 Welcome to Nursing School Explained and this video on Potassium imbalances. So today we're looking to causes, signs and symptoms and treatment of hypo and hyperkalemia. As a quick review here, potassium level usually in the serum is anywhere from 3.5 to 5.0 but depending on the lab reference value they might vary just a little bit so always make sure that you take a look at those reference ranges to make sure that you know if the level is within or without normal limits. And as a quick review here, potassium is a major contributor to the intracellular fluid. So the majority of potassium sits within the cells and it likes to travel with its body magnesium. So those two usually go hand in hand. If one is high the other one will be high and if one is low the other one will be low. And potassium is a major contributor or controls our muscles. So when you think about muscles not only think about the heart but also the muscles of our body. Skeletal muscles as well as smooth muscles of the intestines for example. So muscles we have heart and then the neuromuscular function and that is because we have that sodium and potassium pump and these channels that regulate the influx and outflow of sodium and potassium in order to make the muscle contraction happen. And it's regulated by the kidney. So the kidneys are the ones that either retain or excrete more potassium depending on what's going on in the body and what's also going on with our fluid balance and the sodium levels because it regulates also the fluids here by either excreting or absorbing more sodium and potassium. So what are causes of hypo and hyperkalemia so hypo here in black hyper in blue. So typically we can lose potassium through vomiting but mostly through diarrhea. Vomiting losses are typically high in sodium where GI losses through diarrhea are usually cause low potassium levels but also hemorrhages eating disorders. So think about patients who might suffer from bulimia or anorexia nervosa. They might have a lot of vomiting, binging, purging, diarrhea, a lot of intestinal symptoms and therefore they can have hypokalemia. Also TPN total parenteral nutrition can lead to hypokalemia if we're not carefully administering that. And then third spacing. So think about patients who have ascites or a lot of lymphedema where some of that fluid is sitting in the interstitial space that can also lead to hypokalemia. And then certain medications. So steroids are again a big offender here. Insulin actually leads to hypokalemia because it helps to drive the potassium into the cells and out of the serum. Group diuretics as well as styrocyte diuretics because they work on the kidney to excrete some fluid and then usually potassium will go with it. And also the joxin, a heart medication. And the joxin and potassium really don't get along or the joxin can have a major effect on potassium balance. So if the patient is on both medications, some sort of a potassium replacement and also the joxin you have to be extra, extra careful and diligent checking their potassium level because it can have some significant consequences specifically on the patient's heart. And then for hyperkalemia. So anything that concerns the kidney because the kidney is the one that regulates the potassium balance. So if there's something going on with the kidney, it can lead to hyperkalemia. And those are acute kidney injury, chronic kidney disease or glomerular nephritis. And I have videos about all these separate topics. It's in potassium intake. So that might be a patient who has high blood pressure and they've now been told to decrease their sodium intake and they take some of these supplements that to season their food that are high in potassium rather than sodium. And maybe they're in addition on a potassium sparing diuretic. Now their potassium level is too high. And then with any of these kidney disorders, the patient is always at risk for metabolic acidosis. So that can also cause hyperkalemia as well as burns because when a patient has burn injuries, the cells, they dissolve. And so now as they are injured and burned, the cells dissolve. And now that potassium is kind of free floating there and it gets absorbed into the blood stream leading to hyperkalemia. And then also medication. So anything that regulates or that influences the kidney's ability to regulate our electrolytes and blood pressure. So ACE inhibitors, ARBs, NSAIDs. So NSAIDs can actually be caustic to the kidneys and therefore cause hyperkalemia. Certainly potassium sparing diuretics, if we hold on to a lot of the potassium, we can cause the patient to have hyperkalemia. And then again, here we have this digoxin that can cause either hypo or hyperkalemia. So we need to be very careful in terms of signs and symptoms. So because we know potassium affects muscles, we have to think about muscle contraction and muscle function of the heart as well as the skeletal muscles and the smooth muscles, mostly of the GI system. So for hyperkalemia and a lot of those are very similar. So dysrhythmias is a big, big one here. So and this might be you're either you're detecting an irregular heart rate when you're listening or the patient complaining of palpitations. And then an EKG, when the patient has low potassium, the QRS may be wide or they might have an ST depression or the T-wave may be flat or inverted. On the contrary, for hyperkalemia, again, we have the dysrhythmias, irregular heart rate and the patients complained of palpitations. But for EKG, those changes are different. So it might be a heart block. If the potassium is just slightly elevated, it might just be a first degree heart block, but it can progress to second and third degree. They also might have a peak T-wave. This is something that you commonly see in patients who are maybe on dialysis and they don't come in and they come in now to the emergency department because they've missed some of the dialysis treatment. So they have hyperkalemia. You put them on a monitor and right away you see these peak T-waves. So you know that they are hyperkalemic. Of course, you have to draw their blood to find out exactly what their level is and then go from there. And hyperkalemia can lead all the way to V-fib and V-fib, we know, can be a death lethal rhythm. In terms of the neuromuscular function, so this is