The most common cause of excessive loss of Potassium is often associated with heavy fluid losses that flush Potassium out of . Medical conditions can also cause abnormal potassium levels; therefore, treatment also includes correcting the main cause of abnormal potassium levels. Common concentrations are 10 mEq/100 ml over 1 hour or 40 mEq/250 ml over 4 hours. The signs and symptoms of hypokalemia and hyperkalemia depend on how critical the potassium level is and how rapid the rise and fall in potassium levels happens: Hypokalemia and hyperkalemia typically happen as a result of another problem. Nursing Diagnosis: Risk for Decreased Cardiac Output. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders. 4. Check renal function.Excess potassium can build up in the body if damaged kidneys are unable to eliminate it. Used in the treatment of potassium deficiency when oral replacement is not feasible. Administer prescribed potassium with precautions.Potassium can be administered IV or PO. Other causes include certain medications and some adrenal and genetic conditions. Here are two nursing diagnosis for hyperkalemia and hypokalemia nursing care plans: 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. Because potassium can only be administered slowly and in small doses via a peripheral IV, a central line is recommended to correct hypokalemia more quickly. Potassium levels should be closely monitored during repletion, making sure the level is rising but does not exceed 4.0 mmol/L. The normal serum potassium concentration ranges from 3.5 to 5.0 mEq/L. High potassium levels can be treated through: Nursing Diagnosis: Electrolyte Imbalance related to hypokalemia as evidenced , serum potassium level of 2.9 mmol/L, polyuria, increased thirst, weakness, tachycardia, and fatigue. Hypokalemia can be life-threatening. Potassium replacement is primarily indicated when hypokalemia is due to potassium loss, and there is a . Low potassium (hypokalemia) refers to a lower than normal potassium level in your bloodstream. What is the NANDA nursing diagnosis for pneumonia . 2. ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). 2. A standing weight is the most accurate. Potassium helps in utilizing carbohydrates and protein to produce energy. The goal of nursing care is to restore and maintain normal potassium levels through monitoring and appropriate interventions. Blood test. To give the patient enough information on hypernatremia and its effects to the body. Prepare for and assist with dialysis.May be required when more conservative methods fail or are contraindicated such as severe heart failure. Intravenous calcium, which helps prevent life-threatening conduction disturbances by stabilizing the cardiac muscle cell membrane, should be administered if ECG changes are present.24,25,35 Intravenous calcium has no effect on plasma potassium concentration. 1. Distended neck and peripheral veins. Nursing Diagnosis Excess Fluid Volume May be related to Excess fluid or sodium intake. The main source of potassium is from food. Apply visible fall prevention signage.Informing the patient and the caregiver about fall prevention measures will promote participation and lower the risk for falls. Therefore, potassium helps control the fluid inside the cell, while sodium . 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. Bounding pulses. Kathleen Salvador is a registered nurse and a nurse educator holding a Masters degree. Cardiac enzymes are normal but his potassium level is 2.8 mmol/L. Interprofessional patient problems focus familiarizes you with how to speak to patients. The nerve impulses are created by the movement of sodium and potassium in and out the cells. Wolters Kluwer India Pvt. Monitor pulse rate and blood pressure.Hyperkalemia can cause irregular pulse rates and reduces blood artery wall tension which lowers blood pressure. Brunner and Suddarths textbook of medical-surgical nursing (13th ed.). Administered when potassium levels need to be replenished, as well as, in patients with ongoing potassium loss when it must be maintained. Determine the patients independence in performing activities.Promote and assist in patient ambulation and independence in self care. Some types of diuretics increase potassium excretion through the kidneys. [Twitter moment] Retrieved from. It is advised to dilute the solution no more than 1 mEq/10 mL (1 mmol/10 mL). Although redistributive hyperkalemia is uncommon, a cautious approach is warranted because treatment may not involve attempts to eliminate potassium, and correction of the underlying problem can provoke rebound hypokalemia. Sample Osteoporosis Nursing Care Plans |NANDA Nursing Diagnosis |Interventions with Rationales, Clopidogrel Bisulfate (Plavix) Nursing Implications |Patient Teachings, 19 NANDA Nursing Diagnosis for Fracture |Nursing Priorities & Management, 25 NANDA Nursing Diagnosis for Breast Cancer, 5 Stages of Bone Healing Process |Fracture classification |5 Ps, 9 NANDA nursing diagnosis for Cellulitis |Management |Patho |Pt education, 20 NANDA nursing diagnosis for Chronic Kidney Disease (CKD). Muscular weakness can affect respiratory muscles and lead to respiratory complications. Hypokalemia. Normal Potassium Level 3.5-5.1 ( 2.5 or less is very dangerous) Most of the body's potassium is found in the intracellular part of the cell (inside of the cell) compared to the extracellular (outside of the cell), which is where sodium is mainly found. Typically, the first ECG manifestation of hypokalemia is decreased T-wave amplitude. 