Why give calcium gluconate if it does not lower potassium?

Calcium makes the heart muscle less sensitive to the high potassium, so it protects the heart within minutes. It buys time while insulin with glucose moves potassium into the cells and other treatments remove it from the body. Its effect lasts only about 20 to 30 minutes, so the dose may be repeated.

Why does the nurse check blood glucose after insulin for hyperkalemia?

The insulin moves potassium into the cells, but it lowers the blood glucose too. Glucose is given with the insulin, and hypoglycemia can still occur hours later, especially in kidney failure. Check the glucose as often as the protocol sets.

What is the nursing diagnosis for hyperkalemia?

Many care plans use risk for decreased cardiac output and risk for electrolyte imbalance. Risk for injury fits a client with muscle weakness, and a knowledge problem fits a client who needs teaching about diet and medicines. Use the labels your program teaches.

What foods should a client with hyperkalemia limit?

Common high-potassium foods include bananas, oranges and orange juice, potatoes, tomatoes, dried fruit, avocados and dark leafy greens. Salt substitutes are a hidden source, because most are potassium chloride. A renal dietitian sets the client's own limits.

Which medicines can cause hyperkalemia?

ACE inhibitors, angiotensin receptor blockers, potassium-sparing diuretics such as spironolactone, potassium supplements, NSAIDs, trimethoprim and heparin can all raise potassium. The risk grows when the client has kidney disease or takes more than one of them.

Hyperkalemia nursing interventions, diagnoses and care plan

Hyperkalemia nursing interventions in priority order: monitor the heart, report, stop potassium sources, then protect, shift and remove. With nursing diagnoses, a care plan, client teaching and practice questions.

Key points

First: cardiac monitor, 12-lead ECG, report at once.
Stop every source of potassium.
Protect the heart with calcium. Shift potassium with insulin and glucose. Then remove it.
Check the blood glucose after insulin.
Teach the client to avoid salt substitutes and high-potassium foods.

The priority nursing intervention for hyperkalemia is to protect the heart. Put the client on a cardiac monitor, get a 12-lead ECG and report the result at once. Then stop every source of potassium and give the treatments the provider prescribes: calcium to protect the heart, insulin with glucose to move potassium into the cells, then treatment to remove it from the body.

This page covers the nursing care. For the ECG changes, from peaked T waves to a sine wave, see hyperkalemia ECG changes. For high and low potassium side by side, see potassium and the ECG.

Nursing interventions in priority order

These are the priorities that exam questions test. They describe what a nurse does under a prescriber's orders and a facility protocol. They are study material, not treatment advice for a patient.

Assess the client and put them on a continuous cardiac monitor. Get a 12-lead ECG.
Report the potassium result and the ECG to the provider at once.
Stop every source of potassium: supplements, potassium in IV fluids and salt substitutes. Report drugs that raise potassium.
Give IV calcium gluconate when prescribed. With ECG changes, this comes first because it protects the heart within minutes.
Give IV regular insulin with glucose when prescribed. Check the blood glucose often, because hypoglycemia is the main risk.
Give the treatments that remove potassium, as prescribed, and measure the urine output.
Recheck the potassium as prescribed and prepare for dialysis if the client does not respond.

Nursing assessment

Hyperkalemia often causes no symptoms until an arrhythmia starts. Assess for these findings:

Heart: the rate and rhythm on the monitor, a new slow rhythm, and ECG changes such as peaked T waves, a fading P wave or a wide QRS.
Muscles and nerves: weakness that often starts in the legs, tingling or numbness, and in severe cases flaccid paralysis.
Gut: nausea, cramping or diarrhea.
Kidneys: urine output, creatinine and the dialysis schedule.
Causes: potassium-raising drugs, supplements, salt substitutes, recent blood transfusion, burns, crush injury or diabetic ketoacidosis.
The sample: whether the lab reports hemolysis. A hemolysed sample can show a falsely high potassium.

Many nursing references give the normal range as 3.5 to 5.0 mmol/L. For potassium, 1 mEq/L equals 1 mmol/L. The NCLEX shows mEq/L. The REx-PN shows mmol/L.

Nursing diagnoses for hyperkalemia

Exam questions rarely ask for a diagnosis label. They ask what the nurse does. A care plan still needs one. Many care plans use these labels in the NANDA-I style. Use the wording your program teaches.

Risk for decreased cardiac output, related to the effect of high potassium on the heart's conduction.
Risk for electrolyte imbalance, related to kidney disease, drugs or cell breakdown.
Risk for injury, related to muscle weakness.
A knowledge problem about diet and medicines, often labelled deficient knowledge.

A hyperkalemia nursing care plan

Problem	Goal	Nursing interventions	Evaluation
Risk for decreased cardiac output	The client keeps a stable rhythm.	Continuous cardiac monitoring. A 12-lead ECG. Report changes at once. Give calcium and insulin with glucose as prescribed.	The rhythm is stable and the ECG changes resolve.
Risk for electrolyte imbalance	The potassium returns to the client's target range.	Stop potassium sources. Give binders, diuretics or dialysis as prescribed. Recheck the potassium as ordered. Measure intake and output.	The potassium falls and stays in range on repeat tests.
Risk for injury	The client stays free of falls.	Assess muscle strength. Help the client move. Keep the call bell in reach and the bed low.	The client has no falls, and strength returns as the potassium falls.
A knowledge problem about diet and medicines	The client can name the hidden sources of potassium.	Teach the food limits with the renal dietitian. Review drugs that raise potassium. Teach the client to avoid salt substitutes.	The client states the limits and chooses low-potassium foods.

