Non-ICU Electrolytes Protocol Flashcards
Q: What are the symptoms of hypokalemia?
A: Symptoms include nausea, vomiting, muscle weakness, constipation, paralysis, ECG changes (flattened T wave, elevated U wave, ST-segment depression), cardiac arrhythmias (bradycardia, heart block, ventricular tachycardia/fibrillation), and rhabdomyolysis.
Q: What are the causes of hypokalemia?
A: Causes include metabolic alkalosis, β-adrenergic agonists (e.g., albuterol), insulin, theophylline, caffeine, potassium-wasting diuretics (loop and thiazide), sodium polystyrene sulfonate, corticosteroids (especially fludrocortisones), aminoglycosides, amphotericin B, magnesium depletion, and GI losses (e.g., diarrhea, nasogastric suctioning).
Q: How can hypokalemia affect digoxin toxicity?
A: Hypokalemia can lead to digoxin toxicity even when the digoxin level is normal.
Q: Why should magnesium be monitored and replaced in hypokalemia cases?
A: Magnesium should be monitored and replaced as necessary because potassium repletion is ineffective in the presence of hypomagnesemia.
Q: What is the recommended infusion rate for potassium?
A: Potassium infusion rate should not exceed 10 mEq/hr on progressive care units.
Q: How should potassium chloride be administered?
A: Potassium chloride should NEVER be given by IV push or IM injection. All infusions must be administered via an infusion pump.
Q: What is the preferred method of potassium repletion if a patient can swallow?
A: Oral potassium repletion should use tablets, unless the patient has a nasogastric (NG) tube or cannot swallow, in which case powder packets should be used for better absorption.
Q: Should oral potassium doses be divided?
A: Oral doses do not need to be divided, though dividing doses may minimize gastrointestinal upset.
Q: What are the symptoms of hypomagnesemia?
A: Symptoms include irritability, psychosis, esophageal spasm, tetany, twitching, confusion, arrhythmias, weakness, fasciculations, nystagmus, seizures, prolonged PR and QT intervals, torsades de pointes, and coma.
Q: How is hypomagnesemia related to potassium depletion?
A: Hypomagnesemia is almost always associated with intracellular potassium depletion.
Q: What are the causes of hypomagnesemia?
A: Causes include GI losses, renal losses, surgery, trauma, sepsis, burns, starvation, alcoholism, thiazide and loop diuretics, aminoglycosides, amphotericin B, cisplatin, cyclosporine, and digoxin.
Q: How can hypomagnesemia affect digoxin toxicity?
A: Hypomagnesemia may potentiate digoxin toxicity.
Q: How should magnesium and potassium be administered if both need replacement?
A: If both magnesium and potassium replacement are needed, administer them concomitantly to promote optimal repletion.
Q: What is the recommended rate of magnesium infusion?
A: Each 1 gram of magnesium should be infused over 1 hour.
Summary of Electrolyte Abnormalities:
Hypokalemia (low K+): < 3.5 mEq/L
Hyperkalemia (high K+): > 5.0 mEq/L
Hypomagnesemia (low Mg2+): < 1.7 mg/dL
Hypermagnesemia (high Mg2+): > 2.2 mg/dL
Hypocalcemia (low Ca2+): < 8.5 mg/dL (total)
Hypercalcemia (high Ca2+): > 10.5 mg/dL (total)
Hyponatremia (low Na+): < 135 mEq/L
Hypernatremia (high Na+): > 145 mEq/L
Potassium (K+) + it’s relationship with Digoxin
Low potassium (hypokalemia) increases the risk of digoxin toxicity.
Why? Potassium and digoxin compete for binding sites on the sodium-potassium ATPase pump. Low potassium levels increase the likelihood of digoxin binding to the pump, enhancing its effects and leading to toxicity.
Symptoms of digoxin toxicity include arrhythmias, nausea, vomiting, and confusion, which can be worsened by low potassium.
Magnesium (Mg2+) + it’s relationship with Digoxin
Low magnesium (hypomagnesemia) increases the risk of digoxin toxicity.
Why? Magnesium plays a stabilizing role in cellular membranes and modulates the action of potassium and calcium. Low magnesium can cause increased calcium influx, leading to increased digoxin sensitivity.
