Podcast
Questions and Answers
Which assessment data should the nurse use in the 'related to' portion of the nursing diagnostic statement for Risk for electrolyte imbalance? (Select all that apply)
Which assessment data should the nurse use in the 'related to' portion of the nursing diagnostic statement for Risk for electrolyte imbalance? (Select all that apply)
- Cardiac arrhythmia
- Emesis (correct)
- Muscle cramps
- Diuretic use (correct)
- Diarrhea (correct)
What is the 'related to' data to complete the nursing diagnostic statement for Mr. Johnson's plan of care?
What is the 'related to' data to complete the nursing diagnostic statement for Mr. Johnson's plan of care?
Hypokalemia
According to Maslow, which need supports the nursing diagnosis of Pain?
According to Maslow, which need supports the nursing diagnosis of Pain?
Physiological
Match Mr. Johnson's assessment data with the nursing diagnosis that it supports:
Match Mr. Johnson's assessment data with the nursing diagnosis that it supports:
Match each goal statement for Mr. Johnson's plan of care with its corresponding electrolyte level:
Match each goal statement for Mr. Johnson's plan of care with its corresponding electrolyte level:
Match each nursing diagnosis in Mr. Johnson's care plan with an accurate NOC indicator:
Match each nursing diagnosis in Mr. Johnson's care plan with an accurate NOC indicator:
Which is an accurate goal that the nurse should include for the new nursing diagnosis of Risk for impaired skin integrity?
Which is an accurate goal that the nurse should include for the new nursing diagnosis of Risk for impaired skin integrity?
Which indicators should the nurse monitor to determine if the NOC of Electrolyte and acid-base balance has been achieved? (Select all that apply)
Which indicators should the nurse monitor to determine if the NOC of Electrolyte and acid-base balance has been achieved? (Select all that apply)
Which findings on the nursing assessment may be associated with hypokalemia? (Select all that apply)
Which findings on the nursing assessment may be associated with hypokalemia? (Select all that apply)
Which electrolyte imbalance should the nurse use as the 'as evidenced by' portion for the nursing diagnostic statement of Imbalanced nutrition: less than body requirements?
Which electrolyte imbalance should the nurse use as the 'as evidenced by' portion for the nursing diagnostic statement of Imbalanced nutrition: less than body requirements?
Which nursing diagnosis should the nurse include in the updated patient plan of care for a patient with edema and shortness of breath?
Which nursing diagnosis should the nurse include in the updated patient plan of care for a patient with edema and shortness of breath?
What is an accurate goal statement for a patient with Risk for electrolyte imbalance experiencing nausea, vomiting, and diarrhea?
What is an accurate goal statement for a patient with Risk for electrolyte imbalance experiencing nausea, vomiting, and diarrhea?
Which goal should the nurse include in the plan of care for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances?
Which goal should the nurse include in the plan of care for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances?
Which indicators should the nurse monitor to determine the effectiveness of the current plan of care for Decreased cardiac output related to electrolyte imbalance?
Which indicators should the nurse monitor to determine the effectiveness of the current plan of care for Decreased cardiac output related to electrolyte imbalance?
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Study Notes
Nursing Diagnoses and Electrolyte Imbalances
- Assess for related factors in nursing diagnoses of Risk for electrolyte imbalance including diarrhea, emesis, and diuretic use.
- Muscle cramps and cardiac arrhythmias are symptoms but not direct related factors for electrolyte imbalance.
Patient-Specific Assessment
- Acute pain in Mr. Johnson is evidenced by muscle cramps and directly linked to hypokalemia (potassium level of 2.8 mEq/L).
- Confirm normal serum levels of calcium and sodium to rule out hypocalcemia and hyponatremia as causative factors.
Maslow's Hierarchy of Needs
- Acute pain qualifies as a physiological need, making it a priority according to Maslow's hierarchy.
Matching Assessment Data to Nursing Diagnoses
- Acute pain correlates with muscle cramps.
- Imbalanced nutrition relates to hypokalemia.
- Risk for decreased cardiac output is linked to altered cardiac rhythm.
- Risk for electrolyte imbalance corresponds to vomiting and diarrhea.
Goal Statements for Patient Care
- Serum sodium should reach normal levels (135-145 mEq/L) within 48 hours.
- Serum potassium normal levels should be established (3.5-5.0 mEq/L) within 48 hours.
- Serum calcium and magnesium levels should also normalize within designated time frames.
Nursing Diagnosis Indicators
- For decreased cardiac output, monitor heart rate and rhythm.
- For risk of electrolyte imbalance, track serum potassium levels.
- For imbalanced nutrition, evaluate food and fluid intake.
- For acute pain, assess comfort levels using a comfort assessment scale.
Goals for New Nursing Diagnoses
- Establish a goal for the patient to promptly report any altered sensations or pain in risk areas.
- Goals should be specific, measurable, and time-bound for effective nursing interventions.
Monitoring for Electrolyte Imbalances
- Focus on assessing apical heart rate and rhythm to monitor electrolyte balance.
- Serum potassium levels are critical indicators for managing electrolyte and acid-base balance.
Associated Findings with Hypokalemia
- Hypokalemia can result in bradycardia, poor muscle tone, and poor skin turgor.
- It is not associated with hypertension or increased blood glucose levels.
Nursing Diagnoses for Imbalanced Nutrition
- Use hyperkalemia as the "as evidenced by" portion for Imbalanced nutrition due to anorexia, nausea, and vomiting.
Patient Care in Fluid Management
- Fluid volume excess may be indicated by edema and shortness of breath; include appropriate nursing diagnoses in the care plan.
Goals for Risk of Electrolyte Imbalance
- Patient's serum potassium levels should be stabilized within the normal range of 3.5-5.0 mEq/L throughout hospitalization.
Goals for Acute Pain Management
- Aiming for a muscle cramp pain rating of no more than 3 on a numeric scale within one hour after treatment initiation is key.
NOC Indicators Monitoring
- For patients with decreased cardiac output related to electrolyte imbalance, blood pressure and heart sounds should be routinely assessed to gauge the effectiveness of care plans.
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