Electrolyte
Imbalance
Hypernatremia
Lab Values
Common Causes
> 145
mEq/L
Clinical Manifestations
Nursing Management
Thirst, tachycardia, orthostatic
hypotension, decreased absent
DTR, seizures, coma
Cushing’s
Hyponatremia
Seizures, convulsions, and death
Maintain airway, monitor VS, seizure precautions,
monitor level of consciousness
Coma, seizures, respiratory arrest
< 136
Associated with heart failure
Hyperkalemia
>5.0
Increased risk of cardiac arrest
Rare w normal kidney fx
Associated with diabetic
ketoacidosis
Hypokalemia
<3.5
Overuse of diuretics, increased
aldosterone, NG tube
K+
POTASIUM
Excess potassium loss through
the kidneys is often caused by
such meds as corticosteroids,
potassium-wasting diuretics,
amphotericin B, & large doses
of some antibiotics.
Vs: slow, irreg pulse
Muscle weakness, paresthesia,
paralysis,
Cardiac dysrhythmias, premature
ventricular contraction,
ventricular fib, peaked t waves,
widened qrs
Hyperactive bowel sounds
Oliguria
Metabolic acidosis
Vs: decreased bp, orthostatic
hypotension
Neuro: altered mental status 
acute confusion and coma
Flattened T wave, elevated U
wave, ST depression, prolonged
PR interval
Hypoactive bowel sounds, paralytic
ileus
reduced DTR
Respiratory failure, cardiac arrest
weak and irregular pulse, muscle
weakness, fatigue, and ventricular
dysrhythmias.
Prevent falls, assess for cardiac complications
Calcium gluconate, dialysis
Admin iv with dextrose and regular insulin
Admin sodium bicarbonate to reverse acidosis
Fall precautions due to muscle weakness
IV K supplementation
Food’s high in K = avocados, broccoli, dairy, dried
fruit, cantaloupe, bananas, whole grains
Hypercalcemia
>10.5
Hyperparathyroidism
Bone pain, fatigue, weakness,
lethargic
Ca
CALCIUM
Hypocalcemia
<9.0
Tetany, positive Chvostek’s and
Trousseau’s
thyroidectomy
Hyperphosphatemia >4.5
Hypophosphatemia
<3.0
Hypermagnesemia
>2.1
Hypomagnesemia
<1.3
Hypocalcemia doesn't commonly
have symptoms. Pts may exhibit
tingling of the face, hands and feet
and have a "pins and needles"
sensation
Think of hypocalcemia
Elevations in magnesium levels are
accompanied by hypotension,
nausea, vomiting & facial flushing.
Celiac or Crohn’s
Chronic alcoholism
Sim to hypocalcemia
The treatment of hypocalcemia includes the
monitoring of the client's respiratory and cardiac
status in addition to providing the client with
calcium supplements coupled with vitamin D
because vitamin D is necessary for the absorption of
calcium.
Objectives
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Describe the role of Sodium (Na), potassium (K), Magnesium (Mg), Calcium (Ca), and Phosphate (PO4)
Define hypervolemia and hypovolemia imbalances
Discuss the use of Potassium and Magnesium replacement orders.
Explain the use of Diuretics and impact on blood electrolytes
Give examples of foods high in K, Na, Mg, Ca, PSO4
Identify nursing interventions for early signs and symptoms of potentially life-threatening imbalances in fluids and electrolytes
Discuss the role of delirium in the patient with electrolyte imbalances
TABLE 16.3
Extracellular Fluid Imbalances Causes and Manifestations
ECF Volume Deficit
ECF Volume Excess
Causes
• ↑ Insensible water loss or perspiration (high
fever, heatstroke)
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• GI losses: vomiting, NG suction, diarrhea,
fistula drainage
• Overuse of diuretics
• Inadequate fluid intake
• Third-space fluid shifts: burns, pancreatitis
Manifestations
• Excess isotonic or hypotonic IV fluids
• Heart failure
• Renal failure
• Primary polydipsia
• SIADH
• Cushing syndrome
• Long-term use of corticosteroids
ECF Volume Deficit
• Restlessness, drowsiness, lethargy, confusion
• Thirst, dry mucous membranes
• Cold clammy skin
• Decreased skin turgor, ↓ capillary refill
• Postural hypotension, ↑ pulse, ↓ CVP
• ↓ Urine output, concentrated urine
• ↑ Respiratory rate
• Weakness, dizziness
• Weight loss
• Seizures, coma
ECF Volume Excess
• Headache, confusion, lethargy
• Peripheral edema
• Jugular venous distention
• S3 heart sound
• Bounding pulse, ↑ BP, ↑ CVP
• Polyuria (with normal renal function)
• Dyspnea, crackles, pulmonary edema
• Muscle spasms
• Weight gain
• Seizures, coma
A pt is receiving intravenous fluids
postoperatively following cardiac surgery.
