NANDA describes (Ackley: Nursing Diagnosis Handbook, 9th Edition)
Risk for Electrolyte imbalance
At risk for change in serum electrolyte levels that may compromise health
Diarrhea; endocrine dysfunction; fluid imbalance (e.g., dehydration, water intoxication); impaired regulatory mechanisms (e.g., diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone); renal dysfunction; treatment-related side effects (e.g., medications, drains); vomiting
Outcomes (Nursing Outcomes Classification)Suggested NOC Outcomes:
Electrolyte & Acid Base Balance, Fluid Balance, Hydration, Nutritional Status: Biochemical Measures, Nutritional Status: Food & Fluid Intake, Nutritional Status: Nutrient Intake, Kidney Function
NOC Outcome with Indicators Electrolyte & Acid/Base Balance
as evidenced by: Apical heart rate/Apical heart rhythm/Serum potassium/Serum sodium/Serum calcium (Rate the outcome and indicators of Electrolyte & Acid/Base Balance:
1 = Severe deviation from normal range, 2 = substantial deviation from normal range, 3 = Moderate deviation from normal range, 4 = mild deviation from normal range, 5 = No deviation from normal range.)
Client Outcomes Client Will (Specify Time Frame):
Maintain a normal sinus heart rhythm with a regular rate
Have a decrease in edema
Maintain an absence of muscle cramping
Maintain normal serum potassium, sodium, and calcium
Maintain normal serum pH
Interventions (Nursing Interventions Classification)Suggested NIC Interventions:
Electrolyte Monitoring, Electrolyte Management: Hypokalemia, Electrolyte Management: Hyponatremia, Fluid/Electrolyte Management, Laboratory Data Interpretation
Example NIC Activities—Electrolyte Monitoring
Identify possible causes of electrolyte imbalances; Monitor the serum level of electrolytes......I use ackly as well.
Just because it says risk of electrolyte imbalance doesn't mean you can't make it an actual risk. Actually dehydration, electrolyte imbalance.....potassium, calcium, and magnesium can kill you. One of the saddest codes I have EVER witnesses was a baby that can in so dehydrated we could not save her. Again nit having the WHOLE picture is it very difficult to help you. In your original post you never mentioned the patient had hypocalcemia.
The care plan is all about the patient and the ASSESSMENT of the PATIENT. ALl about what THE PATIENT NEEDS.
Was the calcium the only electrolyte that was abnormal? Look up hypocalcemia: Calcium regulation is critical for normal cell function, neural transmission, membrane stability, bone structure, blood coagulation, and intracellular signaling. The essential functions of this divalent cation continue to be elucidated, particularly in head injury/stroke and cardiopulmonary effects. Depending on the cause, unrecognized or poorly treated hypocalcemic emergencies can lead to significant morbidity or death. Medscape: Medscape Access
again medscape is my favourite go to professional reference.....it requires registration but it is free.
Neuromuscular and cardiovascular findings predominate. Neural hyperexcitability due to acute hypocalcemia causes smooth and skeletal muscle contractions. The patient should be examined for the following:
- Dry skin and psoriasis (if long-term hypocalcemia)
- Perioral anesthesia, cataracts, papilledema, and laryngeal stridor
- Scars over thyroid region
- Recent trauma or surgery to the neck
- Cardiopulmonary effects
- Wheezing, dysphagia, stridor, bradycardia, rales, and S3 may be noted.
- Acute hypocalcemia causes prolongation of the QT interval, which may lead to ventricular dysrhythmias. It also causes decreased myocardial contractility, leading to CHF, hypotension, and angina. Cardiomyopathy and ventricular tachycardia may be reversible with treatment.
- Smooth muscle contraction may lead to laryngeal stridor, dysphagia, and bronchospasm.
- Smooth muscle contraction causes biliary colic, intestinal colic, and dysphagia.
- Diarrhea and/or gluten intolerance (celiac sprue) may result in significant malabsorption and electrolyte abnormalities.
- Preterm labor or detrusor dysfunction may result from smooth muscle contraction.
- Peripheral nervous system findings include tetany, focal numbness, and muscle spasms.
- Classic peripheral neurologic findings include the Chvostek sign and Trousseau sign.
- Chvostek sign: Tap over the facial nerve about 2 cm anterior to the tragus of the ear. Depending on the calcium level, a graded response will occur: twitching first at the angle of the mouth, then by the nose, the eye, and the facial muscles.
- Trousseau sign: Inflation of a blood pressure cuff above the systolic pressure causes local ulnar and median nerve ischemia, resulting in carpal spasm.
- Irritability, confusion, hallucinations, dementia, extrapyramidal manifestations, and seizures may occur.
- Calcification of basal ganglia, cerebellum, and cerebrum may occur.
- Seizures often occur in individuals with preexistent epileptic foci when the excitation threshold is lowered.
So this patient with their history is...... At risk for electrolyte imbalance with documented hypocalcemia R/T.........AEB..........low calcium but........Did this patient show evidence of symptoms of electrolyte imbalance? Making more sense?