NURSING CARE PLAN

Learning Packet Activity 3

DIENIZS LABINI BSN-3E
 HYPERCALCEMIA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for injury r/t Short-term 1. Assess 1. To report any Short-term Goal:

”Madalas na loss of calcium in Goal: neurologic and changes of the pt. After 3 hours,

pagsakit ng aking the bones and the After 3 hours, neuromuscular conditions. patient will be able

mga buto lalo na effect of patient will be function. 2. To increase to verbalize

sa aking paa at hypercalcemia on able to verbalize 2. Insert and excretion of the understanding of

paghina ng aking muscle srength understanding of maintain IV Ca. individual factors

kamay lalo na pag individual factors access. 3. To promote Ca that contribute the

nagbubuhat ako ng that contribute 3. Encourage the excretion. possibility of

mabigat parang the possibility of patient to drink 4. To protect the pt. injury and take

nawawalan ng injury and take 3-4 L of fluid from risk of steps to correct

pwersa ang aking steps to correct unless injuries/fractures. situation.

muscles.” As situation. contraindicated. 5. To prevent

verbalized by the 4. Provide a safe further injuries. Long-term Goal:

patient. Long-term Goal: environment After 7 days,

patient will be free

Objective: After 7 days, and keep side from injury

 Decreasd patient will be rails raised. associated with

muscle free from injury 5. Handle patient calcium excess, as

tone associated with gently—prone evidenced by no

 Bone pain calcium excess, to pathologic falls or near falls

Temp: 36.6 as evidenced by fractures. and no pathologic

PR: 70 bpm no falls or near fractures.

RR: 18 cpm falls and no GOAL WAS

BP: 120/80 mmHg pathologic PARTIALLY

fractures. MET.

HYPOCALCEMIA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for injury r/t Short-term Goal: 1. Monitor VS 1. To assess Short-term Goal:

“Namamanhid ang increased After 6 hours, the and peripheral baseline data. After 6 hours, the

aking labi, pati neuromuscular pt. will be able to pulses; pt. will be able to
narin ang aking irritability verbalize especially the 2. To assist client verbalize

kamay at paa.” As secondary to understanding of respiratory to reduce understanding of

verbalized by the hypocalcemia. individual factors rate for individual risk individual factors

patient. that contribute to dyspnea, factor. that contribute to

Objective: the possibility of stridor and 3. To check for the possibility of

 Muscle injury and take WOF every the increased injury and take

cramps steps to correct hour to every 4 level of the steps to correct

 Irritability situation. hours tetany and situation.

 Tetany depending on neuromuscular

 Diarrhea Long-term Goal: the client’s irritability. Long-term Goal:

Temp: 36.8 After 14 days of situation. 4. To prevent After 14 days of

PR: 65 bpm nursing 2. Provide risk for nursing

RR: 20 cpm interventions, the information Chvostek’s interventions, the

BP: 110/70 mmHg client will be free regarding and client will be free

from injury diseases that Trousseau’s. from injury

associated with may result in associated with

calcium deficit, as increased risk 5. To elevate the calcium deficit, as

evidenced by no of injury. To risks of evidenced by no

falls or near falls assist client to Calcium falls or near falls

and no pathologic reduce or deficit by and no pathologic

fractures. correct taking drug fractures.

individual risk therapy. GOAL WAS MET.

factor. 6. To provide

3. The serum calm, quiet

calcium level environment

should be for the pt.

monitored

closely and

changes

reported.
 4. Check for

signs of

tetany.

5. Administer Ca

replacement

therapy.

