potassium/dialysate bath

[LPN2RNBSN]

Recently, in our unit, there have been a few patients whose potassium is 5.3 and the physician continues to want them on 3K bath. The potassiums are done weekly. Although, routine orders say decrease to 2K, I am wondering if other units function as this one. It would seem that if a patient's K+ level was lower it would be easier to 'fix' then having it too high.. I know that some units allow the nurses to change to bath, write a v.o. according to routine orders but this is perplexing. Why would a physician continue with a 3K when the patient's K+ is above 5.0 and not lower to 2K.? When asked he just says statements i.e. if there is not a problem, we don't fix it.. meaning the patient has had no symptoms, etc.

Also, nausea post dialysis and 'only' post dialysis, no other time indicates what? My training says could be dry weight needs to be adjusted, too much fluid removal..etc? What else? Thx

[DeLana_RN, BSN, RN]

There are some doctors that still prescribe a 0 K bath for some patients. I think it's dangerous and unnecessary and just plain stupid.

Ours do, but only for 30 min, to be followed by 2K for the duration. If the K+ level was very high, stat labs will be drawn after 30-60 min. Of course, we have 1:1 monitoring with such a pt (and still, you have to be very, very careful).

BTW, we have had K+ levels >10 (and the pts made it - at least through that crisis).

DeLana

[LPN2RNBSN]

what are standing orders for other FMC units.. is range of patient's K+ level and what bath should be used?

[LouRN92]

It's been probably 12 years since I worked Dialysis (one of my absolute favorite jobs). But I'll never forget using a K free bath for a high potassium and after 30-45 minutes having the patient complain of severe leg cramps and putting him on the cardiac monitor and seeing the widened QRS and sweating it out. i think he had dropped in the low 2's and then we switched him to a 3K. my memory may be fuzzy about the details, but I do remember the fear. i think i would be hesitant to use K free.

[RNratched]

juanay,

i am interested in travel dialysis...do you have any information or advice for me? i don't have the first clue...:uhoh21:

[Kitty kitty]

Recently, in our unit, there have been a few patients whose potassium is 5.3 and the physician continues to want them on 3K bath. The potassiums are done weekly. Although, routine orders say decrease to 2K, I am wondering if other units function as this one. It would seem that if a patient's K+ level was lower it would be easier to 'fix' then having it too high.. I know that some units allow the nurses to change to bath, write a v.o. according to routine orders but this is perplexing. Why would a physician continue with a 3K when the patient's K+ is above 5.0 and not lower to 2K.? When asked he just says statements i.e. if there is not a problem, we don't fix it.. meaning the patient has had no symptoms, etc.

Also, nausea post dialysis and 'only' post dialysis, no other time indicates what? My training says could be dry weight needs to be adjusted, too much fluid removal..etc? What else? Thx

Hi!

I'm Japanese nurse.

I don't know about pottasium bath.

Please tell me that what is 3K bath...?

I will appreciate your answer.

Sincerely

[CocoaGirl]

At our FMC unit if K > 4.5 use 2K & if 6), the K level is checked every week on these pts. These parameters were set by our Medical Director & work well. My biggest gripe is that even though we have a physician signed "standing order form" with all of the directions on 2k & 3K bath parameters (based on K level) we still have to write out the order & get it signed. There are absolutely no standing 1K orders, that is an individual pt order.

[Kitty kitty]

Hi,CocoaGirl,

Thank you for your answer.

It is easy to understand.

[land27]

I work in the acute setting and my experiance has been that physicians may use a 3k bath instead of the 2k bath in patients who experiance more ectopy at lower K+ levels and viceversa, It is important to remember that each person is different and just because something is high normal or low normal...it doesn't mean it's not appropriate for that patient.......A good example of this is blood glucose levels...while some people live perfectly normal with a blood sugar in the low 80's, others are becoming symptomatic for hypoglycemia. You don't treat the patient who is feeling normal right, you would however encourage the symptomatic patient to eat some crackers.

N/V is generally related to excess fluid removal/or high ultrafiltration rate (which doesn't allow for refilling) the resulting low SBP/loss of equilibrium is the true cause of N/V. We use crit-lines on every patient and by doing so rarely experiance this problem.

