Nursing Care Plan for Hypokalemia

NCP - Nursing Care Plan Patient with Hypokalemia

Assessment

The assessment is the basic thinking of the nursing process which aims to collect information or data about the patient, in order to identify, recognize problems, health and nursing needs of patients, either physical, mental, social, and environmental. (Nasrul Effendy, 1995)

1. Activity or rest
   Symptoms: general weakness, latergi.
2. Circulation
   Signs :
   • Hypotension
   • Pressure Pulse weak or declining, not regular.
   • The sound of distant heart.
   • Changes in the characteristics of the ECG.
   • Disritmis, PVC, tachycardia / ventricular fibrasi.
3. Elimination
   Signs :
   • Nocturia, polyuria when a ballast factor of hypokalemia include GJK or DM.
   • Decrease in bowel sounds, decreased mortilitas, colon, paralytic ilues.
   • Abdominal distension.
4. Food / liquids
   Symptoms: Anorexia, nausea, vomiting.
5. Neurosensori
   Symptoms : parestesia
   Signs :
   • Decrease in mental status / mental chaos, apathy, drowsiness, sensitive to stimulation, coma, hiporefleksia, tetani, paralysis.
   • Decrease in bowel sounds, decreased mortilitas, colon, paralytic ileus.
   • Abdominal distension.
6. Pain / comfort
   Symptoms : pain / muscle cramps
7. Respiratory
   Signs : hypoventilation / decrease in respiratory muscle weakness or paralysis of the diaphragm.
   (Marilyn E. Doenges 2002 p. 1048)

Because hypokalemia can be life threatening, it is important to monitor the incidence of hypokalemia pad-risk patients. The presence of fatigue, anorexia, muscle weakness, decreased bowel mortilitas, parestesia, or dysrhythmias should encourage nurses to check the serum potassium concentration. If available, the electrocardiogram can provide information that bernmanfaat. Patients who received digitalis are at risk of potassium deficiency should be monitored closely for signs of digitalis toxicity due to hypokalemia increase the action of digitalis. In fact, doctors usually choose to maintain serum potassium levels greater than 3.5 mEq / L (SI: 3.5 mmol / L) in patients receiving digitalis. (Brunner & Suddarth, 2002, hal.261)

B. Nursing Diagnosis

1. Impaired sense of comfort, pain related to disease processes hypokalemia.
2. Impaired skin integrity related to physical immobilization due to fatigue.
3. Hipertermi related to the failure to overcome the infection from the disease hypokalemia.
4. Activity intolerance related to fatigue due to decreased muscle function in the body.
5. Changes in nutritional patterns related to anorexia, nausea and vomiting.
6. Lack of knowledge related to the lack of information.