Nursing assessments should focus on which
postoperative complication?
Antidiuretic hormone & aldosterone levels are
commonly increased following the stress
response before, during, & immediately after
surgery. This increase leads to sodium & water
retention. Adding more fluids intravenously can
cause a fluid volume excess & stress upon the
heart & circulatory system.
GERD – caffeine, smoking,
AAA – worried about rupture – to prevent control BP to prevent rupture. If intact = no s/s. if dissecting aneurism = sharp severe pain with sudden onset, priority
to get them to surgery asap bc hemorrhage
Obstructed bile duct – stateroeah (fatty stools bc bile can’t get out to emulsify fats leading to incomplete digestion)
HYPOvalumia = concern for hypoperfusion, BP < 90 (systolic),
CAD – RF smoking, family history, age, gender, HTC (modifiable) Hypertension and hyperlipemia)
Cataracts – blurred vision and photophobia
Ulcerative colitis and Crohn’s disease – NPO to let things calm down,
Complications – nutritional issue not met, fistulas (opening or tunnel where there shouldn’t be one),
Constipation – assess for paralytic ileus listen to bowel sounds HYPO below obstructions HYPER above obstruction
To prevent constipation pt edu : drink 2-3 L, eat high fiber foods – raw green vegetables,
HYPOkalemia – diuretics, NG tube, S/S: cardiac disturbances MONITOR FOR CARDIAC ARRYTHMIAS
Muscle cramps, taking Lasix, complain of cramps – check potassium levels
DVT – lovonox, complication pulmonary embolism,
Fluid overload – pitting edema, crackles in lung sounds, can indicate pulmonary edema, bc can interfere with oxygenation
Glaucoma – increase ocular pressure of optic nerve can cause blindness, NOT curable or reversible
DASH diet and DASH friendly foods
Know normal for electrolytes
Coosysectomy where we remove the gallbladder can be done laparoscopically or via open inscention REVIEW POST OP RESTRICTIONS
To improve communication with pt with hearing loss – slowly but norm, min background noise, eye contact,
Nitroglycerin – vasodilator of blood vessels that perfuse the heart. Under tongue. If still pain after 3 doses, call 911. 3 tabs every 5 minutes, call ems after 3rd
MONA – chest pain: morphine, O2 to improve oxygenation, nitro, aspirin to prevent platelet aggregation (not EC)
Post of complication – adolectis risk of pneumonia, to prevent this encourage early ambulation and incentive spirometry, big deep breaths, cough, frequent turn,
deep breath q 2 hours; dvt why lovonox and emphasize early ambulation
PAD vs PVD
PAD – pain with walking (intermittent claudation), legs will be shiny, pale, loss of hair, limb ischemia
PVD – edema, calf pain, red, ulcers with heavy weepy drainage,
Stop smoking, get good nutrition,
Stable angina – predictably chest pain provoked by known cause like mowing the lawn causes pain relieved with rest and or nitro
s/s that it had progressed to unstable angina – unpredictable, can occur at rest or night time, may or may not be relieved by nitro, can increase in frequency and
severity of pain
Practice1
Review
Glaucoma increased iop leading to optic nerve damage and the number 1 cause of blindness –
Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors.
AT1 Exam 2 mod 7 and 8
Visual Problems (21)
Diff between astigmatism and myopia, etc. 
Visual impairment what is your job – emotional support, GOAL is promote safety and fx abilities 
How do you handle a pt that is blind always walk ahead and let them grab by the arm to the side of the client 
ELDERLY – risk for falls = full precautions, confusion, disorientation 
What do you do? Chemical = continuous eye irrigation with iv tube or morgan lens; penetrate object=cover both eyes=eye shield and then go to
ER 
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Intraocular disorders
Macular degeneration – central loss of vision 
Cataract – opacity of the lens, develops over time, if untreated it’s the number 1 cause of blindness; decreased visual acuity, painless loss of
vision; photosensitivity; halo around lights; absent red reflex (can be tumor also) risk factors – diabetes, older, 
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Prescription glasses, avoid night, 
Surgery – pre op: mydriatic (pupil dilation )or cycloplegic agent, NSAIDs, topical antibiotics, anxiety meds 
Post op avoid increases in IOP photophobia; wear eye patch (risk for falls) until doctor again, pain that doesn’t go away with meds or 
Decrease IOP - don’t bend over waist; avoid sneezing, cough, strain; hyperflexion of head, titling head back to wash hair, limit housework and rapid jerky
movements at least for a month after surgery. Vitamin C and E good
*GLAUCOMA increase in IOP related to problem with optical nerve. TREATABLE BUT NO CURE.
