MANASAN, Chezka Andrea S.

RLE 6.4

NURSING CARE PLAN

NURSING
CUES/CLUES RATIONALE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

CUES: Hypokalemia Potassium is essential for SHORT-TERM: INDEPENDENT:

 “Nagpacheck- many body functions. 1. To verbalize  Monitor heart rate/rhythm.  Changes associated with  Client was able to
up ako. understanding of hypokalemia include verbalize
Mababa daw Hypokalemia refers to a causative factors abnormalities in both conduction and understanding of
Potassium ko.” condition in which the and purpose of contractility. causative factors
 “Dapat nga 15 concentration of interventions and Tachycardia may develop, and and purpose of
minutes ‘di ba Potassium in the blood is medications. potentially life-threatening interventions and
ako mag- low. The most common atrial and ventricular dysrhythmias, medications.
eexercise? Eh cause of excessive loss of e.g., PVCs, sinus
wala, ‘yung 15, Potassium is often bradycardia, atrioventricular (AV)
naging 7.” associated with heavy fluid 2. To demonstrate blocks, AV  Client was able to
(fatigue) losses that “flush” behaviors to dissociation, ventricular tachycardia. demonstrate
Potassium out of the monitor and behaviors to monitor
body—a consequence of correct deficit. and correct deficit.
vomiting and diarrhea. In
addition to this, the patient
may not be sick but he/she  Maintain accurate record of  Guide for calculating
does not take enough urinary, gastric, and wound fluid/potassium replacement needs.
CLUES: Potassium in her diet that LONG-TERM: losses.
 Low Potassium predisposed to this 1. To achieve fluid
results in Blood particular condition. The volume at a  Monitor rate of IV potassium  Ensures controlled delivery of  Client was able to
Chemistry test. patient may experience functional level administration using medication to prevent bolus effect achieve fluid volume
generalized weakness, as evidenced by microdrop or pump infusion and reduce associated discomfort, at functional level as
hypoventilation due to laboratory results devices. Check for side e.g., burning sensation at IV site. evidenced by
Potassium defieciency. of patient. effects. Provide ice pack as When solution cannot be laboratory results of
indicated. administered via central vein and patient.
slowing rate is not
possible/effective, ice pack to infusion
site may help relieve discomfort.

 Encourage intake of foods and  Potassium may be

fluids high in potassium, replaced/level maintained through

1
MANASAN, Chezka Andrea S.
RLE 6.4

NURSING CARE PLAN

e.g., bananas, oranges, dried the diet when patient is allowed oral
fruits, red meat, turkey, food and fluids. Dietary replacement
salmon, leafy vegetables, peas, of 40–60 mEq/L/day is typically
baked potatoes, tomatoes, sufficient if no abnormal losses are
winter squash, coffee, colas, occurring.
tea. Discuss use of potassium
chloride salt substitutes for
patient receiving long-term
diuretics.

 Watch for signs of  Low potassium enhances

digitalis intoxication when used effect of digitalis, slowing
(e.g., reports of cardiac conduction. Note: Combined
nausea/vomiting, blurred effects of digitalis,
vision, increasingatrial diuretics, and hypokalemia may
dysrhythmias, and heart block). produce lethal
dysrhythmias.

COLLABORATIVE:
 Monitor laboratory
studies, e.g.:  Levels should be checked frequently
Serum potassium; during replacement
therapy, especially in the presence of
insufficient renal
function. Sudden excess/elevation
may cause cardiac
dysrhythmias.
ABGs;
Correction of metabolic alkalosis
raises serum potassium
level and reduces replacement needs.
Correction of
acidosis drives potassium back into
cells, resulting in
decreased serum levels and increased
replacement needs.

2
MANASAN, Chezka Andrea S.
RLE 6.4

NURSING CARE PLAN