POTASSIUM

y y y Potassium (K+) is the major cation of intracellular fluid (ICF). Normal plasma potassium level ranges from 3.5 to 5.0 mEq/L or mmol/L Functions of potassium are as follows: (Table 13-4, p.184) o Regulation of intracellular osmolarity o Maintenance of electrical membrane excitability o Maintenance of plasma acid-base balance Potassium is the highest in meat, fish, and many (but not all) fruits and vegetables. It is lowest in eggs, bread, and cereal grains. The sodium-potassium pump moves extra sodium ions from ICF and moves extra potassium ions from the ECF back into the cell; keeping serum potassium levels low and cellular potassium levels high. 80% of potassium removed by kidneys. o Kidney excretion of potassium is enhanced by aldosterone.

y y

HYPOKALEMIA
y y y y Hypokalemia is a serum potassium level less than 3.5 mEq/L (3.5 mmol/L) It can be life threatening because every body system is affected. The cell membranes of all excitable tissues, such as nerve and muscle, are less responsive to normal stimuli. Rapid reduction of serum potassium levels causes dramatic changes in function, whereas gradual reductions may not show changes in function until the level is very low. Common causes (of hypokalemia) include: 1. Inappropriate or excessive use of drugs a. Diuretics b. Digitalis c. Corticosteroids 2. Increased secretion of aldosterone 3. Cushing s syndrome/disease 4. Diarrhea 5. Vomiting 6. Wound drainage 7. Prolonged nasogastric suction 8. Excessive diaphoresis 9. Kidney disease impairing reabsorption of potassium 10. NPO status 11. Alkalosis 12. Hyperinsulinism 13. Hyperalimentation

14. TPN 15. Water intoxication 16. IV therapy with potassium-poor solutions

Assessment
y Obtain patient information about: 1. Age Renal urine concentration decreases with age, therefore, potassium loss increases. 2. Drugs Especially diuretics, corticosteroids, digoxin, beta-adrenergic agonists or antagonists (Can cause potassium loss through kidneys). a. Ask if taking potassium supplement, such as potassium chloride (KCl) or eats food with high potassium concentration such as bananas, citrus fruits or juices, raisins, and meat. 3. Presence of any acute or chronic disease 4. Diet history Asses for and document: 1. Respiratory changes Skeletal muscle weakness results in shallow respirations. Assess at least every 2 hours a. Breath sounds b. Ease of respiratory effort c. Color of nail beds and mucous membranes d. Rate and depth of respiration e. Oxygen saturation 2. Musculoskeletal changes for weakness a stronger stimuli is needed to begin muscle contraction a. Weak hand grasp b. Decreased deep tendon reflexes (hyporeflexia) c. Flaccid paralysis (Severe hypokalemia) d. Check for ability to do ADLs 3. Cardiovascular changes a. Rapid, thready pulse b. Peripheral pulses difficult to palpate c. Dysrhythmias and electrocardiographic (ECG) changes i. ST-segment depression ii. Flat or inverted T waves iii. Increased U waves d. Orthostatic hypotension 4. Neurologic changes a. Altered mental status b. Irritability and anxiety c. Lethargy, acute confusion, coma 5. GI changes changes occur because smooth muscle contractions in the intestinal tract are decreased which leads to decreased peristalsis.

a. b. c. d.

Hypoactive bowel sounds Nausea, vomiting Constipation Abdominal distention assess distention by measuring abdominal girth e. Paralytic ileus absence of peristalsis

Interventions
y y Interventions for hypokalemia aim to prevent potassium loss, increase serum potassium levels, and provide a safe environment for the patient. Medical interventions include: 1. Drug therapy Potassium is a severe tissue irritant and is never given by IM or subcutaneous injection. a. Oral potassium supplements b. IV potassium supplements c. Potassium sparing diuretics i. Spironolactone (Aldactone) ii. Triamterene (Dyrenium) iii. Amiloride (Midamor) 2. Nutrition therapy to increase dietary potassium intake The priorities for nursing care of the patient with hypokalemia are ensuring adequate oxygenation, patient safety for falls prevention, and prevention of injury from potassium administration and monitoring the patient s response to therapy. 1. Implementing safety measures a. Instituting falls precautions b. Eliminating hazards in the ambulation path c. Assisting with ambulation 2. Performing respiratory monitoring at least hourly for severe hypokalemia a. Rate and depth (checking for increasing rate and decreasing depth) b. Oxygen saturation by pulse oximetry c. Patient s ability to cough d. Evaluation of arterial blood gas values checking for decreased blood oxygen levels (hypoxemia) and increased arterial carbon dioxide levels (hypercapnia)

