Shock: NCLEX Review

Shock – What is it?

Shock is a generalized systemic response to inadequate tissue perfusion. The major types are hypovolemic (absolute and relative), cardiogenic, distributive (neurogenic, anaphylactic, and septic), and obstructive shock. While they all generally have the same end result if not treated, the signs, symptoms, and interventions can be different for each type.

Shock is a complex process that can be explained down the the cellular level. We could get into cytokines and neutrophil entrapment, but this post is going to focus on nursing interventions rather than detailed pathophysiology.

As usual, I will be using my favorite textbooks/resources to write this post! Clicking on the links below will take you to an affiliate website where you can purchase them for yourself or browse around for other books.

Phases of Shock

Initial: Decreased cardiac output, decreased perfusion, anaerobic metabolism, lactic acidosis. You want to catch any signs and symptoms before it progresses any further.

Compensatory: The body is responding to the problem by increasing cardiac output and increasing oxygen delivery to tissues. (Sympathetic nervous system is in action here!)

Progressive: Compensation is not working and cells are starting to die off because anaerobic metabolism is not enough. (Systemic Inflammatory Response System)

Refractory: Shock is unresponsive to treatment and death is the probable outcome. (Multiple Organ Dysfunction Syndrome)

Hypovolemic Shock

This is the most common type of shock. It is caused by either a loss of volume (hemorrhage) or a displacement of volume (burn patients).

Signs/Symptoms/Assessment

  • Weak and rapid pulse
  • Hypotension
  • Restlessness/Altered mental status
  • Tachypnea
  • Cool, clammy skin
  • Oliguria
  • Sluggish capillary refill
  • Absent bowel sounds
  • Poor peripheral pulses

Interventions

  • Treat the cause!
  • If hemorrhage, hold pressure, replace fluids/blood
  • Insert 2 large bore IVs
  • Notify the HCP/rapid response team
  • Administer oxygen (high flow if necessary)
  • Maintain patent airway
  • Monitor vital signs
  • Monitor I/O
  • Assess skin color, temperature, turgor, moisture
  • Assess lung sounds
  • Elevate the legs (contraindicated if patient has spinal anesthesia)

Cardiogenic Shock

This is defined by a failure of the heart to pump adequately, which reduces cardiac output. This means that tissues are not being adequately oxygenated just as in hypovolemic shock. Some causes are myocardial infarction, valvular problems, and ventricular failure (reduced ejection fraction).

Treatment goals are to support cardiac output and improve coronary artery blood flow.

Signs/Symptoms/Assessment

  • Same as above
  • Pulmonary congestion
  • Chest discomfort

Interventions

  • Administer oxygen
  • Administer morphine
  • Administer vasodilators
  • Maintain patent airway
  • Administer vasopressors and positive inotropic medications
  • Treat problem–prepare for cath lab, IABP, CABG
  • Monitor I/O
  • Assist with insertion of Swan-Ganz
  • Monitor CVP, PAWP, and MAP
  • Monitor circulation (cap refill, pulses, mucous membranes)

Review Cardiac Medications Here!

Anaphylaxis

This type of shock is different from hypovolemic and cardiogenic shock. You will see that the assessment data, signs and symptoms, and interventions are also different. Anaphylaxis, or anaphylactic shock, is a sudden, severe cascade response (hypersensitivity) to an allergen. Antibodies combine with antigens and set off mast cells and histamines and cause massive vasodilation.

Signs/Symptoms/Assessment

  • Pruritus, angioedema, erythema, urticaria
  • Headache, dizziness, paresthesia, feeling of impending doom
  • Hoarseness, coughing, wheezing, stridor, dyspnea, tachypnea, sensation of narrowed airway, respiratory arrest
  • Hypotension, dysrhythmias, tachycardia, cardiac arrest
  • GI cramping, abdominal pain, N/V/D

Interventions

  • Remove the suspected allergen (stop blood transfusion, stop iodine contrast, etc.)
  • Assess respiratory status, maintain patent airway
  • notify HCP and/or rapid response team
  • administer oxygen
  • infuse normal saline (try for 2 large bore IV’s)
  • Medications: epinephrine, antihistamines (benadryl), steroids (hydrocortisone), beta-agonist
Image credit: Lonnie Millsap (lonniemillsap.com)

Neurogenic Shock

This is another type of distributive shock that impairs perfusion from vasodilation. It is most common in patients with recent injuries above T6. This can lead to pooling of blood in blood vessels.

