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Hypokalaemia. Normal levels in blood: 3.5 – 5.0mmol/L (Jones, 2011). Hypokalaemia : symptoms. Palpitations Skeletal muscle weakness – cramps Paralysis, paraesthesias Constipation Nausea, vomiting Abdominal cramp Polyuria , nocturia , polydispepsia Psychosis, delerium , hallucinations

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hypokalaemia

Hypokalaemia

Normal levels in blood: 3.5 – 5.0mmol/L (Jones, 2011)

hypokalaemia symptoms
Hypokalaemia: symptoms
  • Palpitations
  • Skeletal muscle weakness – cramps
  • Paralysis, paraesthesias
  • Constipation
  • Nausea, vomiting
  • Abdominal cramp
  • Polyuria, nocturia, polydispepsia
  • Psychosis, delerium, hallucinations
  • Depression
physical findings consistent with severe hypokalaemia garth et al 2009
Physical findings consistent with severe hypokalaemia(Garth et al., 2009)
  • Ileus
  • Hypotension
  • Ventricular arrhythmia
  • Cardiac arrest
  • Bradycardia or tachycardia
  • Premature atrial or ventricular beats
  • Hypoventilation, respiratory distress
  • Respiratory failure
  • Lethargy
  • Decreased muscle strength
  • Decreased tendon reflexes
  • Cushingoidappearence: oedema
hypokalaemia causes garth et al 2009
Hypokalaemia: causes (Garth et al., 2009)
  • Renal losses and leukemia
  • GI losses
    • Diarrhoea and vomiting
    • Enema, laxative use
    • Ileal loop
  • Medications
    • Diuretics
    • Beta adrenergic agonists
    • Steroids
  • Transcellular shift
    • Insulin
    • Alkalosis
  • Malnutrition
    • Decreased intake inc. Anorexia nervosa
    • Parenteral nutrition
hypokalaemia investigations garth et al 2009
Hypokalaemia: investigations (Garth et al., 2009)
  • Serum K+ level <3.5mmol/L
  • Creatinine
  • Magnesium
  • Digoxin use?
    • Hypokalemia can potentiate digitalis induced arrythmia
  • ECG
    • T wave flattening
    • QT prolongation
    • ST segment depression
    • Ventricular and atrialarrythmia
  • Thyroid function: TSH, free T3, free T4
  • ABC
  • Cardiac monitoring
hypokalemia treatment the merck manual online
Hypokalemia: treatment (The Merck Manual; online)
  • 1) oral potassium
    • Mild to moderate hypokalemia (2.5-3.5mmol/L)
    • Large dose = GI irritation so give divided doses
    • Wax impregnated preps better tolerated than liquid preps – take with or after food
  • 2) IV potassium
    • Severe hypokalemia: ECG changes or severe symptoms
    • K+ solution irritate peripheral veins
    • Concentration should not be more than 40mmol/L
  • 3) If Hypokalemia induced arrythmia can give more than 40mmol/L must use central vein or multiple peripheral veins
  • MUST HAVE CONTINUOUS CARDIAC MONITORING AND HOURLY SERUM POTASSIUM
  • Do not use glucose preparation due to insulin interference (may decrease K+ levels further)
  • Normally between 100-120mmol/L K+ in 24 hours
  • Regular Mg and Ca levels
toxic megacolon devuni et al 2009
Toxic megacolon (Devuni et al., 2009)
  • a.k.a Toxic Megacolon: clinical term for acute toxic colitis
  • “toxic colitis” preferred as possible without megacolon dilatation
  • Potentially lethal
  • Systemic toxicity
  • Colonic dilatation = transverse colon >6cm
toxic colitis devuni et al 2009
Toxic colitis (Devuni et al., 2009)
  • 1st criterion = x ray
  • 2nd criterion = any 3 of:
    • Fever
    • Tachycardia >120bpm
    • Leukocytosis
  • 3rd criterion = any 1 of:
    • Dehydration
    • Altered mental state
    • Electrolyte abnormality
    • hypotension
toxic colitis devuni et al 20091
Toxic colitis (Devuni et al., 2009)
  • Inflammatory causes