Magnesium deficiency is often associated with low potassium levels, which further complicates the risk of digoxin toxicity.
Calcium (Ca2+) + its relationship to Digoxin
High calcium (hypercalcemia) enhances the effects of digoxin and can increase the risk of toxicity.
Why? Digoxin increases intracellular calcium through its effects on the sodium-potassium ATPase pump, and high calcium levels may exacerbate this effect, potentially leading to arrhythmias (such as torsades de pointes).
Q: What are the symptoms of hypophosphatemia?
A: Symptoms include impaired diaphragmatic contractility and acute respiratory failure, tissue hypoxia, decreased myocardial contractility, paralysis, weakness, paresthesias, neurologic dysfunction, and seizures.
Q: What are the causes of hypophosphatemia?
A: Causes include malnutrition, alkalosis, diabetic ketoacidosis (DKA), alcoholism, vomiting, insulin, diuretics, antacids, sucralfate, and carbohydrate load.
Q: How should intravenous phosphorus products be administered?
A: Intravenous phosphorus products are generally administered over 4-6 hour
Q: What should be done if the separate use of sodium phosphorus and KCl increments presents challenges for the patient or nurse?
A: If fluid volume issues, limited IV access, or the need for both potassium and phosphorus replenishment arise, the RN should contact the provider and suggest using a KPhos increment instead of sodium phosphorus as outlined in the protocol.
Q: How does the absorption of oral phosphorus products get affected?
A: The absorption of oral phosphorus can be affected by the concomitant use of magnesium, calcium, and aluminum-containing products.
Recommendation: Separate the administration of phosphorus and these products by at least 2 hours.
Q: How should phosphorus packet repletion be managed in patients who cannot swallow pills or have feeding tubes?
A: Phosphorus packets can be used in these cases to facilitate absorption. Contact the provider or pharmacy for assistance in determining the correct dose.
Important: Dilute phosphorus packets with 2.5 oz. (75 mL) of water or juice before administration.
Q: What are the guidelines for potassium (K+) replacement?
A:
- Goal: Potassium should be repleted to a level of ≥ 3.1 mEq/L.
- Recommended for: Otherwise healthy patients with controlled hypertension (HTN) and no history of coronary artery disease (CAD), heart failure (HF), arrhythmias, or cirrhosis.
- Avoid in: Patients with renal insufficiency (Cr >1.5), end-stage renal disease, or diabetic ketoacidosis.
- Co-replacement with Magnesium (Mg+): If both magnesium and potassium replacement are needed, administer magnesium and potassium together whenever possible for optimal repletion.
- Important note: Potassium levels < 3.5 mEq/L will be flagged as low in Powerchart, but potassium should only be repleted if K+ is < 3.1 mEq/L.
- Infusion rate: Potassium chloride (KCl) infusion should not exceed 10 mEq/hr on SAC/floor units.
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Typically, 10 mEq of potassium chloride (KCl) can increase the serum potassium level by about 0.1 mEq/L in an average adult.
Q: What are the guidelines for potassium (K+) replacement based on different patient conditions and potassium levels?
Q: What are the guidelines for magnesium (Mg+) replacement based on patient conditions and magnesium levels?
Q: What are the guidelines for phosphorus (PO4) replacement?
Goal: Phosphorus should be repleted to a level of ≥ 2.5 mg/dL.
Recommended for: All patients, except as otherwise indicated.
Avoid in: Renal insufficiency (Cr >1.5), end-stage renal disease, or diabetic ketoacidosis.
If challenges arise: If the use of separate sodium phosphorus and KCl increments presents issues (e.g., fluid volume, limited IV access, need for both K+ and phosphorus repletion), contact the LIP provider to suggest using a KPhos increment instead of sodium phosphorus as outlined in the protocol.
Q: How much can a typical dose of potassium, magnesium, sodium, and phosphorus increase their respective serum levels?
Potassium (K+): 10 mEq KCl → Increase ~0.1 mEq/L
Magnesium (Mg+): 1 gram magnesium sulfate → Increase ~0.1-0.2 mg/dL
Sodium (Na+): 1 mEq NaCl → Increase ~0.1 mEq/L
Phosphorus (PO4): 1 gram phosphorus → Increase ~0.3-0.5 mg/dL