Signs/Symptoms/Assessment

  • Hypotension
  • Bradycardia
  • Decreased cardiac output
  • Inability to sweat below the level of the injury (skin is warm and dry)

Interventions

  • Monitor vital signs
  • Notify HCP/rapid response team
  • IV fluids
  • Administer vasopressors
  • Administer atropine for bradycardia
Image source: Wikipedia

Septic Shock

Septic shock is the most extreme reaction to an infection; it is a subset of sepsis in which there is profound circulatory, cellular, and metabolic abnormalities. It is vasodilation caused by endotoxins from microorganisms.

Signs/Symptoms/Assessment

  • Tachypnea > 22 breaths/minute
  • Altered mental status – GCS < 15
  • Systolic blood pressure < 100
  • Lactic acid > 2 mmol/L
  • Unresponsive to fluid resuscitation
  • symptoms of infection – fever >100.2 F or <96.8 F

Interventions

  • Assist with placing central line
  • Monitor CVP
  • Fluid resuscitation
  • Vasopressors
  • Monitor urine output
  • Ensure cultures have been sent
  • IV antibiotics

Knowing the signs and how to manage different types of shock is essential for any nurse! I hope this review helps spark your memory for the NCLEX! Check out some of my other NCLEX review posts below:


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Stages of Labor NCLEX Review

Stage 1

Defined as the first onset of contractions through the complete dilation of the cervix, with 3 separate phases. Stage 1 is the longest phase. Throughout this phase, keep in mind the following interventions:

  • Monitor maternal and fetal vital signs.
  • Continually assess FHR before, during, and after contractions.
  • Assess fetal descent, cervical dilation, and effacement.
  • Assess fetal station presentation and position.
  • Encourage frequent position changes and/or ambulation if not contraindicated.
  • Involve patient and support person in labor process and what to expect.

Latent Phase

To start, I will add another definition here, prodromal labor. This is latent phase labor that has lasted several days.

The latent phase is usually defined by:

  • Cervical dilation is 1 to 4 cm.
  • Uterine contractions occur q15-30 mins and last 15-30 sec.
  • Lasts an average length of 5-8 hrs
  • Contractions are of mild intensity

In this stage, mom’s will most likely be feeling a variety of emotions. They are also usually able to participate in their own care and may not quite ask for pain control interventions at this time. Keep in mind that each mom is unique and requires individual assessment!

Active Phase

This phase consists of:

  • Cervical dilation of 4 to 7 cm.
  • Uterine contractions q3-5 min and last 30-60 sec.
  • Lasts an average length of 2-5 hrs.
  • Some fetal descent.
  • Contractions are moderate-strong intensity.

During this phase of labor, mom’s behavior will start to shift. She will start breathing heavier and may not be able to talk through contractions. She will benefit from a quiet environment and pain control interventions. Pain interventions do not have to be medication, as promoting comfort with back rubs, sacral pressure, and position changes can be effective and beneficial.

Transition Phase

This phase is arguably the “most difficult” phase of labor.

  • Cervical dilation is 8 to 10 cm.
  • Uterine contractions occur q2-3 min and last 45-90 sec in duration.
  • The contractions are of strong intensity.
  • Fetal descent.

During this phase, mom may have increased anxiety, apprehension, and discomfort. She will experience increased pressure, bloody show, and may verbalize the urge to push. Contrary to the active phase of labor, she may not want to be touched. Rest is encouraged between contractions.

Stage 2

Stage 2 is defined as the period from complete cervical dilation and effacement to the delivery of the fetus, or “Expulsive” phase.

  • Contractions continue to occur q2-3 min lasting 60-75 sec.
  • Increase in bloody show occurs.
  • Mom will experience voluntary or involuntary urge to “bear down.”
  • This stage can last minutes to 4 hours.

Sources of pain during the 2nd stage of labor change from pain in a more generalized area to localized to the distention of the vagina and perineum and pressure on adjacent structures.

It is important to complete assessments every 5 minutes. Normal FHR is 110-160 bpm before, during, and after contractions.

