Blood pressure medications. This must be given at a controlled slow rate as potassium solution may cause a burning sensation on the infusion site. A slow intravenous potassium solution is given to raise the potassium level in the blood stream. Diuretics, or water pills, help your body get rid of extra potassium when you urinate. Risk for Infection NCLEX Review Care Plans Nursing Care Plans for Risk for Infection Risk …, Your email address will not be published. She was hyperkalemic (7.3), but they hadnt 100% determined the cause. Nursing Diagnosis: Ineffective Renal Tissue Perfusion related to glomerular malfunction secondary to chronic renal failure as evidenced by increase in lab results (BUN, creatinine, uric acid, eGFR levels), oliguria or anuria, peripheral edema, hypertension, muscle twitching and cramping, fatigue, and weakness Hemolysis or breakdown of red blood cells, Rhabdomyolysis or the breakdown of muscle tissues, Burns, trauma, and other tissue injuries can also cause the release of potassium from the cells. Saunders comprehensive review for the NCLEX-RN examination. Medication intake. Which of the following is a priority nursing intervention… Create a daily weight chart and a food and fluid chart. Required fields are marked *. Nursestudy.net © Copyright 2021, All Rights Reserved, Hyperkalemia & Hypokalemia Nursing Care Plans Diagnosis and Interventions. Obtain daily blood sample from the patient. Nursing diagnoses handbook: An evidence-based guide to planning care. nursing interventions for hyperkalemia treatment; nursing interventions for hyperkalemia management; nursing interventions for diabetes; nursing interventions for depression; nursing interventions for … Monitor vitals. In providing nursing interventions… Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Boiling potatoes and cutting vegetable sin small pieces are also recommended. The steps to address hyperkalemia include stabilization, redistribution, and excretion/removal of potassium. With conditions predisposing to hyperkalemia and/or associated with increased sensitivity to potassium, such as patients with severe renal impairment, acute dehydration, extensive tissue injury or burns, certain cardiac disorders such as congestive heart failure. Hyperkalemia, which is a potassium level greater than 5.2 mEq/L, can be life threatening; the signs and symptoms associated with hyperkalemia include muscular weakness, paralysis, weakness, nausea and possible life threatening cardiac dysrhythmias. The topics focus on various issues impacting heart failure and heart failure nurses. P. otassium functions to maintain fluid balance, to regulate nerve signals, and to help with muscle contractions. A. Please follow your facilities guidelines and policies and procedures. spironolactone or other potassium-sparing diuretics and/or angiotensin-converting enzyme inhibitor, or even potassium supplementation therapy) or by hemolysis and will not be the subject of this article, which is focused on hypokalemia. Nursing Diagnosis: Imbalanced Nutrition Less than Body related to hypokalemia as evidenced by nausea, vomiting, weakness, loss of appetite, and verbalization of decreased energy levels. This site is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. Foods like bananas, you probably already knew that one before you started nursing school. IV insulin + glucose – insulin shifts glucose and potassium into the cells, so it is utilized in hyperkalemia to … To effectively monitory the patient’s daily nutritional intake and progress in weight loss goals. Biochemistry is needed to check for the level of serum potassium. IF the patient is hyperkalemic, and the doc doesn’t ask…make sure s/he knows…one of the commonly used intubation meds is succinylcholine which causes a transient hyperkalemia. Potassium sparing diuretics caused diuresis without loss of potassium unlike other diuretics. The