Fluids and Electrolytes

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 Fluids
Fluid Volume Excess
Causes

● Excessive fluid intake

● PO intake
● IV fluid administration
● Excessive sodium intake

● Kidney failure
● Congestive heart failure
● Liver failure
Assessment

● High blood pressure

● Jugular venous distention
● Edema
● Weight gain
● Crackles
● Shortness of breath
Complications

● High blood pressure

● Third spacing
● Fluid in the lungs
● Dilutional Hyponatremia
● Dilutional anemia
Nursing Interventions

● Monitor I&O’s
● Daily weight
● Diuretics
● Hypotonic IVF
● Dialysis
 Fluids
Fluid Volume Deficit
 Causes

Isotonic Hypertonic Hypotonic

● Water loss = solute loss ● Water loss > solute loss ● Water loss < solute loss
● Trauma ● There is more solute in the ● There are less solutes in
● Diarrhea blood and less water the blood and more water
● Vomiting ● Cells are “shriveled up” ● Hyponatremia
● Sweating ● Polyuria ● Cells are swollen
● DKA
● ESRF
● Severe fluid restriction
Assessment

● Low blood pressure

● Tachycardia
● Weak pulses
● Concentrated urine
○ High specific gravity
○ High urine osmolality
● Thirsty
Complications

● Decreased perfusion to organs

● Hypovolemic shock
● MODS
Nursing Interventions

● Strict I&O’s
● Monitor BP and HR
● Daily weight
● IV fluids
○ Isotonic dehydration - give isotonic IVF
○ Hypotonic dehydration - hive hypertonic IVF
■ Will help pull water out of swollen cells
○ Hypertonic dehydration - give hypotonic IVF
■ Will help move water into shriveled up cells
 IV Fluids
Must know types and uses!
Isotonic IV Fluids

IV fluid with osmolarity similar to blood. Does NOT cause a shift in fluid.

● 0.9& Sodium Chloride (Normal Saline)

● Lactated Ringers (LR)
● D5W
Uses

● Increase the intravascular volume

● Blood loss
● Surgery
● Isotonic dehydration
● Fluid loss
● Maintenance fluids
● Patients who are NPO
Hypotonic IV Fluids

IV fluid with osmolarity lower than blood. Moves fluid out of blood vessels into cells and interstitial spaces.

● 0.45% Sodium Chloride (½ Normal Saline)

● 0.33% or 0.2% Sodium Chloride
● 2.5% Dextrose in Water (D2.5W)
Uses

● DKA
● HHNS
● Hypernatremia
Hypertonic IV Fluids

IV fluid with osmolarity higher than blood. Moves fluid out of cells and interstitial spaces and into blood
vessels.

● 1.5%, 3%, or 5% Sodium Chloride

● D5NS
● D5LR
● D10W
Uses

● Hyponatremia
● Cerebral edema
Hyponatremia
Fluids and electrolytes
Definition

Low sodium level in the blood.

Sodium - Na+

● The most abundant extracellular cation

● Regulates water in the cells of the body
● Water follows sodium
● Sodium is important in:
○ The brain
○ Nerves
○ Muscle cells
Lab Values

Normal sodium: 135 - 145 mEq/L

Less than 135 mEq/L is considered hyponatremic

Euvolemic hyponatremia

Water in the body increases, but the sodium level stays the same.

Causes:

● SIADH
● Adrenal insufficiency
● Addison’s disease
● Polydipsia
● Excessive hypotonic IVF
Hypovolemic hyponatremia

Water and sodium are both lost.

Causes:

● Vomiting
● Diarrhea
● NG suction
● Diuretics
● Burns
● Excessive sweating
Hypervolemic hyponatremia

Water in the body increases, which dilutes the amount of sodium in the serum causing a ‘dilutional’ or
‘relative’ hyponatremia.

Causes:

● CHF
● Kidney failure
● Nephrotic syndrome
● Liver failure
● Water intoxication
● Freshwater submersion
● Psychogenic polydipsia
● Excessive IV administration of hypotonic fluids
 Assessment Musculoskeletal

● Abdominal cramps
Neuro CV ● Weakness
● Shallow respirations
● Seizures ● Decreased deep tendon reflexes
● Confusion
● Hypovolemia
● Muscle spasms
● Lethargy ○ Weak pulse
● Orthostatic hypotension
● Stupor ○ Tachycardia
● Cerebral edema ○ Hypotension GI/GU
● Increased ICP ○ Dizziness
● Hypervolemia ● Decreased UOP
○ Bounding pulses ● Loss of appetite
○ Hypertension ● Hyperactive bowel sounds
Treatment

Hypovolemic hyponatremia Euvolemic hyponatremia

● Must restore volume AND sodium ● Restrict free water

● Mild - 0.9% NS (isotonic) ● Demeclocycline
● Severe - 3% NS (hypertonic) ● Tolvaptan
● Sodium tablets
Hypervolemic hyponatremia ● Encourage high salt foods