Cardinal movements of labor:

  • Descent
  • Flexion
  • Internal Rotation
  • Extension
  • Restitution
  • External Rotation
  • Expulsion

Stage 3

The process of labor does not stop once the baby has been born! This 3rd stage is from the delivery of the infant to the expulsion of the placenta. Contractions continue to occur until this is completed.
Image source: https://www.newlifeblessings.com/blog/category/placenta

  • Schultze Mechanism: “Shiny shultze” – center of the placenta separates first, and the shiny portion of the placenta emerges first.
  • Duncan Mechanism: “Dirty duncan” – the margin of the placenta separates first and the dull, rough, red portion of the placenta emerges first.

Signs of placental separation:

  • Uterus becomes globular shaped
  • Rise of the fundus in the abdomen
  • Sudden gush or trickle of blood
  • Further protrusion of the umbilical cord out of the vagina

Be sure to continue involving the mother and support person in this stage about the steps of delivering the placenta while also promoting parental-neonatal attachment. The uterine fundus should be firm and should be located 2 fingerbreadths below the umbilicus.

A placenta is considered retained if more than 30 minutes has elapsed since the birth of the infant.

Stage 4

Stage 4 is known as the Recovery Stage. This stage is defined from the delivery of the placenta to the immediate recovery of the mother.

It is important to perform maternal assessments q15min for 1 hour, q30min for 1 hour, and hourly for 2 hours, or according to facility policy. Apply ice packs to the perineum, and massage the uterus as needed to keep it firm.

The mother may also experience chills, a hypotonic bladder, and a variety of emotions related to the birth process. Encourage continued bonding between the infant and parents, and provide breast-feeding support as needed.

References and Additional Resources

All image sources are linked near or under the image on this page. I do not own the rights to images posted on this page.

Continue your NCLEX Review Journey by checking out some of my other NCLEX Review posts!


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How to Answer Priority and Delegation NCLEX Questions

Everytime I see one of these questions, I want to pull my hair out! They intimidate me and I often feel the least prepared for these types of questions. Here I will break down how to answer NCLEX-style priority and delegation questions.

A lot of this material comes from the Saunder’s Comprehensive NCLEX Review💎. If you’ve seen any of my other posts, you have probably run across this book. I wish I would have purchased this book my first semester of school. I bought it my third semester and kicked myself for not getting it sooner. It has been worth every penny to me!

Another great resource is the Brilliant Nurse💎 Course for NCLEX prep. It has practice questions, detailed rationales, videos, strategy sessions, and case studies. The prices are very competitive with other similar online NCLEX-prep websites.

Priority

Prioritizing patient care is an essential nursing skill. It will determine who gets care first, and the order in which you perform your tasks. Often in the clinical setting, it can be easier to spot your priorities because you have access to a lot of information. NCLEX-style questions can be tough simply because you are given 1-2 sentences of limited information with which you must make the decision.

These types of questions can be multiple choice, select all that apply, ordered response, exhibit questions, etc. Any type of question is game!

Priority Guidelines

  • ABC’s – Airway, Breathing, Circulation
  • Remember Maslow’s Hierarchy of Needs
  • Consult your patients about their priorities and needs
  • Use the nursing process to guide you

When you are given a set of choices, read them all before making your decision. Hopefully you can eliminate 1-2 choices right off the bat. After that, use your ABC’s. If any answer choices fall into that, it is probably your answer.

Delegation

The key to answering delegation questions is understanding the scope of practice for yourself and each of your colleagues. You must also analyze the tasks that need to be done and the importance of completing them. Then, assign tasks to a competent individual.

When you assign a task to someone else, the nurse who owns the task is accountable for it.

Always ensure patient safety when delegating tasks. In general, non-invasive interventions such as ambulation and hygiene measures can be delegated to UAP’s (Unlicensed Assistive Personnel). An LPN or LVN can do some invasive procedures such as catheterization and suctioning.

Remember that a Registered Nurse is responsible for assessment, planning care, initiating teaching, and administering medications intravenously.

Never assign an unstable patient to UAP’s or LVN’s.

I hope this helps explain how to approach these questions! Practice makes perfect. Use one of the resources listed above to do practice questions! The more you expose yourself to these tough questions, the better you will get at it!


