Chemistry” Or Chem Panel Electroyte Panel ‘Lytes

4/19/20

METABOLIC PANEL INTERPRETATION

Sherri Cozzens, RN, MS

April 2020 copyrighted

Basic Metabolic Panel + ”Chemistry” or Chem Panel Electroyte panel ‘Lytes

´ Alerts us to overall kidney function, acid-base balance, fluid balance

´ This is a fasting blood test ´ Patients should be npo p MN

Sodium (Na+)

´ Major cation & most abundant solute in extracellular fluid ´ Normal range = 135-145 meq/L

´ Plays significant role in fluid balance, nerve, and muscle function ´ Combines with chloride and bicarb to regulate acid-base balance

´ Best friends with water

1 4/19/20

Sodium (Na+)

´ Excreted in kidneys, GI tract, sweat ´ When sodium level rises:

´ Increased thirst ´ Release of ADH (post pituitary) ´ ADH tells kidneys to retain water

´ This ”dilutes” the blood and normalizes osmolality ´ Once osmolality decreases, thirst and ADH secretion are suppressed, and kidneys excrete more water to restore balance

Sodium (Na+)

´ Other processes that regulate ECF sodium levels: ´ Aldosterone ´ Sodium-potassium pump

´ Requires energy, Mg++ and P as carrier

´ This also creates the electrical charge in the cell, which allows transmission of neuromuscular impulses

Sodium – potassium pump

2 4/19/20

Causes of Sodium (Na+) Imbalance

HYPONATREMIA HYPERNATREMIA Sodium loss: diuretics, vomiting, Water loss: severe diarrhea, diuresis, diarrhea, fistulas, GI suctioning, HHNC excessive sweating Inadequate intake of H20 Inadequate intake of sodium Insensible loss: fever, tachypnea, burns Overconsumption of water or IV fluids Overconsumption of sodium Burns Excessive administration of sodium CHF solutions Cirrhosis Excess of adrenocortical hormones Renal conditions/disease/failure Diabetes Insipidus Adrenal insufficiency SIADH

Hyponatremia

´ Na+ <135 ´ Serum osmolality <280 mOsm/kg

´ S/sx may not be apparent until late in the game ´ If present, usually neuro in nature

´ Diminished LOC/attention span

´ Headache, vomiting, muscle twitching, seizures ´ Dilutional hyponatremia - hypervolemia ´ Depletional hyponatremia - hypovolemia

Treatment of Hyponatremia

´ Mild ´ Fluid restriction (if due to hypervolemia) ´ High sodium diet, oral sodium supplements possible ´ Isotonic IV fluids (if due to hypovolemia) ´ Severe <110 mEq/L

´ Usually in ICU ´ Hypertonic saline solution infusion (3% or 5% saline)

´ VERY slow rate, can cause fatal fluid overload ´ Concurrent furosemide (Lasix) administration

´ Treat underlying endocrine disorders, if present

3 4/19/20

Nursing Considerations for Hyponatremia

´ Monitor serum sodium and chloride ´ Report extreme changes promptly to HCP ´ Monitor & document ´ VS, esp BP & HR ´ Neuro status – assess for lethargy, muscle twitching seizures, and coma ´ Notify HCP promptly if decline is noted ´ Accurate intake and output ´ Maintain strict fluid restrictions ´ High sodium diet if prescribed ´ Daily weight ´ Assess skin turgor ´ Excellent oral care

Nursing Considerations for Hyponatremia

´ Administer prescribed sodium (oral, IV) ´ Frequent assessment for fluid overload, cerebral edema

´ Seizure precautions if needed ´ Educate about causes and treatment of hyponatremia ´ Educate about, and enforce, strict fluid restriction

´ Educate on dietary sources of sodium ´ Educate about daily weights – report gain of 2# in 24-hr period ´ Educate about reportable signs and symptoms

