Fluid & Electrolytes
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  • Fluid & Electrolytes/Acid Base BalanceGoal: Reestablish & maintain normal balance -assess clients likely to develop imbalances -monitor clients for early manifestations -implement collaborative interventions
  • Necessary for cells to be able to carry out their work. Body fluids are in constant motionBody fluids maintain healthy living conditions for body cells
  • nutrients in foodnormal digestive processesnormal volume, composition, distribution, & pH of body fluids
  • Homeostasis involvesDelivery of essential elements such as oxygen and glucose to the cellsRemoval of wastes such as carbon dioxide from the cells
  • Intracellular fluid 40% total body weightEssential for normal cell functionProvides medium for metabolic processes
  • Extracellular fluid 20% total body weightInterstitial fluid: spaces between cellsIntravascular fluid (plasma-arteries, veins, capillaries)Transcellular fluidUrine, digestive secretions, perspirationCerebrospinal, pleural, synovial fluidsIntraocular, gonadal, pericardial fluids
  • 82 year old women
  • Isotonic dehydration, the most common type of fluid deficit, is caused by loss of plasma volume. In this case, the client lost volume by excessive vomiting and diarrhea
  • Urine specific gravity >1.010 Urine volume decreased Serum sodium normal Serum hct & hgb increasedBUN normal or increased Serum osmolality normal
  • Orthostatic hypotension and flat neck veins
  • Increased sympathetic discharge
  • Rapid hydration of IVF
  • D5W
  • Urinary output
  • crackles
  • weight
  • Distended hand and neck veins
  • All except diminished peripheral pulses, thirst, orthostatic hypotension
  • Restrict free water
  • Stop IV
  • Urine output
  • ElectrolytesMaintain fluid balanceRegulate & maintain acid-base balanceContribute to enzyme reactionsEssential for neuromuscular activityMeasured in mEq/L of watermEq-measure of chemical binding power of the ion
  • Heart rhythm
  • Cardiac monitoring
  • Bacon, fresh fruit salad if it contains bananas, cantalope, kiwi, orange) potato, spinach, & dried fruit; salt subsitute
  • Deficit knowledge related to dietary intake of potassium as evidenced by dietary intake of potassium rich foods such as potatoes, bacon, and salt subsitute. Deficit knowledge related to lack of familiarity with information resources as evidenced by inaccurate follow through on instructions for medication and dietary intake of potassium rich foods
  • Loose diarrhea stools. Symptoms are a result of the excess potassium moving from ICF to ECF creating an stimulation of the bowel and resulting in diarrhea.
  • There is no need to clarify the order. GI s/s of hyperkalemia are increased motility, hyperactive bowel sounds and diarrhea. The kayxalate will reduce the potassium levels consequently the intestinal motility decreases if the enema is successful
  • Spironolactone is a potassium sparing diuretic and should be d/c.Teach diet, medications, and recognition of s/s of hyperkalemia. Importance of follow up care
  • Seizure precautions
  • Because of her symptoms and history knowing that dehydration can be characteristic of hypernatremia the sodium level is expected to be elevated. Assessment: CNS, neurovascular, and CV manifestations Treatment fluid replacement with isotonic solution (NaCl) Teaching sodium content in foods and beverages, safety measures (physiologic changes in the elderly, s/s of dehydration to report, prevention of dehydration and hypernatremia by drinking adequate water
  • High Ca can cause constipation, polyuria which causes increased thirst; cardiac arrestLow Ca Lethargy, coma
  • Heart rhythm-dysrhythmias, ECG changes possible HTN, cardiac arrest
  • Severe Low phos affects every major organ
  • Magnesium

Fluid & Electrolytes Fluid & Electrolytes Presentation Transcript

  • Fluid & Electrolytes
    C. Washington RN, MSNEd
  • Homeostasis Depends On
  • Homeostasis Depends on
  • Fluid Balance
  • Body Fluid Distribution
    • ICF
    • Potassium, magnesium, & phosphate
    • Glucose, oxygen
    • ECF
    • Sodium, chloride, bicarbonate, calcium
    • High Na+ concentration regulates body fluid volume
  • Body Fluid Movement
  • Body Fluid Movement
    • Osmolality 275-295 mOsm/kg
    • Used to describe concentration of body fluids
    • # solutes /kg H20 (by weight)
    • Estimated by doubling serum Na concentration
    • Osmolarity of ECF depends on Na+ concentration
  • Body Fluid Movement
    Diffusion
    Molecules -> from an area of ↑ concentration to an area of ↓ concentration
    Osmotic Pressure
    • Power of fluid to draw H20
    across a membrane
  • Body Fluid Movement
    Filtration
    H2O & dissolved substances -> from an area of > hydrostatic pressure to an area of < hydrostatic pressure
  • Body Fluid Movement
  • Fluid Replacement
  • Fluid Replacement
  • Why should you care?