● Restrict free water intake

● Osmotic diuretics
● Avoid high salt foods
Replacing sodium

● Replace sodium slowly

● 0.5 mEq/hr
● Changing the sodium level too quickly causes fluid shifts
○ Cerebral edema
○ Central pontine Myelinolysis (CPM)
■ Monitor for numbness and weakness in the feet!
Nursing interventions

● Encourage increased oral sodium intake

○ Bacon
○ Butter
○ Canned food
○ Cheese
○ Hot dogs
○ Lunch meat
○ Processed food
○ Table salt
● Sometimes sodium tablets prescribed
● Monitor lithium levels if applicable
● Monitor neuro status!
NCLEX Question

The nurse is caring for a patient with a sodium level of 122 mEq/L. Which of the following
assessment findings does she suspect? Select all that apply.

a. Confusion
b. Abdominal cramps
c. Increased urine output
d. Hypoactive bowel sounds
Answer: A and B
A is correct. A sodium level of less than 135 mEq/L is indicative of hyponatremia - too little sodium in the blood. When
sodium falls below 125 mEq/L, it is considered "severe" hyponatremia. Confusion is a common neurological symptom of
acute or severe hyponatremia. Sodium plays a very important role in the brain, and low levels of this electrolyte can be
devastating producing symptoms ranging from confusion, lethargy, and stupor, to seizures and cerebral edema

B is correct. Abdominal cramps is another symptom of hyponatremia. Because water follows sodium, when there are
decreased levels of sodium in the blood there is decreased fluid. This creased a fluid volume deficit, decreased urine
output, muscle spasms, and abdominal cramping.

C is incorrect. Increased urine output is not a sign of hyponatremia. Decreased urine output rather would be a symptom
the nurse might observe if there are decreased levels of sodium in the blood. This is due to the relationship of sodium with
water. With decreased levels of sodium, less water is pulled into the extracellular space and the intravascular volume is
decreased causing decreased renal blood flow and therefore decreased urine output.

D is incorrect. Hypoactive bowel sounds are not a sign of hyponatremia. Hyperactive bowel sounds rather would be a
symptom the nurse might observe if there are decreased levels of sodium in the blood. Sodium plays an important role in
muscle cells as well, and when levels are too low there is cramping, spasms, and hyperactive bowel sounds.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
Hypernatremia
Fluids and electrolytes
Definition

High sodium level in the blood.

Sodium - Na+

● The most abundant extracellular cation

● Regulates water in the cells of the body
● Water follows sodium
● Sodium is important in:
○ The brain
○ Nerves
○ Muscle cells
Lab Values

Normal sodium: 135 - 145 mEq/L

Greater than 145 mEq/L is considered hypernatremic

 Causes

Hypervolemic hypernatremia Hypovolemic hypernatremia Euvolemic hypernatremic

Sodium gains > water gains Water deficit > Sodium deficit ● Increased insensible water
loss
● Hypertonic IVF ● Dehydration ○ Hyperventilation
○ (⅕%, 3%, 5%) ● NPO ● Central DI
● Sodium bicarbonate ● Diarrhea ● Nephrogenic DI
administration ● Vomiting
● Increased sodium intake ● Fistulas
● Corticosteroids ● Osmotic diuretics
● Cushing’s ● Post-obstructive diuresis
● Hyperaldosteronism
● Conn’s Syndrome The loss of fluids leads to a relative
increase in the amount of Na+ in the
● Insufficient free water with
blood.
enteral tube feeds
Assessment
Neuro
CV
● Restless Assessment
● Agitated ● Fever findings depend
● Lethargic ● Edema
● Drowsy on the type of
● Stupor ● +/- BP hypernatremia -
● Coma ● Weak - bounding pulses volume status is
Musculoskeletal Other important!
● Twitching
● Cramps ● Flushed skin
● Weakness ● Decreased UOP
● Dry mouth
 Treatment

Hypervolemic hypernatremia Hypovolemic hypernatremia Euvolemic hypernatremic

● Find the causative agent and ● Free water administration

● Isotonic fluid
discontinue ○ Based on the
administration
○ 3% administration? free water deficit
○ NS is “relatively ● PO intake better than IV
○ Aldosterone excess?
● Loop diuretics hypotonic” to the body because patient is euvolemic
● Free water administration in hypernatremia.