6. Environmental

Management

HYPERKALEMIA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Short-term Goal: 1. Assess VS 1. To provide Short-term Goal:

“Madalas ang Electrolyte After 3 hours of 2. Monitor I and O baseline data After 3 hours of

aking pagkahilo Imbalances r/t health teachings: 3. Monitor heart rate. for health teachings:

at pagtatae. renal disease Be aware that

Namamanas din secondary to  The patient cardiac arrest can hyperkalemi  The patient

ako at ang hina ng hyperkalemia will be able occur. a. will be able

katawan ko” as to 4. Monitor respiratory 2. In kidney to recognize

verbalized by the recognize rate and depth. failure, the s/sx of

patient. the s/sx of Encourage deep potassium is hyperkalemi

hyperkalem breathing and retained a.

Objective: ia. coughing exercise. because of  Identify

 Dry skin  Identify 5. Monitor serum improper measure to

 Abdomin measure to potassium and ECG excretion. prevent

al prevent closely during 3. Potassium hyperkalemi

Cramping hyperkalem treatment. excess a.

 Edema ia. 6. Instruct patient in depresses  Participate in

 Oliguria  Participate use of potassium myocardial treatment

 Weakness in treatment containing foods conduction. regimen.

 Irregular regimen. and salt substitutes. 4. Clients may

Pulse 7. Health Teachings: hypoventilat

Temp: 37.3 Long-term Goal:  Select food e and retain Long-term Goal:

PR: 110 bpm After 5 days, the that don’t carbon After 5 days, the

RR: 28 cpm patient will be able stimulate dioxide patient will be able

BP: 140/90 to maintain the peristalsis. resulting in to maintain the

mmHg serum potassium  Explain s/sx respiratory serum potassium

level within normal of acidosis. level within normal

ranges. hyperkalemi 5. Evaluate ranges.

a. therapy GOAL WAS MET.

8. Loop diuretics such needs and

as furosemide. effectiveness

9. Prepare for assist .

with dialysis. 6. Prevention

of

hyperkalemi

a can be

managed
 with diet,

supplement

and

medications.

7. It facilitates

reduction of

potassium

levels and

may prevent

recurrence of

hyperkalemi

a.

8. Promotes

renal

clearance

and
 potassium

excretion.

9. Maybe

required

when more

conservative

methods fail.

HYPOKALEMIA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Altered Short-term Goal: 1. Monitor VS 1. To provide Short-term Goal:

“Ilang araw na ang Electrolyte After 1 hour of accurately. baseline data. After 1 hour of

aking pagtatae at Balance r/t health teaching, 2. Monitor for the 2. Carefully health teaching,

pagsusuka, kaya active fluid loss client will be able s/sx of assess patient client will be able

ngayon ng hihina secondary to to: hypokalemia. with to:

na ang aking hypokalemia

katawan.” As vomiting and  Identify 3. Monitor ECG because it is  Identify

verbalized by the diarrhea measure to continuously. life- measure to

patient. prevent 4. Strict monitoring threatening prevent

hypokalemia of intake and for high risk hypokalemia

Objective:  Participate output. patients.  Participate

 Muscle in the 5. Health 3. The ECG can in the

Weakness treatment Teachings: provide treatment

 Diarrhea: regimen.  If client is useful regimen.

watery on information

stool for 4 Long-term Goal: digoxin for Long-term Goal:

times in a After 2 days, the therapy, hypokalemia. After 2 days, the

day for 2 patient will be able teach 4. Careful patient will be able

days to maintain serum patient to monitoring to maintain serum

 Oliguria potassium levels recognize of fluid I and potassium levels

Temp: 38.6 with normal range. and report O is with normal range.

PR: 115 bpm s/sx of necessary GOAL WAS MET.

BP: 90/50 mmHg digoxin because 40

toxicity. mEq/ of

 Assist potassium is

client in lost for every

selecting liter of urine.

food rich 5. It is

in important for

potassium the patient to

6. Insert and have

maintain IV awareness

access especially and prevent

intravenous toxicity.

potassium 6. To facilitate

supplement and the normal

oral potassium values of

supplement. potassium
 and evaluates

the

effectiveness

of the drug

therapy.