    ↑ sodium concentration in ECF
    Causes H2O to shift from ICF -> ECF compartment
    Treatment: 0.45% NS (hypotonic) facilitates H2O back into intracellular space
  • Body Fluid Regulation
  • Renin-Angiotensin-Aldosterone System
  • Hydration: Important for Good Health
  • Assessment of Fluid Balance
    Diagnostic and Laboratory Data
    Osborn page 420
  • Assessing Fluid Balance
  • Assessing Fluid Balance
  • Assessing Fluid Balance
  • Assessing Fluid Balance
  • Nursing Diagnosis: Fluid Imbalances
    Fluid volume excess
    Fluid volume deficit
    Fluid volume deficit, risk for
    Gas exchange, impaired
    Cardiac output, decreased
    Knowledge deficit
    Breathing pattern, ineffective
    Anxiety
    Thought processes, altered
    Injury, risk for
    Oral mucous membrane, altered
  • Fluid Balance: Common Interventions
    Monitoring daily weight
    Measuring vital signs
    Measuring intake and output
    Providing oral hygiene
    Initiating oral fluid therapy
    Maintaining tube feeding
    Monitoring intravenous therapy
  • Fluid & Electrolyte disorders
    Excess fluids result from excessive intake or decreased output, from any cause
    Fluid deficits result from poor intake or excessive output, from any cause
    Both occur from shifts that occur with various health disorders
  • FVD: Cause
  • FVD: Cause
  • FVD: Cause
  • FVD: Cause
  • Fluid Volume Deficit
    Hypovolemia
    Loss of extracellular fluid volume
    Isotonic fluid volume deficit
    Electrolytes loss along with fluid
  • FVD
    Third spacing
    Shift of fluid into vascular space
    abdomen, pleural/ peritoneal space
  • Signs & Symptoms: FVD
    • Weight loss
    • 1 liter of body fluid weighs 1 kg (2.2lb)
    • ↓interstitial fluid→ diminished skin turgor
    • ↓skin turgor less accurate in elderly
    • More accurate indicator of FVD
    • Assess tongue for size, dryness, longitudinal furrows
  • Test Yourself
    • You are caring for a patient taking the diuretic furosemide.
    • Yesterday, the patient’s weight was 62 kg.
    • After the dose of furosemide yesterday, the patient’s urine output was 2,500 ml.
    • What do you expect the patient’s weight to be today?
  • Signs & Symptoms: FVD
    • Hypovolemia
    • Orthostatic hypotension
    • >15 mmHg drop in SBP from lying to standing
    • Loss of intravascular volume
    • ↑HCT
    • Venous pressure falls
    • Flat neck veins
  • Signs & Symptoms: FVD
    • To conserve water & sodium pt may experience
    • Tachycardia
    • Pale, cool skin (vasoconstriction)
    • Decreased urine output
    • Specific gravity increases as water is reabsorbed in the tubules
  • Diagnostic Tests: FVD
    Serum electrolytes
    Isotonic deficit Na+ wnl
    Water loss only Na+ ↑
    ↓ K+ common
    Serum osmolality ↑ with water loss
    Serum Hgb & Hct ↑
    Urine specific gravity & osmolality ↑
  • Assessment: FVD
    • Health History
    • Medication
    • Renal or endocrine disease
    • Hot weather
    • Excessive exercise
    • Lack of access to fluids
    • Recent illness accompanied by fever, vomiting/diarrhea
  • Assessment: FVD
    Physical Assessment
    Weight
    Vital signs
    Peripheral pulses/capillary refill
    Jugular neck vein
    Skin color
    Temperature
    Turgor
    LOC/mentation
    Urine output
  • Fluid Management: FVD
    Isotonic Electrolyte solutions
    0.9% NaCL/Ringer’s solution
    Expand plasma volume (↓ BP pt’s)
    Replace abnormal losses
    Total body water deficits
    D5W
    Dextrose is metabolized to carbon dioxide & water ->availability of free water for tissue needs
  • Fluid Imbalance
    Nursing Process: Patient Care Plan for
    Dehydration
    Osborn page 421
  • Dehydration
    • When more water is lost from the body than is replaced.