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How to Study Health Assessment in Nursing School

Assessment is one of the skills that set you apart from a lot of other medical careers. CNA’s, MA’s, Techs, and other UAP’s do not have the assessment skills that registered nurses have. It is one of those skills that is pounded in nursing school, but never truly mastered until years and years of practice. This guide will hopefully give you a better idea of how to study Assessment in Nursing School and answer HESI and NCLEX style questions.

Your textbook may be different, but we used Jarvis’s Physical Examination and Health Assessment, 7th ed.💎

Anatomy & Physiology

Most programs in the United States require A&P I and II. I’ve rarely seen some programs squish all of that in one class. You need to be a master at your anatomy and physiology. Review cardiopulmonary, abdomen, and neuro anatomy before school starts. You will need to be able to pretty much label and/or draw from memory most of your body systems. A lot of people in my class had trouble with Assessment most likely because they were weak in anatomy. I personally had trouble with the cardiovascular system for this very reason.

Vocabulary

There will be a lot of big medical terms that you’ll need to know! Hopefully you’ve picked up a lot from A&P, Patho, and your other Biology classes. When you study, make flashcards of all of the terms you do not know and study them every single day. These words WILL be on your exams, HESI, and NCLEX. Learn them now.

Normal vs. Abnormal

Assessment is all about knowing what you are supposed to be seeing, hearing, and feeling (namely inspecting, auscultating, and palpating). Establishing this foundation is very important! I took notes in two columns. One side was “normal” findings, and the other side was “abnormal” findings.

In your practice, you should be able to tell when something is wrong. You may not know 100% what is going on, but you should be able to tell your doctor over the phone what your findings are.

Study Habits + Repetition

Assessment is a tough subject. It is a lot to chew, especially with your other classes. You need to establish excellent study habits. This means no more going out every weekend, no more binge watching TV. You gotta get up earlier and go to bed later. Check out my Top 10 Study Tips to get some more tips on how to establish excellent study habits!⬇️

Repetition is key with Assessment. I probably studied each set of material more than ten times. I rewrote notes, drew pictures, and answered plenty of practice questions. I made it a goal to know the material inside and out. I probably spent the most amount of time studying for the class during my first semester.

Practice

As much fun reading out of a book is, nursing isn’t all about reading a patient’s chart. You need to practice! Practice on everyone that will let you. Friends, family, strangers (JK, that might be weird). Get used to going through your full head to toe on different people. Talk through your assessment, even if the other person has no idea what you’re saying!

Patience

These skills will come to you. Like I said in the beginning, you will not master these skills until you’ve been in practice for a long time. Don’t be too hard on yourself and don’t be afraid to seek help! As always, I am here to answer your questions!



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Cardiac Drugs Quick Sheet!

Just a quick overview for the major cardiac/ACLS drugs as pertaining to adults. This is essentially what my flash cards would pertain!

Digoxin

  • Action
    • Positive inotrope – increases the force of cardiac contraction
    • Decrease HR
    • Allow for more complete emptying of the ventricles, thus increasing CO
    • Decrease conduction through the AV node, reduce automaticity of the SA node
  • Indications
    • Heart failure
    • A-fib and A-flutter
    • Paroxysmal atrial tachycardia
  • Special Considerations
    • Monitor potassium levels
    • Count apical for 1 min prior to administration

Atropine

  • Action
    • An anticholinergic drug and increases the firing of the SA node by blocking the action of the vagus nerve.
    • Increases HR
  • Indications
    • 1st line for symptomatic bradycardia
  • Special Considerations
    • Anticholinergic S/E
    • Increases myocardial oxygen demand à be careful in presence of myocardial ischemia

Adenosine

  • Action
    • Antiarrhythmic that decreases conduction through the AV node
  • Indications
    • Paroxysmal Supraventricular Tachycardia
  • Special Considerations
    • Commonly causes a few seconds of asystole
    • Very short half-life (6-10 seconds)
    • Push FAST
    • Patient may feel “like they got punched in the chest”

Amiodarone

  • Action
    • Delay repolarization resulting in prolonged duration of action potential and refractory period
    • Class III Potassium Channel Blocker
    • Decreases heart rate and contractility
  • Indications
    • Pulseless V-fib or V-tach
    • Oral – Atrial fibrillation
  • Special Considerations
    • Do NOT use with cardiogenic shock or severe sinus bradycardia à may cause hypotension
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Epinephrine

