Documentation Guidelines

• Fluid balance and nutrition: Intake and output, color of urine, amount and type of volume resuscitation, "sliding scale" and response to insulin, signs of hypoglycemia or hyperglycemia, daily weights, signs of dehydration or rehydration

• Effectiveness of diet, medications, and activity on blood glucose

• Patient's understanding of teaching: Pathophysiology of underlying disorder, nutrition education, insulin and technique of administration, oral hypoglycemic medication, exercise program, self-monitoring of blood glucose (if appropriate), prevention of complications

• Complications such as skin lesions, hypoglycemic reactions

Teach the patient strategies for managing the disorder. Provide a written list of all medications, including dosage, route, time, and side effects. If appropriate, give the patient a phone number to call if he or she has any problems with self-administration of insulin or self-monitoring of blood glucose. Provide the patient with a list of referrals, such as an outpatient diabetic clinic or community contacts, for follow-up care and information. Provide a list of equipment and materials needed for home care. Give the patient any pamphlets or written materials about the management of hyperglycemia.

Normal serum levels of potassium range from 3.5 to 5.5 mEq/L. Hyperkalemia, defined as a potassium level greater than 5.5 mEq/L, is usually associated with impaired renal function, but it may also be produced by treatments for other disorders. Mild hyperkalemia is from 5.5 to 6.0 mEq/L, moderate hyperkalemia is from 6.1 to 7.0 mEq/L and severe hyperkalemia is 7.0 mEq/L and greater. It is diagnosed in up to 8% of hospitalized patients. Increased potassium intake, reduction in potassium excretion, and shift of potassium out of the cells all may result in hyperkalemia. Because potassium plays a key role in cardiac function, a high serum potassium level is of great concern. It is sometimes the first symptom of cardiac arrest.

Potassium functions as the major intracellular cation and balances sodium in the extracellular fluid (ECF) to maintain electroneutrality in the body. It is excreted by the kidneys: The normal ratio is approximately 40 mEq of potassium in 1 L of urine. Potassium is not stored in the body and needs to be replenished daily through dietary sources. It is also exchanged for hydrogen when changes in the body's pH call for a need for cation exchange. This situation occurs in metabolic alkalosis or other alterations that lead to increased cellular uptake of potassium, including insulin excess and renal failure. Potassium is regulated by two stimuli, aldosterone and hyperkalemia. Aldosterone is secreted in response to high renin and angiotensin II or hyperkalemia. The plasma level of potassium, when high, also increases renal potassium loss.

Factors that result in decreased potassium excretion include oliguric renal failure, potassium-sparing diuretics (such as spironolactone), multiple transfusions or transfusions of stored blood, decrease in adrenal steroids, and nonsteroidal anti-inflammatory medications. Too much potassium is taken into the body by overuse of oral potassium supplements, inappropriate intravenous (IV) administration of potassium, or excessive use of potassium-based salt substitutes.

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