HYPERKALEMIA
y y Hyperkalemia is a serum potassium level greater than 5.0 mEq/L (5.0 mmol/L). Decreased differential between ECF and ICF potassium levels increases cell excitability; as a result, excitable tissues respond to less intense stimuli and may even discharge spontaneously 3

Causes (of hyperkalemia) include: 1. Over ingestion of potassium-containing foods or drugs a. Salt substitutes b. Potassium chloride c. Potassium-sparing diuretics 2. Rapid infusion of potassium containing IV solution 3. Bolus IV potassium injections 4. Transfusions of whole blood or packed cells 5. Adrenal insufficiency (Addison s disease, adrenalectomy) 6. Kidney failure 7. Tissue damage 8. Acidosis 9. Hyperuricemia 10. Uncontrolled diabetes mellitus The problems that occur with hyperkalemia are related to how rapidly extracellular fluid (ECF) potassium levels increase. Sudden rises in serum potassium cause severe problems at potassium levels between 6 and 7 mEq/L. When serum potassium rises slowly, problems may not occur until potassium levels reach 8 mEq/L or higher.

Assessment
y Obtain patient information about: 1. Age Renal function decreases with age 2. Chronic illnesses (particularly kidney disease and diabetes mellitus) 3. Recent medical or surgical treatment 4. Urine output, including frequency and amount of voidings 5. Drugs particularly potassium-sparing diuretics and ACE inhibitors. 6. Diet history to determine if intake of potassium-rich foods or the use of salt substitutes (which contain potassium) 7. Palpitations, skipped heartbeats, and other cardiac irregularities 8. Muscle twitching and weakness in the leg muscles 9. Unusual tingling or numbness in the hands, feet, or face 10. Recent changes in bowel habits, especially diarrhea Assess for and document: 1. Cardiovascular changes a. Bradycardia b. Hypotension c. Electrocardiographic (ECG) changes i. Tall, peaked T waves ii. Prolonged PR intervals iii. Flat or absent P waves iv. Wide QRS complexes 2. Neuromuscular changes, early

a. Skeletal muscle twitches b. Tingling and burning sensations followed by numbness in the hands and feet and around the mouth 3. Neuromuscular changes, late a. Muscle weakness b. Flaccid paralysis first in hands and feet, then moving higher 4. Intestinal changes a. Increased motility b. Hyperactive bowel sounds c. Frequent watery bowel movements Interventions y Interventions for hyperkalemia are aimed at rapidly reducing the serum potassium level, preventing recurrences, and ensuring the patient safety during the electrolyte imbalance. y Drug therapy 1. IV therapy a. Discontinuing potassium-containing infusions b. Keeping the IV catheter open c. Administering IV preparation of 100 mL of 10% to 20% glucose with 10 to 20 units of regular insulin (Insulin increases the activity of the sodium-potassium pumps, which move potassium from the ECF into the cell). 2. Withholding oral potassium supplements 3. Potassium-excreting diuretics, such as furosemide 4. Sodium polystyrene sulfonate (Kayexalate) exchange resins (for patients with renal problems). y Hemodialysis or ultrafiltration y Nursing care priorities include: 1. Cardiac monitoring for early recognition of dysrhythmias and other manifestations of hyperkalemia on cardiac function 2. Teaching patient to avoid: a. Meats, especially organ meats and preserved meat b. Dairy products c. Dried fruit d. Fruits high in potassium (bananas, cantaloupe, kiwi, oranges) e. Vegetables high in potassium (avocados, broccoli, dried beans or peas, lima beans, mushrooms, potatoes, soybeans, spinach)