all concerning the heart in terms of neuromuscular function. So think skeletal muscle as well as the smooth muscle. So bowel sounds and hyperkalemia will be decreased and then hyperkalemia will be increased or hyperactive. And then it can also lead to general weakness, muscle cramping and twitching on both sides. So if there's any of these occurring, you definitely just want to notify the provider and get a potassium level check to see which one of the two it is. In terms of treatment, if the potassium is low, we need to replace it. And so that can either be done PO if it's just mildly low or it needs to be done in the IV and there are actually a couple of really important tidbits here. So first of all, for PO potassium, it is awful. So make sure that you dilute it in something that the patient is able to drink or is part of their diet and that can maybe mask the flavor of the liquid. And then for IV replacement, the maximum rate is 10 MEQs of potassium per hour. And potassium typically comes in very small IV piggybacks, 10 MEQs per 50 ml. And you want to put those on a separate channel. You do not want to piggyback that into your main line, into your regular maintenance fluids because if something goes wrong with the pump, the pump won't know if it's infusing from the main line or the piggyback. And if something goes wrong, you might give the patient more than these 10 MEQs per hour and then they can have this rithmius and they can end up in V-fib from us giving them too much potassium right away. So very, very careful here. We also want to check the IV side closely. Potassium burns the veins. So you want to make sure you have a fairly good vein. You do want to use a 22 gauge in their pinky finger, but maybe a 20 gauge at least or an 18 gauge in their AC in a larger blood vessel. And then you can also sometimes dilute it. So some facilities have protocols as to how to do it. So you could have your maintenance IV fluids and your potassium, both on different channels that regulate the rate that get administered. But right before they hit the patient's vein, you hook them together. So as the potassium gets infused, the maintenance fluids that's running in at the same time dilutes the potassium that goes in. And there are also sometimes protocols where you can actually dilute the potassium in the bag with some lidocaine, some numbing agent so it doesn't burn the veins as much. And the patient will be able to tolerate the infusion much better. So always check your hospital policies and rules about potassium and what you can do to ease the infusion. Now if we have high potassium levels, we need to get rid of it. So first of all, decrease potassium in their diet. Check all of their medications because we have a list over here of things that can cause a lot of problems with hyperkalemia. And really think about all those medications that affect blood pressure from the RAS as well as NSAIDs. They are big contributors here. And then if the potassium level is so high and we just are unable to give the patients enough diuretics, then the patient has to go on hemodialysis. And then depending on the cause, if it's a acute renal injury for some reason, then it might be temporary. But if this is maybe some chronic kidney disease that has been developing from stage 2, 3 to now stage 4, then they might need to be on hemodialysis for the rest of their life to help them filter out the potassium. And then there are certain medications and other electrolytes we can give the patients to bring the potassium level down. And actually what happens, we don't necessarily get rid of it by excreting it, but we make the potassium go from the serum back into the cell where it belongs. Because remember, we have a serum level here measured as 3.5 to 5.0. We want to have a relatively low level of potassium in the serum. We wanted to go back where it belongs into the cells where it does all these wonderful things for our cells. And so what helps with that is IV calcium, IV glucose and insulin because the combination of the two, in terms of the electric charge, the potassium then is driven back into the cell. Sodium bicarbonate is a buffer that helps to combat metabolic acidosis. So bicarbonate helps to more alkalinize the blood. And then albuterol also helps to drive the potassium back into the cells. So we are not only buying the patient time to maybe until they need or can have the hemodialysis treatment because, as you can imagine, it's not something that can be usually done very quickly. But we can give them all these medications and hopefully shift the potassium back into the cell to at least get it a little bit lower to where they don't have any of these possibly lethal arrhythmias and these complaints about their hearts because that's really what we're worried about the most. And for nursing considerations, so we want to clearly check their vital signs frequently and have them on a heart monitor so we can see any of these EKG changes hopefully improving as we're getting the patient treated. We want to keep an eye on their labs. So that's definitely their potassium as well as their magnesium because we know they go together. They're sodium because we know of that sodium potassium pump in these channels and also their blood sugars because we're given the patient insulin, we're given it with glucose but we don't want them to go hypoglycemic. We want to check their neuromuscular function. So check all for general weakness and muscle cramping and twitching as well as their bowel sounds because here we said it can affect that. We want to have fall precautions because again if they're weak and maybe not quite as able to move around they are likely to have a fall. And then IV axis so as I talked about over here for the IV administration of not only the potassium if it's slow but also these other medications here that are super important. So potassium is a very very important electrolyte and always think about the heart and the neuromuscular function when it comes to abnormalities and therefore you can kind of deduce what's going on, what kinds of signs and symptoms and what do I have to do to treat this patient. Please also check the other videos on the other electrolyte imbalances and I'll see you soon right here back on Nursing School Explained. Thanks for watching.