ Magnesium Other ions

FUNCTIONS of ELECTROLYTES in the body

 Sodium — controls and regulates volume of body fluids
 Potassium — chief regulator of cellular enzyme activity and water content
 Calcium — nerve impulse, blood clotting, muscle contraction, B12 absorption
 Magnesium — metabolism of carbohydrates and proteins, vital actions involving enzymes
 Chloride — maintains osmotic pressure in blood, produces hydrochloric acid
 Bicarbonate — body’s primary buffer system
 Phosphate — involved in important chemical reactions in body, cell division and hereditary traits

FLUID & ELECTROLYTE Interrelationship

 Balance implies “homeostasis.”
 Balance in fluid and electrolytes are interdependent. The electrical charge of electrolytes are of critical
importance in fluid balance.

PRIMARY ORGANS OF HOMEOSTASIS

 Kidneys normally filters 170L plasma, excretes 1.5 L urine.
 Cardiovascular system pumps and carries nutrients and water in body.
 Lungs regulate oxygen and carbon dioxide levels of blood.
 Adrenal glands help body conserve sodium, save chloride & water, and excrete potassium.
 Thyroid gland increases blood flow in body and increases renal circulation.
 Parathyroid glands regulate the level of calcium in ECF.
 GI tract absorbs water and nutrients that enter body though this route.
 Nervous system is a switchboard to inhibit and stimulate fluid balance (thirst center and ADH storage).

Movement of F&E between ECF & ICF

1. Diffusion (solutes=higher to lower)
2. Osmosis (water=higher to lower)
3. Filtration (F&E)
Membranes:
 1. Permeable: allows all substances, solutes & solvent, to cross.
2. Semipermeable: allows only some substances to cross.

Diffusion
- Spreading of solute particles from an area of greater concentration to lesser concentration.
- Example: O2 diffuses from lungs to bloodstream. CO2 diffuses from bloodstream to lungs.
o Passive: no energy needed.
o Active: Assisted or energy needed.

Osmosis
- Movement (diffusion) of water through a semi-permeable membrane from a region of higher water
concentration to an area of lower water concentration.
- Only water moves. Solutes do not.
- Higher concentrations of sodium (Na) solutes increases osmolality that attracts water into its area across the
semi-permeable membrane.

Filtration
- Fluids & solutes move through cell membranes by hydrostatic pressure from area of higher pressure to lower
pressure.
- Hydrostatic pressure is the force F&E exert against a permeable membrane. The molecules passing through
the membrane are determined by the pore size of the membrane. Tissue fluids are formed by filtration.
- Fluids & solutes move in & out of compartment.
o Pressure in the arteriole is greater than interstitial (between cells) pressure, causing fluids with
dissolved substances to move out of capillaries.
o Pressure in venuoles is less than interstitial fluid pressure, causing fluids and waste products to
move back into capillaries.

IV SOLUTIONS
1. ISOTONIC
 Isotonic to human cells, little osmosis occurs (same osmolality as body fluids).
o 0.9%Na Cl (Sodium Chloride)
o Normal Saline Solution (NSS)
o 5% Dextrose in Water
o 5% Dextrose in 0.225 Saline
o Lactated Ringer Solution
2. HYPOTONIC
 Solution contains lower concentration of salt (solute) or more water than isotonic. Lower osmolality or lower
pull (low solute concentration) than body fluids.
 Water shifts from extracellular to intracellular compartment. Body cells enlarge or may drown from too much
water.
o 0.225 NaCl
o 0.33% NaCl
o 0.45 NaCl
3. HYPERTONIC
 Solution has a higher concentration of solutes. Higher osmolality (pull) than body fluids.
 Results in fluid shift from intracellular to extracellular. Body cells shrivel & shrink.
o 3% NaCl
o 5%NaCl
o 10% Dextrose in water
o 5% Dextrose in 0.9% NaCl
o 5% Dextrose in 0.45% NaCl
o 5% Dextrose in Ringer’s Lactate solution

