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Hyperkalemia - Chronic Renal Failure (Exam 4)

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Alfred Jarvis

on 5 August 2015

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Transcript of Hyperkalemia - Chronic Renal Failure (Exam 4)

ATI - Overview

Hyperkalemia is the result of an increased intake of potassium, movement of potassium out of the
cells, or inadequate renal excretion resulting in a serum potassium level greater than 5.0 mEq/L.

Exam 4
Risk Factors -
Causes of hyperkalemia:
»Increased total body potassium –

PO and IV potassium administration, salt substitute

»Extracellular shift -

Decreased insulin, acidosis (diabetic ketoacidosis), tissue catabolism (sepsis, trauma, surgery, fever, myocardial infarction)
Risk Factors -
Causes of hyperkalemia:
»Hypertonic states -

Uncontrolled diabetes mellitus
»Decreased excretion of potassium –

Renal failure, severe dehydration, potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, NSAIDs, adrenal insufficiency
»Older adult clients are at a greater risk due to the increased use of salt substitutes, ACE
inhibitors, and potassium-sparing diuretics.
Subjective Data and Objective Data
»Vital signs -

Slow, irregular pulse, hypotension
»Neuromusculoskeletal -

Restlessness, irritability, weakness to the point of ascending flaccid paralysis, paresthesias
»ECG -

Premature ventricular contractions, ventricular fibrillation, peaked T waves, widened QRS
»Gastrointestinal -

Nausea, vomiting, increased motility, diarrhea, hyperactive bowel sounds
»Other signs -

Laboratory Tests

Serum potassium: increased (greater than 5.0 mEq/L)
Diagnostic Procedures -

Will show dysrhythmias (ventricular fibrillation, peaked T waves, widened QRS)

Arterial blood gases: metabolic acidosis (pH less than 7.35)
Patient-Centered Care

Stop the infusion of IV potassium.
»Report abnormal findings to the provider.
Nursing Care -
»Cardiac protection: Prepare to administer calcium gluconate or calcium chloride.
»Decrease potassium intake

Withhold oral potassium.

Provide a potassium-restricted diet (avoid foods high in potassium [avocados, broccoli, dairy
products, dried fruit, cantaloupe, bananas]).
Patient-Centered Care

Administer IV fluids with dextrose and regular insulin.
Nursing Care -
»Promote movement of potassium from ECF to ICF

Administer sodium bicarbonate to reverse acidosis.
»Monitor the client’s cardiac rhythm, and intervene promptly as needed.

Medications (to increase potassium excretion)
Patient-Centered Care
»Administer loop diuretics (furosemide [Lasix]) if kidney function is adequate.

Loop diuretics increase the depletion of potassium from the renal system.

Maintain IV access.
Nursing Considerations
Client Education

Educate the client on a potassium-restricted diet.

Instruct the client to hold oral potassium supplements until further advised by the provider.
Patient-Centered Care
»Administer cation exchange resins (sodium polystyrene sulfonate [Kayexalate]).

Works as a laxative and excretes excess potassium from the body. Can be used with clients who have renal disorders.
Nursing Considerations

If potassium levels are extremely high, dialysis may be required.
Client Education

Educate the client on a potassium-restricted diet.

Instruct the client to hold oral potassium supplements until advised by the provider.
Teamwork and Collaboration
»Nephrology may be consulted if dialysis is needed and for electrolyte and fluid management.
»Nutritional services may be consulted for food choices containing potassium-restricted foods.
»Cardiology may be consulted for dysrhythmias.
Patient-Centered Care
»Client Education
Care After Discharge

Educate the client about potassium-restricted foods to consume.

Teach the client ways to prevent an increase in potassium by reading food labels and avoiding
salt substitutes containing potassium.
»Cardiac Arrest
Nursing Actions -

Treat dysrhythmias.

