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학습 자료 둘러보기 →| Option | Clinical Reasoning |
|---|---|
| 1. Administer calcium gluconate | Calcium gluconate antagonizes the cardiac effects of hyperkalemia by stabilizing myocardial cell membranes, but it does not lower serum potassium levels [1]. It is indicated when ECG changes (peaked T waves, widened QRS) or arrhythmias are present, serving as a temporizing measure while definitive potassium-lowering therapies are initiated. In the absence of documented ECG changes or arrhythmia, establishing renal elimination through hydration takes precedence. |
| 2. Restrict fluid intake | Fluid restriction is contraindicated in TLS. The syndrome’s primary danger is renal obstruction from crystal deposition, which aggressive hydration prevents. Restricting fluids would concentrate urinary solutes, accelerate tubular blockage, and worsen both hyperkalemia and renal failure [1]. |
| 3. Monitor serum potassium every 4 hours | While potassium monitoring is essential in TLS, checking every 4 hours is insufficient during the acute phase when cell lysis peaks 24–72 hours post-chemotherapy. More frequent monitoring (every 4–6 hours initially, or more often if levels are rising rapidly) is required. More importantly, monitoring alone does not treat the underlying problem — the immediate nursing action must be to facilitate potassium excretion through hydration and urine output [1]. |
For a patient with suspected tumor lysis syndrome (TLS) presenting with altered mental status and muscle cramps, the immediate priority is to ensure adequate hydration and urine output. Initiate IV normal saline at a rate of 200–250 mL/hour to rapidly expand intravascular volume.
This intervention directly addresses the pathophysiology by increasing renal blood flow and glomerular filtration rate, which enhances the excretion of potassium, uric acid, and phosphate. High urine flow also dilutes intratubular concentrations, preventing crystal precipitation and acute kidney injury.
Do not administer calcium gluconate as the first action unless there are ECG changes from hyperkalemia. It protects the heart but does not correct the underlying electrolyte imbalance. Fluid restriction is contraindicated in TLS.
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