Regulation of F&E
 To maintain health, there should be a balance of fluids & electrolytes lost & replaced daily. The loss of around
2.5L fluids through: Skin, Lungs, GI (feces), Kidneys (urine).
 Sodium is the main electrolyte that promotes the retention of water (into circulation) or excretion (out of
circulation). Water follows sodium.
 The ff causes the kidneys to conserve water (homeostatic compensatory mechanisms):
 o ADH Antidiuretic Hormones: produced by Hypothalamus, kept & released by the Posterior
Pituitary Gland. Promotes water retention.
o Aldosterone: Produced in Adrenal cortex which causes reabsorption of Sodium (in renal tubules)
& water retention in the ECF (increases volume).
o Renin: Released by the juxtoglomerular cells of the kidneys. Renin promotes vasoconstriction &
the release of aldosterone.

ADH (Anti-Diuretic Hormone) is released

If there is…
1. Decreased amount of water in the body, or
2. Increased amount of Na+ in the body, or
3. Increased blood osmolality (blood too concentrated) or
4. Decreased circulating blood volume
5. All of these lead to: Stimulation of Hypothalamic osmoreceptors  Release ADH  Stimulation of thirst
response  increased drinking
ADH works at the kidneys…
1. it increases permeability of kidney tubules to water
2. increases reabsorption of water from kidney tubules back into blood vessels (PC).
Note: Without ADH, water would have been released out as urine. With ADH water is conserved, not excreted.

WATER entry & exit in 24 hrs

SOURCE TOTAL INTAKE SOURCE OUTPUT
Water in foods 700 ml Lungs 350 ml
Ingested liquids 1500 ml Skin
ormed by Catabolism 200 ml By diffusion 350 ml
TOTAL 2400 ml By sweat 100 ml
Kidneys (urine) 1400ml
Intestine (feces) 200 ml
TOTAL 2400 ml

FLUID ABNORMALITIES
DEFICIT
1) WATER: DEHYDRATION
2) BLOOD: HEMORRHAGE/HYPOVOLEMIA

EXCESS
1) WATER: EDEMA
2) BLOOD: HYPERVOLEMIA/POLYCYTHEMIA

DEHYDRATION
Hypovolemia – Deficiency of water & electrolytes in ECF, with near normal water to electrolyte proportions
Dehydration – Decreased volume of water and electrolyte
Third-space fluid shift –Distributional shift of body fluids into body spaces

DEHYDRATION SCALE
0 NORMAL
2 Thirst, stronger thirst, Loss of appetite, Increasing hemoconcentration
4 Economy of movement, sluggish pace, flushed skin, sleepiness, apathy, emotional instability, nausea
6 Tingling of arms, hands, feet, headache, heat exhaustion, increases in temperature, PR, RR
8 Labored breathing, dizziness, cyanosis, indistinct speech, increased weakness and mental confusion
10 Spasticity, inability to close eyes, delirium, swollen tongue, circulatory insufficiency, failing kidney function,
increasing hemoconcentration, decreased blood volume
15 Shriveled cracked skin, inability to swallow, dim vision, sunken eyes, painful urination, deafness, stiffened
eyelids, oliguria
20 Bare survival limit
DEATH
DEHYDRATION
Mild: Elevated BUN, high or low sodium in a patient taking diuretics. Increased thirst in a patient with
diarrhea for 2 days but still drinking adequate amounts of fluid
Moderate: Mildly increased lethargy or confusion, decreased BP in a patient with a sodium level of 155 mEq/L
whose consumption of food and fluids is reduced as a result of a flu.
 BUN elevation to >100 mg/dl
Severe: Rapid recent in a patient whose BUN was normal a month ago. Rapidly increasing lethargy & confusion
in a patient. With a recent illness whose Na is now 123 mEq/L or who is hypotensive.

HEMORRHAGE
 What happens if one loses 500 ml of blood?
o The capillary hydrostatic pressure (Pc) drops especially at the venous end.
o The net pressure into capillary increases and the balance is no longer maintained so fluid is
retrieved into the circulation from the interstitial space until Pc is restored.

