Which of the following conditions would cause the nurse to monitor for hyperkalemia

In order to function properly, the body requires several electrolytes, one of which is potassium. The majority of potassium is stored in the intracellular compartment. While some can be found in the bones, liver, and red blood cells, 98% is found in the muscle cells. Potassium regulates fluid and facilitates muscular contraction and nerve activity. It is also responsible for keeping the heartbeat regular and promotes the movement of nutrients into and waste out of the cells.

The normal blood potassium level is 3.5 – 5.0 mEq/L. Imbalances in blood potassium levels are referred to as hypokalemia and hyperkalemia.

• Hypokalemia – serum potassium level < 3.5 mEq/L (3.5 mmol/L) 
• Hyperkalemia – serum potassium level > 5.0 mEq/L (5.0 mmol/L)

Possible causes of hypokalemia include the following:

• Potassium loss due to:
  • Excessive use of potassium-wasting diuretics
  • Increased production of aldosterone (water and salt regulating hormone) – (such as in Cushing’s syndrome)
  • Vomiting, diarrhea
  • Wound drainage 
  • Prolonged nasogastric suction
  • Excessive diaphoresis
  • Kidney disease impairing the reabsorption of potassium
• Poor potassium intake such as through eating disorders
• Potassium movement from extracellular to intracellular fluid due to:
  • Alkalosis
  • Hyperinsulinism
• Serum potassium dilution due to:
  • Water intoxication
  • IV therapy with potassium-deficient solutions

Possible causes of hyperkalemia include the following:

• Excessive potassium intake
• Rapid infusion of potassium-containing IV solutions

• Decreased potassium excretion
  • Potassium-sparing diuretics
  • Kidney disease
  • Adrenal insufficiency (such as in Addison’s disease)
• Potassium movement from intracellular to the extracellular fluid
  • Tissue damage (burns)
  • Acidosis
  • Hyperuricemia
  • Hypercatabolism

Signs and symptoms of potassium imbalance include:

• Hypokalemia
  • Thready, weak, and irregular pulses 
  • Muscle weakness, leg cramps, deep tendon hyporeflexia, and paresthesias 
  • Nausea, vomiting, constipation, and abdominal distention
  • ECG changes: ST depression, inverted T waves, and prominent U waves
• Hyperkalemia
  • Heart palpitations and chest pain
  • Hypotension
  • Dyspnea
  • Myalgia, cramps, and paresthesias 
  • 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

The Nursing Process

To ensure proper functioning and homeostasis the body must maintain a dynamic equilibrium of fluids and electrolytes. Organ system dysfunction, such as life-threatening dysrhythmias, can occur when potassium is not balanced. Nurses must closely monitor patients’ lab results and correct imbalances to prevent complications.

Nursing Care Plans Related to Hyperkalemia and Hypokalemia

Electrolyte Imbalance Care Plan

Electrolyte imbalance associated with potassium imbalance (hypokalemia/hyperkalemia) can be caused by conditions affecting the regulation, intake and excretion, and movement of potassium in the cellular space.

Nursing Diagnosis: Electrolyte Imbalance

Related to:

• Changes in the regulation of potassium
• Changes in the intake of potassium
• Difficulty excreting potassium
• Conditions that affect the movement of potassium in the cellular space

As evidenced by:

• Alterations in the electrical conductivity of the heart
• Ineffective respirations
• Muscle weakness and cramps
• Neuromuscular alterations
• Changes in bowel habits

Expected outcomes:

• Patient will demonstrate serum potassium levels within normal limits
• Patient will verbalize the absence of muscle pain or cramping
• Patient will not experience dysrhythmias

Electrolyte Imbalance Assessment

1. Monitor blood potassium levels.
Serum potassium levels should be monitored closely and redrawn as ordered to monitor for hypo/hyperkalemia.

2. Check renal function.
Excess potassium can build up in the body if damaged kidneys are unable to eliminate it. Assess urine output and kidney function through BUN, GFR, and creatinine levels.

3. Review the patient’s current medications.
Imbalanced potassium levels can be caused by drugs including diuretics, beta-blockers, and aminoglycosides. Hyperkalemia can result from taking potassium chloride or salt substitutes.

4. Review the patient’s diet.
Potassium levels can be influenced by the amount of potassium that is being consumed. Eating disorders such as bulimia nervosa and anorexia nervosa can lead to deficits in potassium.

Electrolyte Imbalance Interventions

1. Include or limit potassium in the diet.
Educate the patient on their prescribed diet depending on the condition. Potassium can be obtained as a dietary supplement but is naturally available in many foods. Bananas, spinach, broccoli, and some fish are high in potassium. If experiencing hyperkalemia, limit these foods in the diet.

2. Administer prescribed potassium with precautions.
Potassium can be administered IV or PO. If administering IV, infuse secondarily to a compatible IV solution such as 0.9% normal saline to minimize burning at the IV site.

3. Monitor strict intake and output.
Monitor urine output as well as bowel movements. Imbalanced levels can be caused by alterations in the intake and excretion of potassium.

4. Treat underlying conditions.
Potassium imbalances can be caused by kidney disease, diabetes, alcoholism, Addison’s disease, and more. Treating these conditions involves monitoring and preventing hypo/hyperkalemia.

Risk for Decreased Cardiac Output Care Plan

Risk for decreased cardiac output associated with potassium imbalance is caused by a disruption in the electric signals in the myocardium resulting in dysrhythmias.