patient needs to avoid foods high in potassium such as bananas. Hyperkalemia nursing interventions Assess H & P, EKG monitoring, treat imbalance (force fluids, IV saline, diuretics). Volume depletion is typically accompanied by increased potassium excretion in the kidneys. Explain to the patient the relation of altered potassium levels to nausea and vomiting and loss of appetite. ... Potassium– elevation indicates kidney disease from lack of excretion or selective retention and leads to hyperkalemia . The diagnosis of hyperkalemia includes history taking and physical examination. Absorption: 60–75% absorbed following oral administration (decreased by food). Medical conditions can also cause abnormal potassium levels; therefore, treatment also includes correcting the main cause of abnormal potassium levels. Short term goals: After 1 hour of health teaching, client will be able to: … • Monitor abdomen for bowel sounds, distention, and pain. Inadequate or too much intake of potassium-rich food can alter the blood levels of potassium. Some blood pressure medications such as angiotensin-converting enzymes inhibitors, beta blockers, and angiotensin-receptor blocker are known to cause hyperkalemia. Calcium may help prevent the symptoms of hyperkalemia, such as cardiac arrhythmias. Educate the patient about hyperkalemia. Low potassium diet include eating apples, berries, pineapple, breads, and cereals. No intervention but continue to monitor the client's hemodynamic status ; Encouraged intake of potassium-rich foods, such as bananas ; Oral intake of potassium by electrolyte preparations … A blood test is performed to check the levels of electrolytes in the blood including potassium. 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. Risk for Imbalanced Fluid Volume Renal failure is a major cause of hyperkalemia… Learn how your comment data is processed. Independent nursing functions include those things such as the initiation of coughing and deep breathing exercises and back massage, and dependent nursing functions, which are interventions that the nurse can only perform with a doctor's order, include things like the administration of analgesic medications and intravenous fluid replacements. • Monitor intravenous site for redness, swelling, and pain. 4 0 obj << /Linearized 1 /O 6 /H [ 1454 243 ] /L 64136 /E 63718 /N 1 /T 63939 >> endobj xref 4 52 0000000016 00000 n 0000001384 00000 n 0000001697 00000 n 0000001927 00000 n 0000002180 00000 n 0000003083 00000 n 0000003699 00000 n 0000004490 00000 n 0000005286 00000 n 0000005696 00000 n 0000006314 00000 n 0000007133 00000 n 0000007914 00000 n 0000008374 00000 n 0000008900 00000 n 0000008939 00000 n 0000008960 00000 n 0000009992 00000 n 0000010013 00000 n 0000010948 00000 n 0000010970 00000 n 0000012122 00000 n 0000012676 00000 n 0000013014 00000 n 0000013337 00000 n 0000013612 00000 n 0000014206 00000 n 0000014493 00000 n 0000014611 00000 n 0000014632 00000 n 0000015680 00000 n 0000015701 00000 n 0000016672 00000 n 0000016693 00000 n 0000017661 00000 n 0000018456 00000 n 0000018975 00000 n 0000018997 00000 n 0000020089 00000 n 0000020110 00000 n 0000020965 00000 n 0000026079 00000 n 0000028756 00000 n 0000034905 00000 n 0000042312 00000 n 0000047594 00000 n 0000055059 00000 n 0000057645 00000 n 0000061064 00000 n 0000063590 00000 n 0000001454 00000 n 0000001676 00000 n trailer << /Size 56 /Info 3 0 R /Root 5 0 R /Prev 63930 /ID[<33ea0d48621138cb5ca004c9c7642e0d><33ea0d48621138cb5ca004c9c7642e0d>] >> startxref 0 %%EOF 5 0 obj << /Type /Catalog /Pages 2 0 R /Outlines 1 0 R >> endobj 54 0 obj << /S 36 /O 144 /Filter /FlateDecode /Length 55 0 R >> stream Participate in treatment regimen within level of ability/situation. Treatment of hyperkalemia. Nursing Interventions Monitor cardiovascular, respiratory, neuromuscular, renal, and gastrointestinal … Inform the patient of the need to undergo