FLUID EXCESS
1) Hypervolemia – Excessive retention of water & sodium in ECF
2) Overhydration – Above normal amounts of water in ECF spaces
3) Edema – Excessive ECF accumulates in tissue spaces
4) Interstitial-to-plasma shift – Movement of fluid from space surrounding cells to blood

EDEMA
 Presence of abnormally large amounts of fluid in the intercellular tissue / interstitial spaces of the body.
 May be due to:
o Retention of electrolytes in the extracellular fluid
o Increase in capillary blood pressure (Pc)
o Decrease in the concentration of plasma proteins normally retained in the blood

Review of the Normal Electrolyte Distribution

SOLUTES
ELECTROLYTES
􏰀 Cations – positive
􏰀 Sodium (Na+)
􏰀 Potassium (K+)
􏰀 Calcium (Ca)
DIOXIDE

􏰀 Anions – negative
􏰀 Chloride (Cl-)
􏰀 Bicarbonate (HCO -) 3
􏰀 Phosphate (HPO -) 4

NON-ELECTROLYTE
UREA
GLUCOSE
OXYGEN
CARBON

SODIUM = Na+
1) The major component of ECF
2) Generally, water and sodium disturbances occur simultaneously. Sodium levels indicate overall fluid balance.
3) Sodium levels are regulated by the kidney, through aldosterone & other related factors.
4) Na is found mostly in body fluids outside the cells (ECF). It is important for maintaining BP. Na is also needed for
nerves, muscles, and other body tissues to work properly.
5) When the amount of Na in fluids outside cells drops (ECF), water moves into cells (ICF) to balance the levels.
This causes the cells to swell with too much water. Brain cells are especially sensitive to swelling, causing many
symptoms of hyponatremia.

SODIUM IMBALANCE
Normal
Serum Na level= 135-145 mmol/L
HYPONATREMIA
Serum Na level <135 mmol/L
HYPERNATREMIA
Serum Na level >145 mmol/L
SODIUM Food Sources
1) Bacon 7) Ketchup 13) Snack Food
2) Butter 8) Luncheon meat 14) Soy Sauce
3) Canned Foods 9) Milk 15) Table Salt
4) Cheese 10) Mustard 16) White & whole wheat bread
5) Chips 11) Pack Noodles
6) Frankfurters 12) Processed Foods

HYPONATREMIA
CAUSES:
1) Abnormal loss of GI secretion (vomiting, diarrhea, wound drainage), diuretics.
2) Losses from skin (diaphoresis)
3) Hormonal – SIADH
4) NPO, Low salt diet
5) Decreased Aldosterone secretion (adrenal insufficiency)

Manifestations: Sodium Levels <115:

1) Affects CNS: causes headache, taste impairment
2) Rapid pulse, BP normal or low.
3) Anorexia
4) Feeling exhausted, muscle cramps, focal weakness(hemiparesis, ataxia - incoordination)

Interventions/Treatment:
1) Replace sodium & fluid losses
2) Restore normal ECF volume
3) Correct any other electrolyte losses

HYPERNATREMIA
CAUSES:
1) Persons who cannot respond to thirst, NPO, Increased water loss, Heat stroke
2) Excessive Na ingestion, administration of Na containing solutions, Hypertonic tube feeding, Drowning in
seawater
3) Decreased Na excretion (Corticosteroid, Cushing’s Syndrome, Renal failure, Hyper-aldosteronism)

MANIFESTATIONS:
1) Marked thirst
2) Temperature changes
3) Swollen tongue
4) Disorientation
5) Irritability
6) Hyperactivity
7) Red, dry, sticky membranes

Intervention/TREATMENT:
1) Infuse hypotonic saline solution or D5W 2 Use diuretics that promote sodium loss 3 Restrict Na as Rx.

POTASSIUM = K+
 The major component of ICF (98%- located intra-cellularly). Maintains water balance in ICF compartment.
 Plasma K levels gives indirect measure of intracellular K+
 Potassium imbalances result in altered function of excitable membranes (eg. heart, CNS)
 Normal renal function is required to prevent hyperkalemia. The kidneys filter excess K.
 Normal range in ECF serum 3.5-5.0mEq/L.
 Potassium affects normal nerve & muscle activity especially of the heart. Slight changes affect physiological
functions.
 Potassium assists in the cellular metabolism of carbohydrates & protein. The kidney prefers to retain Na &
excrete K even when both electrolytes are depleted. When K is lost from cells, Na & H move into cells. This
aids in regulating acid base balance. ICF potassium deficit may coexist with an excess of ECF potassium.