Causes of Sodium (Na+) Imbalance

4 4/19/20

Hypernatremia

´ Na+ > 145 mEq/L ´ Serum osmolality >300 mOsm/kg

´ Most important signs will be neuro – restlessness, agitation, weakness, confusion, muscle twitching, stupor, seizures, coma ´ Acronym SALT ´ Skin flushed

´ Agitation ´ Low grade fever ´ Thirst – body’s main defense against hypernatremia

Treatment of Hypernatremia

´ Correct underlying disorder ´ Sodium restriction

´ Gentle hydration – PO if able ´ Replace over 48 hrs to avoid shifting water into brain cells ´ If IV, D5W (no sodium) initially. Once serum sodium levels are normal, then half- normal saline to prevent hyponatremia and cerebral edema ´ Diuretic therapy to increase sodium loss

Nursing Considerations for Hypernatremia

´ Monitor serum sodium and chloride ´ Report extreme changes promptly to HCP

´ Monitor & document: ´ VS, esp BP and HR ´ Neuro status

´ ALOC, lethargy, headache, muscle twitching, seizures

´ Report any deterioration promptly to HCP ´ Accurate intake and output

´ Enforce fluid restriction ´ Daily weight

5 4/19/20

Nursing Considerations for Hypernatremia

´ Administer prescribed fluids ´ Frequent assessment for fluid overload, cerebral edema

´ Seizure precautions if needed ´ Educate about causes and treatment of hypernatremia ´ Educate about, and enforce, sodium restriction

´ Educate on dietary sources of sodium & to avoid/control ´ Avoid OTC meds containing sodium ´ Educate about daily weights – report gain of 2# in 24-hr period ´ Educate about reportable signs and symptoms

Potassium (K+)

´ Most abundant cation in the ICF ´ Vast majority intracellular

´ Normal range = 3.5 – 5.0 mEq/L ´ Essential for cardiac & neuromuscular function, acid-base balance ´ Gained through intake, lost by excretion

´ Must be ingested daily (body cannot conserve it)

´ Minimum daily requirement = 40 mEq ´ 80% is excreted by kidneys

´ 1 L urine = 20 – 40 mEq K + ´ Remaining is excreted in feces and sweat

6 4/19/20

Potassium (K+)

Hypokalemia Hyperkalemia Lack of intake Increased dietary intake of potassium Loss of potassium: suction, prolonged Excessive use of salt substitutes vomiting or diarrhea, diuresis, Renal insufficiency/failure excessive diaphoresis Addison’s / hypoaldosteronism Drugs: K+ wasting diuretics,insulin, Injury: burns, trauma, severe infection, corticosteroids, some Abx, laxative crush injuries abuse, adrenergics, others Drugs: B-blockers, ACE inhibitors, Shift from ICF to ECF NSAIDS, K+ sparing diuretics, Magnesium depletion chemo Diseases: Cushing’s, liver disease, CHF, Older banked blood alcoholism, malabsorption, nephritis Periods of high stress

Hypokalemia

´ K+ < 3.5 mEq/L ´ Major concerns: arrhymias (may lead to cardiac arrest) and respiratory muscle weakness (may lead to respiratory arrest) ´ Major signs & symptoms (think “suction”) ´ S = skeletal muscle weakness ´ U = U wave – EKG changes ´ C = constipation, ileus ´ T = toxicity of Dig (from hypoK+) ´ I = irregular, weak pulse ´ O = orthostatic hypotension ´ N = numbness (paresthesia)

7 4/19/20

Treatment of Hypokalemia

´ High potassium diet ´ Replacement with KCL is common; use PO before IV if possible ´ Give PO replacement in divided doses if >40 mEq are needed

´ Powder can be sipped over time

´ Pills are large and can be broken in half but not crushed ´ If administering IV, give no more than 10 mEq/hr ´ When administering IV, NEVER give IV push ´ Carefully assess IV line for infiltration and phlebitis before and during each IV dose ´ Small dose of lidocaine may be prescribed to add to replacement to decrease IV site pain ´ Might also/instead try a warm blanket or compress to site to decrease site pain ´ Might consider slowing the rate to decrease site pain