dialysis, if indicated by the physician. Select all that apply. Insulin causes the entry of potassium to the cells. Then there’s patient and family education, medication reconciliation, communication with other healthcare professionals, and transferring and discharging patients. Inform him/her the target range for serum potassium levels. However, potassium will need to be given intravenously in the following conditions: Treating of underlying disease. HYPERKALEMIA. Potassium is a main intracellular electrolyte. The effect can cause slow peristalsis which can lead to constipation. Nurse Tutoring, Nursing school help, nursing school, Nursing student, nursing student help, NCLEX, NCLEX Practice exams A nurse is caring for a client who has had thyroid surgery. Teach the patient on how to follow a low potassium diet. To treat the kidney disease if this is the underlying cause of hyperkalemia. Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. St. Louis, MO: Elsevier. Nursing Study Guide on Hypokalemia and Hyperkalemiaif(typeof __ez_fad_position != 'undefined'){__ez_fad_position('div-gpt-ad-nursestudy_net-medrectangle-3-0')}; Hypokalemia and Hyperkalemia are conditions that refer to abnormal levels of potassium in the blood. Calcium in-creases the risk of digitalis toxicity. Check vitals sign … Quiz on Hyperkalemia & Hypokalemia. Urine test. Initiate potassium restricted diet and remember foods that are high in potassium Studies suggest that some antibiotics can cause high potassium levels. C. Place patient on a potassium restrictive diet. 9. Folic acid deficiency. peripheral pulses. Ineffective Airway Clearance 5 Nursing Care Plans. This is ‘A Nuanced Approach to Emergency Management of Hyperkalemia’ on EM Cases. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Nursing Care Plans for Chronic Renal Failure Nursing Care Plan 1. Insert indwelling urinary catheter unless contraindicated for infection . Diuretics. Desired Outcome: Patient will be able to re-establish a normal electrolyte and fluid balance. Prepare the patient for dialysis and place the patient on a cardiac monitor. High alcohol intake. Magnesium helps the movement potassium in and out the cells. The aggressiveness of therapy for hyperkalemia is directly related to the rapidity with which the condition has developed, the absolute level of serum potassium, and the evidence of toxicity. Buy on Amazon, Gulanick, M., & Myers, J. L. (2017). These are vital nursing interventions done in patients who are taking diuretics: Administer drug with food or milk if GI upset is a problem to buffer drug effect on the stomach lining. (2020). Treatment. 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). Nursing Tips Your everyday practice is filled with assessments, documentation, planning, interventions, and evaluations. Muscular cramps or twitching – hyperkalemia or high potassium levels in the blood can cause alteration in the voltage of the nerve cells causing unregulated muscle contractions. Which of the following interventions is priority? Hyperkalemia and hypokalemia can also cause paralysis and weakness. Assess for signs of hypercalcemia ; Administer intravenous furosemide Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). The normal serum potassium level is between 3.5 to 5.2 mmoL/L. Limit the amount of potassium you eat: Foods that are high in potassium include bananas, tomatoes, oranges, turkey, and milk. Urinalysis can also show the presence of potassium in the urine. However, since potassium is a potent electrolyte, increased potassium can cause increased contraction that may result to dysrhythmias. This is commonly done through the administration of oral potassium supplement and high potassium diet. H�b``0b``]� ���(- �P�� ����a��Dհ�G�`Q�ć}�y�8�d&0x\S�ײC��-G����� ��5 LNx�jV%�o7[)}ѕi����%�>S���4# A� endstream endobj 55 0 obj 131 endobj 6 0 obj << /Type /Page /Parent 2 0 R /Resources 