POTASSIUM Imbalance
Normal ECF Value
 K = 3.5–5.1 mmol/L (ICF150mEq/L)
HYPOKALEMIA
K <3.5 mmol/L
HYPERKALEMIA
K >5.5 mmol/L
Moderate >6.0
Severe >7.0

POTASSIUM Food Source

 Avocado  Mushrooms  Spinach
 Bananas  Oranges  Strawberries
 Cantaloupes  Potatoes  Tomatoes
 Carrots  Pork, Beef, Veal
 Fish  Raisins

HYPOKALEMIA
- K deficit is life threatening as it affects every system.
CAUSES:
 Sweat losses or prolonged gastric losses: over suctioning, Laxative overuse, vomiting diarrhea, wound
drainage in GI. Increased secretion of aldosterone (Cushing’s syndrome).
 Decrease reabsorption. Potassium-wasting diuretic therapy. Drugs such as sodium penicillin, carbenicillin,
glucocorticoids.
 Dilution of serum K with water, IV without K.

TREATMENT:
1) Mild Cases: Dietary K supplement (Kalium Durule). Increase K food sources.
2) Moderate To Severe Cases: Potassium IV drip. Note: Hypokalemia should be treated slowly: Do not exceed
0.5-1 mEq K+/kg/hr, also maximum concentration 40 mEq/L.

MANIFESTATIONS:
1) Neuromuscular changes: Shallow respirations. Fatigue, muscle weakness, flaccid paralysis, diminished deep
tendon reflexes. Anorexia, nausea.
2) ECG changes: ST segment depression, flattened or inverted T wave & U-wave. Thready, weak (peripheral),
irregular pulse, Tall, thin, peaked T-waves
3) Increased sensitivity to digitalis. Orthostatic Hypotension.

HYPERKALEMIA
 The body needs delicate balance of potassium to help your heart and other muscles to work properly. Too
much K in your blood can lead to dangerous & deadly changes in heart rhythm.
Causes of hyperkalemia are:
1. Kidneys do not work properly to remove K.
2. Aldosterone decreases (Addison’s Disease) which decreases removal or increases reabsorption of K.
3. Diet: excess potassium.
4. Cells release too much potassium
a. Hemolysis: breakdown of RBC
b. Rhabdomyolysis: breakdown of muscle tissue
c. Injury: Burns, trauma etc.
d. DM (uncontrolled).
5. Medications: Some meds make it harder for the kidneys to remove K. Some drugs increase K (Antibiotics:
penicillin, trimethoprim. Azole antifungals. ACE inhibitors, ARBs, Betablockers, Herbals, Heparin, NSAIDs,
K-sparing diuretics.

TREATMENT:
1) Restrict dietary potassium
2) Administer regular insulin (10-25 U) in hypertonic dextrose solution to move K into cells.
3) Sodium polysterene sulfonate removes K
4) Peritoneal dialysis if Kidney cannot filter K

CALCIUM = Ca+
 Calcium is a + ion, important for many body functions:
1) Bone formation
2) Hormone release
3) Muscle contraction
4) Nerve & brain function

 Vital ion in normal neuromuscular activity, cardiac rhythm & contraction, cell membrane function, and
coagulation .
 Parathyroid hormone (PTH) & Vitamin D help manage calcium balance in the body. PTH is made by the
parathyroid glands which are 4 small glands located in the neck behind the thyroid glands. Vitamin D is
obtained when the skin is exposed to sunlight & from dietary sources such as:
o Egg yolks
o Fortified cereals
o Fish
o Fortified dairy products

CALCIUM Food Sources

1) Cheese 4) Rhubarb 7) Tofu
2) Collard Greens 5) Sardines 8) Yoghurt
3) Milk & Soy Milk 6) Spinach

CALCIUM IMBALANCE
Normal Value = 8.50-10.00mg/dL
2.15-2.55mmol/L
HYPOCALCEMIA < 8.50 mg/dL
HYPERCALCEMIA >10.00 mg/dL

HYPOCALCEMIA
CAUSES:
1) Inadequate oral intake of calcium.
2) Lactose intolerance.
3) Malabsorption syndromes such as Celiac or Crohn’s disease.
4) Inadequate Vitamin D intake.
5) End stage renal disease.
6) Wound drainage, especially GI.