Nursing Considerations for Hypokalemia

´ Monitor serum potassium ´ Report extreme changes promptly to HCP ´ Monitor & document: ´ VS, esp BP, HR and rhythm, and Resp ´ orthoBP, irreg heartbeat, resp weakness/paralysis can occur! ´ Assess telemetry for QRS complex changes ´ Follow standardized procedure and notify MD for changes prn ´ Assess for s/sx of Dig toxicity ´ Accurate intake and output ´ ABG’s for metabolic alkalosis

´ Irritability, paresthesia

Nursing Considerations for Hypokalemia

´ If K+ is low and not responding to replacement, request a mag draw ´ If Mg+ is low, replace it before replacing K+

´ Adequate Mg+ is necessary for K+ absorption & utilization ´ Educate about condition and how/why it happens ´ Educate on how to prevent future episodes

´ Educate about the meds carefully and thoroughly ´ Educate on a potassium rich diet ´ Educate the reportable signs and symptoms

8 4/19/20

Hyperkalemia

´ K+ >5 mEq/L ´ May be the most dangerous of the ‘lyte disorders

´ K+ > 7 mEq/L may cause serious arrhythmias and cardiac arrest ´ Nonspecific signs and symptoms; serum K+ and ECG tracings are best indicators ´ Tall T wave

´ Irritability ´ Skeletal muscle weakness à flaccid paralysis that may involve resp muscles ´ Smooth muscle hyperactivity: nausea, abdominal cramping, diarrhea ´ Decreased HR, irreg pulse, hypoBP, decreased cardiac output à arrest

Treatment of Hyperkalemia

´ Mild ´ Loop diuretics ´ Dietary restriction ´ Med review to stop/adjust those that increase potassium ´ Moderate to Severe ´ Above measures ´ Telemetry ´ Kayexalate or Sorbitol ´ Hemodialysis ´ Emergent ´ Calcium gluconate (is short acting) ´ Correct acidosis c bicarb ´ Insulin and D10%

Nursing Considerations for Hyperkalemia

´ Monitor, trend and document: ´ Serum Potassium ´ Telemetry monitoring / ECG’s ´ Assess VS ´ Monitor intake and output

´ Report an output of less than 30 mL / hr ´ Monitor # and character of BM’s

´ Administer prescribed meds ´ Prepare for a slow calcium gluconate IV infusion for severe hyperK+ ´ Assess for hypoglycemia if receiving insulin and glucose treatment

9 4/19/20

Nursing Considerations for Hyperkalemia

´ Check donation date of blood; obtain fresh blood for the pt c hyperK+ ´ Safety measures for muscle weakness or paresthesias

´ Educate about causes and treatment of hyperkalemia ´ Educate on dietary sources of potassium & to avoid

´ Educate about reportable signs and symptoms

Chloride (CL-)

´ Normal range = 96 – 106 meq/L ´ Friends with sodium

´ Plays role in metabolism, digestion, moving fluids in & out of cells, and acid/base balance ´ Assists in C02 transport in the RBC’s ´ Levels depend on PO intake and renal absorption/excretion

´ Hypo – GI losses ´ Metabolic alkalosis ´ Hyper – rarely occurs alone (usually r/t metabolic acidosis)

Carbon Dioxide (C02)

´ Normal range = 23 -29 meq/L ´ 23-31 older adults

´ One indicator of blood oxygen ´ Used in evaluation of acid-base balance ´ Basis for the principal buffering system of ECF

´ Remember that a chemistry is VENOUS blood; do not use this value for ABG interpretation ´ Interpretation requires clinical information and evaluation of other electrolytes

10 4/19/20

Glucose

´ Normal range ´ Fasting <100 mg/dl non-diabetic ´ Fasting <130 mg/dl diabetic ´ Random <200 mg/dl ´ Energy source for most cells

´ A major product of carbohydrate breakdown ´ Critical to neuro function ´ Diabetics require a great deal of education & support

