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NCP Electrolyte Imbalance

The client reports dry mouth and is exhibiting signs of dehydration including pale conjunctiva and decreased skin turgor. The nurse's goals are to improve the client's hydration status through encouraging fluid intake, monitoring intake and output, and providing comfort measures. The client also demonstrates a need for education regarding electrolyte imbalance and dehydration as evidenced by questions. The nurse plans to provide learning materials and teach the client to identify support systems and risk factors to promote understanding and adherence to treatment.

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Sarah Benjamin
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2K views2 pages

NCP Electrolyte Imbalance

The client reports dry mouth and is exhibiting signs of dehydration including pale conjunctiva and decreased skin turgor. The nurse's goals are to improve the client's hydration status through encouraging fluid intake, monitoring intake and output, and providing comfort measures. The client also demonstrates a need for education regarding electrolyte imbalance and dehydration as evidenced by questions. The nurse plans to provide learning materials and teach the client to identify support systems and risk factors to promote understanding and adherence to treatment.

Uploaded by

Sarah Benjamin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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ASSESSMENT

Subjective
>Client reports dryness of
her oral mucosa
Objective
>Vital signs
T:35.4
PR:60
RR:22
BP:100/60
>pale conjunctiva

PLANNING
Short-term goal

INTERVENTION
RATIONALE
Independent
>Assess for the signs of
>To determine the cause
At the end of this shift, the dehydration including skin of pharyngeal pain. This
client exhibit signs of
turgor, oral mucosa, etc.
will provide a data that
improvement in hydration
could be used to evaluate
status.
the proper intervention
that the client needs.

EVALUATION
After doing the necessary
nursing interventions and
teachings, the client:

>Review ways to improve


the clients hydration
status

>normal appetite
>has intermittent fever

>Ensure that the client is


receiving right amount of
maintenance fluids.

>decreased skin turgor


>normal capillary refill
time
>elevated WBC count

>Provide comfort
measures

>Achieved appropriate
urine output

>Encourage the client to


increase the fluid intake.

>To reduce the dryness of


the oral mucosa

>Participated in health
teaching

>Monitor I & O and IV


fluids

>To determine if IV fluid


and electrolyte
replacement are needed

>Followed the prescribed


pharmacological regimen.

>Keep a quiet
environment and calm
activities.

>To reduce stress and


anxiety

>Provide health teachings


on avoidance of
dehydration

>To promote awareness on


related factors

>Demonstrated use of
relaxation skills to reduce
anxiety

PRIORITY #2: Deficient knowledge (Learning need) regarding electrolyte imbalance as evidenced by verbalization of
questions and concerns.
ASSESSMENT
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective:
Short term goal:
>Assess level of
>Some clients may need
>Client responded to the
>Verbalization of
>Assist client to use given knowledge of the client.
the help of SO or
learning plan and actions
questions:
information in all
caregivers to learn.
performed.
Ano bang causes ng
applicable areas including
dehydration at
environmental causes
>Determine the clients
>Client might not be
gastroenteritis?
readiness and barriers to
physically or emotionally >Client provided a
>Provide information and learning.
capable at this time.
positive feedback and
self-learning modules
adherence to the teaching.
Objective:
regarding her disease
>Identify support persons. >Reinforcement learning
>Vital signs
(e.g. mother, other family process allows the client to
T:35.4
members)
proceed at her own pace.
>Client was able to deal
PR:60
>Give information
with her anxiety.
RR:22
accurately and clearly.
BP:100/60
>Teach the client to cease >To give awareness on the
alcohol consumption
possible complications of
>Inaccurate understanding
because of the possible
having vices
of her disease
complications.
(pathophysiology)
>Begin with the info the
>Can arouse interest/limit
client already know and
sense of being
move to what she does not overwhelmed.
know, progressing from
simple to complex.

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