MANIFESTATIONS:
1) Neuromuscular symptoms (numb fingers, muscle cramps, twitches, seizures) Laryngospasm & tetany like
contractions, Active deep tendon reflexes.
2) (+)Positive Trousseau’s signs (Carpal spasm)
3) (+) Chvostek’s sign (Facial muscle contract)
4) Anxiety, Irritability, memory impairment, Delusions
5) Prolonged ST interval, Prolonged QT interval
6) Decreased HR, Hypotension, Decreased Pulse

TROUSSEAU’S SIGN
 In a patient with hypocalcemia, carpal spasm may be elicited by occluding the brachial artery.
 To perform: a BP cuff is placed around the arm and inflated to a pressure greater than the systolic blood
pressure and held in place for 3 minutes.
 Carpal spasm – manifested as flexion at the wrist and meta-carpophalangeal joints, extension of the distal
interphalangeal and proximal interphalangeal joints, and adduction of the thumb and fingers

CHVOSTEK SIGN
 AKA Weiss sign.
 1 of the signs of tetany seen in hypocalcemia.
 It refers to an abnormal reaction to the stimulation of the facial nerve (CN7). When the facial nerve is tapped at
the angle of the jaw, the facial muscles on the same side of the face will contract momentarily (typically a
twitch of the nose or lips).
 Cause is hypocalcaemia or hypomagnesemia and hyperexcitability of nerves.

TREATMENT:
1) Monitor cardiovascular, respiratory, neuromuscular, GI (& hypercalcemia).
2) Administer calcium supplements orally or IV. Ex. calcium gluconate (oral or IV)
3) Administer meds that increase calcium absorption (Aluminum hydroxide, Vitamin D).
4) Eat foods high in Calcium.
5) Initiate seizure precautions. Decrease stimuli.

HYPERCALCEMIA
 Too much calcium in the blood. It weakens your bones, creates kidney stones and interfere with the work of
your brains and heart.
CAUSES:
1) Diet excess in Calcium (mild alkalisyndrome: >2000ml) & Vitamin D.
2) Release of calcium from the bones (multiple fractures, cancer & tumors, bed bound & not moving for long time)
3) Hyperparathyroidism, Renal failure.
4) Medications & over-use of calcium containing antacids. Drugs: thiazide diuretics, IV lipids, use of lithium &
tamoxifen.
MANIFESTATIONS:
1) Abdominal: constipation, nausea, vomiting, pain, poor appetite.
2) Kidney: Flank pain, frequent thirst & urination (note calcium kidney stones)
3) Muscle: Muscle twitching & weakness.
4) Psychological: Apathy, dementia, depression, irritability, memory loss
5) Skeletal: bone pain, loss of height & bowing of shoulders, spinal curvature, pathological fractures
Exam & Test:
1) ECG Shortened ST segment, widened T wave.
2) Serum Calcium & Vitamin D
3) Serum PTH, PTHrP (Parathyroid Hormone & related protein)
4) Urine Calcium
TREATMENT:
 Discontinue IV solutions with Calcium & Vit D. Discontinue thiazide diuretics. Give diuretics that excrete
calcium. Administer Rx meds that inhibit calcium resorption from the bone such as phosphorus, calcitonin
(Calcimar) biphosphonates, & prostaglandin synthesis inhibitors (aspirin,NSAID)
 Prepare for dialysis if meds fail to neutralize. Monitor for fractures & calcium stones (flank pain)

MAGNESIUM
 Magnesium the 2nd most common intracellular cation. It plays a vital role in many cellular metabolism.
 Magnesium is:
o Required for deoxyribonucleic acid (DNA) and protein synthesis.
o A necessary cofactor for most enzymes reactions. It is also important for parathyroid hormone
synthesis.