  • Action
    • Stimulate beta1 receptors à cardiac stimulation
    • Increased HR, CO, and contractility
  • Indications
    • Cardiogenic shock, Anaphylactic shock, Septic shock
    • Cardiac arrest, pulseless ventricular tachycardia, ventricular fibrillation, asystole
  • Special Considerations
    • Raises BP and increases HR à may cause myocardial ischemia, angina
    • May contribute to post-resuscitation myocardial dysfunction

Dopamine

  • Action
    • Positive inotropic
    • Increased myocardial contractility, increased automaticity, increased AV conduction, increased HR, CO, BP, MAP
  • Indications
    • Cardiogenic shock
    • 2nd line for symptomatic bradycardia
  • Special Considerations
    • Correct hypovolemia with volume replacement before using dopamine
    • DO NOT mix with Sodium Bicarb

Lidocaine

  • Action
    • Sodium channel blocker
  • Indications
    • V-fib, V-tach – with and without pulse
  • Special Considerations
    • *REMOVED from ACLS Guidelines*
    • Can cause toxicity!

Sources: 2018 ACLS Guidelines (Provider Manual), Medical-Surgical Nursing : Assessment and Management of Clinical Problems, 10th Ed (Lewis)💎



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Pharmacology: Seizures and Epilepsy

Definitions:

Convulsion: abnormal motor phenomena (jerking, movements, tics, rigors)
Seizure: a sudden, excessive synchronous electrical discharge of neurons in the brain that can spread to other foci
Epilepsy: group of chronic neurological disorders characterized by recurring seizures

Main Types of Seizures:

Simple Partial: discrete motor, sensory, autonomic and psychoillusionry symptoms. No loss of consciousness. Persists 20-30 seconds.
Tonic-Clonic: major convulsions characterized by a period of muscle rigidity (tonic phase) followed by synchronous muscle jerks (clonic phase). Immediate loss of consciousness. Followed by postictal state. Lasts 90 seconds or less.

Therapeutic Goals:

  • Enable patient to live a normal life.
  • Ideally eliminate seizures, but may not be possible

How do Anti-Epileptic Drugs Work?

  • suppress discharge of neurons within a seizure focus
  • suppress the spread of seizure activity from the focus to other areas of the brain
  • decrease in sodium influx, decrease in calcium influx, increase in potassium influx

Traditional AED’s

  • Phenytoin (Dilantin): Therapeutic range: 10-20mcg/mL, can cause gingival hyperplasia and nystagmus
  • Carbamazepine (Tegretol): Also treats trigeminal neuralgia and bipolar disorder. Contraindicated if patient has bone marrow depression or hypersensitivity. Avoid grapefruit juice!
  • Valproic Acid (Depakote): Also treats migraines and bipolar disorder. Therapeutic range: 50-100mcg/mL. Highly teratogenic! Can cause hepatotoxicity, pancreatitis and hypersensitivity.
  • Ethosuximide (Zarontin): Treats absence seizures. Therapeutic range: 40-100mcg/mL. Generally devoid of adverse effects.
  • Phenobarbital: Older drug, long-acting. Toxicity can cause nystagmus and ataxia. Overdose can cause respiratory depression and possibly death. Has a sedative effect, cognitive/learning impairment, CNS depression and drug dependence. May make children hyper.

Status Epilepticus

A MEDICAL EMERGENCY in which a patient is continually having tonic-clonic seizures for 20-30 minutes and is not conscious the whole time.

Immediate treatment includes: turning patient to the side, administering oxygen, removing objects that could potentially harm, having padded bedrails, suction secretions, and DO NOT restrain the patient or put anything in their mouth. Administer one of the following medications:

  • Diazepam (Valium): Used for emergency treatment of status epilepticus. Short half-life. May develop physical dependence and withdrawal symptoms.
  • Lorazepam (Ativan): Drug of choice used in status epilepticus because of prolonged effects. A rectal gel is available for out of hospital use.

Source: Lehne Pharmacology for Nursing Care, 9th Edition, Chapter 24💎



Pharmacology: Parkinson’s Disease Quick Sheet

Parkinson’s disease (PD) is a chronic and progressive movement disorder, meaning that symptoms continue and worsen over time. Nearly one million people in the US are living with Parkinson’s disease. The cause is unknown, and although there is presently no cure, there are treatment options such as medication and surgery to manage its symptoms.

