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Advanced Cardiovascular Assessment for nurses | Assessing the Heart

The advanced cardiovascular assessment is important for every nurse to know, as the heart and cardiovascular system is so important in the body.

Proper evaluation of the heart involves auscultation for normal and abnormal heart sounds, palpating the PMI and peripheral pulses, checking vital signs, evaluating for Jugular Venous Distention, and evaluating the cardiac rhythm

Why is the Cardiovascular Assessment Important?

This may seem like an obvious question, but it is important to address regardless. The cardiovascular assessment is so important in nursing because the heart is so important in the body. The heart, brain, and lungs are the most important organs in your body, and are essential to every minute you are alive.

Additionally, heart disease is the leading cause of mortality globally. By detecting heart disease and cardiovascular complications early, we can literally save patients lives.

There are so many complaints and diseases that bring patients into the hospital that are related to the heart, including:

  • Chest Pain
  • Heart Attacks (myocardial infarction)
  • Hypertensive episodes
  • Heart Failure
  • Myocarditis
  • Aortic Dissections
  • and more!

Patients with cardiac risk factors become even more important to do a thorough cardiac examination on them.

Utilizing many of these standard and advanced cardiovascular assessment techniques can give us a great insight into the function of a patient’s heart and overall health. This is important even when our patients are healthy, but essential when our patients are sick and in the hospital and/or ER settings.

When should a Cardiovascular assessment be done?

The heart assessment should be done pretty much with EVERY single focused and comprehensive physical examination. However – there are times when the heart will not be evaluated at all and assumed to be healthy (a walkie-talkie patient in an outpatient setting).

Because the heart is so important and can lead to so many different symptoms, it generally is always at least auscultated to by the doctor and nurses, especially in the hospital setting. Blood pressure is almost always checked during every appointment or evaluation, and usually heart rate and pulse ox as well in the ER or inpatient settings.

The advanced portion of the cardiovascular assessment usually includes things like finding the PMI heart location, JVD assessment, murmur evaluation, and 12-lead ECG /telemetry evaluation. Some of this responsibility lies on the provider, but it is important for nurses to know how to assess and evaluate these as well.

The Advanced Cardiovascular Assessment

The history

While this article focuses on the physical examination of the cardiac assessment, never forget just how important the patient history is. The history will guide the physical examination and will help lead to a proper diagnosis and appropriate treatment.

The nurse and provider team should be collecting information about:

  • Personal history of coronary artery disease or other heart disease , diabetes, or other associated conditions
  • Family history of coronary artery disease /heart disease
  • Current symptoms and related information (PQRST)
  • Cardiac medications they may be taking
  • Social habits (alcohol, smoking, etc)

Vital Signs

Vital signs like blood pressure and heart rate provide a snapshot patient’s overall stability – if their vital signs are bad, then the patient is unstable and likely needs immediate intervention.

Many of the vital signs evaluate how well the heart is functioning, including the blood pressure, the heart rate, and the pulse ox. These are essential to evaluate when patients have chest pain, shortness of breath, or other similar complaints.

  • A picture of the sphygmomanometer showing high blood pressure >140 mmHg

    Blood Pressure

    Blood pressure is a direct measure of the force exerted by the circulating blood on the walls of the blood vessels (the arteries). It is composed of two numbers – a top and a bottom number.

    The blood pressure number on top is the systolic pressure, which is the pressure when the heart is beating. The blood pressure number on the bottom is the diastolic pressure, which is the pressure between beats, when the heart is at rest. These are measured in mm of mercury (mmHg… i.e. 120/80 mmHg).

    The blood pressure helps blood continue to flow throughout your body – if the pressure was 0, then your blood would not be circulating!

    When one or both of the blood pressure numbers are high, this can be from acute or chronic causes often related directly to the heart (i.e. hypertensive heart disease, fluid overload, etc). Over time, high blood pressure leads to stiff vessels and increased risk of heart attacks and strokes, and other issues.

    When the blood pressure is low, this often means the patient has low blood volume, heart failure with cardiogenic shock, vasodilation, or caused by medications or other conditions.

    Normal systolic blood pressure is anything less than 120 mmHg. If the systolic blood pressure is above 140 mmHg, this is considered high blood pressure or hypertension and in need of treatment.

    Normal diastolic blood pressure is anything less than 80 mmHg. If the diastolic blood pressure is above 90 mmHg, this is considered hypertension and in need of treatment as well.

    Elevated blood pressure is often asymptomatic, but acute and significant rises in blood pressure can cause symptoms of chest pain and chest pressure, shortness of breath, and more!

