Professional Documents
Culture Documents
Nursing Management
Nursing Care Plan
Discharge Planning
Core Competencies
Ca
K Cl
Na Mg
Marnela Kathleen V. Pasamba, RN
Staff Nurse – Executive Care Unit 1
St. Luke’s Medical Center – Global City
Nursing Care Plan
Priorities
Restore homeostasis
Prevent/minimize complications
Provide information about condition/prognosis and
treatment needs
Discharge Goals
Homeostasis be restored
Free of complications
Condition/prognosis and treatment understood
Plan in place to meet needs after discharge
Fluid Imbalances
Predisposing Factors
- Excess Na intake
- Rapid administration of hypertonic/isotonic
fluids
- Increased release of ADH
- Decreased plasma proteins
- CKD/ARF; Heart failure
Fluid Volume Excess
Assessment
- Fatigue
- Increased BP
- Edema
- Decreased UO; polyuria (normal kidneys)
- Increased abdominal girth
- Weight gain
- LOC changes
- SOB; increased RR with or without dyspnea
Fluid Volume Excess
Desired Outcomes
Patient will demonstrate stabilized fluid volume as evidenced
by balanced I & O, vital signs within normal range, stable
weight and absence of edema.
Patient will verbalize understanding of individual dietary/fluid
restrictions.
Patient will demonstrate behaviors to monitor fluid status and
prevent/limit its recurrence.
Fluid Volume Excess
Interventions
1. Vital signs taking, also CVP
2. Auscultate lungs and heart sounds
3. Assess for presence of edema, neck and peripheral
distention
4. Maintain accurate I & O; note urine output and fluid
balance on 24 hour calculations
5. Weigh as indicated
6. Give oral fluids with caution
7. Monitor infusion of fluids
Fluid Volume Excess
Interventions
8. Encourage deep breathing exercise
9. Maintain semi-fowler’s position
10. Turn, reposition and provide skin care
11. Provide safety precautions
Fluid Volume Excess
Interventions
(Collaborative)
- Assist with identification and treatment of underlying
cause
- Monitor lab studies
- Provide balanced CHON, decrease Na in diet and restrict
fluids
- Prepare to administer diuretics
Fluid Volume Deficit
Predisposing Factors
- Excessive fluid losses
- Decreased fluid intake
- Systemic infections, fever
- Intestinal obstruction or fistulas
- DI, Kidney disease
Fluid Volume Deficit
Assessment
- Decreased BP
- Flattened neck veins
- Decreased urine volume
- Weight loss
- Tingling of extremities
- Increased RR, rapid shallow breathing
Fluid Volume Deficit
Desired Outcomes
Patient will maintain fluid volume at a functional level as
evidenced by adequate urine output with normal specific
gravity, stable vital signs, moist mucous membranes, good
skin turgor and prompt capillary refill.
Patient will verbalize understanding of causative factors and
purpose of therapeutic interventions.
Patient will demonstrate behaviors to monitor and correct
deficit.
Fluid Volume Deficit
Interventions
1. Vital signs taking, also CVP; watch out for postural BP
changes and observe for fever
2. Palpate peripheral pulses; note capillary refill
3. Monitor urine output and measure/estimate fluid losses
from all sources
4. Weigh as indicated and compare with 24 hours fluid
balance
5. Evaluate patient’s ability to swallow
6. Ascertain patient’s beverage preference
Fluid Volume Deficit
Interventions
7. Turn frequently, massage skin and protect bony
prominences
8. Provide skin and mouth care
9. Apply lotion as indicated
10. Provide safety precautions
11. Investigate reports of sudden sharp chest pain, dyspnea,
cyanosis and restlessness
Fluid Volume Deficit
Interventions
(Collaborative)
- Assist with identification and treatment of cause
- Monitor laboratory studies
- Administer IV solutions as indicated
- Administer sodium bicarbonate, if indicated
- Provide tube feedings, including free water
Electrolyte Imbalances
Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Hypochloremia
Hyperchloremia
Hypocalcemia
Hypercalcemia
Hypomagnesemia
Hypermagnesemia
Sodium
135-145 mEq/L
Major cation of ECF
Neuromuscular conduction/transmission of
impulses
Maintains acid-base balance
Potassium
3.5-5.0 mEq/L
Major cation of ICF
Regulates neuromuscular excitability
Aids in maintenance of acid-base balance
Helps in synthesis of protein and metabolism
of carbohydrate
Chloride
95-108mEq/L
Aids cell integrity by osmotic pressure
Acid-base balance
Water balance
Competes with bicarbonate to combine with
sodium
Usually in combination with hydrochloric
acid and sodium chloride
Calcium
1.5-2.5 mEq/L
Influences carbohydrate metabolism
Affects secretion of PTH, Na/K transport
across the cell membrane and synthesis of
protein and nucleic acid
Electrolyte Imbalance Care Plan
Predisposing Factors
Assess for the contributing factors that may lead to excess or deficit of a
specific electrolyte.