7 0 R /Contents [ 20 0 R 22 0 R 24 0 R 33 0 R 35 0 R 37 0 R 41 0 R 43 0 R ] /MediaBox [ 0 0 612 783 ] /CropBox [ 60.44678 34.54102 575.30017 468.53284 ] /Rotate 0 >> endobj 7 0 obj << /ProcSet [ /PDF /Text /ImageC ] /Font << /F5 14 0 R /F9 15 0 R /F11 8 0 R /F18 11 0 R /F20 10 0 R /F21 27 0 R /F23 38 0 R /F24 25 0 R >> /XObject << /Im15 52 0 R >> /ExtGState << /GS1 53 0 R >> /ColorSpace << /Cs6 18 0 R >> >> endobj 8 0 obj << /Type /Font /Subtype /Type1 /FirstChar 0 /LastChar 208 /Widths [ 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 355 556 556 889 667 191 333 333 389 584 278 333 278 278 556 556 556 556 556 556 556 556 556 556 278 278 584 584 584 556 1015 667 667 722 722 667 611 778 722 278 500 667 556 833 722 778 667 778 722 667 611 722 667 944 667 667 611 278 278 278 469 556 333 556 556 500 556 556 278 556 556 222 222 500 222 833 556 556 556 556 333 500 278 556 500 722 500 500 500 334 260 334 584 278 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 556 556 0 0 0 0 0 737 0 0 0 278 0 0 278 584 278 278 0 556 278 278 278 278 278 0 0 278 0 0 0 0 0 278 0 278 278 0 0 0 278 0 0 0 0 0 556 ] /Encoding /MacRomanEncoding /BaseFont /MLCDKG+Helvetica /FontDescriptor 12 0 R >> endobj 9 0 obj << /Type /FontDescriptor /Ascent 699 /CapHeight 662 /Descent -217 /Flags 34 /FontBBox [ -168 -218 1000 898 ] /FontName /MLCDMI+Times-Roman /ItalicAngle 0 /StemV 84 /XHeight 450 /StemH 84 /CharSet (/C/h/a/n/g/e/s/space/i/t/o/r/m/l/d/b/u/c/p/f/y/period/T/x/hyphen/comma/w\ /quoteright/parenleft/H/parenright/N/v/k/E/q/M/D/F/I/B/W/colon/bullet/P/\ A/six/zero/percent/semicolon/five/four/two/L/endash/one/plus/O/z/slash/S\ /bracketleft/bracketright/K/three/seven/nine/eight/j/R/V/U/greater/quote\ dblleft/quotedblright/less/G/Q/ampersand/emdash/J/Y/underscore/exclam/X) /FontFile3 49 0 R >> endobj 10 0 obj << /Type /Font /Subtype /Type1 /FirstChar 32 /LastChar 213 /Widths [ 250 333 420 500 500 833 778 214 333 333 500 675 250 333 250 278 500 500 500 500 500 500 500 500 500 500 333 333 675 675 675 500 920 611 611 667 722 611 611 722 722 333 444 667 556 833 667 722 611 722 611 500 556 722 611 833 611 556 556 389 278 389 422 500 333 500 500 444 500 444 278 500 500 278 278 444 278 722 500 500 500 500 389 389 278 500 444 667 444 444 389 400 275 400 541 250 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 500 500 0 0 0 0 0 760 0 0 0 250 0 0 250 675 250 250 0 500 250 250 250 250 250 0 0 250 0 0 0 0 0 250 0 250 250 0 0 0 250 0 0 0 0 0 500 889 0 0 0 333 ] /Encoding /MacRomanEncoding /BaseFont /MLCEDP+Times-Italic /FontDescriptor 17 0 R >> endobj 11 0 obj << /Type /Font /Subtype /Type1 /FirstChar 32 /LastChar 213 /Widths [ 250 333 408 500 500 833 778 180 333 333 500 564 250 333 250 278 500 500 500 500 500 500 500 500 500 500 278 278 564 564 564 444 921 722 667 667 722 611 556 722 722 333 389 722 611 889 722 722 556 722 667 556 611 722 722 944 722 722 611 333 278 333 469 500 333 444 500 444 500 444 333 500 500 278 278 500 278 778 500 500 500 500 333 389 278 500 500 722 500 500 444 480 200 480 541 250 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 500 500 0 350 0 0 0 760 0 0 0 250 0 0 250 564 250 250 0 500 250 250 250 250 250 0 0 250 0 0 0 0 0 250 0 250 250 0 0 0 250 0 0 0 0 0 500 1000 444 444 0 333 ] /Encoding /MacRomanEncoding /BaseFont /MLCDMI+Times-Roman /FontDescriptor 9 0 R >> endobj 12 0 obj << /Type /FontDescriptor /Ascent 718 /CapHeight 718 /Descent -207 /Flags 32 /FontBBox [ -166 -225 1000 931 ] /FontName /MLCDKG+Helvetica /ItalicAngle 0 /StemV 88 /XHeight 523 /StemH 88 /CharSet (/seven/eight/nine/N/a/plus/K/M/g/two/C/P/l/s/m/I/n/t/e/r/i/f/u/d/c/zero/\ five/one/A/T/O/S/H/three/endash/four/period/space/o/six/hyphen/x/h/v/E/q\ /slash/L/p/B/b) /FontFile3 51 0 R >> endobj 13 0 obj << /Type /FontDescriptor /Ascent 712 /CapHeight 712 /Descent -232 /Flags 32 /FontBBox [ -55 -250 1144 835 ] /FontName /MLBBLI+MyriadMM_406_600_ /ItalicAngle 0 /StemV 88.66 /XHeight 