Perform continuous cardiac monitoring.
A. Description
1. A serum potassium level that exceeds 5.0 mEq/L
2. Pseudohyperkalemia: a condition that can occur due to methods of blood specimen collection and cell lysis; if an increased serum value is obtained in the absence of clinical symptoms, the specimen should be redrawn and evaluated
B. Causes
1. Excessive potassium intake
a. Over-ingestion of potassium-containing foods or medications, such as potassium chloride or salt substitutes
b. Rapid infusion of potassium-containing IV solutions
2. Decreased potassium excretion
a. Potassium-retaining diuretics
b. Kidney disease
c. Adrenal insufficiency, such as in Addison’s disease
B. Causes
3. Movement of potassium from the intracellular fluid to the extracellular fluid
a. Tissue damage
b. Acidosis
c. Hyperuricemia
d. Hypercatabolism
C. Assessment
D. Interventions
1. Monitor cardiovascular, respiratory, neuromuscular, renal, and gastrointestinal status; place the client on a cardiac monitor
2. Discontinue IV potassium (keep the IV catheter patent), and hold oral potassium supplements.
3. Initiate a potassium-restricted diet
4. Prepare to administer potassium-excreting diuretics if renal function is not impaired
5. If renal function is impaired, prepare to administer sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin that promotes gastrointestinal sodium absorption and potassium excretion
D. Interventions
6. Prepare the client for dialysis if potassium levels are critically high
7. Prepare for administration of intravenous calcium if hyperkalemia is severe to avert myocardial excitability
8. Prepare for the IV administration of hypertonic glucose with regular insulin to move excess potassium into the cells.
9. Monitor renal function
D. Interventions
10. When blood transfusion are prescribed for a client with a potassium imbalance the client should receive fresh blood, if possible transfusions of stored blood may elevate the potassium level because the breakdown of older blood cells releases potassium.
11. Teach the client to avoid foods high in potassium
12. Instruct the client to avoid the use of salt substitutes or other potassium-containing substances
Monitor the serum potassium level closely when a client is receiving a potassium-retaining diuretic
Foods Rich in Potassium to Avoid
»B. Etiology

1. Hypertensive nephropathy
Lippincott's - Chronic Renal Failure
A. Description
Chronic renal faliure is the end result of progressive, irreversible loss of functional renal tissue. It usually develops gradually, possibly taking up to several years to develop. In some cases, it may occur rapidly because of an acute disorder (e.g., unresolved acute renal failure)

2. Diabetic nephropathy

3. Chronic glomerulonephritis

4. Chronic pyelonephritis

5. Lupus nephritis

6. Polycystic kidney disease

7. Chronic hydronephrosis
»1. Three basic stages of chronic renal failure have been identified

a. Decreased renal reserve. During this stage, renal function is 20% to 50% of normal and homeostasis is maintained
Lippincott's - Chronic Renal Failure
C. Pathophysiology
Decreased renal function results in an accumulation of waste products (i.e., uremia) in the bloodstream. Uremia develops and adversely affects every system in the body

b. Renal insufficiency. During this stage, renal function 20% to 40% of normal; glomerular filtration rate (GFR), clearance, and urine concentration are decreased; and homeostasis is altered

c. End-stage-renal disease. During this stage, renal function is less than 10% to 15% of normal; all renal functions are severely decreased; and homeostasis is significantly altered
»2. In chronic renal failure, retention of sodium and water leads to edema, heart failure, and hypertension. Conversely, episodes of diarrhea and vomiting may lead to sodium and water depletion, which can exacerbation uremia and produce hypotension and hypovolemia
Lippincott's - Chronic Renal Failure

a. Increased serum phosphate
»3. Metabolic acidosis occurs, interfering with the kidney's ability to excrete hydrogen ions, produce ammonia, and conserve bicarbonate
»4. Decreased GFR results in:

b. decreased serum calcium

c. increased parathormone but depleted bone calcium, leading to bone changes (e.g., uremic bone disease, osteomalacia)

d. increased serum magnesium
»5. Erythropoietin production decreases, resulting in anemia
Lippincott's - Chronic Renal Failure

a. altered mental function
»6. Neurologic complications develop such as:

b. personality and behavioral changes

c. convulsions

d. coma
»D. Assessment findings

in decreased renal reserve
, the client is asymptomatic as long as there is no exposure to severe physologic or psychologic stress
1. Clinical manifestations
of chronic renal failure depend on the stage of the disorder:

b. In renal insufficiency,
clinical manifestations include polyuria, nocturia, and signs and symptoms of mild anemia

c. In end-stage renal disease,
widespread systemic manifestations are evident
2. Laboratory and diagnostic study findings. Blood analysis reveals

a. anemia

b. elevated blood urea nitrogen (BUN) and serum creatinine levels

c. elevated serum phopshorus level

d. decreased serum calcium level

e. decreased serum protein (particularly albumin) levels

f. low blood pH
»E. Nursing management
Lippincott's - Chronic Renal Failure
1. Administer prescribed medication;
which may include ion exchange resin, alkalizing agents, antibiotics, erythropoietin, folic acid supplements, iron supplements, phosphate-binding agents, calcium supplements, histamine receptor antagonists, and proton pump inhibitors
2. Provide conservative therapy, as indicated

a. Maintain strict fluid control; daily fluid intake should equal 500 m (insensible loss) plus the amount of the previous 24 hours' urinary output; daily weight; and strict intake and output

b. Encourage intake of high biologic value protein foods, such as eggs, diary products, and meats (causes positive nitrogen balance needed for growth and healing)

c. Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between meals

d. Encourage alternating activity with rest. Encourage independence as much as possible

e. Assess the client and family's response to chronic illness. Encourage therapeutic conversations to help cope with chronic illness

f. Provide symptomatic treatment

g. Be prepared to identify and treat complications, which include hyperkalemia, periarditis, pericardial effusion, pericardial tamponade, hypertension, anemia, and bone disease
3. Prepare the client for peritoneal dialysis,
if indicated. Assist with the procedure as instructed, maintaining septic technique and monitoring for signs and symptoms of peritonitis (e.g., rigid, boardlike abdomen; fever; cloudy peritoneal fluid)
Lippincott's - Chronic Renal Failure
4. Prepate the client for and assist with hemodialysis;
if indicated. Provide proper shunt care, and assess for possible complications (e.g., bleeding due to heparinization; hypovolemia and hypotension due to excessive water removal; dialysis disequilibrium syndrome [headache, confusion, and seizures] due to rapid removal of urea from plasma).
5. Prepare the client for kidney transplantation, if indicated.

a. Provide postoperative care for any client who has undergone major surgery, with special attention to catheter patency and adequacy, intake and output, fluid replacement, and protection from infection

b. Monitor for signs and symptoms fo complications, such as graft rejection (e.g., fever, elevated white blood cell count, electrolyte abnormalities, abnormal renogram) and infection stemming from immunosuppressive therapy (e.g., sepsis pneumonia, wound infection, and urinary tract infection)
ATI - Chronic Renal Failure
Chronic kidney disease (CKD) is a progressive, irreversible kidney disease.
»A client who has a diagnosis of CKD may be asymptomatic except during periods of stress (infection, surgery, trauma). As kidney dysfunction progresses, clinical manifestations become apparent.
»Older adult clients are at an increased risk for chronic kidney disease related to the normal aging process (decreased number of functioning nephrons, decreased GFR).
»Older adults clients who are on bed rest, confused, have a lack of thirst, and do not have easy access to water are at a higher risk for dehydration leading to chronic kidney disease.
ATI - Chronic Renal Failure
Risk Factors and Causes of Chronic Kidney Disease -
» Acute kidney injury
» Diabetes mellitus
» Chronic glomerulonephritis
» Nephrotoxic medications (gentamicin, NSAIDs) or chemicals
» Hypertension, especially if African American
» Autoimmune disorders (systemic lupus erythematosus)
» Polycystic kidney
» Pyelonephrosis
» Renal artery stenosis
» Recurrent severe infections
ATI - Chronic Renal Failure
CKD is comprised of five stages:
» Stage 1: Minimal kidney damage with normal GFR (greater than 90 mL/min)
» Stage 2: Mild kidney damage with mildly decreased GFR (60 to 89 mL/min)
» Stage 3: Moderate kidney damage with moderate decrease in GFR (30 to 59 mL/min)
» Stage 4: Severe kidney damage with severe decrease in GFR (15 to 29 mL/min)
» Stage 5: Kidney failure and end-stage kidney disease with little or no glomerular filtration (less than 15 mL/min)
ATI - Chronic Renal Failure
Health Promotion and Disease Prevention of Chronic Kidney Disease
» Encourage clients to drink at least 3 L of water daily. Consult with the provider regarding any restrictions.
» End-stage kidney disease exists when 90% of the functioning nephrons have been destroyed and
are no longer able to maintain fluid, electrolyte, and acid-base homeostasis.
» Dialysis or kidney transplantation can maintain life, but neither is a cure for CKD.
» Promote smoking cessation.
» Encourage diet and activities to control or prevent diabetes and hypertension.
» Teach the client the importance of adherence to a medication regimen when prescribed.
» Encourage yearly testing for albumin in the urine if the client has diabetes or hypertension.
» Instruct the client to take all antibiotics until completed.
» Limit over-the-counter NSAIDs.
ATI - Chronic Renal Failure
Health Promotion and Disease Prevention of Chronic Kidney Disease