MAGNESIUM IMBALANCE
Normal Blood Value = 1.6 - 2.6 mg/dL
HYPOMAGNESEMIA <1.6 mg/L
HYPERMAGNESEMIA >2.6 mg/L

MAGNESIUM Food Sources

 Avocado  Green leafy vegetables  Pork, Beef, Chicken
 Canned white tuna (spinach, brocolli)  Potatoes
 Cauliflower  Milk, Oatmeal  Raisins, Yoghurt
 Peanut butter, Peas

HYPOMAGNESEMIA
CAUSES:
1) Chronic alcoholism, diuretics - Malnutrition & starvation
2) Malabsorption syndrome, Celiac & Crohn’s Dse
3) Prolonged diarrhea, nasogastric suctioning
4) Intracellular movement of Mg in Hyperglycemia, Insulin administration, Sepsis
MANIFESTATIONS:
1) Tall T waves, depressed ST segments
2) Neuromuscular symptoms, hyperactive reflexes
3) Coarse tremors, muscle cramps, positive
4) Chvostek’s signs & Trousseau’s sign
5) Seizures, parasthesia of the legs and feet
6) Painfully cold hands and feet
7) Disorientation, Tachycardia, Hypertension - Increased potential for digitalis toxicity
TREATMENT:
1) Administer oral magnesium salts (& calcium because Mg & Ca losses usually coincide)
2) Administer 40 mEq (5g) magnesium sulfate added to 1L of 5% DW
3) Administer 1-2 g of 10% solution of magnesium sulfate by direct IV push at rate of 1.5 m/min

HYPERMAGNESEMIA
CAUSES:
1) Increased or excessive magnesium administration in pre-eclampsia /eclampsia (Mg SO4), & Mg containing
antacids & laxatives.
2) Decreased renal excretion of Mg in Renal Insufficiency/Failure, Hyperparathyroidism, Hyperthyroidism
MANIFESTATIONS:
1) Hypotension, bradycardia, dysrhythmias (heart block), Cardiac arrest (>15 mEq/L)
2) Prolonged PR interval, wide QRS complex
3) Respiratory insufficiency (Depressed), Weak or absent cry in neonates
4) Neuromuscular: skeletal muscle weakness, weak- absent deep tendon reflex
5) CNS: Drowsy, Lethargy, sedation, progressing to coma.
TREATMENT:
1) Administer calcium gluconate to antagonize the action of magnesium. Diuretics.
2) Decrease Magnesium in diet. Avoid Mg contatining laxatives & antacids.

PHOSPHATES
Normal Blood Value = 2.7-4.5mg/dL
HYPOPHOSPHATEMIA <2.70 mg/dL
HYPERPHOSPHATEMIA > 4.5mg/dL

PHOSPHATES Food Sources

 Fish  Pork, Beef, Chicken
 Organ Meats  Whole grain breads and cereals
 Nuts

HYPOPHOSPHATEMIA
CAUSES
1) Insufficient phosphorous intake, malnutrition & starvation
2) Increased phosphorous excretion (hyperparathyroidism, malignancy), use of aluminum hydroxide based Mg
based antacids
3) Intracellular shifts
4) Decrease phosphorus level is accompanied by calcium level
MANIFESTATIONS
1) Decreased cardiac output
2) Slowed peripheral pulses
3) Neuromuscular: weakness, decrease deep tendon reflex
4) Decrease bone density
5) CNS :Irritability, confusion, seizures
6) Decrease platelet aggregation & increased bleeding 7 Immunosuppression
Treatment
1) Monitor CardioV, Respiratory, NM, CNS
2) Discontinue contributory meds
3) Administer phosphorus orally with Vitamin D supplement
4) Administer IV if Phosphorous falls below 1mg/dL
5) Assess renal system carefully before Phosphorous

HYPERPHOSPHATEMIA
Effects & Causes
1) Body tolerates hyperphosphatemia.
2) Accompanied by a decrease in Calcium.
3) The problem is hypocalcemia.
Manifestation & Treatment
1) Same as Hypocalcemia.
2) Avoid phosphorous containing medications & food.