Monitor neuro status

Correct imbalance SLOWLY - Risk for cerebral
edema
NCLEX Question

The nurse is caring for a patient whose most recent serum sodium level was 152 mEq/L.
Which of the following signs and symptoms does she suspect are caused by the patient’s
sodium level? Select all that apply.

a. Lethargy
b. Dry mucous membranes
c. Tachypnea
d. Cyanosis
Answer: A and B
A is correct. Sodium plays a very important role in the brain, and imbalances in the serum sodium level can cause major
neurological changes. The patient who is hypernatremic, or has a sodium level greater than 145 mEq/L is at risk for
changes in their level of consciousness ranging from restlessness and agitation to lethargy, stupor, and coma.

B is correct. The patient who has a high sodium level, greater than 145 mEq/L will have dry mucous membranes. This is
due to the relationship sodium has with water. Water follows sodium, so where there is an increased level of sodium in the
extracellular space, water leaves the cells and follows the sodium into the extracellular space. This causes the dry mouth
and mucous membranes.

C is incorrect. Tachypnea, or an increased respiratory rate, is not a symptom of hypernatremia. Sodium plays a very
important role in the brain and nerves as well as water balance. The major symptoms to monitor for will be neurological, not
respiratory.

D is incorrect. Cyanosis, or a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of
the blood, is not a symptom of hypernatremia. Sodium imbalance can cause many devastating neurological symptoms, but
will not result in cyanosis.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Hyperkalemia
Fluids and electrolytes
Definition

High potassium level in the blood.

Potassium
● Found mostly inside the cells - most abundant intracellular cation.
● Normal value is for serum level - the potassium in the blood, outside of the cells.
● Responsible for nerve impulse conduction
● Important in muscle contraction - heart muscle and skeletal muscle.
● Important in acid-base balance
○ Acidotic → increased K+
Lab Values

Normal potassium: 3.5 - 5.0

Greater than 5.0 is considered hyperkalemic.

Causes

● Too much potassium moved from intracellular to extracellular

○ Burns
○ Tissue damage
● Adrenal insufficiency
● Renal failure
● Dehydration
● Excessive K+ intake
● Acidosis
● Diabetic ketoacidosis
● ACE inhibitors
● NSAIDS
● Potassium-sparing diuretics
Assessment

● Muscle weakness
● Muscle twitches
● Numbness
● Cramping
● Shallow respirations → respiratory failure
● Impaired contractility
○ Weak pulses
○ Bradycardia
○ Hypotension
● Decreased UOP
● Hyperactive bowel sounds
● Diarrhea
● EKG CHANGES
 EKG Changes

● Wide, flat P waves

● Prolonged PR interval
● Widened QRS interval
● Depressed ST segment
● Tall, peaked T waves

Can lead to heart block, asystole, or V-fib

Treatment
Interventions depend on severity of hyperkalemia and the symptoms present

● MONITOR CARDIAC RHYTHM ● Drive potassium into cells

● Also watch the respiratory, renal, and GI ○ D5W + regular insulin
complications
○ Albuterol
● Discontinue any potassium supplements
○ Bicarbonate
○ IV potassium
○ PO supplements
● Reduce total body potassium
● Potassium restricted diet ○ Kayexalate
● IV Calcium gluconate or chloride ○ Diuretics
○ Given if EKG changes are present to ■ Hydrochlorothiazide
protect the myocardium ■ Lasix
● Dialysis
○ Used when severe hyperkalemia is
not responding to other interventions
NCLEX Question

The nurse is evaluating her patient’s lab results and notes that the potassium is 5.5
mEq/L. She reviews the telemetry monitor, looking for which of the following signs?
Select all that apply.

a. Inverted T waves
b. Widened QRS interval
c. Tall, peaked T waves
d. Prominent U-waves
Answer: B and C

A is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This patient is experiencing hyperkalemia. In
hyperkalemia, there are Tall, peaked T waves. Inverted T waves is a sign of hypokalemia.

B is correct. A widened QRS interval is a very important EKG finding in hyperkalemia. Other EKG changes
patients may experience when they are hyperkalemic include wide, flat P waves, a prolonged PR interval, a
depressed ST segment, and tall, peaked T waves.

C is correct. Tall, peaked T waves is a hallmark sign of hyperkalemia on an EKG. Remember this one - it is a
very common topic for NCLEX questions!! Hyperkalemia leads to serious arrhythmias, and can progress to heart
block, ventricular fibrillation, or even asystole if left untreated.

D is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This patient is experiencing hyperkalemia.
Prominent U-waves are a sign of hypokalemia, or a potassium less than 3.5, not hyperkalemia.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes
Hypokalemia
Fluids and electrolytes
Definition

Low potassium level in the blood.

Potassium
● Found mostly inside the cells - most abundant intracellular cation.
● Normal value is for serum level - the potassium in the blood, outside of the cells.
● Responsible for nerve impulse conduction
● Important in muscle contraction - heart muscle and skeletal muscle.
● Important in acid-base balance
○ Acidotic → increased K+
Lab Values

Normal potassium: 3.5 - 5.0

Less than 3.5 is considered hypokalemic.

