Fluids and Electrolytes

Potassium
 Potassium is the major cation of the intracellular fluid and
is responsible for maintaining intracellular osmotic pressure.
 Potassium also regulates neuromuscular excitability,
 Aids in maintenance of acid-base balance,
synthesis of protein, and metabolism of carbohydrates.
 Normal serum range is 3.5–5.0 mEq/L (body total of 42 mEq/L).
 K– most abundant intracellular cation, normal value= 3.5-5 mEq/L
 exchanges with H ions to maintain acid-base balance
 alkalosis = hypoK
 acidosis = hyperK
 affected by insulin levels
Functions of K+
 muscular (esp heart) contraction
 neuromuscular contraction, including smooth muscles
 part of sodium-potassium pump
 Glucose uptake into the cells need K
Source: dried fruits (prunes), fruits (banana, cantaloupe, grapefruit, orange, apricots, avocado),
vegetables (spinach, broccoli, green beans) nuts, milk, meat, coffee & cola, salt substitutes
• RDA: 40-60 mEq/day
IMBALANCES IN K+
1. HYPOKALEMIA (Potassium Deficit)  serum K – less than 3.5mEq/L
Causes:
1. inc.K loss- inc. use of diuretics, inc. use of laxative,enemas,inc.GIT suction,drainage,excessive
vomiting,diarrhea,inc.aldosterone
2. Decrease K intake
3. Increase K use by cells:
metabolic acidosis, TPN, Healing phase in Burns,hyponatremia

PREDISPOSING/CONTRIBUTING FACTORS
Renal loss: Use of potassium-wasting diuretics, diuretic phase of ATN, healing phase
of burns; diabetic acidosis; Cushing’s syndrome; nephritis, hypomagnesemia;
use of sodium penicillins, amphotericin B, carbenicillin steroids; licorice abuse
GI loss: Profuse vomiting, excessive diarrhea, laxative abuse, prolonged gastric
suction, inflammatory bowel disease, fistulas
Inadequate dietary intake: Anorexia nervosa, starvation, high-sodium diet
Shift into cells: TPN, alkalosis, or excessive secretion or administration of insulin
Other: Sweat losses (heavily perspiring person acclimated to heat); liver disease
Patient Assessment
ACTIVITY/REST
May report: Generalized weakness, lethargy, fatigue, muscle weakness, paresthesias, coma

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 Fluids and Electrolytes
CIRCULATION
May exhibit: Hypotension
Pulses weak/diminished, irregular
Heart sounds distant
Dysrhythmias, e.g., premature ventricular contractions
(PVCs), ventricular tachycardia/fibrillation,
arrythmia/cardiac arrest
ECG: depressed ST segment, prominent U wave
ELIMINATION
May exhibit: Nocturia, polyuria if factors contributing to hypokalemia include HF or DM
Bowel sounds diminished, decreased bowel motility, paralytic ileus
Abdominal distension
FOOD/FLUID
May report: Anorexia, nausea/vomiting
Thirst
NEUROSENSORY
May report: Paresthesias
May exhibit: Depressed mental state/confusion, apathy, drowsiness, irritability, coma
Hyporeflexia, tetany, paralysis (flaccid quadriparesis)
PAIN/DISCOMFORT
May report: Muscle pain/cramps
RESPIRATION
May exhibit: Hypoventilation/decreased respiratory depth due to muscle weakness/paralysis of
diaphragm; apnea, cyanosis
DIAGNOSTIC STUDIES
Serum potassium: Decreased, less than 3.5 mEq/L.
Serum chloride: Often decreased, less than 98 mEq/L.
Serum glucose: May be slightly elevated.
Serum magnesium: Levels often decreased when potassium deficit is present.
Plasma bicarbonate: Increased, greater than 29 mEq/L.
Urine osmolality: Decreased.
ABGs: pH and bicarbonate may be elevated (metabolic alkalosis).
ECG: Low voltage; flat or inverted T wave, appearance of U wave, depressed ST segment, peaked P
waves; prolonged QT interval, ventricular dysrhythmias.
MANAGEMENT
 IV: no more than 1mEq/10 ml
- make sure patient has voided
 Oral: kalium durule (give with meals)
 Diet: high potassium
Monitor drug levels of cardiac glycosides
Protect from injury
Nsg. Diagnosis
1. Alteration in C.O. deficit rel.to cardiac dysfunction potential
2. Impaired breathing pattern rel.to respiratory paralysis potential
3. Alteration in nutrition rel. to dec.GIT mobility

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 Fluids and Electrolytes
Goal of Care
1. Correct level of serum K to w/in normal
2. Prevent serious resp.and cardiovascular complication
3. Improve nutritional status
4. Restore physical mobility and strength
5. Relief of anxiety via adequate information

