February 22, 2022 • 21 mins
Our first episode dedicated to a class of medications. This episode we explore the autonomic nervous system and medications that can affect it called Adrenergic and Cholinergic Medications.
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Stacey Hobbick (00:01):
Hey friends and welcome to nursing with Dr.
Hobbick. Today I am thinkingabout electrolytes. Still
thinking a little bit about thatfluid balance. These two
concepts are pretty interwoven.
And in a later episode I'll getinto acid base. Today I want to
talk about electrolytes and howthey can be imbalanced. The
(00:22):
first thing I want you to thinkabout is intake, absorption,
distribution, and output.
Electrolytes can be imbalancedthrough intake if they're not
taking in enough or they'retaking in too much. Absorption
can affect your electrolytebalance by not absorbing
(00:43):
electrolytes appropriately, wecould end up with low levels
distribution. This is big whenwe're talking about things like
potassium, calcium andmagnesium, especially potassium.
Because the levels of theseelectrolytes inside the cells in
the intracellular compartmentare much higher than they are in
(01:05):
the extracellular compartment.
Remember that when we're testingthe levels of these
electrolytes, we're testing thelevels in the bloodstream in the
serum in the extracellularspace, the difference between
the levels is pretty dramatic.
Sodium is the most abundant canion in the extracellular
(01:27):
compartment. Potassium is themost abundant cat ion in the
intracellular compartment. Andyou'll see the huge difference
when you look at the levels thatwe would see a normal level. Now
I want you to understand thatyou will see some variants in
reference ranges, don't let thatworry you too much. Just
(01:48):
memorize some set that you'reusing in your current program.
And you'll get through justfine. So if I use reference
ranges that are different thanwhat you're used to, they
shouldn't be way off. If theyare Gosh, send me a message on
one of my platforms. You canfind me on Facebook, Instagram,
YouTube, Tik Tok, where else I'meverywhere, let's say potassium,
(02:10):
the normal range for potassiumis 3.5 to five. Now that's the
serum level, the normal rangefor sodium is 135 to 145, you
may see 136 to 145, it doesn'tmatter that much. Obviously,
there's a huge differencebetween the number or the amount
(02:32):
rather of sodium then potassium,consider this if my patient has
blunt force, trauma, or burns,or something that is going to
cause a lot of cells to burst,those cells will release all of
their intracellular contents,including their high
concentrations of these otherelectrolytes, that's going to
(02:55):
really mess up my balance ofelectrolytes in the bloodstream
in the extra cellular space.
That would be a imbalance ofdistribution, we can have an
output. If there is too muchoutput or not enough output of
electrolytes that can also causeimbalance output, we normally
lose electrolytes through urine,feces a little bit through sweat
(03:17):
abnormally we could lose itthrough vomiting, wound
drainage. Now we're talkingabout a lot of drainage not like
that little paper cut, we alsoneed to talk about other GI
losses gastric suction, if youput an end G tube into your
patient and it's to suction, youmight want to think about their
electrolyte balance. Just likeif they were vomiting, it's the
(03:40):
same thing. And if your patienthas diarrhea, they could be
losing electrolytes. Thefunctions of the large intestine
are really to absorb water andelectrolytes. If we have
diarrhea, that stuff's movingthrough there so fast, he can't
do its job, we're going to losefluid. And electrolytes that
way, remember that fluid iswater with things dissolved in
(04:00):
it. In that case, we're losingboth electrolytes and water,
let's just get an idea of plasmaversus intracellular
concentration. So I told youthat the plasma volumes for
potassium is 3.5 to five forsodium it's 135 or 136 to 145.
(04:21):
inside the cell, we have about14 mil equivalents per liter of
sodium only 14 When outside thecell we have 135 to 145. inside
the cell, we have 140 Milletequivalents per liter of
potassium were outside the cellwe have 3.5 to five, you can see
that the concentrations of theseare very different on either
(04:43):
side. The reason for that has todo with how the body creates
energy, how the body createsnerve and muscle contraction.
That's really what ourelectrolytes do for us besides
also contributing to osmolaritylike we talked about last week.
So we'll talk briefly aboutthese different electrolytes,
sodium in some textbooks isreally described as an
(05:06):
osmolarity imbalance. In otherwords, it's a concentration
issue in the bloodstream, thepatient could have too much
sodium or too little water, orthey could have a water excess
or too little sodium. If youneed to go back and refresh on
some of the anatomy of the restsystem ADH hormone metric
(05:30):
peptide, I recommend the KhanAcademy videos they are
fantastic on review forpathophysiology. These are
important concepts for you tounderstand if you're going to
understand sodium and fluidbalance despite potential
variations in diet, our kidneysreally manage our sodium pretty
(05:50):
well. Low serum sodium levelsare going to inhibit the
secretion of ADH and NP andtrigger the RAS system. This
will increase sodium levels byincreasing the reabsorption of
sodium and enhancing the loss ofwater. If your patient has high
serum sodium that's going toinhibit aldosterone secretion
(06:12):
and stimulate secretion of ADHand NP. So these hormones and
the kidneys all together aregoing to maintain that water and
sodium balance. I know that youall had an instructor who told
you if you take a cell and dropit into a hypotonic solution,
the cells gonna swell. Myinstructor said Hi, Bo, oh, you
(06:35):
can imagine me spreading my armsout as I exaggerate the cell
swelling. If a sodium imbalanceis a osmolality imbalance, that
means that it's a concentrationimbalance. If my patient is
hyponatremia check, their bloodessentially becomes hypotonic.