  • A black background with green heart rate and cardiac telemetry at 92 bpm

    Heart Rate

    The heart beat or pulse is the amount of times your heart beats in 1 minute. This provides immediate insight into a patient’s heart function, as well as other conditions going on.

    Normal heart rate in adults is 60-100 bpm.

    Many conditions can cause high heart rate (tachycardia), including dehydration, shock, arrhythmias, fevers, stress, exercise, chest pain, etc.

    Low heart rates are sometimes normal, especially if sleeping or in athletes. However, often this is from a cardiac arrhythmia or heart block if it is significantly low, or caused by a medication.

    The regularity of the pulse or heart rate is also important, as this can clue you into arrhythmias which are often irregular.

  • A finger with a pulse ox on it

    Pulse oximetry

    Pulse oximetry measures oxygen saturation of the blood, which is an indirect marker of respiratory AND circulatory efficiency (your heart and your lungs).

    Normal SPo2 ranges from 94-100%, and low levels often are related to acute respiratory or cardiovascular conditions.

Cardiac Auscultation

Auscultation involves listening with a stethoscope – this is super important for the cardiac and respiratory assessments, especially if the patient is complaining of chest pain or shortness of breath, or similar complaint.

When listening to the heart, you should be listening for:

  • Regularity
  • Normal/expected heart sounds
  • any presence of abnormal heart sounds

If the heart is irregular, this can mean an arrhythmia such as atrial fibrillation.

How to auscultate the heart

Listening to heart sounds involves placing your stethoscope at 4-5 different areas of the heart and listening for the normal and any abnormal heart sounds at each location.

Why do we use each location? Essentially you are listening at the sites where you can hear each heart valve the best. When heart valves are damaged or diseased, they often lead to murmurs or abnormal heart sounds, caused by abnormal blood flow through these doorways in the heart.

The different heart areas include:

  • Aortic: Right 2nd intercostal space at the sternal border
  • Pulmonic: Left 2nd intercostal space at the sternal border
  • Erb’s point: Essentially right in the middle, located at 3rd intercostal space left of the sternum
  • Tricuspid: Left lower sternal border
  • Mitral (apex): left fifth intercostal space at the midclavicular line

The 5 different areas of cardiac auscultation

Heart sounds

So what heart sounds are you listening for? There are normal ones, and then plenty of abnormal ones as well.

  • S1 and S2 heart sounds

    S1 and S2

    S1 and S2 are the normal expected heart sounds. These are the “lub” (S1) and the “Dub” (S2) with every heartbeat.

    S1 indicates the closure of the mitral and tricuspid valves, and mark the beginning of systole (the heart beating).

    S2 indicates the closure of the semilunar valves – the aortic and pulmonic valves, indicating the end of systole and the beginning of diastole.

  • S3S4 heart sounds

    S3 and S4

    S3 and S4 are extra heart sounds that typically are not heard in a healthy heart. However, they can sometimes be heard in kids and adults under the age of 40 and be considered “normal”. A pathologic S3 can be associated with heart failure or even elevated blood pressure, and S4 can be associated with stiffness of the ventricle.

  • Murmurs

    Murmurs

    Murmurs are sounds produced by turbulent blood flow through the heart valves or nearby structures. These are characterized by their timing, intensity, pitch, and quality. Each valvular issue (i.e. aortic stenosis) have a specific murmur sound associated with them, as well as location that is loudest.

    Benign murmurs can be normal in young growing hearts, and these are termed physiologic murmurs.

    Valvular issues can be caused from pressure issues, as well as lead to pressure issues within the heart. This can lead to heart failure, arrhythmias, or other severe complications.

    Aortic stenosis is the most common valvular issue, and commonly occurs over time (so is fairly common in elderly patients with less-than-ideal hearts with some cardiac disease).

    Valvular issues can also lead to atrial fibrillation or other arrhythmias as well.

  • Rubs

    Rubs

    Pericardial friction rubs may be heard in conditions such as pericarditis. These are high-pitched scratchy sounds, best heard with the diaphragm of the stethoscope.

A vector drawing of water inside the lungsAuscultating the lungs

Don’t forget the lungs can also clue us into the function of the hearT! Crackles heard in the lungs is also a great indicator of the heart failure and fluid volume overload, flash pulmonary edema, etc.

Read all about Rapid Sequence Intubation here!

PMI heart

The PMI stands for Point of Maximal Impulse. This is where the heart beat is most powerfully palpated on the chest wall.