Causes

● Loop diuretics
● Vomiting
● Laxatives
● Glucocorticoids ● Diarrhea
● Potassium deficient diet ● Wound drainage
● Polydipsia
● Sweating
● Cushing’s syndrome
● NGT suction ● Alkalosis
● Hyperinsulinism
Assessment
● Decreased deep tendon reflexes
● Weakness
● Flaccidity
● Shallow respirations
● Confusion → Lethargy
● Decreased LOC
● Orthostatic hypotension
● Weak, thready pulse
● Polyuria
● Constipation
● Nausea/vomiting
● Decreased bowel sounds
● Cardiac dysrhythmias
 EKG Changes

● Slightly prolonged PR interval

● Slightly peaked P wave
● ST depression
● Flat/shallow/inverted T waves
● Prominent u-waves
Treatment

● Place on cardiac telemetry

● Monitor respiratory and renal status
● Monitor other electrolytes
○ Magnesium, sodium, calcium, and glucose are all inter-related!
● Hold lasix or other potassium wasting drugs
● Hold digoxin
● Diet rich in potassium
● Oral potassium supplements
○ Give with food to prevent GI upset
● IV potassium supplements
IV potassium supplement administration

● NEVER GIVE IV PUSH

● Give according to instructions; SLOWLY
● Monitor IV site very carefully
○ Can cause phlebitis
○ If extravasation occurs will cause tissue damage
NCLEX Question

The nurse is reviewing her patient assignment for the shift and has each of
the following patients. Which patient is most at risk for hypokalemia?

a. A patient with hyperemesis gravidarum

b. A patient in renal failure
c. A patient in diabetic ketoacidosis
d. A patient with third degree burns
Answer: A
A is correct. Hyperemesis gravidarum is a pregnancy complication that is characterized by severe nausea, vomiting,
weight loss, and possibly dehydration. The intense vomiting is why this condition puts the patient at risk for hypokalemia.
Gastrointestinal fluids are rich in potassium, and any patient losing large amounts of their stomach acid will be at risk for
hypokalemia. This could include vomiting, NG tube suctioning, or diarrhea.

B is incorrect. A patient in renal failure will be at risk for hyperkalemia, not hypokalemia. The kidneys will be unable to
excrete potassium as they normally do, and there will be a build up of potassium in the blood leading to hyperkalemia.

C is incorrect. A patient in diabetic ketoacidosis will be at risk for hyperkalemia, not hypokalemia. When a patient is in
diabetic ketoacidosis (DKA) glucose is unable to be transported into cells due to the lack of insulin. The body resorts to
breaking down fat cells for energy, which produce ketones and drive the blood pH down. Due to the acidity and high
glucose content of the blood, fluid and potassium are driven out of the cells and into the blood, causing hyperkalemia. If the
patient was experiencing an alkalosis, they would be at risk for hypokalemia.

D is incorrect. A patient with third degree burns will be at risk for hyperkalemia, not hypokalemia. Burns destroy tissue and
lyse cells, causing large amounts of intracellular potassium to be released into the vascular space therefore causing
hyperkalemia.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Hypercalcemia
Fluids and electrolytes
Definition

High level of calcium in the blood.

Calcium

● Stored in the bones, absorbed in the GI system, and excreted by the kidneys
● Plays an important role in bones, teeth, neves, and muscles
● Important for coagulation
● Is controlled by PTH and Vitamin D
● Has an inverse relationship with Phosphorus
Lab Values

Normal calcium: 8.4 - 10.2

A calcium level greater than 10.2 is considered

hypercalcemia.
Causes

● Hyperparathyroidism
● Cancer of the bones
● Thiazide diuretics
● Renal failure
● Vitamin D toxicity
● Excessive intake of calcium
● Excessive intake of Vitamin D
● Glucocorticoids
● Immobility
Assessment

Neuromuscular Cardiovascular Gastrointestinal

● Weakness ● Bradycardia ● Decreased peristalsis

● Flaccidity ● Cyanosis ● Hypoactive bowel
● Decreased deep ● Deep vein sounds
tendon reflexes thrombosis ● Abdominal pain
● Nausea
Neuro ● Vomiting
● Constipation
● Fatigue ● Kidney stones
● Decreased LOC
EKG Changes

Shortened QT interval

Prolonged PR interval
Treatment

● Encourage PO hydration
● IV fluids - NS preferred
● Reduce dietary intake of calcium
● Loop diuretics
● Calcium binders
● Corticosteroids - useful when the cause is Vitamin D toxicity
● Calcium reabsorption inhibitors
○ Phosphorus
○ Calcitonin
○ Bisphosphonates - Especially useful if the cause is malignancy
○ NSAIDS
● Dialysis
● Cardiac monitoring
NCLEX Question