BEST TREATMENT IS PREVENTION

• Correct K loss daily. Average normal requirement for K 40mEq/L via dietary intake
• K replacement: give IV drip in of KCL sol.
– K acetate solution
– K PO4 sol.
TAKE NOTE:
 Incorporate in IVF. Never administer in concentrated form or IV bolus or IV push.Mix with IVF
thoroughly
 Usual concentration – 40mEq/L in D5W in 1L of infusion
 Concentration greater than 60 mEq/L are not administered in peripheral veins – CAUSES PAIN
and SCLEROSIS
 For routine management: Administer at a rate NOT FASTER than 10mEq/L per hour
 Always check for adequate urine flow before administering. Oliguria less than 20ml/hour x 2
consecutive hours is indication for stopping KCL infusion. Administer with caution in adults.
 Observe EKG closely where in giving KCL infusion for potential hyperkalemia

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Display heart rhythm and laboratory results WNL for patient, absence of muscle weakness,
paresthesias, cognitive impairment.

NURSING ACTIONS/INTERVENTIONS
Electrolyte Management: Hypokalemia
Independent
1. Monitor heart rate/rhythm.
2. Monitor respiratory rate, depth, effort. Encourage cough/deep-breathing exercises; reposition
frequently.
3. Assess level of consciousness and neuromuscular function, e.g., strength, sensation, movement.
4. Auscultate bowel sounds, noting decrease/absence or change.
5. Maintain accurate record of urinary, gastric, and wound losses.
6. Monitor rate of IV potassium administration using microdrop or pump infusion devices. Check
for side effects. Provide ice pack as indicated.
7. Encourage intake of foods and fluids high in potassium, e.g., bananas, oranges, dried fruits, red
meat, turkey, salmon, leafy vegetables, peas, baked potatoes, tomatoes, winter squash, coffee,
colas, tea. Discuss use of potassium chloride salt substitutes for patient receiving long-term
diuretics.

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 Fluids and Electrolytes
8. Review drug regimen for potassium-wasting drugs, e.g., furosemide (Lasix), hydrochlorothiazide
(Diamox), IV catecholamines, gentamicin (Garamycin), carbenicillin (Geocillin), amphotericin B
(Fungizone).
9. Discuss preventable causes of condition, e.g., nutritional choices, proper use of laxatives.
10. Dilute liquid and effervescent K supplements (K-Tab, K-Lyte/Cl) with 4 oz water/juice and give
after meals.
11. Watch for signs of digitalis intoxication when used (e.g., reports of nausea/vomiting, blurred
vision, increasing atrial dysrhythmias, and heart block).
12. Observe for signs of metabolic alkalosis, e.g., hypoventilation, tachycardia, dysrhythmias, tetany,
changes in mentation.

Collaborative
1. Assist with identification/treatment of underlying cause.
2. Monitor laboratory studies, e.g.: Serum potassium; ABGs; Serum magnesium; Serum chloride.
3. Administer oral and/or IV potassium.

2. HYPERKALEMIA (Potassium Excess) (K+ greater than 50 mEq/L)

ETIOLOGY:
• Increased in K intake ex.excessive adm.of KCL,,Pen G K / improper mixing of KCL
Causes
 Decreased excretion or loss
 Renal failure
 Addison’s
 Overuse of K-sparing diuretics
 K Shift from cells to blood
 Metabolic acidosis
 Insulin deficiency
 Massive cell damage (burns, tumor lysis syndrome, blood cell hemolysis)
 Blood transfusions

PREDISPOSING/CONTRIBUTING FACTORS
Potassium retention: Decreased renal excretion (e.g., renal disease/acute failure,
hypoaldosteronism, Addison’s disease), hypovolemia, use of potassium-
conserving diuretics, especially when associated with potassium supplements,
use of NSAIDs
Excessive potassium intake: Salt substitutes, drugs containing potassium (e.g.,
penicillin), improper use of oral potassium supplements, too-rapid IV
administration of potassium, massive transfusion of banked blood
Shift or release of potassium out of cells: Severe catabolism, burns, crush injuries,
myocardial infarction (MI), severe hemolysis, rhabdomyolysis, chemotherapy
with cytotoxic drugs, respiratory or metabolic acidosis, anoxia, hyperglycemia
with insulin deficiency, use of some -adrenergic blockers, profound digitalis
toxicity
Other: Use of certain medications such as captopril, heparin, cyclosporin