    • Dehydration refers to loss of water alone
    • Caused by water deprivation, excessive urine production, profuse sweating, diarrhea, and extended periods of vomiting.
  • Nursing Diagnosis: FVD
    Deficient Fluid Volume
    Ineffective Tissue Perfusion
    Risk for Injury
  • Test Yourself
    • In prioritizing patient care, you recognize that the pt most at risk for FVD is
    • A 30 year old man with a fractured tibia
    • An 82 year old women with a fractured hip
    • A 62 year old man with a heart attack
    • A 35 year old woman who just delivered a baby
  • Ms. Hicks
    39 year old female
    history of vomiting & diarrhea from the flu
    rapid pulse
    orthostatic hypotension
    urine output of 20 mL/hr
    skin turgor poor with tenting
    increased respiratory rate
  • Ms. Hicks
    Which type of
    dehydration do you
    suspect that this
    Ms. Hicks has? Explain
    your answer.
  • Ms. Hicks
    In evaluating the
    client’s laboratory
    values, would you
    expect the following
    values to be normal,
    elevated, or
    decreased?
    Urine specific gravity
    Urine volume
    Serum sodium
    Serum hct & hgb
    BUN
    Serum osmolality
  • Ms Hicks
    When assessing a patient with FVD, the nurse would expect to find:
    Increased pulse rate and BP
    Dyspnea and respiratory crackles
    Headache and muscle cramps
    Orthostatic hypotension and flat neck veins
  • Ms Hicks
    What compensatory mechanism responsible for the client’s rapid pulse?
  • Ms Hicks
    What immediate interventions are necessary to correct this client’s fluid volume imbalance?
  • Ms Hicks
    Admitted with hypovolemia. Which IV solution would the nurse anticipate administering?
    Ringer’s solution
    10% dextrose in water
    3% sodium chloride
    0.24% sodium chloride
  • Ms Hicks
    What would be most important to monitor to determine the client’s response to corrective interventions?
  • Mr Hicks
    What assessment data would indicate that the client is having a negative response to fluid resuscitation?
  • Fluid Volume Excess (FVE)
    • Results from water & sodium retention
    • Hypervolemia
    • Excess intravascular fluid
    • Edema
    • Excess interstitial fluid
  • FVE: Causes
  • FVE: Cause
  • FVE: Cause
  • FVE: Cause
  • Signs & Symptoms: FVE
  • Signs & Symptoms: FVE
  • Signs & Symptoms: FVE
    Weight gain >5% of body weight
  • Diagnostic Tests: FVE
    To determine cause
    Serum creatinine
    BUN
    liver enzymes
  • Medications: FVE
    Diuretics
    Inhibit Na+ & water reabsorption
    Increase urine output
  • Diuretics: Pt & Family Teaching
    Take in morning and afternoon
    Change position slowly
    Weigh daily
    Avoid salt shaker & processed foods
    Read food labels
    ↑ potassium foods (banana/orange juice)
    Potassium sparing diuretics do not use salt substitute
  • Assessment Data: FVE
    • Health history:
    • Meds or change of meds
    • Heart failure; recent illness
    • Acute/chronic renal or endocrine disease
    • Change in diet/recent weight gain
    • Persistent cough, SOB
    • Swelling of feet and ankles
    • Difficulty sleeping when lying down
  • Assessment Data: FVE
    • Physical Assessment
    • Weight, vital signs
    • Peripheral pulses & capillary refill
    • Jugular neck vein distention, edema
    • Lung sounds (crackles or wheezes)
    • dyspnea, cough, & sputum
    • Urine output
    • Mental status
  • Edema
    Amount of interstitial fluid (fluid in tissue spaces around each cell) returning to the circulatory system lessens
    Fluid accumulate in the tissue spaces, the tissues become swollen.