The nurse is caring for a patient who has a serum calcium level of 13.2 mg/dL. Which of the
following medications does she expect to administer? Select all that apply.

a. Phosphorus
b. Calcitonin
c. Vitamin D
d. IV calcium gluconate
Answer: A and B

A is correct. The normal serum calcium level is 8.4-10.2 mg/dL. This patient has a high serum calcium level, or
hypercalcemia. Phosphorus is a medication the nurse would expect to administer to treat hypercalcemia. Phosphorus and
calcium have an inverse relationship, so by increasing the serum level of phosphorus the nurse can decrease the serum
level of calcium. Oral phosphate is the preferred method of administering phosphorus. If given IV, Calcium Phosphate
forms and precipitates in the tissues. This “precipitation phenomenon” reduces serum calcium levels very quickly.

B is correct. Calcitonin is a medication the nurse would expect to administer to treat hypercalcemia. Calcitonin is a thyroid
hormone that decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium
concentration.

C is incorrect. Vitamin D should be avoided in hypercalcemia. Vitamin D enhances the absorption of calcium and can
therefore increase the level of serum calcium, which we do not want to do when the patient’s level is already high.

D is incorrect. IV calcium gluconate is given to patients that are hypocalcemic, not hypercalcemic. It can treat the tetany
that occurs when a patient is severely hypocalcemic. It can also be given to protect the cardiac muscle if a patient has
severe hyperkalemia or hypermagnesemia.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes
Hypocalcemia
Fluids and electrolytes
Definition

Low level of calcium in the blood.

Calcium

● Stored in the bones, absorbed in the GI system, and excreted by the kidneys
● Plays an important role in bones, neves, and muscles
● Important for coagulation
● Is controlled by PTH and Vitamin D
● Has an inverse relationship with Phosphorus
Lab Values

Normal calcium: 8.4 - 10.2

A calcium level less than 8.4 is considered

hypocalcemia.
Causes

● Renal failure
● Acute pancreatitis
● Malnutrition
● Malabsorption
○ Celiac disease
○ Crohn’s disease
● Alcoholism
● Bulimia
● Vitamin D deficiency
● Hypoparathyroidism
● Hyperphosphatemia
Assessment

Neuromuscular Cardiovascular Gastrointestinal

● Irritability ● Decreased ● Hyperactive bowel

● Paresthesias contractility sounds
● Tetany ● Bradycardia ● Cramping
● Muscle spasms ● Hypotension ● Diarrhea
● Seizures ● Weak pulse
● Chvostek’s sign
● Trousseau’s sign
EKG Changes

Prolonged ST segment

Prolonged QT interval
Treatment

● PO calcium supplements
○ Administer with Vitamin D
○ Increases absorption
● IV calcium supplements
● Muscle relaxants
● Decreased stimuli
● Calcium rich diet
NCLEX Question

The nurse is reviewing her patients laboratory findings and notes that one of her patients has a
serum calcium level of 7.2 mg/dL. She knows that of each of the following patients, which ones are
most likely to have this result? Select all that apply.

a. The patient with breast cancer and bone metastases

b. The patient with obesity
c. The patient with Vitamin D toxicity
d. The patient with hypoparathyroidism
e. Patient with chronic renal failure
 Answer: D and E
A is incorrect. The patient with malignancy and bone metastases are more likely to have hypercalcemia, not hypocalcemia. This is due to
bone destruction from osteoclasts and the leak of calcium into blood. In addition, malignancies often cause "paraneoplastic hypercalcemia"
by secreting substances called "PTH-related peptides" that have actions similar to Parathormone ( PTH).

B is incorrect. Obesity is not a risk factor for hypocalcemia. Malnutrition and malabsorption, such as in celiac and crohn’s disease patients,
can cause hypocalcemia due to decreased absorption, but obesity would not cause this.

C is incorrect. The patient with Vitamin D toxicity would put a patient at risk for hypercalcemia, or a serum calcium level greater than 10.2
mg/dL. This is due to the relationship between Vitamin D and calcium; Vitamin D enhances the absorption of calcium. Therefore, Vitamin D
toxicity would lead to increased absorption of calcium and a hypercalcemic state.

D is correct. The patient with hypoparathyroidism is most likely to suffer from hypocalcemia. The normal calcium level is 8.4-10.2 mg/dL, so
with this patient’s level of 7.2 they have too little calcium in the blood. The patient who experiences hypoparathyroidism has too little
parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When
there is too little PTH, there are decreased calcium levels, or hypocalcemia.