To assess the PMI, the patient should be placed supine or in a left lateral decubitus position. Nurses should use the pads of their fingers to palpate the chest wall and feel for the strongest pulse.

The PMI should be located on the fifth intercostal space at the midclavicular line (same as the mitral area where you listen).

The site demonstrating where the location of the PMI should be - midclavicular line, 5th intercostal space

When evaluating, it is best to start from the right sternal border and move laterally toward the apex of the heart. Once found, the following aspects should be evaluated:

  • Location: A displaced PMI (not in the expected location) can suggest an enlarged heart if laterally displaced, or if inferiorly displaced, it can indicate a diaphragmatic hernia or abdominal mass.
  • Size: The PMI is typically only felt within a 2.5cm diameter. If enlarged, this can indicate left ventricular hypertrophy
  • Amplitude: If the force is stronger or weaker than expected (hyperdynamic), this can indicate Inotropy of the heart (how strong the heart is beating)
  • Duration: Sustained impulse that lasts more than 2/3 of the systole suggests left ventricular hypertrophy

Peripheral Pulses

Palpating the peripheral pulses provides insight to the body’s systemic arterial circulation – basically how well the heart is circulating the blood throughout the body.

The presence, quality, and regularity of the peripheral pulses can provide important clues about the cardiac output and peripheral vascular health.

Palpating the peripheral pulses

An illustration of the locations of the peripheral pulsesPeripheral pulses should be palpated in the upper and lower extremities. Not EVERY single peripheral pulse needs checked, although this would be the most thorough.

Peripheral pulse options include:

  • Radial pulse
  • Brachial pulse
  • Carotid pulse
  • Femoral pulse
  • Popliteal pulse
  • Dorsalis pedis pulse
  • Posterior Tibial pulse

When documenting the assessment of peripheral pulses like the radial pulse, nurses use a grading scale to describe the amplitude or strength of the pulse:

  • 0: Absent pulse, no detectable pulse under normal conditions
  • +1: Thready or weak pulse, difficult to palpate, may fade in and out
  • +2: Normal pulse, easily palpable, not easily obliterated
  • +3: Bounding pulse

Weak or absent pulses may suggest arterial occlusions or significant hypotension (or even ventricular arrhythmia or asystole).

Bounding pulses may occur with fever, anemia, hyperthyroidism, states of stress, etc.

Asymmetrical pulses may reveal peripheral vascular disease or aortic dissection.

Absent pulse in extremity?

A doppler obtaining a pulse of a footIf you ever cannot detect a pulse in a patient’s extremity, this is a major deal and you should notify the provider team immediately. This is usually in the feet and and from patients who have peripheral arterial disease and poor circulation. There may be color changes as well and decreased capillary refill.

To be sure, it is best to check the pulses with a doppler to see if you can hear the pulse. This is also what the provider team will likely want you to do anyway, so its a good idea to just do it in the first place to make sure.

Be sure to check both the dorsalis pedis pulse and the posterior tibial pulse, and do a complete evaluation of the extremity (Circulation, Motor control, and Sensation).

Bruits & Thrills

An illustration of an ARM with an AV fistula, with words Bruit is a French word meaning “noise” and indicates turbulent blood flow. Essentially this is like a murmur that is auscultated with the stethoscope over an artery (instead of the heart). This is not normal and can indicate carotid stenosis (or other artery stenosis). Abdominal bruits may indicate renal artery stenosis or abdominal aortic aneurysm.

Thrills are vibrations felt that indicate a severe form of turbulent bloodflow, often due to a valvular heart disease or arterial obstruction.

In an AV fistula, it is normal to have both a bruit and a thrill, and this is a good sign that the fistula is in proper working order!

Jugular Venous Pressure

Jugular Venous pressure (JVP) reflects the pressure in the venous system by visualizing the internal jugular vein. This offers insight into the right atrial pressures and central venous pressures.

Jugular Venous Distention (JVD) can occur when this pressure is elevated, often in conditions such as:

  • Fluid overload states
  • Right ventricular failure
  • Tricuspid valve disease
  • Pericardial constriction or tampanode
  • Pulmonary hypertension

How to assess Jugular Venous Pressure

JVP is primarily assessed with two different signs: Kussmaul’s sign, and the hepatojugular reflux.