  • Pitting Edema
    Extravasation & accumulation of interstitial fluid in tissues
    Dependent areas of the body
    Leaves indentation when skin surface is pressed by a finger
    Reflects high right atrial pressure, for example, in heart failure
    More severe than non-pitting edema
  • Nursing Diagnosis: FVE
    Excess fluid volume
    Risk for Impaired Skin Integrity
    Risk for Impaired Gas exchange
  • Mrs. Hsu
    • Admitted to the hospital with a decreased serum osmolality and a serum sodium of 126 mEq/L.
    • You recognize that dehydration or overhydration may accompany hypotonic conditions.
  • Mrs. Hsu
    A priority assessment for this client with FVE is:
    Mental status
    Weight
    Postural vital signs
    Urine output
  • Mrs Hsu
    In further assessing the client, what assessment data would indicate that the client has fluid volume excess?
    Distended hand & neck veins
    Decreased urine output
    Decreased capillary refill
    Increased rate and depth of respirations
  • Mrs. Hsu
    Increased, bounding pulse
    JVD
    Diminished peripheral pulses
    Presence of crackles
    Thirst
    Elevated blood pressure
    Orthostatic hypotension
    Skin pale & cool to touch
    Which of the following
    assessments would
    indicate that Mrs. Jones
    has fluid volume excess?
  • Mrs Hsu
    After determining the client is not dehydrated, which of the following interventions would be appropriate to correct this hypotonic overhydration?
    Administration of 0.9% NS
    Restriction of free water
    Administration of antihypertensives
    Restriction of potassium
  • Mrs. Hsu
    A patient is exhibiting sudden onset of crackles in the lungs, moist respirations, & rapid respiratory rate. Which intervention should be performed first?
    Weigh the patient
    Assess capillary refill
    Measure edema
    Reduce IV rate
  • Mrs Hsu
    What would you assess for evidence of a worsening hypotonic condition?
    Mental status
    Urine output
    Skin changes
    Bowel sounds
  • Potassium (K+) 3.5 to 5.5 mEq/L
    Major cation in the ICF
    Affects cardiac muscle concentration, electrical conductivity, & cell excitability
    Aids neuromuscular transmission of nerve impulses.
    Alteration in K+ balance will result in acid-base imbalance
    Regulation of protein synthesis
    Regulation of glucose use & storage
  • Hypokalemia K+ <3.5 mEq/L
  • Hypokalemia K+ <3.5 mEq/L
  • Hypokalemia K+ <3.5 mEq/L
  • Hypokalemia K+ <3.5 mEq/L
    Hyperaldosteronism
  • Diagnostic Tests: ↓ K+
  • Assessment: Hypokalemia
    Health history
    Anorexia, nausea, vomiting, abdominal discomfort
    Muscle weakness or cramping
    Diuretic use
    Prolonged vomiting or diarrhea
    Diabetes, Addison or Cushing disease
    Current medications
  • Assessment: Hypokalemia
    • Mental status
    Physical assessment
    • Vital signs, including orthostatic
    • Apical and peripheral pulses
    • Bowel sounds, abdominal distention
    • Muscle strength & tone
  • Treatment: ↓ K+
    Oral potassium supplements
    Oral: dilute liquid K+ in fruit or vegetable juice or cold water
    Never give K+ if pt is not voiding
    Chill to increase palatability
    Give with food to minimize GI effects
    Parental potassium supplements
  • Pt Teaching: K+ Supplement
    • No K+ supplement if taking K+ sparing diuretic
    • Do not chew enteric-coated tablets
    • Take with meals
    • Do not use salt substitutes (potassium based)
  • Foods High in K+
  • Nursing Diagnosis: ↓K+
    Activity intolerance
    Decreased cardiac output
    Risk for Imbalanced Fluid Volume
  • The assessment of a patient with hypokalemia should focus on
    BP
    Edema
    Chvostek’s sign
    Heart rhythm
    • Laboratory results for a patient show a potassium level of 2.2 mEq/L. Which of the following nursing actions is highest priorty for this patient?