Glucose

Hypoglycemia Hyperglycemia Inadequate intake Diabetes Type 1 or Type 2 Excess insulin by injection Non-adherence with insulin therapy Not eating enough to cover insulin and/or lifestyle prescribed for a dosage diabetic Excess exercise Stress Malabsorption syndromes Liver disease Hypothyroidism Pancreatic disease Steroids, SSRI’s, other meds

Hypoglycemia

´ Signs/symptoms may include: ´ Irritability, anxiety ´ Shakiness, sweating ´ Hunger ´ Fatigue ´ Tachycardia ´ Tingling or numbness of the lips, tongue, cheek

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Hypoglycemia

´ Severely low glucose level will produce: ´ Confusion ´ Abnormal behavior ´ Visual disturbances, often blurry vision ´ Seizures ´ Loss of consciousness

´ Death, if untreated

Treatment of Hypoglycemia

´ Sugar! Simple (fast acting) carbs followed by a small meal to stabilize blood sugar & glycogen stores ´ IV dextrose if can’t take PO

´ Glucagon if no IV access ´ Monitor blood glucose 15 min after treatment and then periodically afterwards

Glucose

12 4/19/20

Hyperglycemia

´ Early signs/symptoms may include: ´ Thirst ´ Frequent urination ´ Blurry vision ´ Fatigue ´ Headache

Hyperglycemia

´ Later signs/symptoms may include: ´ Fruity-smelling breath ´ Nausea/vomiting ´ SOB ´ Weakness ´ Confusion ´ Abdominal pain ´ Coma ´ DKA or HHNC

´ Severe dehydration

Treatment of Hyperglycemia

´ Fluid replacement ´ Potassium replacement therapy

´ Insulin therapy ´ Frequent blood sugar monitoring

´ Diabetic teaching ´ Diabetic educator consult ´ Dietician consult

13 4/19/20

Calcium (Ca++)

´ Normal range = 8.5 – 10.5 ´ Slightly lower in older adults ´ Essential for cardiac & skeletal muscle contractility, nervous system function ´ Affects contraction of cardiac muscle, smooth muscle, & skeletal muscle ´ Plays a role in cell membrane permeability & impulse transmission ´ Important for formation of bones & teeth ´ Measured in one of two ways ´ Total serum calcium ´ Adjusted relative to serum albumin levels ´ Ionized calcium

´ Unchanged r/t serum albumin levels ´ Reflects the available calcium that can be used by body

Calcium (Ca++)

´ Calculating calcium & albumin levels ´ For every 1 gm/dl drop in serum albumin, total calcium decreases by 0.8 mg/dl

´ Should be corrected (some labs correct or “adjust” it for you)

Total serum calcium + 0.8 (4-albumin level) =

Corrected calcium

Calcium (Ca++)

´ Affected by body stores & dietary intake ´ Influenced by parathyroid hormone

´ When calcium levels are low, parathyroid releases parathyroid hormone

´ Draws calcium out of bone ´ Influenced by calcitonin

´ When calcium levels are too high, thyroid releases calcitonin ´ Inhibits bone resorption – keeps it there

´ Influenced by Vitamin D ´ Promotes absorption in gut, resorption from bone, and kidney reaborption

14 4/19/20

Calcium (Ca++)

´ Influenced by phosphorus ´ Inverse relationship between calcium and phosphorus ´ When calcium levels are high, inhibits calcium absorption in intestines (opposite of Vit. D) ´ When calcium levels are low, kidneys retain calcium ´ Influenced by serum pH ´ Inverse relationship with ionized calcium level

´ When pH level drops, less calcium binds to protein (albumin) & the calcium level rises ´ When pH level rises, more calcium binds with protein & the calcium level drops

Calcium (Ca++)

Hypocalcemia Hypercalcemia Inadequate dietary intake Hyperparathyroidism Excessive amounts are lost Cancer Malabsorption of calcium Hyperthyroidism Alcoholics particularly prone Decreased excretion by kidneys Diuretics Hypophosphatemia Renal disease Acidosis Decreased function of parathyroid Excessive Vit. D ingestion Hypomagnesemia Thiazide diuretics Hypoalbuminemia Alkalosis Meds Burns

