Nursing Diagnosis: Electrolyte Imbalances

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)

Emesis (correct)

Diuretic use (correct)

Diarrhea (correct)

Cardiac arrhythmia

Muscle cramps

What is the "related to" data to complete the nursing diagnostic statement for Mr.Johnson's plan of care regarding acute pain?

Hypokalemia

Which need according to Maslow supports the nursing diagnosis of Pain as a priority?

Physiological

Match Mr.Johnson's assessment data with the nursing diagnosis that it supports:

Acute pain = Muscle cramps Imbalanced nutrition: Less than body requirements = Hypokalemia Risk for decreased cardiac output = Altered cardiac rhythm Risk for electrolyte imbalance = Vomiting and diarrhea Signup and view all the answers

Match each goal statement for Mr.Johnson's plan of care with its corresponding electrolyte level:

Patient's serum Na level will be within normal limits within 48 hours. = 135-145 mEq/L Patient's serum K level will be within normal limits within 48 hours. = 3.5-5.0 mEq/L Patient's serum Ca level will be within normal limits within 48 hours. = 8.4-10.2 mg/dL Patient's serum Mg level will be within normal limits within 48 hours. = 1.5-2.0 mEq/L Signup and view all the answers

Match each nursing diagnosis in Mr.Johnson's care plan with an accurate NOC indicator:

Decreased cardiac output related to electrolyte imbalance = Heart rate and rhythm Risk for electrolyte imbalance related to diarrhea, vomiting, loop diuretic = Serum potassium Risk for imbalanced nutrition: less than body requirements = Food and fluid intake Acute pain related to electrolyte imbalances = Comfort level assessment scale Signup and view all the answers

Which is an accurate goal that the nurse should include for the new nursing diagnosis of Risk for impaired skin integrity?

Patient will report altered sensation or pain at risk areas as soon as noted. Signup and view all the answers

Which indicators should the nurse monitor for the NOC of Electrolyte and acid-base balance? (Select all that apply)

Apical heart rate and rhythm Signup and view all the answers

Which findings on the nursing assessment may be associated with hypokalemia? (Select all that apply)

Poor skin turgor Signup and view all the answers

Which electrolyte imbalance should the nurse use as the "as evidenced by" portion for the nursing diagnostic statement of Imbalanced nutrition?

Hypercalcemia Signup and view all the answers

Which nursing diagnosis should the nurse include in the updated plan of care for a patient with edema and shortness of breath?

Fluid volume excess related to electrolyte imbalances, as evidenced by edema and shortness of breath. Signup and view all the answers

What is an accurate goal statement for a patient experiencing nausea, vomiting, and diarrhea?

Patient's serum potassium level will be within the normal range of 3.5-5.0 mEq/L during the hospitalization. Signup and view all the answers

Which goal should the nurse include for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances?

Patient will report a muscle cramp pain rating of no more than 3 on a 1 to 10 numeric scale within 1 hour of implementing prescribed treatment. Signup and view all the answers

Which indicators should the nurse monitor to determine the effectiveness of the current plan of care for Decreased cardiac output related to electrolyte imbalance?

Blood pressure = Effective cardiac function Heart sounds = Assessment of heart activity Signup and view all the answers

Study Notes

Risk for Electrolyte Imbalance Factors: Diarrhea, emesis, and diuretic use are key contributors to electrolyte imbalances.
Acute Pain Related to Electrolyte Imbalances: Hypokalemia is identified as the "related to" factor in Mr. Johnson’s acute pain due to muscle cramps.
Maslow's Hierarchy: Pain is categorized under physiological needs, making it a priority in care.

Assessment and Nursing Diagnoses

Matching Assessment Data:
- Acute pain is linked to muscle cramps.
- Imbalanced nutrition results from hypokalemia.
- Risk for decreased cardiac output is indicated by altered cardiac rhythm.
Goal Statements for Electrolyte Levels: Establish goals for serum sodium (135-145 mEq/L), potassium (3.5-5.0 mEq/L), calcium (8.4-10.2 mg/dL), and magnesium (1.5-2.0 mEq/L) within 48 hours.

Nursing Outcomes Classification (NOC)

Indicators:
- Decreased cardiac output is monitored through heart rate and rhythm.
- Electrolyte imbalance is evaluated using serum potassium levels.
- Imbalanced nutrition is assessed via food and fluid intake.
- Acute pain measurement involves using comfort level assessment scales.

Caring for Patients with Skin Integrity Issues

Risk for Impaired Skin Integrity: An accurate goal includes patients reporting pain or altered sensations in at-risk areas promptly.

Monitoring Electrolyte Imbalances

NOC Indicators for Electrolyte Balance:
- Monitor apical heart rate and rhythm, as well as serum potassium levels for signs of electrolyte balance.
Associated Findings of Hypokalemia: Bradycardia, poor muscle tone, and poor skin turgor are symptoms related to low potassium levels.

Nutrition and Electrolyte Imbalances

Nutritional Assessment: If imbalanced nutrition is in the care plan due to anorexia, nausea, and vomiting, hypercalcemia should be considered as part of the assessment.

Nursing Diagnosis for Fluid Overload

Fluid Volume Excess: Indicated by shortness of breath and edema due to electrolyte imbalances.

Goal Setting for Patient Care

Goals for Electrolyte Levels: Aim for normal serum potassium during hospitalization for patients at risk for electrolyte imbalance.
Pain Management Goals: Focus on achieving reduced muscle cramp pain ratings within an hour of implementing treatment.

Indicators for Cardiac Effectiveness

Monitoring for Decreased Cardiac Output: Blood pressure and heart sounds should be regularly checked to assess treatment effectiveness for electrolyte imbalance.

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Description

This quiz focuses on nursing diagnoses related to electrolyte imbalances, particularly assessing factors that contribute to the risk of imbalances. Participants will learn to identify relevant assessment data such as diarrhea, emesis, and diuretic use that are crucial for planning effective nursing interventions.