HYPERNATREMIA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid Volume After 24 hours of 1. Monitor 1. To assess After 24 hours of

“Kahit kunti lang Deficit r/t nursing vital signs as baseline nursing

iniinom ni Llolo na inadequate fluid interventions, the appropriate. data. interventions, the

tubig ay marami intake, vomiting patient will be able 2. Obtain 2. Urine patient will be able

padin siyang naiihi and diarrhea as to maintain fluid specimen analysis to maintain fluid

at madalas.” As evidenced by volume level as for analysis provide volume level as

evidenced by the decreased urine evidenced by of altered information evidenced by

patient’s relative. outputs, fever, adequate urinary sodium adequate urinary

 extreme thirst, slow output with normal levels as about loss of output with normal

Objective: turgor, weakness, specific gravity, indicated. sodium. specific gravity,

 Decreased dyspnea and stable VS, and good 3. Weigh daily 3. Weighing stable VS, and good

skin turgor increased BP. skin turgor. and monitor the patient skin turgor.

 Generalized activities. daily will GOAL WAS MET.

body 4. Monitor assess the

weakness Input and fluid

 Dry mucous Output balance.

membranes record. 4. Accurate

Temp: 37.2 5. Give IV records are

PR: 96 bpm therapy as critical in

RR: 25 cpm prescribed. assessing

BP: 140/90 mmHg 6. Provide patient’s

frequent oral fluid

hygiene. balance.
 5. To replace

loss volume.

6. Oral mucous

membrane

become dry

and sticky

due to loss

of fluid.

HYPONATREMIA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid Volume Short-term Goal 1. Monitor and 1. To assess Short-term Goal

“Kanayon nga Excess r/t increased After 3 hours, the record VS. baseline After 3 hours, the

agsakit etoy ulo’k, SIADH as patient will be able 2. Obtain a data. patient will be able

haan nak unay evidenced by to demonstrate urine sample 2. To measure to demonstrate

makaisisbo ken weakness, sufficient and blood the level of sufficient

agkakapsotak” as irritability and knowledge of sample of circulating knowledge of

verbalized by the decrease urinary SIADH and its the patient. ADH in the SIADH and its

patent. output. management. 3. Restrict body. management.

fluid intake. 3. To prevent

Objective: Long-term Goal: 4. Monitor more build Long-term Goal:

 Generalized After 3 days, the neurologic up fluid in After 3 days, the

weakness patient will be able status the body. patient will be able

 Fatigue to re-establish a frequently. 4. To check to re-establish a

 Restlessness normal electrolyte 5. Monitor I the status of normal electrolyte

 Oliguria and fluid balance. and O neurologic. and fluid balance.

 Irritability accurately. 5. To GOAL WAS MET.

 Poor skin 6. Weigh accurately

turgor patient. measure the

7. Increase input and

 Hypertension
intake of Na output of the

patient and
  Rapid 8. Administer to ensure

bounding IV as that fluid

pulse ordered. restriction is

Temp: 36.3 performed.

PR: 110 bpm 6. To

RR: 23 cpm effectively

BP: 149/90 mmHg monitor the

patients

daily

nutritional

intake and

output and

progress of

weight loss

goals.
 7. To helps

regulate

acid-base

balance.

8. To maintain

normal fluid

balance.

HYPERMAGNESEMIA
ASSESSMENT DIAGNOS PLANNING INTERVENTION RATIONALE EVALUATION

IS

Subjective: Risk for Short-term Goal: 1. Monitor VS 1. To assess baseline Short-term

“Nadaras nak nga Electrolyte After 1 hour of accurately. data. Goal:

mabannog, narigat Imbalance health teachings, 2. Neuromuscular After 1 hour of

nak makanges ken the patient will be transmission is health teachings,

kanayon r/t Renal able normalize 2. Assess blocked by excess the patient will

agkakapsot detoy Dysfunction the s/sx of neuromuscular Mg, resulting in be able

muscles ko’ as hypermagnesemi system. respiratory normalize the

verbalized by the a and participate 3. Restrict dietary Mg muscular weakness. s/sx of

patient. in treatment intake and avoid 3. Limit dietary intake hypomagnesemi

regimen. giving medications to help avoid a and participate

Objective: with Mg. increased in treatment

 Generalize Long-term Goal: 4. Provide adequate magnesium. regimen.