    • An illustration of increased JVP
      Kussmaul’s Sign: An increase in JVP on inspiration, suggestive of constrictive pericarditis or severe right-sided heart failure.
    • Illustration of palpation on the liver causing increased JVP
      Hepatojugular Reflux: An increased in JVP with manual pressure placed over the liver, suggesting heart failure and fluid overload.
    Kussmaul's Sign
    Hepatojugular Reflux

    To measure the JVP, place the patient semi-fowlers at a 30-45 degree angle. Have the patient turn their head to the left. Visualize the external jugular vein, but remember that the internal jugular vein is a more accurate reflection of CVP.

    The internal jugular vein is observed between the sternal and clavicular heads of the sternocleidomastoid muscle, and you should be able to visualize the pulsations.

    Identify the top of the venous pulsations of the external jugular vein, or preferably the internal jugular vein. Use a pen to “draw” or visualize a horizontal line from the top of the pulsations to above the sternal angle.This is the notch where the sternum begins. Now measure how high this horizontal line is above the skin. Then add 5cm because the right atrium is approximately 5cm deep. The total is the patient’s estimated central venous pressure (CVP).

    For more information on this technique, check out this article here.

    Measurements > 4cm indicate JVD and suggest elevated central venous pressures.

    ECG and Telemetry Evaluation

    Electrocardiography (ECG) and telemetry monitoring are essential components of a cardiovascular assessment, especially for ER and inpatient settings. If the patient has chest pain, shortness of breath, or some other symptom, this becomes even more important to rule out a myocardial infarction, cardiac ischemia, or cardiac arrhythmia.

    • A vector drawing of an 12-lead ECG machine

      12-Lead ECG Evaluation

      A 12-lead ECG is the gold standard of electrocardiography. This gives a comprehensive view of the heart’s electrical activity from multiple different angles.

      This is most important in ruling out any active cardiac ischemia or infarction going on (a heart attack or lack of blood flow to the heart). It is also important in evaluating cardiac arrhythmias like atrial fibrillation, ventricular tachycardia, and more!

      Findings can also give insight into the size of the heart, previous heart attacks, cardiac ectopy, and more!

    • A vector image of a portable cardiac monitor

      Continuous Cardiac Monitoring

      Continuous cardiac monitoring (aka telemetry) is often performed on patients in the ER who have potential cardiac or respiratory complaints such as chest pain, shortness of breath, weakness, dizziness, etc.

      Pretty much ALL ESI level 1 and 2s should be on cardiac monitors, and some level 3s. In the hospital, this is often ordered for patients going to a telemetry unit, progressive care, or other higher levels of care.

      This consists of a cardiac monitor (whether bedside or portable) hooked up to the patient’s chest with 3-5 wires on their chest to detect 3-5 different views of the cardiac rhythm. Usually lead II is monitored for cardiac arrhythmias and heart rate.

      Evaluating the rate and rhythm is common and often needed to be done at least once per shift, more in critical patients or with changes.

      To help you understand how to evaluate cardiac rhythms – check out “How to Read an ECG Rhythm Strip“.

    Wrapping it up

    Nurses play a pivotal role in the early detection and management of cardiac disease and heart complications. The comprehensive techniques outlined – from vital signs to jugular venous pressure evaluation, from auscultation to ECG and telemetry interpretation – equip nurses with the tools necessary to make critical decisions that can alter the course of a patient’s care.

    References

    American Heart Association. (2020). 2020 Handbook of Emergency Cardiovascular Care for Healthcare Providers. American Heart Association.

    Bickley, L. S., & Szilagyi, P. G. (2017). Chapter 9. In Bates’ Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

    Jarvis, C. (2019). Physical Examination & Health Assessment (8th ed.). Saunders.

    Treatment for Hyperkalemia: A nurse’s comprehensive guide to high potassium levels

    Treatment for Hyperkalemia is essential in the hospital and acute care settings, as it can be deadly!

    Hyperkalemia is when a patient’s serum potassium level rises above 5.0 mEq/L. This potentially life-threatening medical condition is one that nurses must be familiar with, as this can lead to cardiac arrhythmias and cardiac arrest. 

    Nurses are crucial in preventing, detecting, and managing hyperkalemia through various nursing interventions and treatment options. This article will discuss the causes of hyperkalemia, nursing interventions, and treatment of hyperkalemia, providing nurses with the knowledge and tools necessary to identify and manage this deadly condition.

    If you haven’t read the article on Hypokalemia, be sure to read that post first as it has some great background information about how the body regulates potassium in the body!

    Learn about the causes, nursing assessment, and treatment for hyperkalemia in this comprehensive guide for nurses and medical professionals.