Hypocalcemia

´ Serum Ca++ <8.9 mg/dl ´ Ionized Ca++ <4.5 mg/dl ´ Always interpret with serum albumin in mind ´ Most common cause is decreased function of the parathyroid gland ´ Signs/symptoms include: ´ Neurologic: Anxiety, confusion, irritability ´ May progress to seizures ´ Cardiac: characteristic ECG changes ´ Neuromuscular: paresthesias around mouth, fingers, toes; twitching, muscle cramps, tremors; hyperactive DTR’s, abdominal or laryngeal spasms ´ May progress to tetany

´ Check Chvostek’s & Troussea’s signs

15 4/19/20

Hypocalcemia

´ Chvostek’s sign

´ Facial twitching when the facial nerve is tapped ´ Trousseau’s sign

´ Carpal spasm when the upper arm is compressed

Treatment of Hypocalcemia

´ Correct/address underlying cause ´ Acute: immediate correction

´ EITHER IV calcium gluconate or IV calcium chloride ´ Monitor Mg+ ´ Chronic: Calcium supplementation, Vit. D supplements to facilitate GI absorption of calcium

´ Diet should include adequate intake of calcium, Vit. D, & protein.

16 4/19/20

Nursing Considerations for Hypocalcemia

´ Monitor and trend Ca++, albumin, Mg+ levels ´ Monitor VS

´ Frequent respiratory assessment ´ Cardiac telemetry to assess for arrhythmias

´ Assess for Chvostek’s and Trousseau’s signs ´ Insert and maintain IV catheter ´ If patient is recovering from parathyroid or thyroid surgery, have calcium gluconate readily available as precaution for a sudden drop in Ca++

Nursing Considerations for Hypocalcemia

´ Administer IV and/or PO replacements as prescribed ´ Monitor IV site & patency carefully, can cause extravasation ´ PO should be administered 60-90 min after meals

´ If GI upset occurs, give with milk

´ Safety measures for patient with ALOC or seizures

´ Teach importance of and sources of high calcium diet ´ Teach importance of adherence to calcium supplementation ´ Teach importance of exercise to prevent calcium loss from bones ´ Teach reportable signs and symptoms

Calcium (Ca++)

17 4/19/20

Hypercalcemia

´ Serum Ca++ >10.1 mg/dl ´ Ionized Ca++ >5.1 mg/dl ´ Always interpret with serum albumin in mind ´ Most common cause is hyperparathyroidism, followed by cancer ´ Can be life-threatening arrhythmias and cardiac arrest ´ Signs/symptoms include: ´ Fatigue ´ Confusion ´ Personality changes ´ Lethargy

´ May progress to coma in severe cases

Hypercalcemia

´ S/Sx cont’d. ´ Muscle weakness hyporeflexia, decreased muscle tone ´ Hypertension ´ Arrhythmias (bradycardia) ´ Can lead to cardiac arrest ´ Dig toxicity ´ GI – anorexia, N/V, constipation, abd pain, even ileus

´ Often the first signs noticed by pt ´ Renal issues – polyuria, thirst, dehydration, stones, failure ´ Pathologic fractures

Treatment of Hypercalcemia

´ Manage underlying cause ´ Hydration

´ Loop diuretics ´ Low calcium diet

´ Corticosteroids to block bone resorption and decrease calcium absorption from GI tract

´ Biphosphonates (Etidronate, Pamidronate) to decrease bone resorption ´ Dialysis in extreme cases