d weakness After 48 hours, fluids. Oral/IV. 4. Increased hydration

 Lethargy the client will be 5. Administer promotes excretion Long-term

 Occasional able to display medication as of Mg; however Goal:

nausea heart rate, indicated. fluid intake must be After 48 hours,

 Irritability rhythm, muscle  Loop cautious in the event the client will be

 Shallow strength, and diuretics of cardiac or renal able to display

breathing laboratory results and IV failure. heart rate,

within normal fluids. rhythm, muscle

  Hypotensi limits for client  Ca 5. Administer strength, and

on and absence of Gluconate medication as laboratory

Temp: 36.8 neuromuscular  Hemodialys indicated: results within

PR: 58 bpm irritability. is- Mg-free  Promotes normal limits for

RR: 12 cpm dialysate. renal client and

BP: 80/60 mmHg clearance of absence of

Mg if kidney neuromuscular

fx is normal. irritability.

 Antagonize GOAL WAS

action and MET.

reverses

symptoms of

Mg toxicity

to improve

neuromuscul

ar function.
  Dialysis

may be

indicated to

lower Mg

levels, in

case of

presence of

renal failure.

HYPOMAGNESEMIA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Short-term 1. Monitor 1. Magnesium Short-term Goal:

“Narigat nak nga Electrolyte Goal: cardiac rate influences Na After 1 hour of

makatilmon ken Imbalance r/t After 1 hour of and rhythm and K health teachings,

kanayon ti Malnutrition health teachings, and transport the patient will be

panagsarwak the patient will be characteristics across the cell able normalize the
karaman na pay ti able normalize of ECG membrane and s/sx of

panagsakit toy the s/sx of changes. affects hypomagnesemia

tomeng ko” as hypomagnesemia 2. Monitor signs excitability of and participate in

verbalized by the and participate in for Digoxin cardiac tissue. treatment regimen.

patient. treatment intoxication 2. Mg deficit

regimen. when used, may Long-term Goal:

Objective: including precipitate After 48 hours, the

 Dysphagia Long-term Goal: reports of digoxin client will be able

 Poor skin After 48 hours, nausea. therapy. to display heart

turgor the client will be 3. Assess level of 3. Confusion, rate, rhythm,

 Leg cramps able to display consciousness irritability and muscle strength,

 Weakness heart rate, and psychosis may and laboratory

 Weight rhythm, muscle neuromuscular occur. results within

loss strength, and status. 4. Laryngeal normal limits for

 Vomiting laboratory results stridor and client and absence

Temp: 37. 5 within normal dysphagia can

PR: 110 bpm limits for client 4. Monitor status occur when of neuromuscular

RR: 16 cpm and absence of of airway and depletion is irritability.

BP: 120/80 mmHg neuromuscular swallowing. moderate to GOAL WAS

irritability. 5. Encourage severe. MET.

range of 5. Reduces

motion deleterious

exercises. effects of

6. Encourage muscle

intake of dairy weakness.

products, 6. Provide oral

whole grain, replacement

green leafy for mild Mg

vegetables, deficit; may

meat and fish. prevent

7. Instruct client reoccurrence.

in proper use
 of laxatives 7. Deficit maybe

and diuretics. the results of

8. Observe for abuse of these

signs of drugs.

magnesium 8. Excessive IV

toxicity during replacement

replacement may lead to

therapy. toxicity and

9. Monitor life-

laboratory threatening

status as serum complications.

Mg, calcium, 9. Evaluates

and K levels. therapy needs

an

effectiveness.