IOP NORMAL 10-21 MM HG
OPEN ANGLE MILD PAIN AND GRADUAL LOSS OF PERPHERAL VISION (TUNNEL vision) POAG Abnormal IOP between 22-32 mm Hg; drop therapy
Closed angle: sudden, EXTREME pain “extreme, severe, sudden”
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Acute, medical emergency 
Severe pain 
Caused by 
Blurry vision or halos 
N&V bc of pain 
Iop > 30 mm Hg 
MGMT chronic (open) meds can slower progression
How do you help prevent glaucoma – early detection
HOW DO YOU TEACH YOUR PT TO PREVENT GLACOM? - tell them to get eye exams 2-4 if 40-64; if >65 eye exam q 1-2 yrs
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Retinopathy - ,.. 
What stage of hypertension
Why? Secondary –acute kidney disease causes
PRIMARY HYPERTENSIN es or idiopathic (African American)
persistent increased SVR (systemic vascular resistance) most common – who has it?
CAUSES – soda = stress, smoking, sedentary life; obesity, oral contraceptives; diet high sodium high cholesterol, diseases DM, renal disease, HF, Hyperlipidemia;
A – African men and age
CHAPTER 37
Vascular disorder
Arteries – peripheral artery disease – progressive narrow and degeneration of arties in bilateral upper and lower extremities.
r/f: smoking, CKD, HTN, Hyper lipidemia
S/S: PAD =ARTS (absent pulses, absent hair=cool legs, round red sores (blood pooling), toes and feet pale or black (eschar), sharp calf pain (intermittent
claudication)
PVD s/s VEINY
Compression socks for PVD
Pt edu – positioning pvd veins=elevate
Constriction Cross legs
Constrictive clothing
Cigarettes
Caffeine
Cold temp
Toenails trimmed only by dr.
Xxxxxxcc
FLUID BALANCE
Monitor level of consisnes no matter
Calcium 9.0-10
Hypocalcemia – trousseau and chovkes ii DTR assessment
Hypervolemia – pulmonary edema; I
Hypovolemia – low BP
Test Review
GI System – endoscopy known what this is
Endoscopy: EGD
Vegan diet – supplements
Types of nutrition – oral, enteral, parenteral
PAD – problem not enough blood
No hair, complain of muscle aches, foot and hands are cold and blue and pale, ulcers, nails are thick and brittle, cold
why does a person have DVT? DVT - Impaired flowing, thrombosis, ephitalial damage hyper coagulable states --> clot can dislodge and go to lungs are cause
pulmonary edema or to brain=stroke
PVD – edema in the legs, normal pulse, no sores no pain, pain with standing, hyperpigmentation, huge veins, warm, POOLING OF BLOOD TOO MUCH
compression socks, legs up to increase venous return, NO MASAGE if known clot they should be on bed rest and encourage to elevate legs IF SOB AND SHARP
CHEST PAIN and (unilateral leg) one sided pain likely pulmonary edema and must contact provider
Strider, sternal retraction, use of accessory muscles are signs of respiratory failure (Calcium effects muscle)
exam 2 on March 9th
Adult Theory
DIGESTIVE SYSTEM diff between upper and lower GI and know the organs in each
Assessment
Objective data
Gerontological considerations
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Decrease appetite; carries, periodontal disease; diminished taste buds; lesee sense of smell; decreased saliva production
More susceptible to dehydration
Dx studies for GI system
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Know what do you teach – mri, endoscopy,
GI SERIES – issues with the upper GI
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Drink barium
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Prep pts with clear liquid diet 1 day before the exam; NPO after midnight; increase fluid intake to flush out barium, stools will be white
for 24-72 hours
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Endoscopy
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Bowel prep and NPO;
Chapter 39
Diets – lacto ovo vegetarian, etc. What do you have to teach a person that wants to be a vegetarian – have to have more vitamins and teach them to eat
proteins
