PLACE LABEL HERE
ELECTROLYTE REPLACEMENT
PROTOCOL
The following orders will be implemented per physician order of this protocol.
Initial the bottom of each page when indicated (multipage).
1.
D/C this protocol if any of the following are present and call physician if electrolyte
replacement needed:

Glomerular Filtration Rate (GFR) or Creatinine Clearance (CrCl) < 30 ml/min

Serum creatinine (SCr) ≥ 2.5 mg/dL

D/C magnesium replacement in patients with acute exacerbation of Myasthenia Gravis
2.
D/C all other orders for PRN potassium and magnesium supplementation (IV and PO)
3.
For Potassium (K+) level < 3.0 mmol/L, place patient on telemetry without pulse oximetry,
may not be off for tests (form # 36084). Call physician and follow instructions below until
physician calls back.
For potassium (K+) level < 3.5 mmol/L, give potassium replacement per chart below:
Potassium
(K+) Level
(mmol/L)
K+ =
3.0 - 3.4
K+ =
2.6 – 2.9
K+ =
< 2.6
Potassium Supplementation Orders
Additional Orders
Give potassium orally or per tube unless the
patient is NPO, having n/v, or watery diarrhea
DC all other prn potassium and
magnesium orders (IV or PO)


Chem-7 in AM
OR
 KCL 20 mEq/100 ml IVPB over 2 hrs x 2
doses
 D/C below orders if GFR or CrCl is < 30 or
SCr is ≥ 2.5
 KCL 20 mEq po or per tube q 2 hr x 4 doses
(if elixir, dilute in juice or water)




OR

Notify physician (panic lab value)
Place patient on telemetry.
Repeat K+ level 2 hrs after the last dose.
Replace potassium per chart if level
remains < 3.5,
Obtain Mg2+ level if not checked in last
24 hrs (may use blood in lab).
Replace magnesium per chart below if
level < 1.8
Notify physician (panic lab value)
Place patient on telemetry.
STAT re-draw K+ and begin
replacement while result is pending
Obtain Mg2+ level if not checked in last
24 hrs (may use blood in lab).
Replace magnesium per chart below if
level < 1.8
Repeat K+ level 1-2 hrs after last IV
dose.
Replace potassium per chart if level
remains < 3.5

D/C below orders if GFR or CrCl is < 30 or
SCr is ≥ 2.5
KCL 20 mEq po or per tube q 2 hr x 2 doses
(if elixir, dilute in juice or water)

KCL 20 mEq/100 ml IVPB over 2 hrs x 4
doses


D/C below orders if GFR or CrCl is < 30 or
SCr is ≥ 2.5
KCL 40 mEq po or per tube x 1 dose NOW
(if elixir, dilute in juice or water)
AND
KCL 20 mEq/100 ml IVPB over 2 hrs x 2
doses NOW






OR, if npo, give IV only:



KCL 20 mEq/100ml IVPB over 2 hs x 4
doses NOW
Copy to pharmacy
*3-21340*
Order writer’s initials _________
FORM 3-21340 REV. 06/2015
Page 1 of 2
PLACE LABEL HERE
ELECTROLYTE REPLACEMENT
PROTOCOL
Copy to pharmacy
*3-21340*
Order writer’s initials _________
FORM 3-21340 REV. 06/2015
Page 2 of 2
PLACE LABEL HERE
ELECTROLYTE REPLACEMENT
PROTOCOL
The following orders will be implemented per physician order of this protocol.
Initial the bottom of each page when indicated (multipage).
4.
For magnesium (Mg2+) level < 1.8 mg/dL, give magnesium replacement per chart below
Magnesium
Additional Orders
Magnesium
(Mg2+) Level
(mg/dL)
Mg2+ =
1.5-1.7
Mg2+ =
1.2-1.4
Mg2+ =
< 1.2

D/C below orders if GFR or Crcl is < 30 or
SCr is ≥ 2.5, or if patient has myasthenia
gravis

Magnesium sulfate 2 gms IVPB over 1 hr x 1
dose

D/C below orders if GFR or CrCl is < 30 or
SCr is ≥ 2.5, or if patient has myasthenia
gravis

Magnesium sulfate 2 gms IVPB over 1 hr x 2
doses

D/C below orders if GFR or CrCl is < 30 or
SCr is ≥ 2.5, or if patient has myasthenia
gravis

5.
DC all other prn potassium and
magnesium orders (IV or PO)
Supplementation Orders

Magnesium level in AM

Magnesium level in AM


Notify physician (panic lab value)
Repeat magnesium level 1- 2 hrs after
last infusion completed.
Replace magnesium per chart if level
remains < 1.8

Magnesium sulfate 2 gms IVPB over 1 hr x 3
doses NOW while waiting for physician to
return call
For phosphorus level < 2.0 mg/dL, give phosphorus replacement per chart below
Phosphorus
Level
Phosphate Supplementation Orders
Additional Orders
(mg/dL)