    Hyperkalemia And Normal Potassium Levels

    Potassium Levels

    The normal range for potassium levels within the body is 3.5-5.0 mEq/L. Hyperkalemia is any level that is higher than 5.0 mEq/L

     

    • Normal = 3.5 – 5.0 mEq/L
    • Mild Hyperkalemia: 5.1 – 5.9 mEq/L
    • Moderate Hyperkalemia: 6.0 – 6.9 mEq/L
    • Severe Hyperkalemia: > 7.0 mEq/L

    The higher the level, the more likely your patient will experience side effects or complications from hyperkalemia.

    Remember that this is the level of potassium that is OUTSIDE the cells of the body. The actual amount (3.5-5mEq/L) is very low. However, the inside of the cell usually has 120-150mEq/L… That’s 30 times the level from the outside! This is why conditions that cause lysis of cells on a large scale can cause large increases in hyperkalemia.

    Causes Of Hyperkalemia:

    We discussed in the previous article about how potassium regulates the body and understanding how potassium works and then also what causes high potassium levels is important to understand before diving into the treatment for hyperkalemia.

    There are various causes of hyperkalemia, including:

    Renal Failure

    The kidneys are the main way the body regulates potassium levels. When potassium levels are too high, the kidneys will excrete excess potassium. When the kidneys don’t work like they should and can’t filter out the excess potassium like usual, this is really the primary reason you’ll see potassium levels rise significantly in the blood. This can be from acute or chronic kidney disease.

    A bottle of medications that are prescription

    Medications

    Certain medications can cause an increase in serum potassium levels, such as lisinopril, potassium-sparing diuretics (like Spironolactone), and even NSAIDs. These impact how the kidneys normally excrete potassium. Beta-blockers even can increase potassium levels, but to a lesser degree (usually < 0.5 mEq/L elevation).

    A liquid drop with "H+" indicating acid or acidity or hydrogen ions

    Metabolic Acidosis

    Acidosis, when a buildup of hydrogen ions in the blood, causes a potassium shift from inside to outside the cells, leading to hyperkalemia.

    What about Respiratory acidosis?

    Respiratory acidosis is largely caused by an excess buildup of CO2 in the blood. Since CO2 is a small, uncharged molecule, it can easily diffuse across the cell membrane and does not directly affect potassium levels within cells. Therefore, in respiratory acidosis, potassium levels in the blood are generally not significantly affected.

    An organic chemistry representation of aldosterone the hormone

    Hormones

    Insulin and aldosterone both impact potassium levels.

    A deficiency in insulin (such as with DKA) leads to potassium accumulation outside the cell.

    In hypoaldosteronism (Addison’s disease), there is not enough aldosterone. Aldosterone normally promotes potassium excretion in the kidney. So not having enough leads to higher potassium levels.

    You’ll see later that we can utilize one of these hormones in the actual treatment for hyperkalemia!

    A red cell that is bursting open, releasing its contents into the extracellular space

    Hemolysis & Tissue Injury

    When a cell lyses or splits open, its contents are released into the extracellular space. As we discussed, potassium concentration is much higher in the cells.

    Whenever a condition or injury leads to massive destruction and lysis of cells, this can lead to hyperkalemia.

    These conditions include major trauma, crush injuries, tumor-lysis syndrome, rhabdomyolysis, major burns, and hemolytic anemia.

    A bottle of medications that are prescription

    Medications that Can Cause Hyperkalemia

    • ACEI/ARBs: Lisinopril, ramipril, and losartan can all cause increased potassium levels by reducing/blocking aldosterone.
    • Potassium-Sparing Diuretics: Potassium-sparing diuretics like Aldactone, Spironolactone, and amiloride block the action of aldosterone in the kidneys, leading to decreased potassium excretion.
    • NSAIDs: NSAIDs, such as Ibuprofen or Toradol, interfere with the production of prostaglandins, which regulate potassium levels in the kidneys.
    • Beta-Blockers: While this is usually a mild effect, non-selective beta-blockers (like propranolol or atenolol) decrease potassium uptake into cells, which can lead to a mild increase in potassium.
    • Digoxin: Digoxin can interfere with the sodium-potassium pump and increase blood potassium levels.

      Part of the treatment for hyperkalemia is avoiding these medications!

      A strand of DNA

      Risk Factors for Hyperkalemia

      • CKD: Chronic kidney disease can lead to the inability to regulate potassium levels efficiently
      • Diabetes: Especially with uncontrolled type 1 diabetes, the absolute lack of insulin can lead to elevated potassium levels.
      • Older age: Older patients have less efficient kidneys, as well as often have comorbid conditions.
      • Trauma or Burn patients: As stated above, trauma and burns can cause rapid release of potassium into the blood from damaged tissue.
      • Addison’s Disease: These patients are at increased risk of hyperkalemia due to a lack of aldosterone.