What will happen to the cellslet's think about the brain,
(06:58):
that water is going to leave thebloodstream because there's too
much water and not enough saltin there. And it's going to go
into the cells so the braincells could swell. Most of the
problems that we see related tohyponatremia are because of
reduced excitability of membranedepolarization and cellular
(07:18):
swelling. One of the most commoncauses of low sodium levels is
the overuse of diuretics. Wecould also experience a relative
sodium deficit meaning too muchwater when actually because by
drinking too much water in avery short period of time,
Kidney Failure syndrome ofinappropriate antidiuretic
(07:40):
hormone secretion or si d hheart failure, a too much
hypotonic fluid administration.
Anytime we add water, we couldbe diluting that blood one of
the most obvious things thatwe're going to see in a patient
with hyponatremia is thatcellular swelling which is going
(08:01):
to lead to altered mentalstatus, or changes in level of
consciousness. If you see yourpatient develop, sudden
worsening of confusion,especially if they're elderly or
on diuretics, you could suspecta sodium problem, we'll see some
other changes, maybe generalmuscle weakness, because
(08:21):
neuromuscular changes will seean increase in intestinal
motility that will cause nausea,diarrhea, abdominal cramping and
hyperactive bowel sounds. Anycardiovascular changes that we
see are typically related to thevolume rather than the
hyponatremia itself. If ourpatient has hyponatremia with
(08:43):
hypovolemia, we're gonna have arapid weak thready pulse, we
will have decreased bloodpressure and orthostatic
hypotension. Again, that isrelated to the hypovolemia more
than hyponatremia. If ourpatient has hyponatremia that
occurs with hyperbole, Mia, wewill see full or bounding
(09:05):
pulses, maybe a normal or a highblood pressure, those symptoms
are going to be more related tothat volume than they are the
concentration of the sodiumitself. These are going to be
treated by addressing both thesodium and the volume imbalance.
If the patient is hypovolemicand hyponatremia, you might
(09:27):
expect to give them andhypertonic IV solution like 3%
normal saline if the patient hashyponatremia that's accompanied
by hyperkalemia. Thenmedications are going to be used
to get rid of water but notsodium. Next, let's talk about
hypernatremia. Too much sodium.
This can actually also occurwith a volume imbalance. But if
(09:52):
we have too much sodium we'regoing to have this condition
called irritability. The sodiumis moving rapidly across cell
membranes during depolarization.
And this makes excitable tissueseven more easily excited. They
over respond to stimuli, wateris going to move into the
(10:13):
extracellular compartment inorder to dilute that hyper azmol
or hypertonic extracellularfluid. And so if we have high
sodium levels, we can seecellular dehydration. Remember
that your anatomy and physiologyteacher told you if you drop the
cell into a hypertonic solution,it's going to shrink up. Always
(10:35):
think about the Wicked Witch ofthe West, right? She was either
a cell being dumped into ahypertonic solution or she was a
slug. I'm not sure which kidneyfailure is one of the most
common reasons you're going tosee high sodium levels. Of
course, if we administer toomuch sodium containing IV fluid,
we could see too much sodium inthe bloodstream. A patient who
(10:57):
takes in too much sodium,corticosteroids and Cushing
syndrome, which are going tocause similar problems. We'll
address those in some otherepisodes and hyperaldosteronism.
If we have hypernatremia, as aresult of not having enough
water that causing us to havetoo concentrated a blood or too
much sodium. This might bebecause your patient is not
(11:20):
taking in anything by mouth.
Maybe they have a fever, a feveris going to increase those
insensible losses of just waterhyperventilating, again, an
increase of water loss that'sinsensible, excessive diuresis
if they have watery diarrhea,and this is often something that
we'll see in dehydration,thinking about those brain cells
(11:41):
in this now hypertonic solution,they're going to shrivel up,
they're going to becomedehydrated, we're going to have
altered cerebral function, thispatient will have mental status
changes, changes in cognitivefunction. This patient may have
a very short attention span beagitated or confused. If the
(12:01):
patient has overload also, theycould be lethargic or superest,
or comatose. The most frequenttreatments are going to be 0.9%,
isotonic, or often called normalsaline. You might also see
dextrose 5% in 0.4, or 5% Sodiumchloride. This is often called
(12:26):
half normal saline. If thepatient's problem is excretion
of sodium they may usemedications like furosemide, a
loop diuretic to facilitateexcretion of sodium through the
kidneys. Let's now talk aboutanother major player. Let's talk
about potassium. low potassium.
