Question

5. On day 2 of his hospital stay, Mr. Abdul begins to complain of increased muscle weakness and cramping. Assessment findings include an irregular apical pulse and hypoactive bowel sounds. Provide a possible explanation for these findings and identify appropriate nursing action.

Answer 1

5. The assessment findings of irregular apical pulse and hypoactive bowel sounds indicate that the patient has hypokalemia. Hypokalemia is a clinical condition where the potassium level is below 3.5mEq/L. This occurs when sufficient fluid is not present in the body due to vomiting, diarrhea, or poor oral intake. This leads to the symptoms of fatigue, tiredness, muscle cramps, arrhythmia, and constipation.

Nursing Intervention:

• Monitor heart rate and rhythm.
• Assess the respiratory and renal status.
• Assess the signs and symptoms of the patient.
• Monitor intake and output.
• Check the electrolyte levels of magnesium, sodium, chloride, and glucose.
• Initiate oral or IV supplements.
• Encourage to take potassium rich diet such as orange, potatoes, tomatoes, spinach.