    • Ulcerative colitis, Crohn’s disease, pseudomembranous colitis
  • Infectious colitis
    • Salmonella, Shigella, Compylobacter, Yesinia, C. Diff., EntanoebaHistolytica, Cytomegalovirus
  • Other causes
    • Radiation colitis, ischaemic colitis, nonspecific colitis secondary to chemotherapy, complication of collangeous colitis (rare)
toxic colitis investigations devuni et al 2009
Toxic colitis: Investigations (Devuni et al., 2009)
  • Nutrition & coagulation panel (group & save) in case surgery
  • Imaging – x-ray then CT: loss of colinichaustrations, possible thumbprinting
  • Other – ESR, CRP (usually increased). Nb. These findings are supportive not specific
  • Do not do barium studies due to risk of perforation
  • CBC counts
  • Abdominal x-rays every 12 hours
treatment of toxic colitis devuni et al 2009
Treatment of toxic colitis (Devuni et al., 2009)
  • 1) reduce colonic distortion
  • 2) correct fluid and electrolyte imbalance
  • 3) treat toxemia and precipitating factors
  • Fluid and electrolyte replenishment should be aggressive at first
  • Start broad spectrum IV antibiotic e.g. Ampicillin
  • Stop all meds that reduce colonic mobility e.g. Narcotics, antidiarrhoeals, anticholinergics
  • Bowel rest consider NG tube. Can use long suction tube but needs fluro placement
  • Start IV steroids –IV hydrocortisone for pts on steroids
  • Rolling techniques to redistribute gas
  • Cyclosporin A: last choice before surgery or if surgery not viable because hideous side effects
toxic colitis surgical intervention devuni et al 2009
Toxic colitis: surgical intervention (Devuni et al., 2009)
  • Early surgical consultation
  • Consider if no improvement following 48-72 hrs with medical therapy
  • Perform surgical resection
  • Subtotal colectomy preferred:
    • Patient very ill; shorter procedure
    • Possibilty of ileoanal pouch formation
    • Approx. 50% Crohn’s patients no rectum involvement
toxic colitis surgical intervention devuni et al 20091
Toxic colitis: surgical intervention (Devuni et al., 2009)
  • Complications:
  • Perforation after dilatation has reduced
    • Peritonitis not obvious if steroid use
  • If only do med management = poor prognosis
  • Surgical intervention before perforation = excellent results
toxic colitis patient education devuni et al 2009
Toxic colitis: patient education(Devuni et al., 2009)
  • Patient Education:
  • Nutrition (increase K+: bananas, peaches)
  • IBD (Crohn’s + ulcerative colitis)
  • Ostomy usually permanent – stoma care team
toxic colitis nursing priorities
Toxic colitis: Nursing Priorities
  • Careful and frequent monitoring
  • Manual BP and pulse especially if GI patient: monitoring for bleeds (Christine Whitehead lecture – if patient tachy, monitor for BP drop - call doctor!)
  • Fluid balance – I/O
  • X-rays
  • Repeat K bloods +Mg & Ca
  • NG tube placement
  • Rolling techniques
  • Stoma care team involvement/referral if surgery an option
  • Patient education
references
References
  • Devuni et al., (2009; online @ medscape). Toxic Megacolon: Clinical presentation http://emedicine.medscape.com/article/181054-overview
  • Garth, D. Et al (2009; online @ medscape). Hypokalemia in Emergency Medicine: Clinical Presentation. http://emedicine.medscape.com/article/767448-overview
  • Jones, H. (2011) Nursing and Health – Medical Abbreviations & Normal Ranges: Survival Guide. Pearson Education Ltd.
  • Merck Manual (online) Disorders of potassium concentration: electrolyte disorders http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/electrolyte_disorders/disorders_of_potassium_concentration.html?qt=disorder%20potassium&alt=sh