(12:48):
Minor changes can cause majorchanges in cell excitability and
can be life threatening becauseevery body system is affected by
potassium. Some common reasonsthat we lose too much potassium
would be inappropriate orexcessive use of diuretics or
(13:09):
corticosteroids increasedsecretion of aldosterone,
Cushing syndrome, especiallydiarrhea, vomiting, wound
drainage, particularly gidrainage, prolonged nasal
gastric suction,I mentioned that earlier, it's
the same as that vomiting. Ifthe patient has kidney disease
that impairs the reabsorption ofpotassium, or being nothing by
(13:31):
mouth, meaning not taking inanything in the mouth, we can
also end up with relativepotassium deficits with
alkalosis hypokalemia can beassociated with alkalosis. If
the patient has too muchinsulin, insulin likes to take
potassium out of the bloodstreamand into the cell with glucose.
(13:52):
So if the patient has too muchinsulin, then it can cause that
potassium to go out of thebloodstream. It's the same way
if you give the patient too muchinsulin IV, you can cause that
same thing to happen. If thepatient's on TPN, or total
parenteral nutrition, that'swhere they're getting all their
nutrition through an IV that cancause this. And if we give
(14:14):
patients IV therapy that has notvery much potassium in it, we're
constantly losing potassium outof our kidneys. Normally, if we
don't replace it, then we canend up in this potassium
deficit. When we talk aboutpotassium, most of us are going
to think about the heart but wealso need to think about the
(14:35):
lungs, we can end up with thisrespiratory muscle weakness,
resulting in shallowrespirations that can actually
result in respiratoryinsufficiency. So two big things
you want to monitor with yourpatients who are hypokalemic are
their respiratory rate andrhythm and depth and their
cardiovascular function withoutthat potassium The GI tract
(14:59):
slows down. This can lead tohypoactive bowel sounds, nausea,
vomiting constipation, which canlead to abdominal distension. We
want to monitor for that withour patient auscultate their
bowel sounds, and you can seeECG changes like ST segment
depression, flat or inverted Twaves. There's a hint in
(15:22):
hyperkalemia, we'll see tallpeaked T waves in hypokalemia,
we'll see flat or inverted Twaves. And we might see some
increase in new waves. A starpoint, older patients who are
taking digoxin are particularlyat risk for dysrhythmias. To
replace potassium, we can giveit by mouth, we can give it IV,
(15:44):
a couple more star points foryou. Number one, potassium
should never be mixed on thefloor, it should only be done by
a pharmacist or registeredpharmacist, you should not have
a dilution greater than one milequivalent of potassium per 10
milliliters of solution. And itshould never be given IV push.
(16:08):
When we're giving potassium IVyou should use a pump. And you
should never exceed therecommended rate of infusion is
somewhere around five to 10 milequivalents per hour, but should
never exceed 20 mil equivalentsper hour. Last star point for
this one, if your patient is notmaking urine. And I'm not
(16:31):
talking about urinary retention,I'm talking about a patient
whose kidneys are not makingurine, you should reconsider
administering potassium, thatpatient may not have any way to
get extra potassium out of theirbody. And so we could cause them
to become hyperkalemic. highpotassium levels or hyperkalemia
are really going to affect yourheart. When we think about
(16:55):
sodium we kind of think aboutthe brain and the swelling or
shrinking of brain cells. Whenwe think about potassium, we
often think about the heart,it's really sensitive to
increases in potassium. And thathyperkalemia is going to
interfere with conduction, whichcould lead to heart block or V
fib, which has been tricularfibrillation. Some common
(17:17):
reasons that people end up withtoo much potassium would be over
ingestion. salt substitutes, ifyou look at the bottle may be
potassium. And that could be oneway that you end up with too
much potassium transfusion ofwhole blood or packed red blood
cells. This can be an issue ifthose cells burst or if they
have burst inside the bag, thenthey're going to release that
(17:41):
potassium in the intracellularcompartment which is going to
raise Tassie and level kidneyfailure is going to be a big one
kidneys put out potassium. Ifthey're not working, they can't
put it out. And a patient who'staking potassium sparing
diuretics, the one that comes tomind is Spironolactone. These
encourage the kidneys to hold onto potassium, which can lead to
(18:02):
high levels of potassium,especially if your patient
doesn't know that they shouldn'tbe eating salt substitutes with
that particular medication. Toomuch potassium can also be
caused by tissue damage, like Italked about earlier. Anything
that causes cells to break openand spill their contents
acidosis and hyperkalemia gotogether and uncontrolled
(18:25):
diabetes. The reason is thepatient with uncontrolled
diabetes does not have thatinsulin to move the sugar and
the potassium into themselvesfrom the bloodstream. This is
going to be relatively rare inpeople who have normal kidney
function. The people who mayexperience high potassium levels
(18:45):
are those who are going to betaking a potassium sparing
diuretic, or people who havecertain chronic illnesses. We
could see those tall peaked Twaves as far as cardiovascular
changes, we might see somechanges in our P or QRS complex,
this patient could end up withbradycardia or hypotension. We
(19:08):
want to be monitoring that ECGto correct high potassium
levels, they're either going totry to use a medication that's
going to increase secretion, orthey're going to try to move
potassium from the extracellularto the intracellular space.
medications that excretepotassium would be those loop
(19:29):
diuretics we talked aboutearlier. Or they might prescribe
a solution, an IV solution thatincludes glucose and insulin,
right? I mentioned that thatinsulin will take the glucose
and the potassium into thecells. But we want to make sure
that we don't take all of thesugar out of the bloodstream. So
we're going to give them alittle bit extra facilitate that
movement. We're going to talkabout calcium, low calcium can
(19:52):
be caused by a couple of thingsyou'll want to think about the
thyroid particularly Theparathyroid hypocalcemia and
hyperparathyroidism will gotogether. If the patient doesn't
take in enough calcium, or saythat they're lactose intolerant,
they may not take in enoughcalcium. We could have patients
(20:13):
without absorption problems.
