Hyperkalemia & Hypokalemia (Potassium Imbalances) Nursing Care Plans

Hyperkalemia: Risk For Electrolyte Imbalance

Hyperkalemia, an elevated level of potassium in the blood, can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium, and in patients who have received massive blood transfusions due to the release of potassium from stored blood cells. Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body, leading to a risk for electrolyte imbalance.

Nursing Diagnosis

• Risk for Electrolyte Imbalance

May be related to

• Renal disease.
• Treatment-related side effects such as cytotoxic drugs, NSAIDs, diuretics, potassium-containing medications, and massive transfusion with banked blood.

Possibly evidenced by

• Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• The client will display heart rate, blood pressure, and laboratory results within the normal limit and absence of paresthesia, muscle weakness, and cognitive impairment.

Nursing Assessment and Rationales

Nursing assessment for hyperkalemia patients focuses on monitoring for signs and symptoms of life-threatening cardiac dysrhythmias, as well as identifying and addressing the underlying cause of hyperkalemia.

1. Monitor heart rate and rhythm. Be aware that cardiac arrest can occur.
Potassium excess depresses myocardial conduction. Bradycardia can progress to cardiac fibrillation and arrest.

2. Monitor respiratory rate and depth. Encourage deep breathing and coughing exercise. Elevate the head of the bed.
Clients may hypoventilate and retain carbon dioxide resulting in respiratory acidosis. Muscular weakness can affect respiratory muscles and lead to respiratory complications.

3. Assess the level of consciousness and neuromuscular function, including sensation, strength, and movement.
The client is usually conscious and alert; however, muscular paresthesia, weakness, and flaccid paralysis may occur.

4. Monitor urine output.
In kidney failure, potassium is retained because of improper excretion. Potassium is contraindicated if oliguria or anuria is present.

5. Identify the client at risk or the cause of the hyperkalemia such as excessive intake of potassium or decreased excretion.
Early identification and intervention can avoid complications.

6. Monitor laboratory results, such as serum potassium and arterial blood gases, as indicated.
Evaluate therapy needs and effectiveness.

Electrolytes regulate nerve and muscle function, hydrate the body, balance blood acidity and pressure, and further rebuild damaged tissue. Sodium, calcium, potassium, chloride, phosphate, and magnesium are all electrolytes. When these substances become imbalanced, it can lead to either muscle weakness or excessive contraction.

Electrolyte imbalance can occur due to several factors. Various disorders and their corresponding treatments may put the patient at risk for imbalances in serum electrolyte concentrations. Patients experiencing congestive heart failure frequently end up with rebound hospitalizations due to irregular sodium and potassium levels. Diabetes and hypertension may eventually place a patient in a calcium or magnesium imbalance. Electrolyte losses may occur from draining wounds and fistulas, particularly gastrointestinal fistulas. Irregularities in sodium and chloride concentrations happen frequently in situations associated with fluid imbalances, primarily gastrointestinal fluid losses such as vomiting, diarrhea, or suctioning.

Changes in the secretion of antidiuretic hormone and aldosterone can contribute to sodium imbalances. Patients receiving diuretics may be at risk for potassium imbalances. Thyroid and parathyroid problems place the patient at risk for calcium imbalances. Magnesium imbalances often occur in the same situations as calcium and potassium imbalances.

Electrolytes are vital for the normal functioning of the human body. A proper understanding of these imbalances is essential for current management and future prevention. This care plan and nurse study guide focus on sodium, potassium, calcium, and magnesium imbalances.

Nursing Interventions and Rationales

Nursing interventions for hyperkalemia patients aim to prevent life-threatening cardiac dysrhythmias by reducing serum potassium levels through a combination of medication administration, dietary management, and monitoring. Here are some nursing interventions for patients with hyperkalemia:

1. Encourage frequent rest periods; assist with daily activities, as indicated.
General muscle weakness decreases activity tolerance.

2. Stress the importance of the client’s notifying future caregivers when a chronic condition potentiates the development of hyperkalemia, such as oliguric renal failure.
May help prevent hyperkalemia recurrences.

3. Teach and assist the client with range-of-motion (ROM) exercises, as tolerated.
Improves muscle tone and reduces muscle cramps and pain.

4. Encourage intake of carbohydrates and fats and low potassium food such as pineapple, plums, strawberries, carrots, cauliflower, corn, and whole grains.
Reduces exogenous sources of potassium and prevents metabolic tissue breakdown with the release of cellular potassium.

5. Instruct the client in the use of potassium-containing salts or salt substitutes, and taking potassium supplements safely.
Prevention of hyperkalemia can be managed with diet, supplements, and other medications.

6. Identify and discontinue dietary sources of potassium, such as beans, dark leafy greens, potatoes, squash, yogurt, fish, avocados, mushrooms, and bananas.
Facilitates the reduction of potassium levels and may prevent the recurrence of hyperkalemia.