E is correct. Hypocalcemia is a common problem in chronic renal failure and end-stage renal disease (ESRD). There are two reasons for
hypocalcemia in kidney disease: increased phosphorus and decreased renal production of activated Vitamin D (1,25 Dihydroxy vitamin D).
Phosphorus accumulates in renal failure. Hyperphosphatemia results in binding to calcium and precipitates as calcium phosphate in tissues
and bones, causing hypocalcemia. The kidney is responsible for activating Vitamin D and restoring calcium balance. In the setting of renal
diseases, one loses the capacity to activate vitamin D and calcium level drops. For these reasons, physicians often order phosphate binders
to reduce phosphorus and calcitriol (activated vitamin D, 1,25 Dihydroxy vitamin D) in chronic renal failure/ ESRD.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Hypermagnesemia
Fluids and Electrolytes
Definition

High level of magnesium in the blood

Magnesium

● Stored in the bones and cartilage

● Plays a major role in skeletal muscle contraction
● Important for ATP formation
● Activates vitamins
● Necessary for cellular growth
● Is directly related to calcium
Lab Values

Normal magnesium: 1.6-2.6 mg/dL

A magnesium level over 2.6 mg/dL is considered hypermagnesemia.

Causes

● Excessive dietary intake

● Too many magnesium containing medications
● Over-correction of hypomagnesemia
● Renal failure
Assessment

Neuromuscular Cardiovascular Neuro

● Weakness ● Bradycardia
● Drowsy
● Shallow breathing ● Hypotension
● Slowed reflexes ● Vasodilation ● Lethargy
● Decreased deep ● Cardiac arrest ● Coma
tendon reflexes
EKG Changes

Flat P wave

Prolonged PR interval

Widened QRS complex

Tall T wave
Treatment

● Treat the cause

● Hold any fluids or meds containing Mag
● Loop diuretics
● Calcium gluconate
● Dialysis
NCLEX Question

The nurse is caring for a patient with a serum magnesium level of 3.2 mg/dL.
She knows that which of the following could have caused this electrolyte
abnormality? Select all that apply.

a. Renal failure
b. Alcoholism
c. Anorexia
d. Diarrhea
Answer: A

A is correct. The normal magnesium level is 1.6-2.6 mg/dL. This patient has a level of 3.2, and is experiencing
hypermagnesemia. Renal failure can cause hypermagnesemia due to the fact that the process that keeps the levels of
magnesium in the body at normal levels does not work properly in people with kidney dysfunction.

B is incorrect. Alcoholism is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. Hypomagnesemia
is the most common electrolyte abnormality observed in alcoholic patients. There is a loss of magnesium from tissues and
increased urinary loss, and chronic alcohol abuse depletes the total body supply of magnesium.

C is incorrect. Anorexia is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. This is due to
malnutrition and a lack of dietary intake of magnesium.

D is incorrect. Diarrhea is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. Magnesium is
absorbed in the GI tract, and with diarrhea there is decreased absorption of magnesium leading to hypomagnesemia.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes
Hypomagnesemia
Fluids and Electrolytes
Definition

Low level of magnesium in the blood

Magnesium

● Stored in the bones and cartilage

● Plays a major role in skeletal muscle contraction
● Important for ATP formation
● Activates vitamins
● Necessary for cellular growth
● Is directly related to calcium
Lab Values

Normal magnesium: 1.6-2.6 mg/dL

A magnesium level less than 1.6 mg/dL is considered hypomagnesemic.

Causes

● Alcoholism
● Malnutrition
● Malabsorption
● Hypoparathyroidism
● Hypocalcemia
● Diarrhea
Assessment

Neuromuscular Neuro Gastrointestinal

● Numbness ● Psychosis ● Decreased motility

● Tingling ● Confusion ● Constipation
● Tetany ● Anorexia
● Seizures
● Increased deep
tendon reflexes
EKG Changes

Prolonged QT interval

Flattened T wave
Treatment

● Treat the cause

○ Stop diuretics, aminoglycosides, phosphorus…..
● Monitor cardiac rhythm
● Administer magnesium
○ PO - Magnesium hydroxide
○ IV - given very slowly
NCLEX Question

The nurse is caring for a patient with a magnesium level of 1.1 mg/dL. Which of the following signs and
symptoms does she closely monitor for? Select all that apply.

a. Diarrhea
b. Psychosis
c. Tetany
d. Decreased deep tendon reflexes
Answer: B and C
A is incorrect. While diarrhea can be an initial cause of hypomagnesemia, it is not an assessment finding indicative of
magnesium levels already low. Once the patient has low magnesium levels, they have decreased GI motility leading to
constipation, not diarrhea.

B is correct. Psychosis is an assessment finding consistent with hypomagnesemia. This patient’s magnesium level is
below normal, 1.6-2.6 mg/dL, therefore the nurse will need to monitor for potential signs and symptoms of
hypomagnesemia. From a neurological perspective this can range from confusion to psychosis.

C is correct. Tetany is another assessment finding consistent with hypomagnesemia for which the nurse should monitor.
Other neuromuscular assessment findings consistent with hypomagnesemia include numbness, tingling, seizures, and
increased deep tendon reflexes.