Fatigue, lethargy, involuntary movement of legs, depression, intractable hiccups
Subjective Data
Objective Data

In most cases, findings of chronic kidney disease are related to fluid volume overload and include the following:
» Neurologic –

lethargy, decreased attention span, slurred speech, tremors or jerky movements, ataxia, seizures, coma
» Cardiovascular –

fluid overload (jugular distention; sacrum, ocular or peripheral edema), hypertension, dysrhythmias, heart failure, orthostatic hypotension
ATI - Chronic Renal Failure
Health Promotion and Disease Prevention of Chronic Kidney Disease
Objective Data - Continued
» Respiratory –

uremic halitosis with deep sighing, yawning, shortness of breath, tachypnea, hyperpnea, Kussmaul respirations, crackles, pleural friction rub, frothy pink sputum
» Hematologic –

anemia (pallor, weakness, dizziness), ecchymoses, petechiae, melena
» Gastrointestinal –

ulcers in mouth and throat, foul breath, blood in stools, nausea, vomiting
» Musculoskeletal –

osteodystrophy (thin fragile bones)
» Renal –

urine contains protein, blood, particles; change in the amount, color, concentration
» Skin –

decreased skin turgor, yellow cast to skin, dry, pruritus, urea crystal on skin (uremic frost)
» Reproductive –

erectile dysfunction
ATI - Chronic Renal Failure
Laboratory Tests -
» Urinalysis

Hematuria, proteinuria, and decrease in specific gravity.
» Serum creatinine –

Gradual increase over months to years for CKD exceeding 4 mg/dL. May be as high as 15 to 30 mg/dL.
» BUN–

Gradual increase with elevated serum creatinine over months to years for CKD. May be as high as 180 to 200 mg/dL.
» Serum electrolytes –

Decreased sodium (dilutional) and calcium; increased potassium, phosphorus, and magnesium.
» CBC –

Decreased hemoglobin and hematocrit from anemia secondary to the loss of erythropoietin in CKD.
ATI - Chronic Renal Failure
Diagnostic Procedures -
» Radiologic procedures to detect disease processes, obstruction, and arterial defects.


Kidneys, ureter, and bladder (KUB)

Computerized tomography (CT)

Magnetic resonance imaging (MRI) without contrast dye

Aortorenal angiography


Retrograde pyelography

Kidney biopsy
ATI - Chronic Renal Failure
Patient-Centered Care - Nursing Care
» Abnormal findings to be reported and monitored

Urinary elimination patterns (amount, color, odor, and consistency)
Complications of CKD

Potential complications of kidney failure include electrolyte imbalance, dysrhythmias, fluid overload, hypertension, metabolic acidosis, secondary infection, and uremia.

