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NURC 1021 Fluid and Electrolyte Concept Map.
- Institution
- Eastern Florida State College
This is a comprehensive and detailed concept map on;Fluid and electrolytes for NURC 1021.
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Nursing Diagnosis:Excess fluid volume related to decreased cardiac output
and excessive fluid intake as evidenced by altered Needs Further
CONCEPT
electrolytes.
_________________________________________
Subjective Assessment Assessment MAP
Data Stopped meds without
Goals: lightheadedness informing provider.
Patient will explain what measures can be taken to treat or Upset stomach Teaching about
prevent fluid overload by the end of shift.
Weak legs medications and how
Patient has clear lung sounds as manifested by absence of
Stopped taking her meds they affect other issues.
pulmonary crackles at every 2-hour vital check.
Patient describes symptoms that indicate the need to Vomiting
consult with health care provider by discharge.
____________________________________________
Interventions:
Nurse will assess urine output due to diuretic therapy.
Limit sodium intake as prescribed due to loss of other Concurrent Health
electrolytes. Problems
Educate patient and family members regarding fluid
volume excess and its causes.
Client chronic hypertension,
Explain rationale and intended effect of the treatment Initials: MM hyperlipidemia, and
program. Objective Assessment chronic left-sided heart
Data Diagnosis: failure
Diarrhea Electrolyte Imbalance:
Evaluation hypokalemia,
Difficulty standing
Goals met. hyponatremia,
hypocalcemia
Provider Initials: RH Nursing Diagnosis:
Nursing Diagnosis: Risk for electrolyte imbalance as evidenced by
Electrolyte imbalance related to hypokalemia as diarrhea and vomiting.
evidenced by vomiting and diarrhea. _________________________________________
_________________________________________ Goals:
Goals: Patient will provide a solid stool by discharge.
Patient will take her KCl as prescribed and tell the Pertinent Labs Patient will have no muscle weakness by discharge.
explain to the nurse the schedule by end of shift. ________________________________________
Patient will tell nurse what foods are high in K – 3.2
Interventions:
potassium by discharge. Na – 128
Nurse will explain importance of medications.
_____________________________________ Mg – 1.3
Nurse will use teach back method to explain how
Interventions: Ca – 7.8 diarrhea and vomiting effect the electrolytes in the
Medications Ionized Ca – 4
Nurse will teach that stopping medications suddenly is not body by discharge.
good without talking to your provider. Fasting Glucose – 70
lisinopril 20 mg/daily Nurse will continue to monitor labs for electrolyte
Nurse will encourage a prescribed diet per the provider PO4 – 5 imbalance until end of shift.
until levels normalize by discharge. PO, simvastatin 20 Cl -94
mg/daily PO, Nurse will educate patient about hand hygiene while
Nurse will monitor labs for electrolyte imbalances every 3 Diagnostic Tests
hours or per provider’s orders. furosemide 40 working in the schools, and to make sure they
Blood tests (CBC) continue taking medications unless instructed by their
Nurse will assist patient to ambulate until muscle mg/daily, Serum electrolyte panel
weakness has subsided. KCl 20 meq/daily PO, provider by discharge.
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