MURIEL, STEFFI SHANICE M.

GROUP 3- CCU

NURSING CARE PLAN

ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATION
S

SUBJECTIVE: Impaired SHORT-TERM: INDEPENDENT: Goal was met.

N/A fluid and N/A Monitor heart rate/rhythm. To monitor changes associated
electrolyte with hypokalemia include
OBJECTIVE: s: abnormalities in both
PR = 110 hypokalem conduction and contractility.
bpm ia
RR= 25 Maintain accurate record
Low To serve as a guide for
of urinary, gastric losses. calculating fluid/potassium
Potassium
results 3.1 replacement needs.
in Blood DEPENDENT:
Chemistry Administer Potassium IV as
test. ordered.
LONG-TERM: For potassium correction.
After 24 hours of Monitor rate of IV
nursing potassium administration.
intervention, the To ensure controlled delivery of
client will be able to medication to prevent bolus
maintain serum effect and reduce associated
Monitor laboratory studies discomfort.
potassium levels (Serum potassium)
within normal
range.
Monitor ABGs. To serve as a guide for
calculating fluid/potassium
replacement needs and to
prevent complications.

Levels should be checked

frequently during replacement

1
MURIEL, STEFFI SHANICE M.
GROUP 3- CCU

NURSING CARE PLAN

therapy, especially in the
presence of insufficient
renalfunction. Sudden
excess/elevation may cause
cardiac dysrhythmias.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUAT

SUBJECTIVE: Ineffective SHORT-TERM: INDEPENDENT: Goal was m

N/A tissue N/A Monitor and Record Vital To have a baseline data.
perfusion Signs.
OBJECTIVE: related to
-skin cold to anemia Assess patient general To have a baseline data and
touch condition. note any abnormal findings.
-restlessness
-Vital Signs: Encourage quiet and To conserve energy and lower
RR: 25 restful atmosphere. tissue oxygen demands.
PR: 110
Provide safety by raising Weakness, fatigue and
- Low HGB level:
(normal - ) side rails restlessness are signs
of hypoxia which may cause
- Low HCT level:
LONG-TERM: DEPENDENT: injury to the patient.
(normal - )
After 8 hours of Administer supplemental
-Increased BUN oxygen as ordered Oxygen increase arterial
nursing
and creatinine saturation.
intervention, the
client will be able to Administer IV fluids as
display ordered.
Maintains circulating volume
improvement in to maximize tissue perfusion.
blood (Hgb, Hct) Monitor laboratory studies
levels, as well as Normal values indicate

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MURIEL, STEFFI SHANICE M.
GROUP 3- CCU

NURSING CARE PLAN

BUN and crea such as hemoglobin, adequate tissue perfusion.
levels. hematocrit and RBC.
Blood transfusion increases
Blood component therapy the patients blood volume and
(Blood transfusion) as raising the
ordered.