    Keep the patient on bedrest
    Initiate cardiac monitoring
    Start oxygen at 2L/min
    Initiate seizure precautions
  • Hyperkalemia: K+>5.0 mEq/L
    Causes
  • Hyperkalemia: K+>5.0 mEq/L
  • ↑ K+
  • Hyperkalemia: K+>5.0 mEq/L
  • Diagnostic Tests: ↑ K+
  • Assessment: ↑ K+
    • Health history
    • Numbness, tingling, muscle weakness
    • Nausea, vomiting, abdominal cramping
    • Palpitations
    • Use of salt substitutes & potassium supplements
    • Reduced urine output
    • Renal failure/endocrine disorders
    • Current medications
  • Assessment: ↑ K+
    Physical assessment
    Apical & peripheral pulses
    Bowel sounds
    Muscle strength
    ECG pattern
  • Management: ↑ K+
    Medications
    Calcium gluconate (emergency)
    Regular insulin & 50g of glucose (emergency)
    Sodium bicarbonate (acidosis) (emergency)
    Kayexalate & Sorbital
    Diuretics
    Dialysis
  • Nursing Diagnosis: ↑ K+
    Risk for Activity Intolerance
    Risk for Decreased Cardiac Output
    Risk for Imbalanced Fluid Volume
    • You are caring for a patient with hyperkalemia. You prepare for administration of which medication?
    • Kayexalate
    • K-Lor
    • Kaopectate
    • Keflex
  • Mr. Williams
    Adm for palpitations
    K+ 5.4 mEq/L
    Takes Spironolactone 50 mg daily for HTN
    Missed 1 month follow-up appointment
  • Mr. Williams
    • Day prior to admission he ate:
    • Which foods in his diet contribute to his hyperkalemia?
  • Mr. Williams
    What would be a relevant nursing diagnosis for this client based on the client’s assessed data?
  • Mr. Williams
    C/O abdominal cramping and several very loose diarrhea stools since yesterday.
    What is the etiology of the client’s symptoms?
  • Mr. Williams
    Physician orders Kayexalate retention enema to be given stat.
    Should you clarify the physician’s orders before administering the enema?
  • Mr. Williams
    Will the physician continue the order for Spironolactone? Explain.
    What would be some teaching and learning priorities for d/c.
  • Sodium (Na+) 135-145 mEq/liter
    Normal physiologic function
    Maintains ECF volume
    Maintenance of ECF osmolality.
    Initiation of skeletal muscle contraction
    Initiation of cardiac contractility
    Transmission of neuronal impulses
    Maintenance of renal urine-concentration system
  • Sodium Imbalance
    Affect osmolality of ECF
    Affect water distribution between fluid compartments
    Low Na+ H2O is drawn into cells (swell)
    High Na+ H20 drawn out of cells
  • Signs & Symptoms
    Hyponatremia
    Muscle cramps, Weakness, fatigue
    Dulled sensorium, irritability, personality changes
    Hypernatremia
    Most serious effects are seen in the brain
    Lethargy, weakness, irritability can progress to seizures, coma, death
  • Point to Remember
    Pt’s with low Na+ will present with acute onset of confusion
    Risk for falls in the elderly
  • Foods High in Sodium
  • A patient presents with a serum sodium level of 115 mEq/L. A priority nursing intervention is
    Seizure precautions
    Vital signs every two hours
    Frequent mouth care
    Cardiac rhythm monitoring
    • The nurse caring for a client with hypernatremia includes which of the following in the plan of care? (Select all that apply)
    • Conduct frequent neurologic checks
    • Restrict fluids to 1500 ml per day
    • Orient to time, place, & person frequently
    • Maintain intravenous access
    • Limit length of visits
  • A patient receiving D5W at 100 mL/hr is most at risk for developing
    Hypernatremia
    Hyponatremia
    FVE
    FVD
  • Mrs. Hudson
    77-year-old female
    Found confused, unable to get up to the bathroom
    Weak, anxious, confused to time & place
    P 110; B 108/58
    Skin dry
    Urine Specific gravity 1.028
    Deep tendon reflexes slightly reduced
  • Mrs. Hudson
    Would the client’s serum sodium be elevated, decreased, or normal?
    What would be your priority assessment plan?
    • What treatment would you expect this client to receive at this time?
    • What would be a teaching plan for this client?
  • Chloride (Cl-) 95 to 108 mEq/liter
    Formation of hydrochloric acid in stomach
    Cl- and Na+ levels usually change in direct proportion to one another.
    Works with Na+ to maintain ECF osmotic pressure & water balance
  • Calcium (Ca++)8.5 – 10.5 mEq/dl (4-5.5 mEq/L)
    Functions
    Enhances activity of enzymes or reactions
    Skeletal muscle contraction
    Cardiac contractility
    Helps activate steps in blood coagulation.
