Question

1. A patient has just received an administration of an intravenous potassium too rapidly.

a. Develop one care plan for this case study.. It should contain a NANDA nursing diagnosis, one goal, and at least four nursing interventions. Nursing interventions are not doctor’s orders

Answer 1

Risk for electrolyte imbalance (hyperkalemia) related to massive and rapid infusion of intravenous potassium chloride.

Other related factors that can be included are renal disease, treatment related side effects from NSAIDs, k sparing diuretics, transfusion of banked blood etc.

Expected outcome.

Client will display heart rate, blood pressure, and laboratory results within the normal limit and absence of paresthesia, muscle weakness, and cognitive impairment.

Interventions.

Connect the patient to a cardiac monitor and continously monitor the heart rate and rhythm.

Obtain a 12 lead ecg and observe for hyperkalemia changes such as peaked TWave, prolonged QT interval, loss of P wave and wide QRS complex.

Monitor respiratory rate and depth. Encourage deep breathing and coughing exercise. Elevate the head of the bed.

Monitor urine output.

Review the drug regimen. Administer the following medication as indicated.

Loop diuretics such as frusemide

Beta adrenergic blockers such albuterol nebulisation.

Calcium gluconate

Dextrose with insulin or bicarbonate.

Still potassium is very high plan for dialysis.

Monitor laboratory results, such as serum potassium and arterial blood gasses, as indicated.