D is incorrect. Decreased deep tendon reflexes is not an assessment finding consistent with hypomagnesemia, rather
increased deep tendon reflexes would be. Remember, Magnesium calms the body, so when there are low levels of it the
patient will be excitable - seizures, increased reflexes, and psychosis can occur.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes
Hyperphosphatemia
Fluids and Electrolytes
Definition

High level of phosphorus in the blood.

Phosphorus

● Major role is in cellular metabolism and energy production (ATP)

● Makes up the phospholipid bilayer of cell membranes
● Large component of bones and teeth
● Has an inverse relationship with Calcium
Lab Values

Normal phosphorus: 3.0-4.5 mg/dL

A phosphorus level above 4.5

mg/dL is considered
hyperphosphatemic.
Causes

● Renal failure
● Tumor lysis syndrome
● Excessive dietary intake of phosphorus
● Hypoparathyroidism → Hypocalcemia
Assessment

Not very common! Doesn’t produce many symptoms.

Symptoms are related to the hypocalcemia secondary to hyperphosphatemia.

Neuromuscular Cardiovascular Gastrointestinal

● Numbness ● Decreased ● Hyperactive

● Tingling contractility bowel sounds
● Tetany ● Bradycardia ● Cramping
● Muscle spasms ● Hypotension ● Diarrhea
● Seizures ● Weak pulse
● Chvostek’s sign
● Trousseau’s sign
Treatment

● Phosphate binders
○ Given with food
● Manage hypocalcemia
NCLEX Question

The nurse is caring for a patient with a phosphorus level of 5.0 mg/dL. She knows that
which of the following are possible causes of this condition?

a. Tumor lysis syndrome

b. Hypoparathyroidism
c. Hypercalcemia
d. Renal failure
Answer: A, B, and D
A is correct. This patient has a phosphorus level of 5.0, which is greater than the normal 3.0-4.5 mg/dL. Tumor lysis
syndrome can cause increased phosphorus levels, because when a tumor lyses the cellular contents (including
phosphorus) are spilled out into the blood causing an increase in their serum levels .

B is correct. Hypoparathyroidism is a cause of hyperphosphatemia. The patient who experiences hypoparathyroidism has
too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones,
kidneys, and intestines. When there is too little PTH, there are decreased calcium levels, or hypocalcemia. Because
calcium and phosphorus have an inverse relationship, when there are low levels of calcium there are high levels of
phosphorus. Thus, hypoparathyroidism causes hyperphosphatemia.

C is incorrect. Hypercalcemia is a cause of hypophosphatemia. This patient has a phosphorus level of 5.0, which is
greater than the normal 3.0-4.5 mg/dL, not less than. Phosphorus and calcium have an inverse relationship, when there are
high levels of calcium there are low levels of phosphorus. Thus, hypercalcemia would cause hypophosphatemia.

D is correct. Renal failure is a cause of hyperphosphatemia. Due to reduced kidney function, phosphorus is not able to be
excreted as readily as it normally would and increased levels of phosphorus build up in the blood causing
hyperphosphatemia.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
Hypophosphatemia
Fluids and Electrolytes
Definition

Low level of phosphorus in the blood.

Phosphorus

● Major role is in cellular metabolism and energy production (ATP)

● Makes up the phospholipid bilayer of cell membranes
● Large component of bones and teeth
● Has an inverse relationship with Calcium
Lab values

Normal phosphorus: 3.0-4.5 mg/dL

A phosphorus level below 3.0

mg/dL is considered
hypophosphatemic.
Causes

● Malnutrition
● Starvation
● TPN
● Refeeding syndrome
● Hyperparathyroidism → hypercalcemia
● Alcoholism
● Renal failure
Assessment

Musculoskeletal Cardiovascular Neuro

● Weakness ● Decreased stroke ● Irritability

● Rhabdomyolysis volume ● Seizures
● Decreased bone ● Decreased cardiac ● Coma
density output
● Fractures ● Weak pulses
● Hypotension
Treatment

● Treat the cause

● Stop drugs that decrease phosphorus
○ Antacids
○ Calcium
○ Osmotic diuretics
● Phosphorus replacement
○ PO
○ IV - given slowly
● Phosphorus rich diet
● Diet low in calcium
○ No dairy, decreased greens.
NCLEX Question

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. Which of
the following foods should the nurse review as good choices? Select all that apply.

a. Leafy greens
b. Garlic
c. Nuts
d. Whole milk
Answer: B and C

A is incorrect. While leafy greens are good choices for many vitamins and minerals, they do not contain
a lot of phosphorus. Therefore, this would not be a good choice to recommend to a patient that needs a
diet rich in phosphorus.

B is correct. Garlic is a food rich in phosphorus and would be an appropriate recommendation for the
client needed to incorporate more phosphorus in their diet.