Assessment
Look for specific signs and symptoms characteristic to the electrolyte
imbalances based on their functions in the body.
Desired Outcomes
Make sure that the patient will be able to manifest signs and symptoms
which are stable and leading towards recovery.
Aside from this, patient should manifest behavior geared towards the
attainment of balance in the body: e.g. monitoring dietary intake, noting
fluid and electrolyte balance.
Electrolyte Imbalance Care Plan
Nursing Diagnoses
Depends on the manifestations exhibited by the
patient.
Depends on the current needs both of the
patient and their families.
It is a must to be keen in observing the verbal
and nonverbal cues of the patient and family.
Once needs are identified, prioritize them
well.
Electrolyte Imbalance Care Plan
Interventions
1. Monitor for abnormal serum electrolytes, as available
2. Monitor for manifestations of electrolyte imbalance
3. Maintain patent IV access Administer fluids, as prescribed,
if appropriate
4. Maintain accurate intake and output record
5. Maintain intravenous solution containing electrolyte(s) at
constant flow rate, as appropriate
6. Administer supplemental electrolytes (e.g., oral, NG, and
IV) as prescribed, if appropriate
Electrolyte Imbalance Care Plan
Interventions
7. Consult physician on administration of electrolyte-sparing medications
(e.g., spiranolactone), as appropriate
8. Administer electrolyte-binding or -excreting resins (e.g., Kayexalate)
as prescribed, if appropriate
9. Obtain ordered specimens for laboratory analysis of electrolyte levels
(e.g., ABG, urine, and serum levels), as appropriate
10. Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction,
ileostomy drainage, diarrhea, wound drainage, and diaphoresis)
11. Institute measures to control excessive electrolyte loss (e.g., by resting
the gut, changing type of diuretic, or administering antipyretics), as
appropriate
Electrolyte Imbalance Care Plan
Interventions
12. Irrigate nasogastric tubes with normal saline
13. Minimize the amount of ice chips or oral intake consumed by patients with
gastric tubes connected to suction
14. Provide diet appropriate for patient's electrolyte imbalance (e.g., potassium-
rich, low-sodium, and low-carbohydrate foods)
15. Instruct the patient and/or family on specific dietary modifications, as
appropriate
16. Provide a safe environment for the patient with neurological and/or
neuromuscular manifestations of electrolyte imbalance
17. Promote orientation
18. Teach patient and family about the type, cause, and treatments for electrolyte
imbalance, as appropriate
Electrolyte Imbalance Care Plan
Interventions
19. Consult physician if signs and symptoms of fluid and/or electrolyte
imbalance persist or worsen
20. Monitor patient's response to prescribed electrolyte therapy
21. Monitor for side effects of prescribed supplemental electrolytes (e.g.,
GI irritation)
22. Monitor closely the serum potassium levels of patients taking digitalis
and diuretics
23. Place on cardiac monitor, as appropriate
24. Treat cardiac arrhythmias, according to policy
25. Prepare patient for dialysis (e.g., assist with catheter placement for
dialysis), as appropriate
Core Competencies
Safe and Quality Nursing Care
Management of Resources and Environment
Health Education
Legal Responsibility
Ethico-Moral Responsibility
Personal and Professional Development
Quality Improvement
Research
Records Management
Communication
Collaboration and Teamwork
Safe and Quality Nursing Care
Demonstrates knowledge based on the health and illness status of
individual/groups
Provides sound decision making in the care of individuals/groups
considering their beliefs and values
Promotes safety and comfort
Sets priorities in nursing care based on patient’s needs
Ensures continuity of care
Administer medications and other health therapeutics
Utilizes the nursing process as framework for nursing
Formulates a plan of care in collaboration with patients and other
members of health team
Implements NCP to achieve identified outcomes
Evaluates progress toward expected outcomes
Responds to the urgency of patient’s condition
Management of Resources and
Environment
Organizes work load to facilitate patient care
Utilizes resources to support patient care
Ensures the functioning of resources
Checks proper functioning of equipment
Maintains safe environment
Health Education
Assesses the learning needs of patient and family
Develops health education plan based on assessed
and anticipated needs
Develops learning materials for health education
Implements health education plan
Evaluates the outcome of health education
Legal Responsibility