    Bone strength & density
    Regulation of neural impulse transmission
  • Calcium Imbalance
    Calcium levels regulated by
    parathyroid hormone
    Calcitonin
    Calcitriol
  • Ca+ Imbalance: Signs & Symptoms
    Hypocalcemia
    Tetany, paresthesias, muscle spasms
    Hypotension
    Anxiety, confusion, psychosis
    Hypercalcemia
    Muscle weakness, fatigue
    Personality changes
    Anorexia, nausea, vomiting
  • Foods High in Calcium
  • The most important assessment in a patient with hypercalcemia is
    Heart rhythm
    Urine output
    Trousseau’s sign
    Weight
  • The nurse evaluates teaching about calcium supplement therapy as effective when the patient states that she will take her calcium tablets
    All at one time in the morning
    With meals
    As needed for tremulousness
    With a full glass of water
  • Phosphorus 2.5 – 4.5 mEq/dl
    Vital for intracellular activities
    Activation of B complex vitamins
    Plays major role in acid-base balance through its action as a urinary buffer
    Cell division
    Plays essential role in muscle, RBC, neurological function
    Aids in carbohydrate, protein and fat metabolism
  • Hypophosphatemia
    Muscle pain & tenderness
    Muscle weakness
    Paresthesia
    Confusion
    Manifestations of hypophosphatemia
    Muscle spasms, tetany
    Soft tissue calcifications
  • Magnesium (Mg++) 1.5-2.5 mEq/l
    Muscle contractility
    Carbohydrate and protein metabolism.
    Affects neuromuscular irritability & contractility of cardiac and skeletal muscle.
    Facilitates transport of Na+ and K+ across cell membranes.
    DNA & Protein synthesis
  • Magnesium Imbalance
    Hypomagnesemia
    Muscle weakness & tremors
    Dysphasia
    Tachycardia, HTN
    Mood & personality changes
    Hypermagnesemia
    Depressed DTRs
    Hypotension
    Respiration
    • A patient who is known to be an alcoholic presents with confusion, hallucinations, and positive Chvostek’s sign. Which medication should the nurse anticipate administering?
    • Magnesium sulfate
    • Calcium chloride
    • Insulin and glucose
    • Sodium bicarbinate
  • A patient is experiencing nausea with severe vomiting.
    The nurse realizes that this patient is at risk for which of the following?
  • Interstitial fluid volume overload
    Intracellular fluid volume deficit
    Extracellular fluid volume deficit
    Interstitial fluid volume deficit
  • A male patient’s hematocrit is 56%
    Serum sodium 150 mEq/L and
    Potassium of 5.8 mEq/L
    Which of the following would be indicated for this patient?
  • Prepare to administer a hypertonic IV soultion
    Prepare to administer a hypotonic IV solution
    Prepare to administer an isotonic IV solution
    Implement a fluid and sodium restriction for the patient
  • The nurse is caring for a patient and has just received the laboratory data report.
    Which of the following results would cause the most concern to the nurse?
  • Na+: 115 mEq/L
    K+: 4.0 mEq/L
    Ca+: 9mg/dL
    Mg+: 2.0mg/dL
  • The nurse is caring for a patient with severe vomiting and diarrhea
    Nasogastric tube to low wall suction.
    The nurse realizes that this patient is at risk for which of the following electrolyte imbalances?
  • Hypokalemia
    Hypercalcemia
    Hypermagnesemia
    Hypophosphatemia
  • A patient is admitted to the hospital with a fluid volume excess.
    Which of the following will the nurse most likely assess for this patient?
  • Dependent edema
    Blood pressure: 92/55 mm Hg
    Respiratory rate 14 breaths/minute and unlabored
    Heart rate 86 beats per minute without ectopy
  • The nurse is caring for a patient in renal failure with a serum potassium level of 7.1mEq/L.
    Which of the following should the nurse do first to assist this patient?
  • Assess level of consciousness.
    Measure urine output hourly.
    Have arterial blood gases drawn.
    Obtain an electrocardiogram.
  • The nurse is providing discharge instructions to a patient with hypokalemia.
    Which of the following should the nurse include in these instructions?
  • Take oral Kaexylate as prescribed.
    Limit the intake of spinach and carrots.
    Eat a balanced diet, including tomato juice and potatoes.
    Expect muscle cramps and weakness for at least six weeks.