NCP: Cues Nursing diagnosis Altered fluid and electrolyte balance (..

hypocalim ia potassium loss related to vomiting hyperemesi s gravidarum) Inference Objective Nursing intervention Rationale Evaluation After the nursing intervention, the goals are met. -explain the importance of regular intake of medication as ordered, explain the factors associated with hyperemesis gravidarum -administer kalium durule as ordered. -to help patient understand the treatment regimen and factors associated with the disease

Subjective data: ilang beses na akong sumuka as verbalized by the patient

Objective data: -weak in appearance -vomitus seen in the basin around (100ml) -gravida 1 -para 0 Laboratory result: serum potassium 2.7meq/L Latest exam: 3.5meq/L (april.30,2013)

Hyperemesis Gravidarum-is characterized by intractable nausea, vomiting and dehydration. Malnutrition and other serious complication such as fluid and electrolyte imbalance may result. Hypocalimiaalso known as hypotassemia refers to the condition in which the concentration of potassium in the blood is low, less than 3.5meq/L Can cause fatigue,anorexia,n ausea and vomiting,muscle weakness,leg crumps,decrease bowel motility,paresthes ianumbness and tinglingdysrhytm ea decrease muscle strength tendon reflexes.

After the nursing intervention: Objective: Short term: -After 30 minutes of rendering nursing intervention, the patient will be able to verbalize understandin g of causative factors and purpose of interventions and medication Long term: -After 24 hours to 48 hours of rendering nursing intervention the patient will be able to achieve fluid volume at functional level. -monitor rate of IV potassium administratio n

-used to increase potassium level -guide for calculating fluid potassium replacement needs. -potassium may be replaced/ma intained through this. -ensures controlled delivery of medication to prevent bolus effect and reduce associated discomfort.

-after 30 minutes of rendering nursing intervention, the patient was able to verbalized understanding of causative factors and purpose of interventions and medications.

-monitor accurate record of gastric losses vomiting

-encourage intake of foods and fluids high in potassium.

-after 24 hours to 48 hours of rendering nursing intervention the patient was able to achieve fluid volume at functional level as evidenced by laboratory results of patient serum potassium 3.5meq/L Date: april.30,2013