Phosphorus=
1.0 – 1.9
Phosphorus=


< 1.0
______________
Date
D/C below orders if GFR or CrCl is < 30 or
SCr is ≥ 2.5
Neutra-Phos (potassium phosphate,
sodium phosphate) 2 packets po/per tube
q 6 hrs x 48 hrs

Phosphorus level in AM
Call physician with panic value and obtain
phosphate replacement orders
_______________
Time
_________________________________
Physician Signature
__________
PID Number
Copy to pharmacy
FORM 3-21340 REV. 06/2015
Page 3 of 2
ELECTROLYTE REPLACEMENT
PROTOCOL
Reference Page
(For use with form 21340)
Potassium (K+) level < 3.5 mmol/L, give potassium replacement per chart below.
Potassium
(K+) Level
K+ =
3.0 - 3.4
K+ =
2.6 – 2.9
Potassium Supplementation Orders
Give potassium orally or per tube unless the
patient is NPO, having n/v, or watery diarrhea
D/C below orders if GFR or CrCl is < 30 or SCr is ≥ 2.5
KCL 20 mEq po or per tube q 2 hr x 2 doses
(if elixir, dilute in juice or water)


OR

KCL 20 mEq/100 ml IVPB over 2 hrs x 2 doses

D/C below orders if GFR or CrCl is < 30 or SCr is ≥ 2.5

KCL 20 mEq po or per tube q 2 hr x 4 doses
(if elixir, dilute in juice or water)
OR

KCL 20 mEq/100 ml IVPB over 2 hrs x 4 doses
Additional Orders
DC all other prn potassium and magnesium orders (IV or PO)

Chem-7 in AM




Notify physician (panic lab value)
Place patient on telemetry.
Repeat K+ level 2 hrs after the last dose.
Replace potassium per chart if level remains <
3.5,
Obtain Mg2+ level if not checked in last 24 hrs
(may use blood in lab).
Replace magnesium per chart below if level < 1.8
Notify physician (panic lab value)
Place patient on telemetry.
STAT re-draw K+ and begin replacement while
result is pending
Obtain Mg2+ level if not checked in last 24 hrs
(may use blood in lab).
Replace magnesium per chart below if level < 1.8
Repeat K+ level 1-2 hrs after last IV dose.
Replace potassium per chart if level remains < 3.5

K+ =
< 2.6

D/C below orders if GFR or CrCl is < 30 or SCr is ≥ 2.5

KCL 40 mEq po or per tube x 1 dose NOW
(if elixir, dilute in juice or water)
AND
KCL 20 mEq/100 ml IVPB over 2 hrs x 2 doses NOW
OR, if npo, give IV only:

KCL 20 mEq/100ml IVPB over 2 hs x 4 doses NOW








Magnesium (Mg2+) level < 1.8 mg/dL, give magnesium replacement per chart below
Magnesium
(Mg2+) Level
Mg2+ =
1.5-1.7
Mg2+ =
1.2-1.4
Mg2+ =
< 1.2







Magnesium
Supplementation Orders
D/C below orders if GFR or CrCl is < 30 or SCr is ≥ 2.5,
or if patient has myasthenia gravis
Magnesium sulfate 2 gms IVPB over 1 hr x 1 dose
D/C below orders if GFR or CrCl is < 30 or SCr is ≥ 2.5,
or if patient has myasthenia gravis
Magnesium sulfate 2 gms IVPB over 1 hr x 2 doses
D/C below orders if GFR or CrCl is < 30 or SCr is ≥ 2.5
D/C below orders if patient has myasthenia gravis
Magnesium sulfate 2 gms IVPB over 1 hr x 3 doses
NOW while waiting for physician to return call
Additional Orders
DC all other prn potassium and magnesium orders (IV or PO)

Magnesium level in AM

Magnesium level in AM


Notify physician (panic lab value)
Repeat Mg2+ level 1- 2 hrs after last infusion
completed
Replace magnesium per chart if level remains <
1.8

Phosphorus level < 2.0 mg/dL give phosphorus replacement per chart below
Phosphorus
Level
Phosphorus=
1.0 – 1.9
Phosphorus=
< 1.0
Phosphate Supplementation Orders


D/C below orders if GFR or CrCl is < 30 or SCr is ≥ 2.5
Neutra-Phos (potassium phosphate, sodium
phosphate) 2 packets po/per tube q 6 hrs x 48 hrs

Call physician with panic value and obtain
phosphate replacement orders
Additional Orders

Phosphorus level in AM
Nurse: Write a new order for each needed dose and lab, sign “Per Dr. XX’s order/Your Name, RN”
Reference Use Only. Not part of Medical Record.
PLACE THIS COPY IN MAR SECTION OF CHART DURING EPISODE OF CARE.
(For use with form 21340)