472 /StemH 67.41 /CharSet (/D/i/s/c/u/space/t/h/e/f/n/o/a/d/r/g/l/y/m/w/b/period/C/p/comma/v/hyphen\ /I/R/z/U/P/k/A/S/O/M/x/W/slash/five/bullet/G/N/L/E/X/T/colon/H/F/B/one/t\ wo/zero/three/j/parenleft/parenright/plus/endash/four/q/nine/eight/six/K\ /seven/J/V/quoteright/percent/ampersand/question/Q/Z/semicolon/degree/qu\ otedblleft/quotedblright/Y/emdash/less/equal/greater/fraction) /FontFile3 46 0 R >> endobj 14 0 obj << /Type /Font /Subtype /Type1 /FirstChar 32 /LastChar 218 /Widths [ 212 231 338 498 514 793 606 188 284 284 416 596 208 307 208 343 514 514 514 514 514 514 514 514 514 514 208 208 596 596 596 406 738 613 544 580 667 492 487 647 653 240 371 543 473 805 659 689 533 689 539 494 497 648 559 847 572 542 554 284 346 284 596 500 300 483 570 448 564 502 293 560 556 235 244 470 235 835 556 549 570 563 328 397 332 551 482 737 464 472 428 284 239 284 596 212 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 318 514 514 0 283 0 0 0 677 0 0 0 212 0 0 212 596 212 212 0 551 212 212 212 212 212 0 0 212 0 0 0 0 0 212 0 212 212 0 0 0 212 0 0 0 0 0 500 1000 355 355 0 207 0 212 0 0 418 ] /Encoding /MacRomanEncoding /BaseFont /MLBBLI+MyriadMM_406_600_ /FontDescriptor 13 0 R >> endobj 15 0 obj << /Type /Font /Subtype /Type1 /FirstChar 32 /LastChar 208 /Widths [ 305 278 333 611 611 889 667 222 389 389 444 600 305 333 305 278 611 611 611 611 611 611 611 611 611 611 305 305 600 600 600 444 800 667 556 611 667 500 444 722 611 278 333 611 444 778 667 833 500 833 556 444 444 612 667 889 556 611 556 333 278 333 600 500 222 611 611 444 611 611 278 611 556 222 222 500 222 889 556 611 611 611 278 389 278 556 500 833 500 500 500 333 222 333 600 305 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 611 611 0 0 0 0 0 800 0 0 0 305 0 0 305 600 305 305 0 556 305 305 305 305 305 0 0 305 0 0 0 0 0 305 0 305 305 0 0 0 305 0 0 0 0 0 500 ] /Encoding /MacRomanEncoding /BaseFont /MLBBIE+SerifGothic-Bold /FontDescriptor 16 0 R >> endobj 16 0 obj << /Type /FontDescriptor /Ascent 712 /CapHeight 712 /Descent -228 /Flags 262178 /FontBBox [ -167 -250 1000 935 ] /FontName /MLBBIE+SerifGothic-Bold /ItalicAngle 0 /StemV 100 /XHeight 490 /StemH 92 /CharSet (/A/f/t/e/r/space/c/o/m/p/l/i/n/g/h/s/a/comma/y/u/w/b/colon/M/d/L/k/O/V/E\ /R/I/W/F/N/U/D/C/T/Y/B/G/v/S/K/hyphen/H/P/parenleft/parenright/X/five/en\ dash/one/two/j/x/Z/three/four/eight/nine/J/six/seven) /FontFile3 44 0 R >> endobj 17 0 obj << /Type /FontDescriptor /Ascent 699 /CapHeight 653 /Descent -205 /Flags 98 /FontBBox [ -169 -217 1010 883 ] /FontName /MLCEDP+Times-Italic /ItalicAngle -15.5 /StemV 76 /XHeight 441 /StemH 76 /CharSet (/C/a/t/i/o/n/s/u/v/l/e/comma/d/I/r/c/space/f/parenleft/F/parenright/E/x/\ y/p/m/b/O/T/H/h/z/S/hyphen/period/g/U/V/P/k/w/q/K/j/three/zero/six/L/R/B\ /N/quoteright/emdash/A/D/W/two/semicolon/four/one/five/slash/plus/G/M/Q/\ nine/percent/ampersand/colon/endash/J/seven/eight) /FontFile3 47 0 R >> endobj 18 0 obj [ /ICCBased 45 0 R ] endobj 19 0 obj 954 endobj 20 0 obj << /Filter /FlateDecode /Length 19 0 R >> stream High potassium occurs due to lack of insulin. there are 5 steps to the nursing process and the first three are critical in starting the care plan: assessment (collect data from medical record, do a physical assessment of the patient, assess … During the treatment, however, low potassium may result due to the administration of insulin. Place the patient on high potassium diet as per the physician’s order. Electrocardiogram (ECG). Nursing Mothers. To address the patient’s cognition and mental status towards the new diagnosis of hyperkalemia and to help the patient overcome blocks to learning. To give the patient enough information on hypernatremia and its effects to the body. Gastric fluid contains little amount of potassium. We are compensated for referring traffic and business to Amazon and other companies linked to on this site. Diabetic ketoacidosis. Low magnesium levels.