      What is PseudoHyperkalemia?

      Pseudohyperkalemia is essentially a “false positive” elevation of potassium. This occurs during the blood draw or after the blood has been drawn. It’s important to recognize cases of “fake” high potassium before implementing treatment for hyperkalemia, as this can lead to hypokalemia!

      Possible causes of pseudohyperkalemia include:

      Red blood cells bursting open, indicating hemolysis

      Hemolysis of the blood sample

      Blood sample hemolysis usually occurs when drawing blood draw from mechanical trauma. This often occurs if the catheter is against the vein wall and causes red blood cell lysis during the draw. This blood can have a red tint due to released hemoglobin.

      An animal cell with arrows pointing in and out of the cell membrane, indicating redistribution of potassium across the cell membrane

      Potassium Shifts

      Repeated fist-clenching can cause potassium to shift out of the muscles temporarily. This can lead to elevations by more than 1-2 mEq/L in that forearm.

      A half-eaten banana, indicating low potassium levels

      Leukocytosis or Thrombocytosis

      Significant elevations in platelet levels and very high WBCs (in the setting of chronic lymphocytic leukemia) can cause false potassium elevations, since the white blood cells are very fragile and break after the draw.

      A strand of DNA

      Genetic Condition

      Certain forms of hereditary pseudohyperkalemia exist due to potassium shifting out of red blood cells.

      Whenever a high potassium level comes back and the clinical picture doesn’t make sense (such as normal renal function, no symptoms, and no other findings), then suspect pseudo-hyperkalemia.

      Nursing Assessment Of Hyperkalemia

      Symptoms

      Symptoms of hyperkalemia will vary depending on the patient and how severe the hyperkalemia is. The higher the potassium level, the more likely the patient will exhibit symptoms, and the worse they often are, the more quickly treatment for hyperkalemia will need to be initiated!

      Some possible symptoms of hyperkalemia or high potassium include:

      A weak arm with no muscle, indicating muscle weakness

      Muscle Weakness

      Muscle weakness can also be a sign of hyperkalemia, just as it can be a sign of hypokalemia. As potassium levels rise, there can initially be increased contractions and cause spasms and twitches.

      However, as the potassium level continues to rise, skeletal muscle excitability decreases, resulting in muscle weakness and even paralysis.

      A cardiac monitor showing ventricular tachycardia

      Cardiac Arrhythmias

      Symptoms of cardiac arrhythmias may occur if the patient is experiencing an arrhythmia, such as palpitations, chest pain, Shortness of breath, dizziness, or syncope.

      The colon with liquid diarrhea dripping out

      GI Symptoms

      High potassium levels can affect the smooth muscles of the GI tract, leading to nausea, vomiting, and possibly abdominal pain/cramping or diarrhea.

      A hand with blue electric bolts indicating tingling

      Paresthesias

      Like with hypokalemia, hyperkalemia can also cause numbness or tingling, typically in the extremities or the face.

      A kidney with low fluid levels

      Shortness of breath

      This is usually only in severe cases with severe muscle fatigue of the respiratory muscles, and the patient may even need to be intubated.

      A silhouette of a head with red and orange markings above the head, indicating anxiety

      Anxiety & Irritability

      High potassium levels can also agitate the central nervous system, leading to anxiety or restlessness.

      PHYSICAL EXAM

      The physical assessment of a patient with hyperkalemia will also depend on the severity of the potassium and other factors, but most patients will have no specific physical findings.

      Vital Signs

      • HR: May be fast or slow, depending on any arrhythmias. It may also be abnormal.
      • BP: Severe hyperkalemia can cause hypotension.
      • Respirations: usually normal, but may be increased or decreased if respiratory failure is present
      • SPO2: Usually normal
      • Temp: Normal

      Inspection

      • Abdominal distention or bloating
      • Bradycardia or arrhythmias on the monitor
      • Respiratory distress in severe cases
      • Patient may appear anxious or irritable, restless, or even confused

      Auscultation

      • Listen for slow or irregular heart rhythm, which may be caused by ectopy or arrhythmia from the hyperkalemia. May also have diminished or absent S3 and S4 heart sounds.
      a gloved hand palpating unspecified skin

      Palpation

      • Muscle weakness in the lower or upper extremities, particularly in the legs. These muscles may be tender to palpation.
      • Weak or thready pulses in the extremities (radial pulse)
      • Abdominal tenderness or discomfort

      Treatment for Hyperkalemia

      The treatment for hyperkalemia depends on the underlying cause, severity, and serum potassium level.