[land27]

We still use 0 k baths for patients with high (7+ potassium levels) but only for an hour and then finish the treatment with 1k. some of our physicians will do zero k the first hour, 1k the 2nd hr, and 2k the third hr.

[Aquamarine]

Recently, in our unit, there have been a few patients whose potassium is 5.3 and the physician continues to want them on 3K bath. The potassiums are done weekly. Although, routine orders say decrease to 2K, I am wondering if other units function as this one. It would seem that if a patient's K+ level was lower it would be easier to 'fix' then having it too high.. I know that some units allow the nurses to change to bath, write a v.o. according to routine orders but this is perplexing. Why would a physician continue with a 3K when the patient's K+ is above 5.0 and not lower to 2K.? When asked he just says statements i.e. if there is not a problem, we don't fix it.. meaning the patient has had no symptoms, etc.

Also, nausea post dialysis and 'only' post dialysis, no other time indicates what? My training says could be dry weight needs to be adjusted, too much fluid removal..etc? What else? Thx

I understand the frustration. I have seen the same. But the stage of renal failure also has a play in it. Patients that say they urinate a lot all the time may be losing K+. Also, doc's generally meet once a month in our unit to review the labs with the FA nurse. If I know the doc isn't good about his monthly review I will hold the K+ and call them. I am not going to give anything that is dangerous and I use my head first, follow orders second. But you just can't ignore orders without taking action and documenting. Have the patient chart in front of you when you call. If you notice pre and post dialysis K+, that lower number after will rebound, come up, in a few hours after treatment also.

Some of our patients that understand the K+ refuse it and say they would rather "eat" thier potassium than get it in the jug on the HD machine. and I support that, they have a right to refuse and you document that. Our RD support that and goes to bat for the patient at the meetings.

Also, if a patient ever tells you they just stopped urinating all together LET the MD know. This is critical. We had a young girl who alway had fair K+ values but cheated on her diet all the time. Stopped urination, still cheated, we drew labs...the K+ was 8.6, we thought it must be a bad lab, gave her a Rx for Kayexalate. Redrew the lab to double check. She couldn't get the Kayexalate at her pharmacy filled until monday, the new lab came back at 12.0, she died over the weekend, the doctor came after the RDand the RN to make sure that the patient was educated.

So it is something to pay attention to, to understand, to know about, to educate the patients about while you are working.

Great question.

[Aquamarine]

Pretty discouraging. The nephrologist told one patient, with nausea post dialysis that it was not related to dialysis and to see her primary care physician and to possibly see a gastroenterologist. Now this IS something that is quite disturbing. This neph is suppose to be great. Also do not understand, and he does not explain, why he keeps baths at 3k when K+ is 5.3. The situation with nausea, however, is the part that is most disturbing and that the neph does not realize edw might need to be adjusted. Ofcourse, one of the RNs certainly believes it might be edw needing increase.

Nausea can be for man reasons. One if they are gaining too much weight the treatment will be so much harsher on thier bodies.I encourage them to limit fluids to one cup with meals and one 8oz cut between, giving a general limit of 1500 ml. Of course that is general, check the diet order and speak to the MD or the RD. Also limit Na+ in intake will help with holding fluid. If they gain too much they will have to take more off and there is the issue of the side effects being more with larger weight gains. Blood pressure? where is it at. Can you give Na+ so they don't drop at the end. The profile, can you take more off in the beginning? Ask your charge nurse or the FA and if all else fails, approach the MD, even if he yells you will get some useful information.

K+ has normal ranges but did you know there are "acceptable" ranges that are generally used for dialysis patients? Acceptable is under and up to 6.0.

I know you feel so bad for the patients, and the dry weight often needs adjusting.

I look at the dialysis proceedure as a real team effort and the patient is part of the team. They have to follow the diet, the fluid restriction, the medications taken as Rx'd. If they still have an issue they need to communicate with thier MD, and the staff also. The machine is part of the team, they have to stay for full treatments, and come to all the treatments. Everything involved has a play in that patients health.

If the patient is unable to take care of themselves I tell the social worker thier might be a problem and they can take it to the monthly meeting also. Just document, who you told, and what you do, even your education to the patient. It can save you in more ways than you might know. Good luck.