Vegans – lack B12
Therapeutic communication on diet
Malnutrition
Under or over nutrition than body requirements
Nursing assessment – refer to dietitian
Nursing DX: imbalanced nutrition, self-care deficit, deficient fluid volume, risk for impaired skin integrity (albumin know levels according to Lewis), activity
intolerance; GOALS ideal body weight, consume specified number of calories, have no adverse consequences
Postoperative diet progression
Clear liquids, full liquids, soft diet, reg diet
Types of nutrition support – oral feeding (PO); enteral nutrition (doff hob tube and goes through your mouth, using stomach; more safe; promotes healthy
bowel; 30-45 degree head of bed to prevent aspiration; how to check proper placement of tube –> x-ray bc want to make sure not in lungs; HOB>30; FLUSH TO
MAINTAIN PATENCY IF MEDS (10CC before and after); check position on insertion and before feeding --> before you flush, aspirate to make sure in stomach;
PRIORTY IS MONITORING FOR ASPIRATION and nutrition status (sugar level checks every 6 hours bc at risk for hyperglycemia); parenteral nutrition (PEG tube
goes more risk of infection; right into blood; TPN; use nasogastric tube for decompression of the stomach; BIGGEST disadvantage is that you are not using your
bowels; IF FINISHES A BAG AND NEXT ONE IS NOT READY – HANG 10% DEXTROSE IN WATER TO PREVENT HYPOGLYCEMIA; never do meds)
UlCertive colitis – left lower quadrant
GERD – obesity is number 1 cause; nursing interventions: assess resp changes, edu diff between angina s/s and GERD, assess ability to swallow and gag reflex
GERD know well; N&V notice how to assess, know Zofran; nutrition focus;
Metabolic syndrome
N & V complication = aspirations
Ileostomies and colostomies – avoid gas causing foods – beans, eggs, carbonates beverages; stomal blockage – nuts, raw carrots, popcorn; odor – eggs, fish,
garlic
Cholecystitis – inflammation of the gallbladder
Pain and tenderness in UR pain can radiate to R shoulder
Cataracts S/S change in vision; worse at night; blurred vision; white color pupil
Goals: educate them to min anxiety; prevent infection/complication
Treatment: varies on severity; optimize lighting; change prescription; surgical removal of clouded lens
Post-op prevents increased ocular pressure (IOP- coughing, bending down, vomiting increases); no rubbing eyes; wear sunglasses; report purulent draining (signs
of infection); avoid activities that increase IOP; 4-6 weeks to completely heal; report changes in vision immediately;
Complications of cataract – infection and bleeding PROVIDE PT EDU
Eval – improved vision, control pain, better at ADLS
Age related macular degeneration – loss of central vision, exact etiology unknown; ppl >60 y.o.
Exudative (wet) vs nonexudative (dry) MOST COMMON dry; MOST SERIOUS wet
Risk factors – age, genetics in families, smoking, uncontrolled hypertension, females
Vision loss is not reversible but don’t tell pts that nothing can be done
Glaucoma damage to optic nerve due to increased IOP or due to decrease fluid drainage or overproduction of fluid secretion = increase in IOP
Normal IOP range 10-21 mmHg
POAG – open-angle gradual onset; HA, loss of peripheral vision, IOP>21; ACG – closed-angle sudden onset, medical emergency, rapid onset IOP>30 mmHg, loss
of PERLA, photophobia; sudden any symptoms immediately notify provider
Risk factors – age, diabetes, uncontrol hypertension
Hearing loss in elderly can lead to cognitive deficient
cardiac output --- decreased cardiac output = decreased
Table 32-2 in txt bk
Normal SBP <120 and <80
Elevated 120-129 and
HIGH SALT INTAKE 32-2
Water follows sodium --> eat salt = retain water = increase BP emphasize low sdum diet for pt. with hyper tension
Clinical manifestations of hypertension would you asses? BP. Asymptomatic until severe and target organ disease occurs fatigue, dizziness, HA, etc.