This would be someone withceliac disease or Crohn's
disease, if they don't take inenough vitamin D either through
diet or through sudden end stagekidney disease, diarrhea
sanatoria, which is fattystools, and wound drainage. But
(20:35):
we can also have alkalosis, wecould have medications that bind
to calcium. If the calcium isbound to albumin, it's not free
to help with muscle and nerveconduction in the body. If we
have acute pancreatitis, orimmobility, we can end up with
(20:56):
this symptoms for hypocalcemia.
A lot of these are going to beneuro muscular, so we might see
paraesthesia as a paraesthesiais a numbness or tingling
sensation. It usually starts inthe hands and feet and can
progress to the lips, nose andears. If it gets that far, we
could start to see neuromuscularoverstimulation, that can lead
(21:19):
to tetany. Two tests that youcan do to look for this as
nurses. One is true SOS and oneis Fostex, you'll need to look
these up, it's going to bepretty visual, true SOS is where
I'm going to apply a bloodpressure cuff around the arm and
inflate it higher than thepatient's systolic pressure,
(21:42):
this is going to cause a littlebit of a hypoxic condition. And
what we're going to see is thehand and fingers go into a spasm
in Palmer flexion. So they'regoing to the fingers are going
to come together, and a lot oftimes the hand will supinate a
little bit. Szostak sign iswhere you tap the face just
(22:03):
below and in front of the earand this is going to trigger
facial twitching. A patient whohas chronic hypocalcemia can see
it in their bones, they're notgoing to have the bone density
that we would expect they mighthave unexplained bone pain,
something we'll focus on forthem is going to be injury
prevention. If they have thin,brittle bones, and we're going
(22:24):
to replace calcium. It could bereplaced orally, or it could be
replaced IV depending on whatthe provider wants to do. High
levels of calcium orhypercalcemia can affect
excitable tissues. Those thatwe're going to see here are the
heart that skeletal musclenerves, intestinal smooth
(22:45):
muscles, we're going to seedepending on the severity and
how fast the imbalance occurs,an increase in heart rate and
blood pressure, confusion,lethargy, maybe some decrease in
peristalsis, which will lead toconstipation, anorexia, nausea,
vomiting and abdominaldistension. Bowel sounds will be
(23:09):
hypo active. Too much calciumcan be caused by too much intake
of calcium, too much intake ofvitamin D.
We want to talk to our patientsabout some over the counter
products that include calciumlike Tums, which are calcium
carbonate, kidney failure.
Again, if we can't excrete theseelectrolytes they can end up too
(23:31):
high and our thiazide diuretics,hyperparathyroidism and
hypercalcemia go together.
malignancy, especially thebones, hyperthyroidism,
immobility can cause highcalcium levels use of
glucocorticoids and dehydration.
The next major electrolyte todiscuss is magnesium. low
(23:52):
magnesium levels are typicallycaused by too much excretion of
magnesium often because of athiazide diuretic, or not enough
intake. Simple nursing does myvery favorite video on this
week, he does Magnum magnesium,the sheriff in town, I love the
(24:13):
way that he does that, andallows you to remember that when
magnesium is around when there'smore magnesium, we're going to
have a decrease in a lot ofthings. And if we have low
magnesium, you know, the sharesout of town we're going to have
high wild and crazy stuffhappening. We can have
hypertension, we can have atrialor ventricular fibrillation,
(24:38):
premature contractions of eitheratria or ventricles, increased
nerve impulse transmissionbecause normally magnesium
inhibits that. At the synapse,we'll see hyperactive deep
tendon reflexes, our patient canend up with too much magnesium
through intake maybe an IVreplacement of magnesium or
(25:02):
magnesium containing antacids orlaxatives, like milk of
magnesia. Or once again, kidneyfailure or decreased kidney
excretion of magnesium. Nowwe're going to have depressed
nerve impulse transmission, thepatient might be drowsy or
lethargic, they could end up ina coma, where patients going to
(25:24):
have absent deep tendonreflexes. And we need to think
about cardiac changes likebradycardia, peripheral
vasodilation, which is going tolead to hypotension and we're
going to want to monitor theirrespiratory status because if
the magnesium is decreasingnerve impulses to the lungs,
(25:44):
though it doesn't directlyaffect the lungs, it can cause
the patient to have respiratoryinsufficiency. Thank you for
hanging out with me for an extralong episode. I hope that this
helps you. I'm going to leaveyou with just a couple of things
to keep in mind. Sodium affectsthe brain. Potassium affects the
heart. Calcium affects themusculoskeletal system, and
(26:09):
magnesium affects the nervesslash deep tendon reflexes.
That's all I've got for you fortoday. Reach out if you have
some topics you'd like to hearabout or to let me know that you
enjoy this podcast. Please leavea review. Hopefully it'll be a
good one. And I'll see you nexttime on nursing with Dr.
