Chart — Electrolytes
Potassium Level Management Chart
Potassium management by severity — mild, moderate, and severe ranges for both hypokalemia and hyperkalemia — with ECG correlation, intervention priorities, and nursing considerations.
Educational use only. All potassium management interventions require provider orders. Severity classifications and treatment thresholds may vary by institution and patient-specific factors. Always follow facility protocol and provider orders. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Hypokalemia (K⁺ < 3.5 mEq/L)
| Severity | K⁺ Level | ECG / Symptoms | Intervention Priorities |
|---|---|---|---|
| Mild | 3.0 – 3.4 mEq/L | Flattened T waves, U wave appearance; fatigue, mild muscle weakness, mild constipation | Oral K⁺ replacement if tolerating PO; increase dietary K⁺ (bananas, oranges, leafy greens); cardiac monitoring; recheck K⁺ |
| Moderate | 2.5 – 2.9 mEq/L | Prominent U waves, ST depression, prolonged QU interval; significant weakness, cramps, hypoactive reflexes, ileus | IV K⁺ replacement per order (typically 10 mEq/hr peripheral, 20 mEq/hr central max); continuous cardiac monitoring; check and replace Mg²⁺; fall precautions; NPO if ileus |
| Severe | < 2.5 mEq/L | Torsades de pointes risk, VT, VF; profound weakness to paralysis, respiratory muscle weakness, severe ileus | Critical — immediate provider notification; IV K⁺ replacement via controlled infusion (central access preferred); continuous cardiac monitoring; treat concurrent hypoMg²⁺ first; prepare for potential respiratory support |
IV Potassium Administration — Safety Rules
- NEVER administer IV K⁺ as an IV push or bolus — rapid IV potassium causes cardiac arrest. This is a high-alert medication and one of the most common fatal medication errors in hospitals.
- Peripheral IV: Maximum concentration 10 mEq/100 mL; maximum rate 10 mEq/hr to prevent phlebitis and pain. Higher concentrations cause vessel irritation and chemical phlebitis.
- Central IV: Concentrations up to 20–40 mEq/100 mL; maximum rate 20 mEq/hr (some institutional protocols allow higher rates in critical situations with continuous cardiac monitoring)
- Always confirm: Two-nurse verification for concentrated K⁺ solutions per institutional policy (ISMP high-alert medication)
- Monitor during infusion: Continuous cardiac monitoring during IV K⁺ infusion; check IV site for phlebitis if peripheral; recheck serum K⁺ after replacement to assess response
- Address magnesium: Replace hypomagnesemia concurrently — potassium cannot be maintained without adequate magnesium
Hyperkalemia (K⁺ > 5.0 mEq/L)
| Severity | K⁺ Level | ECG / Symptoms | Intervention Priorities |
|---|---|---|---|
| Mild | 5.1 – 5.9 mEq/L | Peaked (tall, narrow) T waves; often asymptomatic or mild nausea, malaise | Notify provider; cardiac monitoring; hold K⁺-retaining medications (ACE inhibitors, ARBs, K⁺-sparing diuretics, K⁺ supplements); low-K⁺ diet; treat underlying cause; repeat labs |
| Moderate | 6.0 – 6.4 mEq/L | Prolonged PR, flattened P waves, widening QRS; muscle weakness, paresthesias | Continuous cardiac monitoring; insulin (10 units regular) + D50W IV; sodium polystyrene sulfonate (Kayexalate) or newer binders; consider furosemide if adequate renal function; reassess K⁺ |
| Severe | ≥ 6.5 mEq/L or ECG changes | Absent P waves, sine wave, VF, PEA; profound weakness, paralysis, bradycardia | Emergency: (1) Calcium gluconate IV push [stabilize membrane]; (2) Insulin + D50W [shift]; (3) Sodium bicarbonate [shift if acidotic]; (4) Albuterol nebulization [adjunct shift]; (5) Kayexalate/Lokelma [remove]; (6) Furosemide [if renal function adequate]; (7) Hemodialysis [definitive removal — consult nephrology] |
Hyperkalemia Management Framework
| Phase | Goal | Agent | Onset |
|---|---|---|---|
| Stabilize | Protect cardiac membrane — does NOT lower K⁺ | Calcium gluconate IV | 1–3 min (duration 30–60 min) |
| Shift | Move K⁺ from blood into cells — lowers serum K⁺ temporarily | Insulin + D50W, sodium bicarb, albuterol | 15–30 min (temporary) |
| Remove | Eliminate K⁺ from the body — permanent reduction | Kayexalate, Lokelma, furosemide, dialysis | Hours to days (dialysis: immediate) |
Stabilize and shift strategies must always be followed by removal strategies — shift is temporary, and potassium will rebound into the blood as insulin wears off.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with ANA / NANDA Clinical Standards. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →