MANASAN, Chezka Andrea S. RLE 6.

NURSING CARE PLAN

CUES/CLUES CUES: y Nagpacheckup ako. Mababa daw Potassium ko. y Dapat nga 15 minutes di ba ako mageexercise? Eh wala, yung 15, naging 7. (fatigue) NURSING DIAGNOSIS Hypokalemia RATIONALE Potassium is essential for many body functions. Hypokalemia refers to a condition in which the concentration of Potassium in the blood is low. The most common cause of excessive loss of Potassium is often associated with heavy fluid losses that flush Potassium out of the body a consequence of vomiting and diarrhea. In addition to this, the patient may not be sick but he/she does not take enough Potassium in her diet that predisposed to this particular condition. The patient may experience generalized weakness, hypoventilation due to Potassium defieciency. OBJECTIVES SHORT-TERM: 1. To verbalize understanding of causative factors and purpose of interventions and medications. NURSING INTERVENTION INDEPENDENT: y Monitor heart rate/rhythm. RATIONALE EVALUATION

2.

To demonstrate behaviors to monitor and correct deficit.

y Changes associated with y Client was able to hypokalemia include verbalize abnormalities in both conduction and understanding of contractility. causative factors Tachycardia may develop, and and purpose of potentially life-threatening interventions and atrial and ventricular dysrhythmias, medications. e.g., PVCs, sinus bradycardia, atrioventricular (AV) blocks, AV y Client was able to dissociation, ventricular tachycardia. demonstrate behaviors to monitor and correct deficit. y Guide for calculating fluid/potassium replacement needs.

CLUES: y Low Potassium results in Blood Chemistry test.

LONG-TERM: 1. To achieve fluid volume at a functional level as evidenced by laboratory results of patient.

y Maintain accurate record of urinary, gastric, and wound losses. y Monitor rate of IV potassium administration using microdrop or pump infusion devices. Check for side effects. Provide ice pack as indicated.

y Ensures controlled delivery of medication to prevent bolus effect y Client was able to and reduce associated discomfort, achieve fluid volume e.g., burning sensation at IV site. at functional level as When solution cannot be evidenced by administered via central vein and laboratory results of slowing rate is not patient. possible/effective, ice pack to infusion site may help relieve discomfort.

y Encourage intake of foods and fluids high in potassium,

y Potassium may be replaced/level maintained through

MANASAN, Chezka Andrea S. RLE 6.4

NURSING CARE PLAN

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. y Watch for signs of digitalis intoxication when used (e.g., reports of nausea/vomiting, blurred vision, increasingatrial dysrhythmias, and heart block). 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.

y Low potassium enhances effect of digitalis, slowing cardiac conduction. Note: Combined effects of digitalis, diuretics, and hypokalemia may produce lethal dysrhythmias.

COLLABORATIVE: y Monitor studies, e.g.: Serum potassium;

laboratory

y Levels should be checked frequently during replacement therapy, especially in the presence of insufficient renal function. Sudden excess/elevation may cause cardiac dysrhythmias. 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.

ABGs;

MANASAN, Chezka Andrea S. RLE 6.4

NURSING CARE PLAN