(26:31):
Hobbick.
Hey friends and welcome to nursing with Dr.
Hobbick. Today I am thinkingabout electrolytes. Still
thinking a little bit about thatfluid balance. These two
concepts are pretty interwoven.
And in a later episode I'll getinto acid base. Today I want to
talk about electrolytes and howthey can be imbalanced. The
(00:22):
first thing I want you to thinkabout is intake, absorption,
distribution, and output.
Electrolytes can be imbalancedthrough intake if they're not
taking in enough or they'retaking in too much. Absorption
can affect your electrolytebalance by not absorbing
(00:43):
electrolytes appropriately, wecould end up with low levels
distribution. This is big whenwe're talking about things like
potassium, calcium andmagnesium, especially potassium.
Because the levels of theseelectrolytes inside the cells in
the intracellular compartmentare much higher than they are in
(01:05):
the extracellular compartment.
Remember that when we're testingthe levels of these
electrolytes, we're testing thelevels in the bloodstream in the
serum in the extracellularspace, the difference between
the levels is pretty dramatic.
Sodium is the most abundant canion in the extracellular
(01:27):
compartment. Potassium is themost abundant cat ion in the
intracellular compartment. Andyou'll see the huge difference
when you look at the levels thatwe would see a normal level. Now
I want you to understand thatyou will see some variants in
reference ranges, don't let thatworry you too much. Just
(01:48):
memorize some set that you'reusing in your current program.
And you'll get through justfine. So if I use reference
ranges that are different thanwhat you're used to, they
shouldn't be way off. If theyare Gosh, send me a message on
one of my platforms. You canfind me on Facebook, Instagram,
YouTube, Tik Tok, where else I'meverywhere, let's say potassium,
(02:10):
the normal range for potassiumis 3.5 to five. Now that's the
serum level, the normal rangefor sodium is 135 to 145, you
may see 136 to 145, it doesn'tmatter that much. Obviously,
there's a huge differencebetween the number or the amount
(02:32):
rather of sodium then potassium,consider this if my patient has
blunt force, trauma, or burns,or something that is going to
cause a lot of cells to burst,those cells will release all of
their intracellular contents,including their high
concentrations of these otherelectrolytes, that's going to
(02:55):
really mess up my balance ofelectrolytes in the bloodstream
in the extra cellular space.
That would be a imbalance ofdistribution, we can have an
output. If there is too muchoutput or not enough output of
electrolytes that can also causeimbalance output, we normally
lose electrolytes through urine,feces a little bit through sweat
(03:17):
abnormally we could lose itthrough vomiting, wound
drainage. Now we're talkingabout a lot of drainage not like
that little paper cut, we alsoneed to talk about other GI
losses gastric suction, if youput an end G tube into your
patient and it's to suction, youmight want to think about their
electrolyte balance. Just likeif they were vomiting, it's the
(03:40):
same thing. And if your patienthas diarrhea, they could be
losing electrolytes. Thefunctions of the large intestine
are really to absorb water andelectrolytes. If we have
diarrhea, that stuff's movingthrough there so fast, he can't
do its job, we're going to losefluid. And electrolytes that
way, remember that fluid iswater with things dissolved in
(04:00):
it. In that case, we're losingboth electrolytes and water,
let's just get an idea of plasmaversus intracellular
concentration. So I told youthat the plasma volumes for
potassium is 3.5 to five forsodium it's 135 or 136 to 145.
(04:21):
inside the cell, we have about14 mil equivalents per liter of
sodium only 14 When outside thecell we have 135 to 145. inside
the cell, we have 140 Milletequivalents per liter of
potassium were outside the cellwe have 3.5 to five, you can see
that the concentrations of theseare very different on either
(04:43):
side. The reason for that has todo with how the body creates
energy, how the body createsnerve and muscle contraction.
That's really what ourelectrolytes do for us besides
also contributing to osmolaritylike we talked about last week.
So we'll talk briefly aboutthese different electrolytes,
sodium in some textbooks isreally described as an
(05:06):
osmolarity imbalance. In otherwords, it's a concentration
issue in the bloodstream, thepatient could have too much
sodium or too little water, orthey could have a water excess
or too little sodium. If youneed to go back and refresh on
some of the anatomy of the restsystem ADH hormone metric
(05:30):
peptide, I recommend the KhanAcademy videos they are
fantastic on review forpathophysiology. These are
important concepts for you tounderstand if you're going to
understand sodium and fluidbalance despite potential
variations in diet, our kidneysreally manage our sodium pretty
(05:50):
well. Low serum sodium levelsare going to inhibit the
secretion of ADH and NP andtrigger the RAS system. This
will increase sodium levels byincreasing the reabsorption of
sodium and enhancing the loss ofwater. If your patient has high
serum sodium that's going toinhibit aldosterone secretion
(06:12):
and stimulate secretion of ADHand NP. So these hormones and
the kidneys all together aregoing to maintain that water and
sodium balance. I know that youall had an instructor who told
you if you take a cell and dropit into a hypotonic solution,
the cells gonna swell. Myinstructor said Hi, Bo, oh, you
(06:35):
can imagine me spreading my armsout as I exaggerate the cell
swelling. If a sodium imbalanceis a osmolality imbalance, that
means that it's a concentrationimbalance. If my patient is
hyponatremia check, their bloodessentially becomes hypotonic.