Emergency treatment the nurse should expect

The provider prescribes these treatments. Your facility's protocol sets the doses. Remember the order as Protect, Shift, Remove: protect the heart, shift potassium into the cells, then remove it from the body.

Treatment	What it does	What to know
IV calcium gluconate	Protects the heart. It does not lower potassium.	10 to 20 mL of a 10% solution over 5 to 10 minutes. It works within minutes and lasts only 20 to 30 minutes, so it may be repeated.
IV regular insulin with glucose	Moves potassium into the cells	5 to 10 units of insulin with 50 mL of 50% glucose, often followed by a dextrose infusion. The effect peaks at about one hour and lasts several hours. Watch for hypoglycemia.
Inhaled salbutamol (albuterol)	Moves potassium into the cells	10 to 20 mg inhaled over 10 minutes, as an add-on. Not for clients with unstable angina or an acute heart attack.
Sodium bicarbonate	May lower potassium over several hours	Often used, but the evidence for it is limited.
Loop diuretic, such as furosemide	Removes potassium in the urine	Works only when the kidneys still make urine.
Potassium binder	Removes potassium through the gut	Sodium polystyrene sulfonate, patiromer or sodium zirconium cyclosilicate. They act over hours, so they are not the emergency treatment.
Hemodialysis	Removes potassium from the body	Started promptly when emergency treatment does not work, or when the kidneys have failed.

Giving the treatment safely

Calcium gluconate: keep the client on the monitor during the infusion. Check that the IV line runs well, because calcium that leaks into the tissue damages it.
Insulin with glucose: check the capillary blood glucose at the intervals the protocol sets, for several hours. Clients with kidney failure clear insulin slowly and stay at risk longer.
Salbutamol: expect a faster heart rate and a tremor.
Loop diuretic: measure the urine output and watch the blood pressure.
Potassium binders: watch for constipation. Binders can bind other oral medicines, so give those at the time gap the pharmacy advises.
Every treatment: recheck the potassium as prescribed. Calcium and insulin do not remove potassium from the body, so the level can rise again.

Client teaching to prevent high potassium

Most teaching is for clients with kidney disease or clients on drugs that raise potassium.

Do not use salt substitutes. Most of them are potassium chloride.
Follow the potassium limit the renal dietitian sets. Common high-potassium foods are bananas, oranges, potatoes, tomatoes, dried fruit and avocados.
Do not take potassium supplements or over-the-counter NSAIDs such as ibuprofen without asking the provider.
Keep every dialysis appointment.
Report muscle weakness, a slow or irregular pulse, or palpitations.

Three practice questions

Medibara wrote these questions. They are original, not recalled from an exam. If a rationale disagrees with your course, follow your course.

Question 1
A client with chronic kidney disease takes lisinopril and spironolactone. The serum potassium is 6.4 mEq/L (6.4 mmol/L), and the client reports weakness in both legs. What should the nurse do first?
Question 2
The nurse receives handover on four clients. Which client should the nurse assess first?
Question 3Select all that apply
The nurse teaches a client with chronic kidney disease how to prevent high potassium at home. Which statements by the client show that the teaching worked?

For four more questions on the ECG and the first drug to give, see the questions on hyperkalemia ECG changes.

Questions people ask

What is the priority nursing intervention for hyperkalemia?: Put the client on a continuous cardiac monitor and get a 12-lead ECG, then report the result and the ECG to the provider at once. High potassium kills through arrhythmias, so the heart comes first. When the ECG shows changes, IV calcium gluconate is usually the first treatment the provider prescribes.
Why give calcium gluconate if it does not lower potassium?: Calcium makes the heart muscle less sensitive to the high potassium, so it protects the heart within minutes. It buys time while insulin with glucose moves potassium into the cells and other treatments remove it from the body. Its effect lasts only about 20 to 30 minutes, so the dose may be repeated.
Why does the nurse check blood glucose after insulin for hyperkalemia?: The insulin moves potassium into the cells, but it lowers the blood glucose too. Glucose is given with the insulin, and hypoglycemia can still occur hours later, especially in kidney failure. Check the glucose as often as the protocol sets.
What is the nursing diagnosis for hyperkalemia?: Many care plans use risk for decreased cardiac output and risk for electrolyte imbalance. Risk for injury fits a client with muscle weakness, and a knowledge problem fits a client who needs teaching about diet and medicines. Use the labels your program teaches.
What foods should a client with hyperkalemia limit?: Common high-potassium foods include bananas, oranges and orange juice, potatoes, tomatoes, dried fruit, avocados and dark leafy greens. Salt substitutes are a hidden source, because most are potassium chloride. A renal dietitian sets the client's own limits.
Which medicines can cause hyperkalemia?: ACE inhibitors, angiotensin receptor blockers, potassium-sparing diuretics such as spironolactone, potassium supplements, NSAIDs, trimethoprim and heparin can all raise potassium. The risk grows when the client has kidney disease or takes more than one of them.