Question

Nursing Diagnosis (Must have 3)	Goals (Measurable, specific, time line)	Interventions (include 3 for each diagnosis: Assess, monitor, teach).	Rationale (Reason for this intervention)	Evaluation (Met, partially met, not met and explain progress)
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Please Complete the care plan by using NANDA nursing diagnosis as a concept FLUID & ELECTROLYTE with the focus being on fluid and electrolyte.

Answer 1

Ans) Nursing diagnosis:

Goals:

- Patient will sustain normal serum electrolyte balance as evidenced by: sodium level of 136 to 145 mEq/L; potassium level of 3.5 to 5.1 mEq/L; chloride level of 98 to 107 mEq/L; total calcium level of 9 to 10.5 mg/dL; ionized calcium of 4.6 to 5.1 mg/dL; and magnesium level of 1,8 to 3 mg/dL.

Nursing Intervention & Rationale:

- Supply balanced electrolyte IV solutions as directed- Lactated Ringer’s solution has an electrolyte concentration similar to that of extracellular fluid. Isotonic saline (0.9% sodium chloride) may contribute to hypernatremia if used in a long period of time. Extreme use of sodium free IV solutions (e.g., D5W) puts the patient at risk for hyponatremia.

- Administer electrolyte replacements as prescribed- Oral or IV administration of electrolytes may be prescribed to keep electrolyte balance for patients at risk for imbalances.

- Consider measures to reduce excess electrolytes- Hyperkalemia is common in patients with end-stage renal disease and may result in serious electrocardiographic abnormalities. Dialysis is the definitive treatment of hyperkalemia in these patients. Intravenous calcium is used to stabilize the myocardium. Kayexalate may be indicated to patients at risk for electrolyte excesses such as potassium.

- Irrigate nasogastric tubes with isotonic saline, as prescribed- Irrigation of nasogastric tubes with plain water produces electrolyte losses. Plain water attracts electrolytes from mucosal tissue into the stomach, where they are eliminated with suctioning.

- Educate the patient about dietary sources of electrolytes- Electrolytes are salts and minerals, like sodium, potassium, calcium, magnesium, and chloride, in the body that maintain fluid balance and blood pressure. A balanced diet provides the patient with sources of electrolytes to prevent imbalances. Milk, yogurt, dark green, leafy vegetables, and legumes are excellent sources of electrolyte calcium. Whole grains, nuts, fruits, and vegetables are good sources for magnesium and potassium. Bananas are known to be the king of all potassium containing fruits and veggies. Vitamin D is needed for the absorption of calcium from the intestines.

- Educate the patient about limiting the use of over-the-counter antacids and laxatives. Excessive use of antacids that contain magnesium has a laxative effect that may cause diarrhea, and in patients with renal failure, they may cause increased magnesium levels in the blood, because of the reduced ability of the kidneys to eliminate magnesium from the body in the urine.