What will happen to the cellslet's think about the brain,
(06:58):
that water is going to leave thebloodstream because there's too
much water and not enough saltin there. And it's going to go
into the cells so the braincells could swell. Most of the
problems that we see related tohyponatremia are because of
reduced excitability of membranedepolarization and cellular
(07:18):
swelling. One of the most commoncauses of low sodium levels is
the overuse of diuretics. Wecould also experience a relative
sodium deficit meaning too muchwater when actually because by
drinking too much water in avery short period of time,
Kidney Failure syndrome ofinappropriate antidiuretic
(07:40):
hormone secretion or si d hheart failure, a too much
hypotonic fluid administration.
Anytime we add water, we couldbe diluting that blood one of
the most obvious things thatwe're going to see in a patient
with hyponatremia is thatcellular swelling which is going
(08:01):
to lead to altered mentalstatus, or changes in level of
consciousness. If you see yourpatient develop, sudden
worsening of confusion,especially if they're elderly or
on diuretics, you could suspecta sodium problem, we'll see some
other changes, maybe generalmuscle weakness, because
(08:21):
neuromuscular changes will seean increase in intestinal
motility that will cause nausea,diarrhea, abdominal cramping and
hyperactive bowel sounds. Anycardiovascular changes that we
see are typically related to thevolume rather than the
hyponatremia itself. If ourpatient has hyponatremia with
(08:43):
hypovolemia, we're gonna have arapid weak thready pulse, we
will have decreased bloodpressure and orthostatic
hypotension. Again, that isrelated to the hypovolemia more
than hyponatremia. If ourpatient has hyponatremia that
occurs with hyperbole, Mia, wewill see full or bounding
(09:05):
pulses, maybe a normal or a highblood pressure, those symptoms
are going to be more related tothat volume than they are the
concentration of the sodiumitself. These are going to be
treated by addressing both thesodium and the volume imbalance.
If the patient is hypovolemicand hyponatremia, you might
(09:27):
expect to give them andhypertonic IV solution like 3%
normal saline if the patient hashyponatremia that's accompanied
by hyperkalemia. Thenmedications are going to be used
to get rid of water but notsodium. Next, let's talk about
hypernatremia. Too much sodium.
This can actually also occurwith a volume imbalance. But if
(09:52):
we have too much sodium we'regoing to have this condition
called irritability. The sodiumis moving rapidly across cell
membranes during depolarization.
And this makes excitable tissueseven more easily excited. They
over respond to stimuli, wateris going to move into the
(10:13):
extracellular compartment inorder to dilute that hyper azmol
or hypertonic extracellularfluid. And so if we have high
sodium levels, we can seecellular dehydration. Remember
that your anatomy and physiologyteacher told you if you drop the
cell into a hypertonic solution,it's going to shrink up. Always
(10:35):
think about the Wicked Witch ofthe West, right? She was either
a cell being dumped into ahypertonic solution or she was a
slug. I'm not sure which kidneyfailure is one of the most
common reasons you're going tosee high sodium levels. Of
course, if we administer toomuch sodium containing IV fluid,
we could see too much sodium inthe bloodstream. A patient who
(10:57):
takes in too much sodium,corticosteroids and Cushing
syndrome, which are going tocause similar problems. We'll
address those in some otherepisodes and hyperaldosteronism.
If we have hypernatremia, as aresult of not having enough
water that causing us to havetoo concentrated a blood or too
much sodium. This might bebecause your patient is not
(11:20):
taking in anything by mouth.
Maybe they have a fever, a feveris going to increase those
insensible losses of just waterhyperventilating, again, an
increase of water loss that'sinsensible, excessive diuresis
if they have watery diarrhea,and this is often something that
we'll see in dehydration,thinking about those brain cells
(11:41):
in this now hypertonic solution,they're going to shrivel up,
they're going to becomedehydrated, we're going to have
altered cerebral function, thispatient will have mental status
changes, changes in cognitivefunction. This patient may have
a very short attention span beagitated or confused. If the
(12:01):
patient has overload also, theycould be lethargic or superest,
or comatose. The most frequenttreatments are going to be 0.9%,
isotonic, or often called normalsaline. You might also see
dextrose 5% in 0.4, or 5% Sodiumchloride. This is often called
(12:26):
half normal saline. If thepatient's problem is excretion
of sodium they may usemedications like furosemide, a
loop diuretic to facilitateexcretion of sodium through the
kidneys. Let's now talk aboutanother major player. Let's talk
about potassium. low potassium.
(12:48):
Minor changes can cause majorchanges in cell excitability and
can be life threatening becauseevery body system is affected by
potassium. Some common reasonsthat we lose too much potassium
would be inappropriate orexcessive use of diuretics or
(13:09):
corticosteroids increasedsecretion of aldosterone,
Cushing syndrome, especiallydiarrhea, vomiting, wound
drainage, particularly gidrainage, prolonged nasal
gastric suction,I mentioned that earlier, it's
the same as that vomiting. Ifthe patient has kidney disease
that impairs the reabsorption ofpotassium, or being nothing by
(13:31):
mouth, meaning not taking inanything in the mouth, we can
also end up with relativepotassium deficits with
alkalosis hypokalemia can beassociated with alkalosis. If
the patient has too muchinsulin, insulin likes to take
potassium out of the bloodstreamand into the cell with glucose.