Parkinson’s Disease Foundation, 2016

Parkinson’s Disease:

  • Idiopathic degenerative disorder of CNS from loss of dopamine-secreting neurons in the substantia nigra
  • – Clinical presentation: resting tremor, rigidity, bradykinesia, postural disturbances
  • Therapeutic goals: Improve ADL’s

Dopaminergic Drugs:

  • Activates dopamine receptors, increase dopamine levels, inhibit actions of ACH
  • LEVODOPA: metabolic precursor of dopamine that crosses the BBB, converted to dopamine once in the brain. Disappointing long term effects such as “wearing-off” and “on-off” phenomenon. 2% reaches the brain
  • CARBIDOPA-LEVODOPA: carbidopa prevents levodopa from getting destroyed by decarboxylase enzymes in the peripheral blood. Allows for lower dose of levodopa and less side effects
  • Major side effects: N/V, dyskinesias, orthostatic hypotension

Anticholinergic Drugs:

  • Decreases effects of ACH
  • Can reduce tremor, possibly rigidity, but not bradykinesia
  • Less effective than dopaminergic drugs
  • Most used: BENZOTROPINE (COGENTIN) and TRIHEXYPHENIDYL (ARTANE)
  • Major side effects: dry mouth, blurred vision, tachycardia, constipation, urinary retention, decreased sweating, increased body temp

COMT Inhibitors

  • inhibit metabolism of levodopa in the periphery
  • have no therapeutic effects of their own
  • ENTACAPONE and TOLCAPONE

MAO-B Inhibitors

  • inhibit inactivation of dopamine in the brain
  • when combined with levodopa, can reduce “wearing off” effect
  • SELEGILLINE (ELDEPRYL)

Source: Lehne’s Pharmacology for Nursing Care, 9th Edition. Burchum and Rosenthal, Chapter 21.💎 | Medical-Surgical Nursing : Assessment and Management of Clinical Problems, 10th Ed (Lewis)💎



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NCLEX Review: Fluid and Electrolytes

Sodium (135-145 mEq/L)

  • The major cation in the ECF. It has a water retaining effect. When there is excess Na+ in the ECF, more water will be reabsorbed by the kidneys.
  • Functions: maintains body fluids, conduction of neuromuscular impulses via pump, regulates acid-base balance by combining with Cl- or HCO3-.

Hyponatremia

  • Causes: vomiting, diarrhea, NG suction, excessive perspiration, kidney disease, water intoxication, IV D5W, SIADH, burns
  • Signs and Symptoms: apprehension, muscular weakness, postural hypotension, N/V, dry mucous membranes, tachycardia
  • Treatment: water restriction, normal saline IV

Hypernatremia

  • Causes: excessive salt intake, dehydration, CHF, hepatic failure (excess aldosterone secretion), diabetes insipidus
  • Signs and Symptoms: extreme thirst, sticky mucous membranes, dry tongue, fever, postural hypotension, restlessness/agitation/irritability, increased fluid retention/edema, decreased urine output, convulsions
  • Treatment: stop IV normal saline, replace water loss

Potassium (3.5-5.0 mEq/L)

  • The major ICF electrolyte, 80%-90% is excreted by the kidneys.
  • When tissue breaks down, K+ leaves the cells and enters the ECF and is excreted by the kidneys
  • The body does not conserve K+
  • Influences both skeletal and cardiac muscle activity

Hypokalemia

  • ** The most common electrolyte imbalance
  • Causes: vomiting/diarrhea, renal disorder, sweating, crash diets, diuretics
  • S/S: fatigue, anorexia, N/V, muscle weakness, decreased bowel motility, cardiac dysrhythmias, paresthesia or tender muscles
  • Treatment: administer KCl (never give K+ undiluted or IV push. concentrated solutions should be administered through central veins. Use IV pump!)