COMPLICATIONS target organ diseases occur most frequently in heart, brain, (Left ventricular hypertrophy: heart muscle thickens in left ventricle --> when heart
is relaxing it can’t fill up with much blood bc not enough room so then not perfusing significant blood
Peripheral vascular disease
Kidney and eye damage
Diagnostic studies – ECG, chest x-ray for cardio myopathy, screen for diabetes (blood glucose), CMP
ESTABLISH BASELINE BP BEFORE STARTING THERAPY
For pts with high BP – low salt, DASH diet
GOALS – achieve and maintain goal BP
Hydrochlorothiazide – diuretic, take in am not pm (so no night peeing), increase fluids and low sodium, orthostatic hypotension can occur
ANTI-HYPERTENSIVES – exam won’t cover meds
Assess orthostatic abnormal SBP decrease 20 mm Hg or more INCREASED RISK OF FALLS
Nursing implementation: watch fluid, VS, dietician and physical therapist
Home BP monitoring teaching
Reason for poor adherence – unpleasant side effects of drugs so edu in advance to avoid or we can switch them; high cost/lack of insurance;
To increase compliance – educate about risks and complications
How do we know drug therapy is working? - BP down compared to baseline, BUN and creatinine improved, weight loss,
RISK FACTORS AND WHO WOULD BE MOST AT RISK – SMOKING
Chapter 33 CAD & Angina
CAD coronary artery disease type of blood vessel disorder
Cardio exercise is important bc promote collateral circulation in case of vessel occlusion
RF: modifiable and nonmodifiable – focus on mod ones like HDL, LDL, smoking, obesity, etc.
Risk factors for CAD that increase workload of heart and demand for O2,
Health promo – id high-risk person – health hx, fam hx, lifestyle, precense of cardio symptoms
DRUG THERAPY
Lipid-lowering (statins = first line; inhibit cholesterol synthesis, decrease ldl, increase hdl, and lower crp); Rosuvastatin (Crestor) most potent, serious adverse
effects (rare): liver damage and myalgia (CK-MM) and muscle cramps
Chronic Stable Angina
Chronic and progressive, asymp or chest pain, occurs when o2 demand of heart outweighs O2 supply; 2 types (stable vs unstable; ONLY STABLE FOR THIS TEST)
S/S: chest pain with predictable pattern (ie during same activities, relieved by rest or nitroglycerin)
Goal: reduce O2 demand or increase supply to help optimize myocardial profusion
Nitrates – causes vasodilation
Ace inhibit, beta (decrease heart rate), calcium channel
Sit upright, give O2, get 12 lead ekg to rule out mycard infarction, assess VS, heart and breath sounds
PT EDU reducing risk factors – low sodium diet and physical activity; meds nitrates or baby aspirin;
ADMI NITROGLYCERIN 1 tab odt, 1 q 5 minutes up to 3 doses, if still pain --> call 911 bc could be heart attack may cause: HA, dizziness, flushing, orthostat; can be
used prophylactically
DX: 12 lead, labs, echo, exercise stress test
Gold standard to dx and id CAD that can cause stable angina: is cardiac catheterization (procedure) to identify and localize CAD
Stable angina occurs in a predictable pattern and be familiar with nitroglycerin teaching points.
Table 37.1
PAD thickened walls --> decreased profusion --> so loss of hair, etc.
PAD intermittent claudication or rest pain in foot PVD no pain but heaviness in lower extremities venous insufficiency (venous statis in lower extremities)
Fluid and electrolytes
Water maintains of blood volume transport of glucose waste,
2/3 intracellular and 1/3 extracellular
Intracellular = potassium an magnesium
Inter = sodium and chloride
H, na, k, mg, ca + cl, s, phosphate, bicarbonate Number measure what's in ECF
Mg 1.5-2.5
Phosphorus 2.5-4.5
K 3.5 - 5
Ca++ 8.5-10.5
Cl- 95-105
Na+ 135-145 mmEq/L
Mg+ intracellular cation hypermagneisea = muscle relaxation
Hypomagnesaemia = muscles are excited
K intracellular cation – intracellular excitation
Hyperkalemia > 5.0 tall peaked t waves
Muscle twitching/ cramps (early)
Muscle weakness/paralysis (late)
Cardiac dysrhythmias
Caused by k sparing diuretics
HYPOkalemia <3.5 result of body fluid loss or diuretics
Cells cannot repolarize causes spasms and legs cramps
Bradycardia
Flatten t wave
Ca+ 8.5 -10.5 mg/dL
Decreased albumin (made in liver)
Motor neuron excitability HYPERcalcemia – decreased muscle contraction
HYPOcalcemia – trousseaus sign and Chvostek's sign
HYPERcalcemia – decreased DTRs, bone pain, dysthymias, cardiac monitoring loop diuretic=s to promote calcium excretion
NA extracellular excitation
Water follows sodium
Hyponatremia more water than sodium caused by CHF
HYPERnatremia
Too much sodium not enough water s/s thirst dry mucus membranes edema diminished cardio output
Correction and management of underlying causes
GERD avoid – fatty foods, caffeine, chocolate, alcohol, smoking, nicotine, peppermint, and spearmint