1. Educate the patient about high-potassium foods. 3. There are subsets of patients that are susceptible to the development of hypokalemia. Because of their increased risk of developing hyperkalemia, patients with underlying renal dysfunction merit special attention.22, Severe hyperkalemia (more than 6.5 mEq per L [6.5 mmol per L]) can cause muscle weakness, ascending paralysis, heart palpitations, and paresthesias. A low serum potassium concentration is perhaps the most common electrolyte abnormality encountered in clinical practice. Repeat measurement of serum potassium can help identify pseudohyperkalemia, which is common and typically results from potassium moving out of cells during or after sample collection.31 Other laboratory studies include measurement of serum blood urea nitrogen and creatinine, measurement of urine electrolytes and creatinine, and assessment of acid-base status. The goals of acute treatment are to prevent potentially life-threatening cardiac conduction and neuromuscular disturbances, shift potassium into cells, eliminate excess potassium, and resolve the underlying disturbance. By using any content on this website, you agree never to hold us legally liable for damages, harm, loss, or misinformation. Hypokalemia and Hyperkalemia are conditions that refer to abnormal levels of potassium in the blood. Generally, hypokalemia is a medical, not a surgical, condition. Conditions such as alcoholism, eating disorders, and renal disorders can cause a severe case of hypokalemia. Crackles. Obtain ECG and observe signs of dysrhythmias.A potassium imbalance may result in alterations in ECG findings since potassium is essential for both depolarization (contraction) and repolarization (relaxation) of the heart. This may lead to serious heart problems, heart attack or death. Urine test. Herdman, T., Kamitsuru, S. & Lopes, C. (2021). Hyperkalemia and hypokalemia can also cause paralysis and weakness. (2015 Nov 22). Oral potassium does not correct the problem, If hypokalemia is causing abnormal heart rhythms, Switching to potassium-sparing diuretics if needed, Treatment of kidney disease, which includes dialysis, Elimination disorders related to increase in urine volume (polyuria). New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. Hypokalemia refers to a condition in which the concentration of Potassium in the blood is low. 5. Medication use is a common cause of hyperkalemia, particularly in patients with baseline renal dysfunction or hypoaldosteronism.27 Medication-induced hyperkalemia is most often a result of the medication interfering with potassium excretion. 2. INTRODUCTION. PO potassium can cause stomach upset so its best to administer with food or after meals. Help the patient to select appropriate dietary choices to follow a high potassium diet. Identify and discontinue dietary sources of potassium, such asbeans, dark leafy greens, potatoes, squash, yogurt, fish, avocados, mushrooms, and bananas.Facilitates the reduction of potassium levels and may prevent the recurrence of hyperkalemia. There are different types of test and diagnosis for hypokalemia disease, those are given in the below: S. Electrolytes / Potassium, Magnesium, Calcium, Phosphorous, TSH, Aldosterone, ECG, . Hypokalemia or potassium levels can impair the kidneys function to concentrate urine, which may result to polyuria. Nursing diagnosis:- Potential for dysrrythmia r/t hyperkalemia. Renal function should be monitored for patients receiving potassium replacement. Please follow your facilities guidelines and policies and procedures. Nursing Diagnosis: Electrolyte Imbalance related to hypokalemia as evidenced , serum potassium level of 2.9 mmol/L, polyuria, increased thirst, weakness, tachycardia, and fatigue Desired Outcome: Patient will be able to re-establish a normal electrolyte and fluid balance. She received her RN license in 1997. 2023 Nurseslabs | Ut in Omnibus Glorificetur Deus! (fatigue) NURSING DIAGNOSIS Hypokalemia RATIONALE Potassium is essential for many body functions. Findings on ECG are neither sensitive nor specific for hyperkalemia. Nurses pocket guide: Diagnoses, interventions, and rationales (15th ed.). For more information, check out our privacy policy. Perform a fall risk assessment.In acute care and long-term settings, fall risk scales are commonly utilized. Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of hyperkalemia and its management. All the contents on this site are for entertainment, informational, educational, and example purposes ONLY. Advertisementsif(typeof ez_ad_units != 'undefined'){ez_ad_units.push([[300,250],'nurseship_com-large-mobile-banner-2','ezslot_6',662,'0','0'])};__ez_fad_position('div-gpt-ad-nurseship_com-large-mobile-banner-2-0');Risk for decreased cardiac tissue perfusion related to severe potassium deficiency as evidenced by heart palpitations, tachycardia, and presence of PVCs. do you see all the information i began to generate from those two pieces of information? All rights reserved. Nursing Care Plans The goal of nursing care is to restore and maintain normal potassium levels through monitoring and appropriate interventions. (2020). (2022). Hypokalemia and Hyperkalemia Nursing Care Plan 2 Potassium also maintains normal neuromuscular contraction by participation in the sodium-potassium pump. Bradycardia can progress to cardiac fibrillation and arrest. About 98% of the bodys potassium is found inside the cells and the rest is found extracellularly. