NURSING CARE PLAN

Identified Problem: The patient has Acute Kidney Injury and serum potassium level was above normal (6.5meq/l)

Nursing Diagnosis: Electrolyte Imbalance (Hyperkalemia) related to Acute Kidney Injury as evidenced by increased potassium level

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Health Teaching Short term:
After 30 minutes of health 1. Causes of Hyperkalemia Goal met. After 30 minutes of
 Complaints of nausea teaching, the client will be able  Acute Kidney Injury- With a decline in the health teaching, the client will be
and vomiting to verbalize understanding GFR, oliguria, and anuria, patients are at able to enumerate the causes of
 Reports generalized about the cause of high risk for hyperkalemia hyperkalemia and states how his
muscle weakness. hyperkalemia, the importance  Uncontrolled Diabetes- may lead to disease may aggrevate his
 Shortness of breath of treatment regimen respiratory or metabolic acidosis leading Early identification and intervention potassium level. The patient also
and how to prevent to shifting of potassium from ICF to ECF. can avoid complications. verbalized the importance of
hyperkalemia.  Medications- some drugs may elevate treatment an his family was able
potassium level such as Potassium- to participate in the treatment
sparing diuretics regimen.
 Diet- Too much potassium in the diet can .
also contribute to higher levels in your
blood, if your kidneys don’t work well or
you take certain medicines.

2. Treatment Regimen- it may include the diet

Objective: restriction and drug cocktails where the goal is to
 EKG Changes: Loss of decreased the potassium level. Hyperkalemia Discuss the importance of avoiding
P waves, tall peaked T greatly endangers the patient’s well-being as it foods high in potassium to prevent
waves; prolonged QRS greatly affects the heart and it may lead to or control hyperkalemia.
complexes, and ST cardiac arrest. With the help of drug cocktails, it
segment elevation may improve the patient’s health.
Long term:
 Increased Potassium Long term objectives: 3. Hyperkalemia Prevention Goal met. After 3 days of nursing
Electrolyte: After 3 days of nursing  Avoid episodes of fasting, which can intervention, the client’s
8am: 6.5 meq/l intervention, the client will be increase potassium movement out of the Prevention of hyperkalemia can be potassium level was 4.9 meq/l.
able to achieved potassium cells due, managed with diet, supplements,
 ABG level in normal range 3.5-5  Avoid, if possible, drugs that raise the and other medications. May help
pH- 7.31 meq/l serum potassium concentration. If prevent hyperkalemia recurrences
HCO3- 21 mEq/L patient has hypertension, tell the doctor
PaCO2- 50 mmHg about patient’s situation to prescribe
drugs suitable.

Use pump or controller device when to provide medication at desired

administering intravenous electrolyte solutions rate and prevent untoward effects
of excessive or too rapid
delivery.

Patient’s Name / Room No. | 1

 NURSING CARE PLAN
Identified Problem: The patient has Acute Kidney Injury and serum potassium level was above normal (6.5meq/l

Nursing Diagnosis: Electrolyte Imbalance (Hyperkalemia) related to Acute Kidney Injury as evidenced by increased potassium level

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives:  Monitor bowel sounds and the number Hyperactive bowel sounds result Short term:
and character of bowel movements. from the body’s attempt to maintain
homeostasis by causing significant
potassium excretion through the
bowels

 Monitor the patient’s intake and output An inability to excrete potassium

adequately may lead to
dangerously high potassium levels
Collaborative:

 Consult with dietitian or nutritionist for Learning how to incorporate foods

Objective: specific teaching needs. that increase electrolyte intake or
identifying food or condiment
alternatives increases client’s self-
sufficiency and likelihood of
Success
Long term objectives:
 Collaborate in treatment of underlying to prevent or limit effects of
conditions electrolyte imbalances caused by
disease or organ dysfunction.
Long term:

NURSING CARE PLAN

Patient’s Name / Room No. | 2
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

NURSING CARE PLAN

Identified Problem:
Patient’s Name / Room No. | 3
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

NURSING CARE PLAN

Identified Problem:

Patient’s Name / Room No. | 4

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

NURSING CARE PLAN

Identified Problem:

Nursing Diagnosis:
Patient’s Name / Room No. | 5
 CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

NURSING CARE PLAN

Identified Problem:

Nursing Diagnosis:

Patient’s Name / Room No. | 6

 CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

NURSING CARE PLAN

Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Patient’s Name / Room No. | 7
Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

NURSING CARE PLAN

Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Patient’s Name / Room No. | 8

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

NURSING CARE PLAN

Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Patient’s Name / Room No. | 9

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

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