Vital signs (blood pressure may be increased or decreased)

Weight – 1 kg (2.2 lb) daily weight increase is approximately 1 L of fluid retained.
» Assess and monitor vascular access or peritoneal dialysis insertion site.
» Obtain a detailed medication and herb history to determine the client’s risk for continued kidney injury.
» Control protein intake based on the client’s stage of chronic kidney disease and type of dialysis prescribed.
» Restrict the client’s dietary sodium, potassium, phosphorous, and magnesium.
ATI - Chronic Renal Failure
Patient-Centered Care - Nursing Care - Continued
» Provide the client a diet that is high in carbohydrates and moderate in fat.
» Restrict the client’s intake of fluids (based on urinary output).
» Monitor for weight gain trends.
» Adhere to meticulous cleaning of areas on skin not intact and access sites to control infections.
» Balance the client’s activity and rest.
» Prepare the client for hemodialysis, peritoneal dialysis, and hemofiltration if indicated.
» Provide skin care to the client in order to increase comfort and prevent breakdown.
» Protect the client from injury.
» Provide emotional support to the client and family.
» Encourage the client to ask questions and discuss fears.
» Administer medications as prescribed.
ATI - Chronic Renal Failure
» Avoid administering antimicrobial medications (e.g., aminoglycosides and amphotericin B), NSAIDs, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, and IV contrast dye, which are nephrotoxic.

Monitor digoxin laboratory levels due to slow excretion of the medication with CKD.
» Digoxin (Lanoxin), a cardiac glycoside, increases contractility of the myocardium and promotes cardiac output.

Administer digoxin (Lanoxin) after receiving dialysis.
ATI - Chronic Renal Failure
» Sodium polystyrene (Kayexalate) to increase elimination of life-threatening serum potassium, which may cause dangerous cardiac dysrhythmias and peaked T waves.

Restrict sodium intake. Sodium polystyrene contains sodium and can cause fluid retention and hypertension, a complication of CKD.
» Erythropoietin alfa (Epogen, Procrit) to stimulate production of red blood cells, given for anemia
» Ferrous sulfate (Feosol), an iron supplement to prevent severe iron deficiency.
» Aluminum hydroxide gel (Amphojel)

Taken with meals to bind phosphate in food and stop phosphate absorption.

Take 2 hr before or after digoxin.
ATI - Chronic Renal Failure
» Furosemide (Lasix), a loop-diuretic administered to excrete excess fluids.

Avoid administering to a client who has end-stage kidney disease.

Clients may also receive thiazide diuretics, potassium-sparing diuretics, and osmotic diuretics.
ATI - Chronic Renal Failure
Teamwork and Collaboration
» Nephrology services may be consulted to manage dialysis or kidney failure.
» Nutritional services may be consulted to manage the nutritional needs of the client.
Therapeutic Procedures
» Hemodialysis
Care after Discharge
» Nephrology services may be indicated if the client is to receive outpatient dialysis.
» Refer the client to a community support group relating to the disease.
» Nutritional services may be consulted for the client’s dietary needs.
» Refer the client to a smoking-cessation support group and counseling if needed.
ATI - Chronic Renal Failure
Client Education
» Instruct the client to monitor the daily intake of carbohydrates, proteins, sodium, and potassium, according to the provider.
» Instruct the client to monitor fluid intake according to fluid restriction prescribed by the provider.
» Encourage the client who has diabetes mellitus to adhere to strict blood glucose control because uncontrolled diabetes is a major risk factor for chronic kidney disease.
» Instruct the client to avoid antacids containing magnesium.
» Encourage the client to take rest periods from activity.
» Educate the client who is receiving hemodialysis or peritoneal dialysis on an outpatient basis.
» Educate the client on how to measure blood pressure and weight at home.
» Encourage the client to ask questions and discuss fears.
» Encourage the client to diet, exercise, and take medication as prescribed.
» Advise the client to notify the provider if she observes signs of skin breakdown.
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