Hyperkalemia

  • Causes: renal failure, potassium supplements, digoxin toxicity, potassium sparing diuretics, acidosis (DKA), fluid volume deficit. 
  • S/S: anxiety, cardiac arrhythmias (bradycardia, heart block, peaked T wave, widened QRS), muscle weakness, abdominal cramps, diarrhea
  • Treatment: dialysis, Kayexalate, stop supplements

Calcium (4.5-5.3 mg/dL)

  • Ionized (free Calcium) is Calcium not attached to proteins.
  • 99% is located in skeletal system, 1% in serum
  • Necessary for bone and teeth formation
  • Necessary for the transmission of nerve impulses and contraction of the myocardium and skeletal muscles
  • Causes blood clotting by converting prothrombin into thrombin
  • Strengthens capillary membranes

Hypocalcemia

  • Causes: lack of Ca and Vit D in diet, extensive infection, hypoparathyroidism, pancreatitis, chronic renal failure (Phosphorus rises/calcium declines)
  • S/S: Related to diminished neuromuscular and cardiac function – positive Trousseau’s sign, positive Chvostek’s sign, numbness of fingers and around mouth, hyperactive reflexes, tetany, convulsion, spasms/muscle cramps, arrhythmia/ventricular tachycardia. (CATS: convulsions, arrhythmias, tetany, spasms)
  • Treatment: Oral/IV replacement, correct underlying cause

Hypercalcemia

  • Causes: hyperparathyroidism, neoplasm, osteoporosis, prolonged immobilization
  • S/S: anorexia, N/V, lethargy, flank pain from kidney stones, cardiac arrhythmias (heart block, eventual cardiac arrest), muscle flaccidity
  • Treatment: Calcitonin, discontinue antacids, treatment of underlying cause

Phosphate (2.7-4.5 mg/dL)

  • buffer found primarily in ICF
  • functions: acid-base regulation, phosphate and calcium help with bone and teeth development, promotes normal neuromuscular action and participates in CHO metabolism, conversion of glycogen to glucose
  • normally absorbed in the GI tract, regulated by diet, renal excretion, intestinal absorption and PTH

Hypophosphatemia

  • Cause: excretion
  • Symptoms: disorientation, bruising, numbness, bone pain, muscle weakness
  • Treatment: increase dietary intake, IV replacement

Hyperphosphatemia

  • Causes: decreased intake or increased excretion
  • S/S: same as hypocalcemia
  • Treatment: limit phosphate intake, administer aluminum-based antacids.

Chloride (98-106 mEq/L)

  • anion found mostly in ECF, maintains body water balance, plays a role in acid-base balance, combines with H+ to produce acidity in the stomach
  • follows Na+ up or down

Hypochloremia

  • Causes: vomiting, diarrhea, excessive NG drainage, hypokalemia, hyponatremia, adrenal gland deficiency
  • S/S: hyperexcitabilty of the nervous system and muscles, tetany
  • Treatment: treat underlying cause

Hyperchloremia

  • Causes: dehydration, hypernatremia, kidney dysfunction, head injury, hyperparathyroidism
  • S/S: deep, rapid, vigorous breathing, lethargy, weakness
  • Treatment: decrease intake, correct underlying cause

Magnesium (1.5-2.5 mEq/L)

  • Most plentiful in the cells
  • Needed for neuromuscular activity
  • Responsible for the transport of Na and K across the cell membrane

Hypomagnesemia

  • Causes: protein malnutrition, alcoholism/cirrhosis of the liver, aldosterone excess, inadequate absorption (chronic diarrhea, vomiting, NG drainage)
  • S/S: muscle tremors, hyperactive tendon reflexes, confusion, tachycardia
  • Treatment: treat underlying causes, IV replacement if necessary.

Hypermagnesemia

  • Causes: severe dehydration, renal failure, leukemia, antacids/laxatives
  • S/S: flushing, muscular weakness, increased perspiration, cardiac arrhythmias (bradycardia, prolonged QT intervals, AV block)
  • Treatment: treat underlying cause

Helpful Tidbits

  • 4 electrolytes that impact cardiac functioning: K, Mg, Ca, Ph
  • 3 imbalances that contribute to digoxin toxicity: hypokalemia, hypercalcemia, hypomagnesmia
  • 4 imbalances that contribute to seizures: hyponatremia, hypocalcemia, hypomagnesmia, hyperphosphatemia
  • Electrolytes associated with alkalosis: hypomagnesemia, hypokalemia
  • Clinical Dehydration = ECV Deficit + Hypernatremia

Source: Texas Woman’s University College of Nursing, Fundamentals of Nursing – Perry & Potter 2016💎




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