Nursing Diagnosis: Risk for Decreased Cardiac Output

Related to:

• Changes in the conductivity in the heart
• Inability to pump blood effectively
• Disruption in the electric functioning of the heart

As evidenced by:

A risk for diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and nursing interventions are aimed at prevention.

Expected outcomes:

• 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

Risk for Decreased Cardiac Output Assessment

1. Determine cardiovascular status.
Heart dysrhythmias can result from an excess or deficit of potassium that disrupts the normal electric transmission of signals responsible for heart (myocardium) contraction. Patients with heart failure may experience hyperkalemia due to their medications (ACE inhibitors and beta blockers).

2. Monitor pulse rate and blood pressure.
Hyperkalemia can cause irregular pulse rates and reduces blood artery wall tension which lowers blood pressure.

3. 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.

Risk for Decreased Cardiac Output Interventions

1. Administer medications as ordered.
Aldosterone receptor antagonists (such as spironolactone or eplerenone) can be used to treat mild hypokalemia. Potassium supplements are used to treat severe hypokalemia. Hyperkalemia-induced ventricular fibrillation is treated with calcium. Insulin causes potassium to shift inside the cell which can lower potassium levels.

2. Dilute potassium when given IV.
For patients who cannot take PO medications, IV potassium will be administered. It is advised to dilute the solution no more than 1 mEq/10 mL (1 mmol/10 mL). It can quickly lead to cardiac arrest if injected too quickly (bolus) or in a large dose.

3. Implement safety measures when administering IV potassium.
Because IV potassium infusion can cause phlebitis as a complication, the nurse should regularly check the IV site for indications of phlebitis or infiltration. The infusion should be discontinued immediately if this occurs. Continuous telemetry should be implemented when administering medications that affect cardiac status.

4. Prevent sudden hypotension.
Changes in blood potassium levels can cause hypotension due to decreased levels of aldosterone, vasopressin, and responsiveness to the effects of angiotensin II.

Risk for Falls Care Plan

Risk for falls associated with potassium imbalance is caused by a disruption in the electric signals in muscles resulting in muscle weakness, cramping, hyporeflexia, and paralysis.

Nursing Diagnosis: Risk for Falls

Related to:

• Changes in the neuromuscular status
• Muscle weakness
• Paresthesias
• Paralysis

As evidenced by:

A risk for diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and nursing interventions are aimed at prevention.

Expected outcomes:

• Patient will participate in physical therapy sessions
• Patient will be able to maintain or regain muscle strength
• Patient will have no incidence of falls

Risk for Falls Assessment

1. Perform a fall risk assessment.
In acute care and long-term settings, fall risk scales are commonly utilized. These assessments allow the nurse to determine patients at the highest risk for falls to implement precautions.

2. Assess the patient’s neuromuscular status.
Potassium is utilized by muscles to transmit electrical signals to the brain leading to muscle contraction. Muscle wasting and paralysis can result from very low potassium levels.

3. Determine the patient’s independence in performing activities.
Promote and assist in patient ambulation and independence in self care. This helps the patient gain muscle strength and confidence in performing self care. It also decreases the risk of falls and fall related injuries.

4. Check for safety hazards in the patient’s environment.
Assess the following environmental factors:

• Clutter
• Lack of stair railings
• Loose rugs or other tripping hazards
• Lack of grab bars in the bathroom
• Poor lighting

5. Review the patient’s current medications.
Imbalanced potassium and the use of cardiac medications (used to treat dysrhythmias) greatly increase the risk for muscle weakness and potential falls.

Risk for Falls Interventions

1. Institute fall and safety measures.
Institute fall and safety measures due to the neuromuscular effect (muscle weakness) caused by the changes in potassium. These can include assistive devices, braces, and adaptive equipment.

2. Apply visible fall prevention signage.
Informing the patient and the caregiver about fall prevention measures will promote participation and lower the risk for falls.

3. Inform the healthcare team about the patient’s level of risk of falls.
Effective communication among healthcare team members encourages collaboration and teamwork, which promotes the safety and prevention of fall incidents for the patient.

4. Encourage physical therapy.
Encourage participation in physical and occupational therapy sessions as ordered to regain strength and adapt to changes.

5. Position the patient therapeutically.
Elevate the legs when hypotension occurs in hyperkalemia. Encourage the patient to stand up and reposition slowly to prevent faintness and falls.

References and Sources

1. Dewit, S. C., Stromberg, H., & Dallred, C. (2017). Medical-surgical nursing: Concepts & practice (3rd ed.). Elsevier Health Sciences.
2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
3. Harding, M. M., Kwong, J., Roberts, D., Reinisch, C., & Hagler, D. (2020). Lewis’s medical-surgical nursing – 2-Volume set: Assessment and management of clinical problems (11th ed., pp. 2697-2729). Mosby.
4. Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing (13th ed.). Wolters Kluwer India Pvt.
5. Ignatavicius, MS, RN, CNE, ANEF, D. D., Workman, PhD, RN, FAAN, M. L., Rebar, PhD, MBA, RN, COI, C. R., & Heimgartner, MSN, RN, COI, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed., pp. 1386-1388). Elsevier.
6. Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.

Which of the following conditions would most likely result in hyperkalemia?

Which client is at greatest risk for the development of hyperkalemia?

Which assessment is the priority for a patient with hyperkalemia?

Which of the following conditions can cause hyperkalemia A excess aldosterone B acute acidosis C insulin usage D metabolic alkalosis?