      When you get your patient’s results back, and they show hyperkalemia, especially >5.5 mEq/L, then follow the following general interventions:

      Assess the Patient

      Ensure they don’t have any symptoms and are stable, including recent vital signs.

      Cardiac Monitor

      Make sure your patient is on the cardiac monitor. Obtain an ECG if it still needs to be done. Close cardiac monitoring is essential when infusing electrolytes through the IV as well, as some electrolytes like calcium are essential in the treatment for hyperkalemia!

      Notify the Provider

      Notify the provider of the potassium levels, your assessment, and their cardiac rhythm. The treatment for hyperkalemia will be ordered by them!

      Ensure IV access

      Make sure there is at least one IV site, but place a second line if the hyperkalemia is severe.

      Evaluate Medications

      Evaluate if they are on any medications which may lead to hyperkalemia listed above.

      Administer Treatment For Hyperkalemia

      Administer medications that are ordered (discussed below).

      Treatment for Hyperkalemia

      The treatment of hyperkalemia will depend on how severe the level is and any symptoms or cardiac arrhythmias the patient is currently experiencing. The patient’s Provider team will order this. Treatment generally includes:

      The kidneys, with the left one transected so you can see the inside

      Address Underlying Causes

      Identifying and addressing the underlying causes of hyperkalemia. The first thing would be to look at their renal function on their labs – if it is elevated, the high potassium level is likely true. Ensure it is true hyperkalemia instead of pseudohyperkalemia as above.

      A bottle of potassium supplements

      Avoid More Potassium

      Avoid potassium supplements or foods rich in potassium until the potassium has normalized. All medications which can worsen hyperkalemia should be stopped.

      A 10-ml vial of calcium gluconse 10% with 10mL drawn up into a syringe

      IV Calcium

      Calcium is a very important part of the treatment for hyperkalemia. When given, it stabilizes cardiac conduction and decreases the risk of arrhythmias such as Vfib or VTACH.

      Calcium gluconate is preferred, with the dose being 1,000mg (10mL of 10% solution) infused over 2-3 minutes. This dose can be repeated if ECG changes persist.

      As with any electrolyte, your patient should be on the cardiac monitor during this infusion.

      What about Calcium Chloride?

      Calcium chloride (from the code cart) can also be given in a similar dose (500-1000mg).  This does actually deliver 3-times the concentration of elemental calcium. However, it does irritate the vein and can cause tissue necrosis if extravasation occurs.

      IV inuslin bottle with insulin syringe drawn up to 10 units

      IV Insulin

      IV insulin is given to all patients (not just patients with diabetes) with moderate to severe hyperkalemia when dialysis is not readily available/indicated, since insulin drives potassium into the cells. This is a temporary fix but will decrease potassium levels by about 1 mEq/L pretty quickly, lasting for about 4-6 hours. The dose may need to be repeated at that time.

      Please note this should be given with dextrose so it doesn’t cause hypoglycemia. Patients who’s glucose is > 250 can receive the insulin alone.

      Glucose monitoring should be monitored every hour for 5-6 hours.

      A code cart box of dextrose 50% with the auto-injector ready to inject

      IV Dextrose

      Dextrose is given with insulin to prevent hypoglycemia but can also lead to endogenous insulin secretion, which further enhances the potassium-reducing effect.

      The dosage is typically 25gm, or 1 full amp (the total amount in the code cart). This is pushed slowly and is very thick and sticky.

      Even with one amp given, hypoglycemia still occurs in many patients. It’s recommended to start a 10% dextrose infusion at 50-75ml/hr until 5-6 hours after administering the insulin.

      A person with a nebulizer on their face

      Beta-2 Adrenergic Agonist

      Beta-agonists, such as albuterol, are sometimes used as a treatment for hyperkalemia to cause a shift of potassium into the cells (similar to the effect of insulin). This is not always ordered but should be considered in patients with significant symptoms or ECG changes despite the above treatment.

      Beta-agonists can reduce potassium levels by 0.5 – 1.5 mEq/L, and is usually given in an hour-long treatment. SubQ Terbutaline is an alternative to albuterol.

      This will also increase heart rate, and patients with heart disease and at risk for cardiac complications may be better off not getting a beta-agonist.