(13:52):
So if the patient has too muchinsulin, then it can cause that
potassium to go out of thebloodstream. It's the same way
if you give the patient too muchinsulin IV, you can cause that
same thing to happen. If thepatient's on TPN, or total
parenteral nutrition, that'swhere they're getting all their
nutrition through an IV that cancause this. And if we give
(14:14):
patients IV therapy that has notvery much potassium in it, we're
constantly losing potassium outof our kidneys. Normally, if we
don't replace it, then we canend up in this potassium
deficit. When we talk aboutpotassium, most of us are going
to think about the heart but wealso need to think about the
(14:35):
lungs, we can end up with thisrespiratory muscle weakness,
resulting in shallowrespirations that can actually
result in respiratoryinsufficiency. So two big things
you want to monitor with yourpatients who are hypokalemic are
their respiratory rate andrhythm and depth and their
cardiovascular function withoutthat potassium The GI tract
(14:59):
slows down. This can lead tohypoactive bowel sounds, nausea,
vomiting constipation, which canlead to abdominal distension. We
want to monitor for that withour patient auscultate their
bowel sounds, and you can seeECG changes like ST segment
depression, flat or inverted Twaves. There's a hint in
(15:22):
hyperkalemia, we'll see tallpeaked T waves in hypokalemia,
we'll see flat or inverted Twaves. And we might see some
increase in new waves. A starpoint, older patients who are
taking digoxin are particularlyat risk for dysrhythmias. To
replace potassium, we can giveit by mouth, we can give it IV,
(15:44):
a couple more star points foryou. Number one, potassium
should never be mixed on thefloor, it should only be done by
a pharmacist or registeredpharmacist, you should not have
a dilution greater than one milequivalent of potassium per 10
milliliters of solution. And itshould never be given IV push.
(16:08):
When we're giving potassium IVyou should use a pump. And you
should never exceed therecommended rate of infusion is
somewhere around five to 10 milequivalents per hour, but should
never exceed 20 mil equivalentsper hour. Last star point for
this one, if your patient is notmaking urine. And I'm not
(16:31):
talking about urinary retention,I'm talking about a patient
whose kidneys are not makingurine, you should reconsider
administering potassium, thatpatient may not have any way to
get extra potassium out of theirbody. And so we could cause them
to become hyperkalemic. highpotassium levels or hyperkalemia
are really going to affect yourheart. When we think about
(16:55):
sodium we kind of think aboutthe brain and the swelling or
shrinking of brain cells. Whenwe think about potassium, we
often think about the heart,it's really sensitive to
increases in potassium. And thathyperkalemia is going to
interfere with conduction, whichcould lead to heart block or V
fib, which has been tricularfibrillation. Some common
(17:17):
reasons that people end up withtoo much potassium would be over
ingestion. salt substitutes, ifyou look at the bottle may be
potassium. And that could be oneway that you end up with too
much potassium transfusion ofwhole blood or packed red blood
cells. This can be an issue ifthose cells burst or if they
have burst inside the bag, thenthey're going to release that
(17:41):
potassium in the intracellularcompartment which is going to
raise Tassie and level kidneyfailure is going to be a big one
kidneys put out potassium. Ifthey're not working, they can't
put it out. And a patient who'staking potassium sparing
diuretics, the one that comes tomind is Spironolactone. These
encourage the kidneys to hold onto potassium, which can lead to
(18:02):
high levels of potassium,especially if your patient
doesn't know that they shouldn'tbe eating salt substitutes with
that particular medication. Toomuch potassium can also be
caused by tissue damage, like Italked about earlier. Anything
that causes cells to break openand spill their contents
acidosis and hyperkalemia gotogether and uncontrolled
(18:25):
diabetes. The reason is thepatient with uncontrolled
diabetes does not have thatinsulin to move the sugar and
the potassium into themselvesfrom the bloodstream. This is
going to be relatively rare inpeople who have normal kidney
function. The people who mayexperience high potassium levels
(18:45):
are those who are going to betaking a potassium sparing
diuretic, or people who havecertain chronic illnesses. We
could see those tall peaked Twaves as far as cardiovascular
changes, we might see somechanges in our P or QRS complex,
this patient could end up withbradycardia or hypotension. We
(19:08):
want to be monitoring that ECGto correct high potassium
levels, they're either going totry to use a medication that's
going to increase secretion, orthey're going to try to move
potassium from the extracellularto the intracellular space.
medications that excretepotassium would be those loop
(19:29):
diuretics we talked aboutearlier. Or they might prescribe
a solution, an IV solution thatincludes glucose and insulin,
right? I mentioned that thatinsulin will take the glucose
and the potassium into thecells. But we want to make sure
that we don't take all of thesugar out of the bloodstream. So
we're going to give them alittle bit extra facilitate that
movement. We're going to talkabout calcium, low calcium can
(19:52):
be caused by a couple of thingsyou'll want to think about the
thyroid particularly Theparathyroid hypocalcemia and
hyperparathyroidism will gotogether. If the patient doesn't
take in enough calcium, or saythat they're lactose intolerant,
they may not take in enoughcalcium. We could have patients
(20:13):
without absorption problems.
