Nursing 101 Medical Surgical Nursing I Problem # 1 Risk for Alteration in Fluid Balance r/t an Addisionian crisis General

l Goal: The patient will achieve normal fluid and electrolyte balance. Expected Patient Outcome(s): 1.) The patients blood pressure will be within normal limits on day of care. 2.) The patients serum electrolytes will be within normal levels on day of care. Nursing Interventions Rationale Patient Responses to Interventions 1. Patient monitored for VS. HR: 75, BP 118/76, Temp: 1a. Nurse will assess baseline and 1. Allows nurse to evaluate 97.6, RR: 14, SP02: 98%. Within normal limits. continue an ongoing assessment. trends. Completed. 2. Excess fluid can cause peripheral 2. Patient given 250 ml of 0.9% Sodium chloride 1b. Nurse will monitor intake and edema. A large decrease in output to due to a no urine output for the last 4hrs. output. may indicate dehydration. Completed. 1c. Nurse will administer IV fluids and medications as ordered 2a. Nurse will evaluate serum labs 3. Fluid can cause an increase in BP. 4. Labs can distinguish altered serum levels. 5. Patient maintains 5. homeostasis. 3. Patient given 1000 ml of 0.9% Sodium chloride for a BP of 80/60. BP now 120/80. Completed. 4. Patient given 1 mg of Glucagon due to a glucose level of 30. Serum level showed in increase from 30 to 120. Completed. 5. Patient given 4 g of magnesium chloride in 5% dextrose by IV infusion over 3 hours. Patient tolerated it well.

Nurse will provide health teaching 2b,regarding . __________________________ control of serum electrolytes

6. Serum electrolytes are essential in 6. Patient given K-DUR 20 mg due to a potassium level will replenish electrolytes as ___________________ 2c.Nurse ____________________________ their normal levels to obtain maximal of 3.0. Patient stopped cardiac arrhythmia. Completed. needed. body function.

Evaluation: Summarize patient progress toward expected outcomes. What revisions would you make: Patient was hypotensive. Fluid was given to correct the fluid imbalance. Patient tolerated the fluid well. Complete. No revisions need to be made. _______________________________________________________________________________________________________

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