Arshi zeb Nursing Care Plan

Class : Generic BCN 3rd Semester

NURSING
CUES/CLUES RATIONALE OBJECTIVES NURSING INTERVENTION RATIONALE
DIAGNOSIS

CUES: Hypokalemia Potassium is essential for SHORT-TERM: INDEPENDENT:

 “Nagpacheck- many body functions. 1. To verbalize  Monitor heart rate/rhythm.  Changes associated with
up ako. understanding of hypokalemia include
Mababa daw Hypokalemia refers to a causative factors abnormalities in both conduction and
Potassium ko.” condition in which the and purpose of contractility.
 “Dapat nga 15 concentration of interventions and Tachycardia may develop, and
minutes ‘di ba Potassium in the blood is medications. potentially life-threatening
ako mag- low. The most common atrial and ventricular dysrhythmias,
eexercise? Eh cause of excessive loss of e.g., PVCs, sinus
wala, ‘yung 15, Potassium is often bradycardia, atrioventricular (AV)
naging 7.” associated with heavy fluid 2. To demonstrate blocks, AV
(fatigue) losses that “flush” behaviors to dissociation, ventricular tachycardia.
Potassium out of the body monitor and
—a consequence of correct deficit.
vomiting and diarrhea. In
addition to this, the
patient may not be sick  Maintain accurate record of  Guide for calculating
but he/she does not take urinary, gastric, and wound fluid/potassium replacement needs.
enough Potassium in her losses.
diet that predisposed to
this particular condition.  Monitor rate of IV potassium  Ensures controlled delivery
The patient may administration using of medication to prevent bolus effect
experience generalized microdrop or pump infusion and reduce associated discomfort,
weakness, hypoventilation devices. Check for side e.g., burning sensation at IV site.
due to Potassium effects. Provide ice pack as When solution cannot be
defieciency. indicated. administered via central vein and
slowing rate is not
possible/effective, ice pack to infusion
site may help relieve discomfort.
 Encourage intake of foods and
fluids high in potassium,
e.g., bananas, oranges, dried
fruits, red meat, turkey,
salmon, leafy vegetables, peas,
baked potatoes, tomatoes,
winter squash, coffee, colas,
tea. Discuss use of potassium
chloride salt substitutes for
patient receiving long-term
diuretics.
 Potassium may be
replaced/level maintained through
the diet when patient is allowed oral
food and fluids. Dietary replacement
of 40–60 mEq/L/day is typically
sufficient if no abnormal losses are
occurring.

 Watch for signs of  Low potassium enhances

digitalis intoxication when effect of digitalis, slowing
used (e.g., reports of cardiac conduction. Note: Combined
nausea/vomiting, blurred effects of digitalis,
vision, increasingatrial diuretics, and hypokalemia may
dysrhythmias, and heart produce lethal
block). dysrhythmias.

COLLABORATIVE:
 Monitor laboratory  Levels should be checked frequently
studies, e.g.: during replacement
Serum potassium; therapy, especially in the presence of
insufficient renal
function. Sudden excess/elevation
may cause cardiac
dysrhythmias.

ABGs; Correction of metabolic alkalosis

raises serum potassium
level and reduces replacement needs.
Correction of
acidosis drives potassium back into
cells, resulting in
decreased serum levels and increased
replacement needs.
 Nursing Care Plan Hyper Kalemia
Assessment Diagnosis Planning Nursing Rationale Evaluation
Intervention
Subjective cues: Activity Short Term Goal is met:
Verbal report of Intolerance Goal: After 2- 1. Assess 1. Injury may be related to
fatigue or 3h of nursing potential for falls or overexertion..
weakness interventions, physical injury
the patient with activity
Objective cues: will gradually
 SOB resume usual 2. Observe and 2. Close monitoring serves
 Bp : physical document as a guide for optimal
170/100 activities. response to progression of activity. 
activity.
Long Term
Goal: 3. To promote rest. Patients
Pt will with limited activity
demonstrate tolerance need to prioritize
increased 3.  Refrain from tasks.
tolerance to performing
activity by nonessential
discharge. procedures.
4. Acknowledgment that
living with activity
intolerance is both
physically and emotionally
difficult aids coping.
4. Encourage
verbalization of
feelings regarding
limitations.