This would be someone withceliac disease or Crohn's
disease, if they don't take inenough vitamin D either through
diet or through sudden end stagekidney disease, diarrhea
sanatoria, which is fattystools, and wound drainage. But
(20:35):
we can also have alkalosis, wecould have medications that bind
to calcium. If the calcium isbound to albumin, it's not free
to help with muscle and nerveconduction in the body. If we
have acute pancreatitis, orimmobility, we can end up with
(20:56):
this symptoms for hypocalcemia.
A lot of these are going to beneuro muscular, so we might see
paraesthesia as a paraesthesiais a numbness or tingling
sensation. It usually starts inthe hands and feet and can
progress to the lips, nose andears. If it gets that far, we
could start to see neuromuscularoverstimulation, that can lead
(21:19):
to tetany. Two tests that youcan do to look for this as
nurses. One is true SOS and oneis Fostex, you'll need to look
these up, it's going to bepretty visual, true SOS is where
I'm going to apply a bloodpressure cuff around the arm and
inflate it higher than thepatient's systolic pressure,
(21:42):
this is going to cause a littlebit of a hypoxic condition. And
what we're going to see is thehand and fingers go into a spasm
in Palmer flexion. So they'regoing to the fingers are going
to come together, and a lot oftimes the hand will supinate a
little bit. Szostak sign iswhere you tap the face just
(22:03):
below and in front of the earand this is going to trigger
facial twitching. A patient whohas chronic hypocalcemia can see
it in their bones, they're notgoing to have the bone density
that we would expect they mighthave unexplained bone pain,
something we'll focus on forthem is going to be injury
prevention. If they have thin,brittle bones, and we're going
(22:24):
to replace calcium. It could bereplaced orally, or it could be
replaced IV depending on whatthe provider wants to do. High
levels of calcium orhypercalcemia can affect
excitable tissues. Those thatwe're going to see here are the
heart that skeletal musclenerves, intestinal smooth
(22:45):
muscles, we're going to seedepending on the severity and
how fast the imbalance occurs,an increase in heart rate and
blood pressure, confusion,lethargy, maybe some decrease in
peristalsis, which will lead toconstipation, anorexia, nausea,
vomiting and abdominaldistension. Bowel sounds will be
(23:09):
hypo active. Too much calciumcan be caused by too much intake
of calcium, too much intake ofvitamin D.
We want to talk to our patientsabout some over the counter
products that include calciumlike Tums, which are calcium
carbonate, kidney failure.
Again, if we can't excrete theseelectrolytes they can end up too
(23:31):
high and our thiazide diuretics,hyperparathyroidism and
hypercalcemia go together.
malignancy, especially thebones, hyperthyroidism,
immobility can cause highcalcium levels use of
glucocorticoids and dehydration.
The next major electrolyte todiscuss is magnesium. low
(23:52):
magnesium levels are typicallycaused by too much excretion of
magnesium often because of athiazide diuretic, or not enough
intake. Simple nursing does myvery favorite video on this
week, he does Magnum magnesium,the sheriff in town, I love the
(24:13):
way that he does that, andallows you to remember that when
magnesium is around when there'smore magnesium, we're going to
have a decrease in a lot ofthings. And if we have low
magnesium, you know, the sharesout of town we're going to have
high wild and crazy stuffhappening. We can have
hypertension, we can have atrialor ventricular fibrillation,
(24:38):
premature contractions of eitheratria or ventricles, increased
nerve impulse transmissionbecause normally magnesium
inhibits that. At the synapse,we'll see hyperactive deep
tendon reflexes, our patient canend up with too much magnesium
through intake maybe an IVreplacement of magnesium or
(25:02):
magnesium containing antacids orlaxatives, like milk of
magnesia. Or once again, kidneyfailure or decreased kidney
excretion of magnesium. Nowwe're going to have depressed
nerve impulse transmission, thepatient might be drowsy or
lethargic, they could end up ina coma, where patients going to
(25:24):
have absent deep tendonreflexes. And we need to think
about cardiac changes likebradycardia, peripheral
vasodilation, which is going tolead to hypotension and we're
going to want to monitor theirrespiratory status because if
the magnesium is decreasingnerve impulses to the lungs,
(25:44):
though it doesn't directlyaffect the lungs, it can cause
the patient to have respiratoryinsufficiency. Thank you for
hanging out with me for an extralong episode. I hope that this
helps you. I'm going to leaveyou with just a couple of things
to keep in mind. Sodium affectsthe brain. Potassium affects the
heart. Calcium affects themusculoskeletal system, and
(26:09):
magnesium affects the nervesslash deep tendon reflexes.
That's all I've got for you fortoday. Reach out if you have
some topics you'd like to hearabout or to let me know that you
enjoy this podcast. Please leavea review. Hopefully it'll be a
good one. And I'll see you nexttime on nursing with Dr.
(26:31):
Hobbick.
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