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    NCP Risk

    Uploaded by

    Paolo Vittorio Perdigueros Gonzales
    1. Monitor intake and 1. Monitor intake and output. output to determine fluid and electrolyte balance. 2. Monitor vital signs 2. Vital signs changes and level of may indicate fluid consciousness. volume deficit or excess. 3. Monitor lab values 3. Laboratory values for electrolytes. provide objective data to determine effectiveness of interventions. Evaluation: 1. Compare lab values 1. Laboratory values to baseline and provide quantitative normal range. data to evaluate effectiveness of interventions. 2. Note changes in 2. Subjective changes subjective findings. may indicate need for modification of plan of care.

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    NCP Risk

    Uploaded by

    Paolo Vittorio Perdigueros Gonzales
    63 views2 pages
    1. Monitor intake and 1. Monitor intake and output. output to determine fluid and electrolyte balance. 2. Monitor vital signs 2. Vital signs changes and level of may indicate fluid consciousness. volume deficit or excess. 3. Monitor lab values 3. Laboratory values for electrolytes. provide objective data to determine effectiveness of interventions. Evaluation: 1. Compare lab values 1. Laboratory values to baseline and provide quantitative normal range. data to evaluate effectiveness of interventions. 2. Note changes in 2. Subjective changes subjective findings. may indicate need for modification of plan of care.

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    1. Monitor intake and 1. Monitor intake and output. output to determine fluid and electrolyte balance. 2. Monitor vital signs 2. Vital signs changes and level of may indicate fluid consciousness. volume deficit or excess. 3. Monitor lab values 3. Laboratory values for electrolytes. provide objective data to determine effectiveness of interventions. Evaluation: 1. Compare lab values 1. Laboratory values to baseline and provide quantitative normal range. data to evaluate effectiveness of interventions. 2. Note changes in 2. Subjective changes subjective findings. may indicate need for modification of plan of care.

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    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    63 views2 pages

    NCP Risk

    Uploaded by

    Paolo Vittorio Perdigueros Gonzales
    1. Monitor intake and 1. Monitor intake and output. output to determine fluid and electrolyte balance. 2. Monitor vital signs 2. Vital signs changes and level of may indicate fluid consciousness. volume deficit or excess. 3. Monitor lab values 3. Laboratory values for electrolytes. provide objective data to determine effectiveness of interventions. Evaluation: 1. Compare lab values 1. Laboratory values to baseline and provide quantitative normal range. data to evaluate effectiveness of interventions. 2. Note changes in 2. Subjective changes subjective findings. may indicate need for modification of plan of care.

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    Download as docx, pdf, or txt
    of 2

    ASSESSMENT NURSING RATIONALE DESIRED NURSING JUSTIFICATIONS EVALUATION

    DIAGNOSIS OUTCOMES INTERVENTIONS


    Subjective Cues: Risk for electrolyte Profuse sweating After 16 hrs of nursing Independent: After 16 hours of
     Patient has verbalized, imbalance related to without adequate intervention the client nursing intervention,
    “gasakit pa ulo ko.” decrease potassium intake or folks will be able 1. Review laboratory 1. electrolytes include, the patient was able to:
    levels, high sodium to: results for abnormal calcium, potassium, etc.
    Objective Cues: diet and profuse findings. These chemicals are 1. Display Laboratory
     Compromised sweating. electrolyte 1. Display laboratory essential in many bodily results close to normal
    concentration wasting results within functions including fluid range for individual.
     Assisted activities of Definition: For normal range for balance, movement of Goal Partially met.
    daily living change in serum individual. fluid within and between
     Confusion electrolyte levels tha 2. Be free of body compartment, nerve 2. Be free of
     Restless may compromise internal complications conduction, and muscle complications resulting
     Slow movement health. imbalance resulting from contraction. from electrolyte
     Lack of energy electrolyte imbalance. Goal met.
    imbalance. 2. Discuss preventable 2. Provide opportunity for
    Source: electrolyte 3. Identify individual causes of condition client to prevent 3. Identify individual
    Wellness/Strengths Doenges, M. et. Al., imbalance risks and engage in such as nutritional recurrence. Also, dietary risks and engage in
     Good compliance to (2010). Nurse’s participate choices and the control is more palatable participate behaviors or
    medication Pocket Guide: behaviors or proper use of than oral replacement lifestyle changes to
     Cooperative behavior Diagnoses, lifestyle changes to laxatives. medications. prevent or reduce
    of the patient Interventions and prevent or reduce frequency of electrolyte
    th
     Strong family support. Rationales. (12 frequency of 3. Encourage intake of 3. Potassium may be imbalances. Goal met.
     Compliance to diet. ed.). Philadelphia, electrolyte foods and fluids replaced and level
    F.A. Davis imbalances. high in potassium maintained through the
    Company. pp 320 such as bananas, diet when the client is
    Doenges, et al. Nurses oranges, dried allowed oral food and Doenges, et al. Nurses
    Pocket Guide. F.A fruits, red meat, fluids. Dietary Pocket Guide. F.A
    Davis Company 2010. leafy vegetables, replacement of 40- Davis Company 2010.
    P. 312-313 peas, baked 60mEq/L/day is typically P. 313-319.
    potatoes and sufficient if no abnormal
    tomatoes. losses are occurring.

    4. Maintain accurate 4. Guide for calculating


    record of urinary, fluid and potassium
    gastric, and wound replacement needs.
    losses.

    Collaborative:
    1. Assist treatment of 1. Refer to listing of
    underlying cause. predisposing factors
    or contributing factors
    to determine
    treatment needs.
    Note: Hypokalemia is
    life threatening,
    therefore early
    detection is crucial.
    2. Administer oral 2. May be required to
    and/or IV correct deficiencies
    potassium. when changes in
    medication, therapy,
    and/or dietary intake
    are insufficient.

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