ASSESSMENT NURSING PLANNING (with RATIONALE and reference) IMPLEMENTATION EVALUATION

DIAGNOSIS
Risk for Goal of care: After 8 hours of nursing intervention client At the end of 8 hours
SUBJECTIVE CUES: electrolyte will be able to identify ways to promote wellness nursing intervention the
PATIENT imbalance client was able
VERBALISED related  Identify Gastrointestinal fluid losses.  Identified enumerate ways to
vomiting R: Gastrointestinal losses from diarrhea, vomiting, Gastrointestinal fluid promote wellness
I still have a or nasogastric suctioning also are typical causes of losses.
headache and I feel hypokalemia. Vomiting leads to hypokalemia via as evidenced by:
very nauseous complex pathogenesis. Gastric fluid holds little
potassium, around 10 mEq/L. Nevertheless,
vomiting produces volume depletion and  Goal met
OBJECTIVE CUES: metabolic alkalosis, which are accompanied by  Client
 2 episodes increased renal potassium excretion. verbalized
of vomiting  Identify any clinical conditions or situations that  Identified any clinical “now I
 Upon may be a factor for an imbalance in serum conditions or situations understand the
tonometry, electrolytes. that may be a factor importance of
her IOP R: Assessing a patient for electrolyte imbalance for an imbalance in eating
revealed 29 can give health care providers an insight into the serum electrolytes. vegetables and
mmHg homeostasis of the body and can serve as a fruits as they
 BP 140/100 marker for the presence of other illnesses. are sources of
mmHg Prevention of electrolyte irregularities begins with electrolytes”
 Na – 116 the identification of situations that put the patient
mEq/L at risk for imbalance.
Normal  Monitor serum electrolyte levels.  Monitored serum
Range: 135 R: The levels of electrolytes in the body can electrolyte levels
to 145 become too low or too high. Early detection of
abnormality in serum electrolyte levels allows
prompt initiation of measures to prevent further
imbalances.
 Provide adequate dietary consumption  Provided adequate
R: The patient’s fluid and food intake have a direct dietary consumption
impact on the risk of electrolyte imbalance. A
serum sodium level below 135 mEq/L is
 considered hyponatremia. This state can be due to
low levels of sodium or to excess water in
connection to the amount of sodium, referred to
as dilutional hyponatremia.
 Supply balanced electrolyte IV solutions as
directed.  Supplied balanced
R: Lactated Ringer’s solution has an electrolyte electrolyte IV solutions
concentration similar to that of extracellular fluid. as directed.
Isotonic saline (0.9% sodium chloride) may
contribute to hypernatremia if used in a long
period of time. Extreme use of sodium free IV
solutions (e.g., D5W) puts the patient at risk for
hyponatremia.
 Educate the patient about dietary sources of
electrolytes.  Educated the patient
R: Electrolytes are salts and minerals, like sodium, about dietary sources
potassium, calcium, magnesium, and chloride, in of electrolytes
the body that maintain fluid balance and blood
pressure. A balanced diet provides the patient
with sources of electrolytes to prevent
imbalances. Milk, yogurt, dark green, leafy
vegetables, and legumes are excellent sources of
electrolyte calcium. Whole grains, nuts, fruits, and
vegetables are good sources for magnesium and
potassium. Bananas are known to be the king of all
potassium containing fruits and veggies. Vitamin D
is needed for the absorption of calcium from the
intestines.

References:
https://nurseslabs.com/risk-for-electrolyte-
imbalance/
Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2016). Nurse's pocket guide: Diagnoses,
 prioritized interventions, and rationales. F.A.
Davis.

Checked by: Shown to me by :

Name and signature of Clinical Instructor Name and signature of BSN Student

ASSESSMENT NUSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS
Subjective cues: Disturbed sensory perception -After 8 hours of nursing intervention -Initiate expression of -At the end of 8
-“I still have a headache and related to increase ocular the patient will engage with feelings about hours of nursing
blurred vision” patient verbalized pressure or Acute Angle- therapeutic regimen possibility of loss intervention the
closure glaucoma vision client was able to
 Identify acute angle closure - Identify clinical engage with
glaucoma conditions about acute therapeutic
R: Results from the gradual angle closure regimen
deterioration of the trabecular glaucoma - Goal Met
Objective cues: network that, as in the acute -Assist patient to - Client
-Tonometry result
form, blocks drainage of manage visual verbalized that
-Eye patch aqueous humour and causes limitation to view “my eyes isn’t
- Move with assistance IOP to increase. subjects or image blurry anymore it
- Cranial nerves revealed: “blurred If untreated, may result in upon eye movement and I can move
vision, difficulty moving the eyes degeneration of the optic my eyes without
to sides or to an up-down motion” nerve and visual field loss. difficulties
-T-37.2 It is the most common form of
-PR-104 b/min glaucoma, and its incidence
-RR-21 br/min increases with age.
-BP-140/100 mmHg

 Monitor Intra ocular pressure

R: In most ophthalmologist's
offices, eye pressure is
measured using “Goldman
application tonometry,” and
this is considered a “gold
standard” eye pressure
measurement. In this test, the
eyes are anesthetized with
numbing drops

References:
https://www.rnpedia.com/
nursing-notes/medical-
surgical-nursing-notes/
glaucoma-nursing-
management/