Question

PN 200 Fundamentals of Nursing II Concept Map - Hypokalemia 7:30AM Mr. Sam Downs is admitted to your unit from the emergency room. He is 71 y/o/ male. Weight upon admission 156; Ht 5" 11" T 97.2; R 22 and shallow; P 102 and easily obliterated; B/P 102/76. NKA. Primary admitting diagnosis is altered mental status. He is lethargic and has difficulty responding to question rapidly but given time he can answer all questions. He is also very somnolent. He denies pain and can move all extremities freely with no limited range of motion. On assessment you note that the heart rate is irregular and bowel sounds are diminished. You notice a Heparin lock in his left hand. His admission orders are as follows: CMP UA Свс EKG Start an IV of 09 % NS; 1000 cc to run over 12 hours. The drop rate is 15 gtts per cc. Insert retention catheter. Strict I & Regular diet Metropolol 25 mgm by mouth twice daily Lasix 20mgm one tablet by mouth daily Potassium Chloride 10mEq one tablet by mouth daily. . Lipitor 20mgm one tablet by mouth at bedtime. 1. Which of the above medications would you question when verifying orders? You receive the laboratory results and note the following as abnormal values: BUN .45 K 3.2 Hgb 22

Answer 1

Hypokalemia;

Hypokalemia: la level The elctoly t petassium th The Blea you booy neids Spotassium a minesal t wolk nosmally PIE involvR The musu to move, eell t et Nutsient Thoy nasd onol Nesve send the sgnals blocol Flussure om LTt keap igh

Nursing diagnosis;

NIKsioy diagoost Fluid Balanu s-yPuvolemta a typovelemia Enuss fuid volume (Hypuvolemias Deditiont fuid volume t typovole miaj posassium Imbalanus pkalemia High lavel 7 poTassiun HyPokalemia louo level potassium Sodium Tmbalanas- sodium Aypunatramia gh level Hy ponatiemia low avel sadium magnesium tmaTmbalanus manesemia tgh devel1 magnesium p nesemialow lavel magnastum caeium Cas Tnbalanu: percalcemia nuas leuel ealeum dacalcemia low leuel Laliem Blooel

Nursing intervention;

level consuiousness and Nezo musulas fancston montton vital Blood Aussurs, Signg such as Neart Rab, Respiaerto aat, Tempesatu, pu lse rati centaal ven Dus Pessre favailab4 monttas weight The client and, check checle for ipiHing Edema and dyspnea (Lung and heaat sounds. Asuttati uainazy output edema and loualior Assess B0A paisence

Therapeutic intervention;

cliureties as Endtcalad Admintstes 0aal idl wh caurtion ast deep bacahing and toughing Administr EnLourage adiqual Bred EnLousage Excercise Bed in low pasition, Thegunk obsegvarion Such as valu laboratory tesk od uzea manito Nib sodlium, Blo and artrial Blood ses tpw a pota sium,

Positive outcome;

heaat shy Thm and will display client NDRMal limik within the esulta 1aboratory and absence7 Paas husias, musul impaiment for client and weaknoss

Negative outcomes;

Ngatiue outcomis 1u03 2 weakns ss and aligu musele Uamps and Spasms HRait palpitations s Brndthing diffiaulties => vomi disodus ni ting, dianhea, adunal glard Abnoamal ROAt hythms 40.sflp At emi HOP

Evaluation;

Assessment uainary potassium Enaulior 24 hour ine Potassium SPOK usine poassium oncerlalio rine Potassium to ceatinine ato Ass cls Assess merb auid base status metabolic acidosi wh low Seul Encretion Potassium metabolicalkalages wTh louw ral Potassium enaetion du surteptitios vomi tong LTmaging adrenal lands Eleetro caldlio graphygecommended fo patenk with hypokalimia all