18 4/19/20

Nursing Considerations for Hypercalcemia

´ Monitor VS ´ Assess neuro and neuromuscular S/Sx ´ Monitor intake & output ´ Strain urine for stones, if present ´ Monitor & trend Ca++ levels, correlate with albumin ´ Telemetry – assess for arrhythmias ´ Higher risk if Dig toxicity occurs also ´ Push PO fluids (3 to 4 liters per day, unless contraindicated) ´ Insert & maintain IV access for aggressive IV hydration (unless contraindicated) ´ Frequent respiratory assessments for pulmonary edema (crackles, dyspnea, low 02 sats)

Nursing Considerations for Hypercalcemia

´ Ambulate patient frequently to prevent calcium from being released from bones ´ Handle gently to prevent pathologic fractures

´ If bedridden, turn frequently, perform active/passive ROM ´ Low calcium diet ´ Teach dietary and OTC medicine sources of calcium and to avoid

´ Teach importance of maintaining increased fluid intake ´ Teach reportable signs & symptoms ´ If receiving dialysis, will need much multidisciplinary team teaching and support

19 4/19/20

Blood Urea Nitrogen (BUN)

´ Normal range = 8 – 20 ´ Waste product created in liver when body breaks down proteins

´ Measure of renal or liver damage ´ Correlate with Creatinine

´ Susceptible to fluid

Creatinine

´ Normal range = 0.8 – 1.1 ´ By-product of muscle breakdown, eliminated by healthy kidneys

´ True measure of renal function ´ Not susceptible to fluid ´ Elevated Creatinine may indicate renal damage or disease

´ Correlate with BUN

Albumin

´ Normal range = 3.5-5.5 g/dl ´ Large protein molecule; produced by liver

´ Needed to keep fluid from leaking from blood vessels (plasma oncotic pressure) ´ Exerts osmotic “pull” in intravascular space to pull water into capillaries ´ May be used to maintain intravascular volume during 3rd spacing or to pull fluid from lungs into intravascular space, etc. ´ Monitor for fluid overload

´ Also plays role in healing, tissue growth, nutritional status, hormone transport, buffer

20 4/19/20

Total Protein

´ Normal range = 6.0 – 8.3 ´ Gross measure of nutritional status but can also reflect hydration status (hemodilution/concentration), fluid retention (CHF), liver disease and more ´ Will be lower in immobile patients, malnourishment, HF, cirrhosis, chronic alcoholism, Crohn’s, ulcerative colitis ´ Will be higher in dehydration, some chronic liver diseases

Magnesium (Mg+)

´ Normal range 1.5 – 2.5 mg/dl ´ Essential for many processes (>300!)

´ Plays role in regulating potassium and calcium levels, blood pressure, heartbeat, bone strength, skeletal & cardiac muscle contractions ´ Influences vasodilation ´ Takes part in protein synthesis, production of ATP, carbohydrate metabolism

´ Helps Na+ and K+ ions cross the cell membrane – affects both ion levels both inside and outside the cell ´ Influences Ca++ levels through it’s effect on parathyroid hormone

Magnesium (Mg+)

´ Must be interpreted in conjunction with albumin levels ´ 30% is bound with a protein, usually albumin ´ A low albumin will be associated with a low Mg+ ´ Serum Ca++, K+, and P can affect Mg+ levels too ´ Regulated by GI tract and kidneys ´ Small intestine absorbs what body needs ´ Kidneys balance Mg+ by adjusting reabsorption and excretion in urine ´ GI tract can also excrete Mg+

21 4/19/20

Magnesium (Mg+)

Hypomagnesemia Hypermagnesemia Poor intake Excessive retention: renal failure, Poor absorption in GI tract advanced age, Addison’s disease, Excessive GI loss adrenocortical insufficiency, DKA Excessive renal loss Excessive intake – dietary, antacids, Excessive Ca++ or P in GI tract Mg+ infusions, TPN Cancer Pancreatic insufficiency

Hypomagnesemia

´ Mg+ < 1.5 mEq/L ´ Relatively common imbalance, about 10% of hospitalized patients

´ Critically ill patients have highest incidence ´ Commonly linked to hypokalemia & hypocalcemia ´ Symptoms often don’t occur until level is <1 mEq/L ´ Range from mild to life-threatening ´ CNS ´ ALOC, confusion, delusions, hallucinations