      A code cart box of sodium bicarb with the auto-injector ready to inject

      IV Sodium Bicarb

      Sodium bicarbonate can reduce potassium levels in patients with metabolic acidosis. 1 amp (50 mEq) can be given in 50ml, or alternatively 150mEq can be given in 1 L of 5% Dextrose over 2-4 hours.

      This treatment for hyperkalemia should be limited to patients with metabolic acidosis, and multiple doses can lead to hypernatremia.

      A bottle of kayexalate

      Remove Potassium from the Body

      Shifting the potassium into the cells is a great short-term solution to prevent complications from hyperkalemia. Still, the true treatment for hyperkalemia is removing excess potassium from the body.

      Removing potassium from the body is done in 3 main ways.

      1. Through the Urine: Giving loop diuretics, like Lasix, to patients who do not have severe kidney failure can help excrete excess potassium in the urine. This is often given in addition to IV fluids to maintain fluid balance (unless they are hypervolemic to begin with).
      2. Through the Stool: The administration of potassium-binders is standard to remove excess potassium. Traditionally this was usually Kayexalate (sodium polystyrene sulfonate), and is still often used. HOWEVER, there is newer cation exchangers that are preferred with less complications – namely Patiromer (Veltassa) or Sodium Zirocinum Cyclosilicate (SZC). Veltassa is preferred since it has a more rapid onset and is less likely to cause bowel necrosis (a rare complication from Kayexlate).If the patient is NPO for whatever reason, these can also be given as an enema.
      3. Through a Machine: Hemodialysis should be done in patients with severe kidney function impairment and is usually the best option for severe hyperkalemia, especially if the patient already has dialysis access or is newly diagnosed with severe renal failure.

      Monitoring after Treatment for Hyperkalemia:

      Patients with hyperkalemia need good monitoring, especially if they have moderate to severe hyperkalemia.

      A Gold top blood vial filled with blood

      Potassium Levels

      Potassium levels will be redrawn and assessed depending on the severity and what type of treatment for hyperkalemia was ordered.

      Mild to moderate levels can be rechecked in 4-6 hours, but severe hyperkalemia may need to be checked more frequently.

      A Gold top blood vial filled with blood

      Glucose Levels

      If insulin is given, glucose levels must be checked hourly for 4-6 hours, as hypoglycemia is common (even if you administer dextrose).

      A Gold top blood vial filled with blood

      Other Labs

      Closely monitor the patient’s renal function (BUN & Creatinine), other electrolytes, and acid-base balance (CO2).

      A Gold top blood vial filled with blood

      Cardiac Monitoring

      As discussed, high potassium levels can lead to bradycardia and arrhythmias. Continuous cardiac monitoring should be maintained, and intermittent ECGs may also be warranted.

      A Gold top blood vial filled with blood

      Respiratory Function

      Severe hyperkalemia can cause respiratory failure, so monitoring their breathing, lung sounds, respiratory rate, and pulse ox is important.

      A Gold top blood vial filled with blood

      Vital Signs

      Vital signs should be checked per facility protocol.

      A graduated cylinder with urine in it

      Urine Output

      Monitoring urine output is important, especially in patients where loop diuretics are given, and potassium is being wasted through the kidneys.

      Hyperkalemia and Cardiac Arrhythmias

      Potassium is very important in the heart’s conductive system and for each heartbeat. The higher the potassium level, the more likely ECG changes may be seen, and the higher chance that an arrhythmia may occur.

      The more common arrhythmias associated with hyperkalemia are sinus bradycardia, AV blocks, VTACH, Vfib, and asystole.

      On the ECG, hyperkalemia can manifest in a few ways, including:

      • P Waves: Decreased amplitude of P waves is common
      • PR interval: The PR interval is prolonged and delayed, indicating slower transit of the electrical impulse from the SA node through the AV node.
      • QRS: The QRS often widens with hyperkalemia
      • T waves: Tall peaked “tented Ts” are common with hyperkalemia.

      Whenever there are ECG changes, the treatment for hyperkalemia becomes even more essential, as patients with ECG changes are more likely to experience deadly arrhythmias.

      The ECG changes seen on the PQRST with hyperkalemia, which includes P wave flattening, PR prolongation, QRS widening, and Tented or peaked T waves

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      In conclusion, nurses should have an essential understanding of electrolyte abnormalities and the treatment for hyperkalemia.

      Through medications that protect the patient from cardiac arrhythmias (like calcium), medications that shift potassium into cells temporarily (like insulin, albuterol, or sodium bicarb), and treatments for hyperkalemia that remove potassium from the body (like Lasix, Kayexalate, or dialysis), we can successfully reduce our patient’s potassium and save their lives!

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