C is correct. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of
this important mineral. Cashews, almonds, and brazil nuts all are very high in phosphorus.

D is incorrect. Whole milk is rich in calcium, but does not have a lot of phosphorus. This would not be an
appropriate recommendation.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes
Hyperchloremia
Fluids and Electrolytes
Definition

High level of chloride in the blood.

Chloride

● Most abundant extracellular anion

● Works with sodium to maintain fluid balance
● Binds with hydrogen ions to form stomach acid - HCl
● Inversely related to bicarbonate
● Directly related to sodium and potassium
Lab Values

Normal chloride: 96-108 mEq/L

A chloride level greater than 108 is

considered hyperchloremic.
Causes

● Dehydration
● Metabolic acidosis
● Acute renal failure
● Cushing’s disease
Assessment

● Produces very few symptoms

● Signs and symptoms of hypernatremia
Treatment

● Treat the underlying cause

● Correct the imbalance
○ Bicarbonate administration
○ Discontinue any sodium containing meds
○ No NS for IVFs - consider LR instead
● Monitor all electrolytes - it’s usually not the only imbalance!
NCLEX Question

The nurse is caring for a patient who has a chloride level of 115 mEq/L. Which of the
following medications does she prepare to administer?

a. Bicarbonate
b. Normal Saline IVF
c. Lactated Ringers IVF
d. Lasix
Answer: A and C
A is correct. Bicarbonate is a medication commonly used to decrease the chloride level. This patient has hyperchloremia,
as their chloride level is 115 mEq/L, which is above the normal range of 96-108 mEq/L. It is therefore appropriate to
administer bicarbonate to lower the chloride level in this patient.

B is incorrect. Normal Saline, or 0.9% NaCl, contains chloride. As the name suggests - NaCl, or Sodium Chloride. If the
patient has a chloride level of 115 mEq/L, they have hyperchloremia, as their chloride level is above the normal range of 96-
108 mEq/L. It would therefore not be appropriate for the nurse to prepare to administer normal saline to this patient.

C is correct. Lactated Ringers IVF is the appropriate choice for IV fluids for the patient with hyperchloremia. Normal Saline
should be avoided as to prevent increasing the chloride level further. Hydration is a very important component in treating
hyperchloremia, so providing IVF for hydration is appropriate, it just needs to be the correct fluid.

D is incorrect. Lasix, also known as furosemide, is a potassium wasting diuretic. This medication may be used in patients
with hyperkalemia to lower the level of potassium, but it will not have an affect on their chloride level. It would therefore not
be appropriate for the nurse to prepare to administer lasix to this patient.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes
Hypochloremia
Fluids and Electrolytes
Definition

Low level of chloride in the blood.

Chloride

● Most abundant extracellular anion

● Works with sodium to maintain fluid balance
● Binds with hydrogen ions to form stomach acid - HCl
● Inversely related to bicarbonate
● Directly related to sodium and potassium
Lab Values

Normal chloride: 96-108 mEq/L

A chloride level less than 96 is

considered hypochloremic.
Causes

● Volume overload
● CHF
● Water intoxication
● Metabolic alkalosis
● Salt losses:
○ Burns
○ Sweating
○ Vomiting
○ Diarrhea
● Cystic Fibrosis
● Addison’s Disease
Assessment

● Produces very few symptoms

● Signs and symptoms of hyponatremia
Treatment

● Treat the underlying cause

● Correct the imbalance
○ Normal Saline - 0.9% NaCL
● Monitor all electrolytes - it’s usually not the only imbalance!
NCLEX Question

The nurse is assigned to care for a patient with a chloride level of 90 mEq/L. She
knows that which of the following are causes of this electrolyte imbalance? Select all
that apply.

a. Fluid volume excess

b. Metabolic acidosis
c. Vomiting
d. Constipation
Answer: A and C

A is correct. The normal level for chloride is 96-108 mEq/L. Since this patient has a level of 90 mEq/L, which is under the
normal range, they are experiencing hypochloremia. Fluid volume excess is a cause of hypochloremia. This is due to a
dilutional effect. There is not actually less chloride in the blood, but because there is increased fluid volume, there is a
dilutional effect causing a relative hypochloremia.

B is incorrect. Metabolic acidosis is not a cause of hypochloremia. Metabolic alkalosis instead can cause hypochloremia.

C is correct. Vomiting is a common cause of hypochloremia. The stomach acid is hydrochloric acid, or HCl. This acid
contains large amounts of chloride, and when the patient vomits and loses this stomach acid, they lose chloride causing
hypochloremia. This loss of HCl also causes metabolic alkalosis.

D is incorrect. Constipation does not cause hypochloremia. Diarrhea can cause hypochloremia due to excessive loss of
gastrointestinal contents that contain chloride.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes