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Hyperkalemia PDF

This document discusses nursing care for clients with altered fluid, electrolyte, or acid-base balance. It specifically focuses on risks and monitoring for clients with hyperkalemia related to renal failure. Key points include closely monitoring serum potassium and other lab values, maintaining fluid balance, educating clients on diet and medication restrictions to prevent future episodes of hyperkalemia, and using NANDA, NIC, and NOC frameworks in developing nursing care plans. A case study example is provided.

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Haidy Jance
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194 views1 page

Hyperkalemia PDF

This document discusses nursing care for clients with altered fluid, electrolyte, or acid-base balance. It specifically focuses on risks and monitoring for clients with hyperkalemia related to renal failure. Key points include closely monitoring serum potassium and other lab values, maintaining fluid balance, educating clients on diet and medication restrictions to prevent future episodes of hyperkalemia, and using NANDA, NIC, and NOC frameworks in developing nursing care plans. A case study example is provided.

Uploaded by

Haidy Jance
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CHAPTER 5 / Nursing Care of Clients with Altered Fluid, Electrolyte, or Acid-Base Balance 107

• Closely monitor the response to intravenous calcium glu- sodium bicarbonate solution can cause a shift of water into
conate, particularly in clients taking digitalis. Calcium in- the extracellular space.
creases the risk of digitalis toxicity. • Monitor clients receiving cation exchange resins and sorbitol
Risk for Imbalanced Fluid Volume for fluid volume excess. The resin exchanges potassium for
Renal failure is a major cause of hyperkalemia. Clients with sodium or calcium in the bowel. Excessive sodium and water
renal failure also are at risk for fluid retention and other elec- retention may occur.
trolyte imbalances. Using NANDA, NIC, and NOC
• Closely monitor serum potassium, BUN, and serum creatinine. Chart 5–4 shows links between NANDA nursing diagnoses, NIC,
Notify the physician if serum potassium level is greater than 5 and NOC when caring for a client with a potassium imbalance.
mEq/L, or if serum creatinine and BUN levels are increasing.
Serum creatinine and BUN are the primary indicators of renal Home Care
function. Levels of these substances rise rapidly in acute renal Preventing future episodes of hyperkalemia is the focus when
failure, more slowly in chronic renal failure (see Chapter 00). preparing the client for home care. Include the family, a signif-
• Maintain accurate intake and output records. Report an im- icant other, or a caregiver when teaching the following topics.
balance of 24-hour totals and/or urine output less than 30
mL/hour. Oliguria (scant urine) or anuria (no urine output) • Recommended diet and any restrictions including salt sub-
may indicate renal failure and an increased risk for hyper- stitutes and foods high in potassium
kalemia and fluid volume excess. • Medications to be avoided, including over-the-counter and
• Monitor clients receiving sodium bicarbonate for fluid vol- fitness supplements
ume excess. Increased sodium from injection of a hypertonic • Follow-up appointments for lab work and evaluation

Nursing Care Plan


A Client with Hyperkalemia
Montigue Longacre, a 51-year-old African American male, has • Verbalize causes of hyperkalemia, the im-
end-stage renal failure. He arrives at the emergency clinic com- portance of hemodialysis treatments as sched-
plaining of shortness of breath on exertion and extreme weak- uled, and the role of diet in preventing hyperkalemia.
ness.
PLANNING AND IMPLEMENTATION
ASSESSMENT • Monitor intake and output.
Mr. Longacre tells the nurse, Janet Allen, RN, that he normally re- • Monitor serum potassium and ECG closely during treatment.
ceives dialysis three times a week. He missed his last treatment, • Teach causes of hyperkalemia and the relationship between
however,to attend his father’s funeral.During the last several days, hemodialysis and hyperkalemia.
he has eaten a number of fresh oranges he received as a gift. • Discuss the importance of avoiding foods high in potassium to
Physical assessment findings include T 99.2, P 100, R 28, BP 168/96, prevent or control hyperkalemia.
2+ pretibial edema, and a 6 lb (3.6 kg) weight gain since his last
hemodialysis treatment 4 days ago. Laboratory and diagnostic EVALUATION
tests show the following abnormal results. Following emergency treatment and hemodialysis, Mr. Longacre’s
ECG and serum potassium level have returned to normal. His mus-
• K+ 6.5 mEq/L (normal 3.5 to 5 mEq/L) cle strength has returned to near normal, and he verbalizes an un-
• BUN 118 mg/dL (normal 7 to 18 mg/dL) derstanding of his prescribed hemodialysis regimen. Janet Allen
• Creatinine 14 mg/dL (normal 0.7 to 1.3 mg/dL) provides verbal and written information about hyperkalemia, the
• HCO3 17 mEq/L (normal 22 to 26 mEq/L) importance of complying with the hemodialysis regimen, and the
• Peaked T wave noted on ECG importance of limiting intake of dietary sources of potassium in
Mr. Longacre is placed on continuous ECG monitoring, and the renal failure. She also furnishes a list of foods high in potassium
physician prescribes hemodialysis.As an interim measure to lower and cautions against using potassium-containing salt substitutes
the serum potassium, the physician prescribes D50W (25 g of dex- and nonprescription drugs.
trose), one ampule, to be administered intravenously with 10 units
of regular insulin over 30 minutes.
Critical Thinking in the Nursing Process
1. What information given by Mr. Longacre indicated that he
DIAGNOSIS might be experiencing hyperkalemia?
• Activity intolerance related to skeletal muscle weakness 2. Why was continuous ECG monitoring instituted as an emer-
• Risk for decreased cardiac output related to hyperkalemia gency measure?
• Risk for ineffective health maintenance related to inade- 3. What additional emergency measures might have been insti-
quate knowledge of recommended diet tuted if Mr. Longacre’s serum potassium level was 8.5 mEq/L
• Excess fluid volume related to renal failure and his ECG showed changes in impulse conduction?
EXPECTED OUTCOMES 4. Develop a care plan for Mr. Longacre for the nursing diagno-
• Gradually resume usual physical activities. sis anxiety.
• Maintain serum potassium level within normal range. See Evaluating Your Response in Appendix C.

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