´ Seizures

´ Depression, emotional lability

Hypomagnesemia

´ Skeletal muscles weak, nerves & muscles hyperirritable ´ 3 T’s & DTR’s

´ Tremors, twitching, tetany ´ Hyperactive DTR’s

´ Chvostek’s sign ´ Facial twitching when the facial nerve is tapped

´ Trousseau’s sign ´ Carpal spasm when the upper arm is compressed

22 4/19/20

Hypomagnesemia

´ Myocardial irritability, too ´ Esp if hypoK+ and hypoCa++ too ´ Arrythmias – PAC, SVT, VT, VF ´ ECG changes

´ Prolonged PR, QRS, QT intervals

´ Depressed ST

´ Flattened T ´ Prominent U

´ Dig toxicity

Hypomagnesemia

´ STARVED ´ S = seizures ´ T = tetany ´ A = anorexia, arrhythmias ´ R = rapid heart rate ´ V = vomiting ´ E = emotional lability ´ D = deep tendon reflexes increased

23 4/19/20

Treatment of Hypomagnesemia

´ Dietary replacement or oral supplements ´ Replacement may continue for a few days after serum Mg++ level returns to normal ´ Takes longer to replenish Mg++ stores INSIDE cell

´ IV magnesium sulfate ´ May also be given deep IM if no IV access obtainable ´ If alcoholic, implement Alcohol Withdrawal Protocol

Nursing Considerations for Hypomagnesemia

´ Assess VS ´ Assess mental status

´ Assess respiratory status ´ Assess neuromuscular status – hyperactive DTR’s, tremors, tetany, Chvostek’s sign, Trousseau’s sign ´ Assess dysphagia before giving anything by mouth

´ Telemetry – monitor for arrhythmias ´ Prepare for possible seizures ´ Insert & maintain IV access for magnesium replacement therapy

Nursing Considerations for Hypomagnesemia

´ Have calcium gluconate readily accessible during Magnesium Sulfate replacement ´ Assess intake and output

´ Teach high-magnesium diet sources ´ Teach reportable signs and symptoms ´ If alcoholic, monitor for & treat withdrawal symptoms, encourage a chemical dependency consult; arrange if patient agrees ´ Provide alcohol cessation resources, referral to local Alcoholics Anonymous meetings, etc.

24 4/19/20

Magnesium (Mg+)

´ If K+ is low and not responding to replacement, request a mag draw ´ If Mg+ is low, replace it before replacing K+

´ Adequate Mg+ is necessary for K+ absorption & utilization

Magnesium (Mg+)

Hypermagnesemia

´ Mg++ >2.5 mEq/L ´ Depressed neuromuscular symptoms

´ Decreased muscle and nerve activity ´ Hypoactive DTR’s ´ Generalized weakness

´ May progress to flaccid paralysis in severe cases

´ Depressed CNS symptoms ´ Drowsy ´ Lethargy ´ Sometimes, nausea/vomiting

25 4/19/20

Hypermagnesemia

´ Weakens respiratory muscles ´ Slow, shallow, depressed respirations à respiratory arrest

´ Cardiac issues ´ Bradycardia, heart block arrhythmias à cardiac arrest ´ ECG changes ´ Prolonged PR interval, widened QRS complex, & tall T wave ´ Vasodilation lowers BP

Treatment of Hypermagnesemia

´ Fluids, if no renal failure ´ Diuretic

´ Dialysis, if renal failure ´ Emergent: calcium gluconate, mechanical ventilation

Nursing Considerations for Hypermagnesemia

´ Monitor VS, be alert for respiratory depression &/or hypotension ´ Evaluate for changes in mental status

´ Assess DTR’s ´ Monitor & trend Mg++, BUN, Creatinine

´ Telemetry monitoring ´ Trend ECG tracings ´ Administer fluids and diuretics as prescribed

´ Monitor I and O

26 4/19/20

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Questions?