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders. Possible causes of hypokalemia include the following: Possible causes of hyperkalemia include the following: Signs and symptoms of potassium imbalance include: To ensure proper functioning and homeostasis the body must maintain a dynamic equilibrium of fluids and electrolytes. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. 1. Centrally potassium can be administered more quickly and in larger doses via this route. Hypokalemia. The patient needs to avoid foods high in potassium such as bananas. Further progression can lead to ST-interval depression, T-wave inversions, PR-interval prolongation, and U waves. She found a passion in the ER and has stayed in this department for 30 years. Increased thirst -as a result of polyuria, the body will try to compensate to avoid dehydration by increasing the thirst signal. All Rights Reserved. Treatment of hyperkalemia. Hypokalemia is a side effect of diuretic administration and the patient is showing signs of dehydration. Avoid using medical jargons and explain in laymans terms. It is also responsible for keeping the heartbeat regular and promotes the movement of nutrients into and waste out of the cells. Ackley and Ladwigs Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. Potassium levels can fluctuate in the treatment of DKA. Some medications can cause abnormal blood potassium levels. Imbalanced levels can be caused by alterations in the intake and excretion of potassium. The normal serum potassium level is between 3.5 to 5.2 mmoL/L. Adjust the IV potassium dose and rate depending on the available IV access. Elevate the head of the bed.Clients may hypoventilate and retain carbon dioxide resulting in respiratory acidosis. The rapidity and method of potassium repletion depends on the: It should be noted that the recommended dose of nebulized albuterol (10 to 20 mg) is four to eight times greater than the typical respiratory dose. Abnormal potassium levels commonly occur due to the following: Abnormal potassium levels can easily become a medical emergency as it can cause life-threatening cardiac arrhythmias. Educate the patient about hyperkalemia. If able to eat and drink, administer PO potassium. This indicates depletion in the normal potassium levels in the body, a potential life-threatening emergency and can be fatal. As a portion of daily potassium is excreted in the colon, lower GI losses in the form of persistent diarrhea can also result in hypokalemia and may be accompanied by hyperchloremic acidosis.6, Hypokalemia is often asymptomatic. Be aware that cardiac arrest can occur.Potassium excess depresses myocardial conduction. Educate the patient about the role of potassium in the body. 1. Figure 3 is an algorithm for the management of hyperkalemia, and Table 322,30,36 summarizes medications used in the treatment of the condition. If you continue to use this site we will assume that you are happy with it. 2023 nurseship.com. Encourage deep breathing and coughing exercise. P. otassium functions to maintain fluid balance, to regulate nerve signals, and to help with muscle contractions. Dewit, S. C., Stromberg, H., & Dallred, C. (2017). Potassium movement from extracellular to intracellular fluid due to: IV therapy with potassium-deficient solutions, Rapid infusion of potassium-containing IV solutions, Adrenal insufficiency (such as in Addisons disease), Potassium movement from intracellular to the extracellular fluid, Muscle weakness, leg cramps, deep tendon hyporeflexia, and paresthesias, ECG changes: ST depression, inverted T waves, and prominent U waves, Increased motility, hyperactive bowel sounds, and diarrhea, Ascending flaccid paralysis until the respiratory muscles become affected as a toxic level of serum potassium is reached, ECG changes: Tall peaked T waves, widened QRS complexes, and prolonged PR intervals, Conditions that affect the movement of potassium in the cellular space, Alterations in the electrical conductivity of the heart, Patient will demonstrate serum potassium levels within normal limits, Patient will verbalize the absence of muscle pain or cramping, Disruption in the electric functioning of the heart, Patient will display pulse and blood pressure within acceptable limits, Patient will verbalize the absence of angina or palpitations, Patient will demonstrate ECG results of normal sinus rhythm, Patient will be able to verbalize understanding of decreased cardiac output in relation to hypo/hyperkalemia, Patient will participate in physical therapy sessions, Patient will be able to maintain or regain muscle strength. You take medication that makes you pee ( water pills or diuretics) It's possible, but rare, to get . Our website services and content are for informational purposes only. Additionally, this sampleHypokalemianursing care plan comprises nursing assessment, NANDA nursing diagnosis, goal, and interventions with rationales. Treating these conditions involves monitoring and preventing hypo/hyperkalemia.
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