Oh, Care Plans....Hyperkalemia

HH_RN13, ASN, RN · Oct 25, 2012

Just a hint, the electrolyte imbalance wouldn't be a risk, it would be the actual problem since u said she did have hyperkalemia. Try this link for explanation of the relationship between potassium and insulin http://www.ncbi.nlm.nih.gov/m/pubmed/2141843/

Other nursing diagnosis would be risk for decreased cardiac output r/t possible arrhythmias due to high serum potassium

Also definitely the ineffective therapeutic management

It is also easier to come up with nursing diagnosis if u have the data from ur assessment of the patient rather than just lab values.

Did she have edema? Irregular heart rate? Anything else?

Kidney function will eventually be impaired in individuals with dm, especially for those who are not adhering to the treatment plan. That could also be the cause of hyperkalemia.

Stephalump · Oct 25, 2012

Just a hint, the electrolyte imbalance wouldn't be a risk, it would be the actual problem since u said she did have hyperkalemia. Try this link for explanation of the relationship between potassium and insulin Hyperkalemia in diabetes mellitus. - PubMed Mobile
Other nursing diagnosis would be risk for decreased cardiac output r/t possible arrhythmias due to high serum potassium
Also definitely the ineffective therapeutic management
It is also easier to come up with nursing diagnosis if u have the data from ur assessment of the patient rather than just lab values.
Did she have edema? Irregular heart rate? Anything else?
Kidney function will eventually be impaired in individuals with dm, especially for those who are not adhering to the treatment plan. That could also be the cause of hyperkalemia.

Thanks! And thanks for the link. The physician was explaining the possible link between insulin and potassium to me but it was a little too over my head at that point. :whistling:

"Risk for" seemed a bit weird but simply "electrolyte imbalance" wasn't on my NANDA list so I wasn't sure if I could use it. There wasn't really anything to speak of during my assessment because my patient was pretty much back to normal by the time I got there, just some weakness. She had arrythmias when first admitted along with chest pain (suffers from angina normally, though), no mention of edema or anything that I saw.

EricJRN, MSN, RN · Oct 26, 2012

Just out of curiosity, why was the patient concerned about dehydration?

What was the timing of the muscle weakness? I didn't catch that in your description of the patient's story.

Do you have vital signs?

I don't know that activity intolerance is exactly on target. Generalized weakness is listed as a related factor for this nursing diagnosis, but your AEB portion doesn't show that the patient was actually activity intolerant.

Esme12, ASN, BSN, RN · Oct 26, 2012

So I'm doing a care plan on my pt from last week. She was hyperkalemic (7.3), but they hadn't 100% determined the cause. It was discussed that she had gone on vacation for 3 days without taking her insulin with her (type 2) and that could have been the reason for the hyperkalemia, but she told me she might have been dehydrated when she came in which could be another cause? My instructor also mentioned that she could be dealing with renal problems (creatinine was 2.09) but it wasn't ever mentioned in her chart or by the physicians the day I was there. They gave her Kayexalate and lots of normal saline and her levels came down fairly quickly.
So for my diagnoses I have
risk for Electrolyte Imbalance R/T ???,
risk for Unstable Blood Glucose Level R/T lack of adherence to diabetes management
Activity Intolerace R/T left side skeletal muscle weakness and numbness AED patient report of limited feeling on left side
risk for Decreased Cardiac Output r/t hyperkalemia
We have to come up with 3-10 nursing Dxs and priorotize the top 3 and I'm sure I could come up with more if I knew the actual cause of her hyperkalemia, so I guess I'm not sure if I should try to figure it out to be more thorough or just go with the basics from above?
I know this is kind of vague because I'm not 100% sure of what I'm asking either, but any input would be good!

Stephalump.......How does this help know about your pateint? What your assessment is......

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at).

The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

So tell me about your patient.......What do they need? What do they c/o? Did he have a surgical intervention/evacuation of the hematoma? What is your assessment......What does this tell me about the patient?

She was hyperkalemic (7.3), but they hadn't 100% determined the cause. It was discussed that she had gone on vacation for 3 days without taking her insulin with her (type 2) and that could have been the reason for the hyperkalemia, but she told me she might have been dehydrated when she came in which could be another cause?

Think about DKA.........What was YOUR assessment