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 Fluids and Electrolytes
Patient Assessment
Depends on degree of elevation and length of time condition has existed.
ACTIVITY/REST
May report: Vague muscular weakness,
May exhibit: Restlessness, irritability
• Twitching (early) or paralysis (late)
CIRCULATION
May exhibit: Irregular pulse, bradycardia, heart block, asystole
Arrhythmia or dysrhythmias
Slow cardiac rate, decreased BP
ECG: narrow/peaked T wave, widened QRS,
prolonged PR interval, flattered P wave
ELIMINATION
May report: Intermittent abdominal cramps, diarrhea,
May exhibit: Urine volume decreased/oliguria
Hyperactive bowel sounds, Hypermotility
FOOD/FLUID
May report: Nausea/vomiting
NEUROSENSORY
May report: Paresthesias (often of face, tongue, hands, feet)
Slurred speech
May exhibit: Decreased deep-tendon reflexes; progressive, ascending flaccid paralysis;
twitching, seizure activity
Apathy, drowsiness, confusion
PAIN/DISCOMFORT
May report: Muscle cramps/pain

DIAGNOSTIC STUDIES
Serum potassium: Increased, greater than 5.1 mEq/L.
Serum magnesium: Levels may be elevated if renal failure is present.
Renal function studies: May be altered, indicating failure.
Leukocyte or thrombocyte count: Elevation may cause a pseudohyperkalemia, affecting choice of
interventions.
ECG changes: T waves tall and peaked/tented, prolonged PR interval, loss of P waves, widening of QRS
complex, shortened QT interval, and ST segment depression; atrial/ventricular dysrhythmias, e.g.,
bradycardia, atrial arrest, complete heart block, ventricular fibrillation, cardiac arrest.

MANAGEMENT
1. Asses : serum K levels
 EKG changes
 Increased GIT function : bowel sounds
2. Avoid increase in diet:
 coffee,cocoa,tea,dried fruits,beans,whole grain cereals,milk,
eggs,prunes,raisins,watermelon,oranges,banan

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 Fluids and Electrolytes
3. Mix KCL thoroughly
4. Use Thiazides of loop diuretics with K sparing diuretics to prevent incr. of K
5. Avoid use of salt sustitutes because they contain 60mEq/L of K per teaspoon
6. FOR RENAL FAILURE PATIENT,administer:
 Insulin drip- incorporate regular Insulin in D10W 1 L to promote active transport
mechanism of K back to cells. Use D10W to avoid hypoglycemic episodes
 Kayexelate-Na exchanges with K from the blood and binds K in the GIT

Nsg.Diagnosis
1. Potential for dec.C.O. Rel.to Cardiac Dysrhytmias.
2. Potential for ineffective breathing pattern rel.to resp.paralysis
3. Diarrhea rel.to incr. GIT motility
4. Fluid vol.deficit rel. to diarrhea

GOAL OF CARE
1. Restore K level within normal limits 3.5- 5.0 mEq/L
2. Prevent or minimize respiratory and cardiovascular complications

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Electrolyte & Acid/Base Balance
Display heart rate/rhythm and laboratory results WNL for patient; absence of muscle weakness,
paresthesias, cognitive impairment.

NURSING ACTIONS/INTERVENTIONS
Electrolyte Management: Hyperkalemia
Independent
1. Identify the patient at risk; or the cause of the hyperkalemia, e.g., excessive intake of potassium
or decreased excretion.
2. Instruct patient in use of potassium-containing salts (salt substitutes), taking potassium
supplements safely.
3. Monitor respiratory rate and depth. Elevate head of bed. Encourage cough/deep-breathing
exercises.
4. Monitor heart rate/rhythm. Be aware that cardiac arrest can occur.
5. Monitor urinary output.
6. Assess level of consciousness, neuromuscular function, e.g., movement, strength, sensation.
7. Encourage/assist with ROM exercises as tolerated.
8. Encourage frequent rest periods; assist with care activities, as indicated.
9. Review drug regimen for medications containing/
affecting potassium excretion, e.g., penicillin G, spironolactone (Aldactone), amiloride
(Midamor), hydrochlorothiazide (Dyazide, Maxzide).
10. Identify/discontinue dietary sources of potassium, e.g., tomatoes, broccoli, orange juice, bananas,
bran, chocolate, coffee, tea, eggs, dairy products, dried fruits.

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 Fluids and Electrolytes
11. Recommend an increase in carbohydrates/fats and foods low in potassium, e.g., canned fruits,
refined cereals, apple/cranberry juice.
12. Stress importance of patient’s notifying future caregivers when chronic condition potentiates
development of hyperkalemia, e.g., oliguric renal failure.
Collaborative
13. Assist with identification/treatment of underlying cause.
14. Monitor laboratory results, e.g., serum potassium, ABGs, BUN/Cr, glucose as indicated.
15. Administer medications as indicated, e.g.: Diuretics, e.g., furosemide (Lasix); IV glucose with
insulin, sodium bicarbonate; Calcium gluconate; Sodium polystyrene sulfonate (Kayexalate, SPS
suspension), orally, per NG tube, or rectally; Adrenergic agonist, e.g., albuterol (Proventil).
16. Infuse potassium-based medication/solutions slowly.
17. Provide fresh blood or washed RBCs (when possible) if transfusions required.
18. Prepare for/assist with dialysis (peritoneal or hemodialysis).

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