7. Review drug regimen for medications containing potassium or affecting potassium excretion such as spironolactone (Aldactone), hydrochlorothiazide (Maxzide), amiloride (Midamor), and penicillin G.
Requires regular monitoring of potassium levels and may require alternate drug choices or changes in the dosage or frequency.

8. Administer medications, as indicated:

•  8.1. Loop diuretics such as furosemide (Lasix)
  Promotes renal clearance and potassium excretion.

• 8.2. Beta-adrenergic agonist such as albuterol (Proventil)
  The administration of nebulization has been helpful in clients receiving hemodialysis and may also attenuate the hypoglycemic effect of insulin administration.

•  8.3. Calcium gluconate or calcium chloride
  A temporary stopgap measure that antagonizes toxic potassium depressant effects on the heart and stimulates cardiac contractility.

•  8.4. IV glucose with insulin and sodium bicarbonate
  Short-term emergency measures to move potassium into the cell, thus reducing toxic serum levels.

•  8.5. Sodium polystyrene sulfonate (Kayexalate, SPS suspension), given per NGT, orally, or rectally
  Resin removes potassium by exchanging potassium for sodium or calcium in the GI tract. Sorbitol enhances evacuation.

9. Provide fresh blood or washed red blood cells (RBCs), if transfusion is indicated.
Fresh blood has less potassium than banked blood because the breakdown of older RBCs releases potassium.

10. Infuse potassium-based medication or solutions slowly.
Prevents administration of concentrated bolus, allows time for kidneys to clear excess free potassium.

11. Prepare for and assist with dialysis.
May be required when more conservative methods fail or are contraindicated such as severe heart failure.

. Supply balanced electrolyte IV solutions as directed.
Lactated Ringer’s solution has an electrolyte concentration similar to that of extracellular fluid. Isotonic saline (0.9% sodium chloride) may contribute to hypernatremia if used for a long period of time. Extreme use of sodium-free IV solutions (e.g., D5W) puts the patient at risk for hyponatremia.

2. Administer electrolyte replacements as prescribed.
Oral or IV administration of electrolytes may be prescribed to keep electrolyte balance for patients at risk for imbalances.

3. Consider measures to reduce excess electrolytes.
Hyperkalemia is common in patients with end-stage renal disease and may result in serious electrocardiographic abnormalities. Dialysis is the definitive treatment of hyperkalemia in these patients. Intravenous calcium is used to stabilize the myocardium. Kayexalate may be indicated to patients at risk for electrolyte excesses such as potassium.

4. Irrigate nasogastric tubes with isotonic saline, as prescribed.
Irrigation of nasogastric tubes with plain water produces electrolyte losses. Plain water attracts electrolytes from mucosal tissue into the stomach, where they are eliminated with suctioning.

5. Educate the patient about dietary sources of electrolytes.
Electrolytes are salts and minerals, like sodium, potassium, calcium, magnesium, and chloride, in the body that maintain fluid balance and blood pressure. A balanced diet provides the patient with sources of electrolytes to prevent imbalances. Milk, yogurt, dark green, leafy vegetables, and legumes are excellent sources of electrolyte calcium. Whole grains, nuts, fruits, and vegetables are good sources of magnesium and potassium. Bananas are known to be the king of all potassium-containing fruits and veggies. Vitamin D is needed for the absorption of calcium from the intestines.

• 5.1. Sodium: dill pickles, table salt, tomato juices, sauces, and soups.

• 5.2. Potassium: potatoes with skin, beans, orange juices, plain yogurt, and banana.

• 5.3. Calcium: yogurt, milk, ricotta, collard greens, spinach, kale, and sardines.

• 5.4. Chloride: tomato juices, table salt, seaweed, celery, olives, rye bread, and lettuce.

• 5.5. Magnesium: leafy green vegetables, halibut, almonds, cashews, pumpkin seeds, sunflower, whole grains, legumes, lentils, chickpeas, and fatty fish.

6. Educate the patient about dietary sources of sodium and the use of salt substitutes.
Patients need to learn to read labels to identify all sources of sodium in foods. Changing from table salt to a potassium-based salt substitute is another way to shift your sodium-potassium balance, and some preliminary study implies that making this switch may have benefits for the heart. But these potassium-based salt substitutes are not for everyone: Excess potassium can be fatal for people who have kidney disease or who are taking medications that can increase potassium levels in the bloodstream.

7. Educate the patient using potassium-wasting about potassium replacements.
To prevent hypokalemia, the patient needs to understand the importance of potassium replacements that include dietary sources and prescribed oral replacements such as potassium chloride (KCl).

8. Educate the patient about limiting the use of over-the-counter antacids and laxatives.
Excessive use of antacids that contain magnesium has a laxative effect that may cause diarrhea, and in patients with renal failure, they may cause increased magnesium levels in the blood, because of the reduced ability of the kidneys to eliminate magnesium from the body in the urine.