Nursing Problem with Cues
with Rationale
Subjective cues: “I have been
vomiting and experiencing
diarrhea for the past few days.
Now, my body feels very
weak.”
Objective cues:
Decreased fluid intake of
150cc
Urine output of 400cc
Vomitus of yellowish fluid
approximately 70 cc times
three episodes for two days
Diarrhea; Watery stools times
4 episodes for two days
Muscle weakness noted upon
assessment.
Febrile, with temperature of
38.5°C
BP of 90/50 mmHg
Pulse of 115 bpm
Presence of an elevated U
wave on ECG result
Laboratory results
Decreased potassium level of
2.5 mEq/
Nursing Diagnosis Objectives Interventions Rationale for Intervention
Altered electrolyte Long term goal: After 1. Monitor for signs and 1. Hypokalemia can be life
balance related to 48 hours of nursing symptoms of hypokalemia: threatening. Careful
active fluid loss intervention, client will  Fatigue assessment for its early
secondary to vomiting be able to maintain  Anorexia presence is needed especially
and diarrhea. serum potassium levels  Muscle weakness
within normal range. for high risk patients.
 Decreased bowel motility 2. The ECG can provide
Rationale
Potassium is an Short term goals:  Dysrhythmias useful information for
electrolyte needed After 1 hour of health  Shallow respirations hypokalemia. Patients
primarily for muscle teaching, client will be  Weak thread pulse receiving digitalis should be
and nerve tissue able to: 2. Monitor ECG continuously. monitored closely for signs
function. Fluid loss 3. Strict monitoring of intake and
of digitalis toxicity because
from the body such as Identify measures to output.
vomiting and diarrhea prevent hypokalemia. hypokalemia potentiates the
causes depletion of the Independent: action of digitalis.
electrolyte potassium Participate in the Preventing hypokalemia 3. Careful monitoring of
partly because treatment regimen. fluid intake and output is
potassium is actually 4. Assist client in selecting foods necessary because 40 mEq of
lost with gastric fluid. rich in potassium as such as potassium is lost for every
Also, large amounts of banana, fruit juices, melon, citrus
fruits, and fresh vegetables. liter of urine.
potassium found in the
intestinal fluids are 4. Including client in the plan
excreted during Dependent of care elicits participation.
episodes of diarrhea. Also, potassium-rich foods
Depletion of potassium Institute measures to correct in the diet help maintain
occurs and then leads hypokalemia potassium balance.
to altered electrolyte 1. Administered when
balance in the body. Administer the following drugs, as
prescribed: potassium levels need
to be replenished, as
1. Oral potassium well as, in patients
replacement with ongoing
2. Intravenous potassium potassium loss when
replacement it must be
 3. ACE inhibitor maintained.
4. Potassium-sparing diuretic 2. Used in the treatment
of potassium
Collaborative
deficiency when oral
5. Monitor serum potassium replacement is not
levels. feasible.
6. Monitor BUN and 3. Inhibits renal
creatinine levels. potassium excretion,
can ameliorate some
of the hypokalemia
that thiazide and loop
diuretics can cause.
4. Facilitates excretion
of sodium and water
while sparing
potassium.
5. Evaluates
effectiveness of
therapy.
6. Renal function
should be monitored
for patients receiving
potassium
replacement.