A patient with stage 5 chronic kidney disease has missed two scheduled hemodialysis sessions. Serum potassium is 7.4 mEq/L. The cardiac monitor shows peaked T waves and a widening QRS complex. Which orders should the nurse anticipate and carry out promptly? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Severe hyperkalemia with ECG changes is a life-threatening emergency. The correct bundle includes: (1) Notify nephrology and prepare for emergent hemodialysis, as dialysis is the only definitive potassium removal in dialysis-dependent CKD. (2) IV regular insulin 10 units with 25 g dextrose 50% to shift potassium intracellularly; monitor glucose afterward. (4) IV calcium gluconate 1–2 g over 5–10 min for cardiac membrane stabilization without lowering potassium. (5) Nebulized albuterol 10–20 mg as adjunctive intracellular shift therapy; tachycardia and tremor are expected. Option 3, sodium polystyrene sulfonate (SPS), is incorrect for acute severe hyperkalemia because its onset is slow (hours) and it carries a risk of intestinal necrosis; it is not a first-line emergency intervention.
Hyperkalemia with ECG changes follows the SHIFT-AND-REMOVE logic: stabilize the membrane (calcium), shift K+ into cells (insulin/dextrose, albuterol, optionally bicarbonate if acidotic), then remove K+ from the body (dialysis is fastest in dialysis-dependent patients; SPS or patiromer take hours and are inappropriate as the only therapy here).
Stage 5 CKD patient on chronic hemodialysis missed two consecutive sessions. Serum K+ is 7.4 mEq/L. The monitor shows peaked T waves with a widening QRS. The patient is alert but anxious.
Hyperkalemia — Serum K+ greater than 5.0 mEq/L; severe at 6.5 or higher with ECG changes such as peaked T waves, widened QRS, or sine-wave pattern.
Calcium gluconate — First drug given for hyperkalemia with ECG changes — stabilizes the cardiac membrane within minutes without lowering serum K+.
Insulin–dextrose shift — Regular insulin 10 units IV with 25 g of D50 drives K+ intracellularly within 15 minutes; monitor glucose every 15 to 30 minutes for one or more hours.