NAC II Care Maps

Expectations

Presented by Kim Uddo

3/28/05

Critical care diagnoses

• Impaired gas exchange R/T altered oxygen supply secondary to decreased alveolar ventilation present with narrowed airways.

• Decreased cardiac output R/T increased after load secondary to chronic HTN and R/T decreased contractility secondary to necrotic cardiac muscle from MI.

Secondary to portion

• If the medical diagnosis adds clarity to the nursing diagnosis, it can be linked to the nursing diagnosis with secondary to.

• Carpenito(1995)

Top 3 Priority Diagnoses

• What will cause the most dangerous event first? (What will kill them first?)

• What did you spend most of your time doing?

• Why is this patient in ICU as opposed to the med – surg floor ? In the hospital as opposed to home?

Collaborative Problems

• Certain physiologic complications that nurses monitor to detect onset or changes in status…..using physician – prescribed and nursing prescribed interventions to minimize the complications of the events.

• Carpenito ( 1995)

Collaborative

• All collaborative problems begin with (PC) Potential Complication.

• Potential Complication: Hypokalemia

Defining Characteristics

• Nurse identifies when things are present that make the client vulnerable to developing the complication or when the client has Actually experienced the complication.

• Vomiting , diarrhea, T wave depression or inversion, ST dep, wide QRS, actual hypokalemia on patient pick up day.

Application of Content

• Old Content: Things you remember from your past courses and experiences.

• New Content: Nurse Refresher updated information

• Use appropriate resources (lab book) to plan patient care

History

• GI virus for two days with vomiting and diarrhea

• CHF

Treatments

• Normal Saline with 30mEq KCL at 100 ml per hour.

• Daily BMP

• Continuous ECG monitoring

• NPO

Labs

• K – 2.7• pH – 7.47• Serum CO2 – 34• PaCO2 – 48• Mag – 1.4• Osmolality – 300• BUN/Creat – 30/0.8• BE – 6• Dig Level – 2.0

Correlate the Labs

• When K is low look for a low Mag

• K is low in metabolic alkalosis (acid base)

• Keep in mind hydration status and effects on lytes.

• Dig toxicity alert

Medications

• K Rider Orders: If am K is 3.0 or less give KCL 20 mEq in 100cc D5W over one hour and one hour later get serum K level and call me with results.

• Digoxin 0.125mg IVP every day.

• Lasix 40mg IVP every day.

Interventions

• Monitor serum K every am by 7am and provide prn K rider as ordered.

• Implement continuous ECG monitoring• Measure ECG intervals every four hours.• Observe for signs of hypokalemia every 4

hours : Wide QRS, U waves, ST depression, flat T waves, dysrhythmias, muscle weakness, cramps, decreased bowel sounds, weak pulses, dec reflexes

Interventions

• Observe for dig toxicity: halos, nausea, vomiting, serum level greater than 2.0

• Never give KCL IVP, always use infusion pump, do not give 20 meq faster than one hour.

• Observe IV site for reddness , if becomes painful, slow the rate and attempt to start a new peripheral IV . Collaborate with MD concerning central line if chronic problem.

Interventions

• Never add KCL to a bag hanging from the IV pole so concentrated KCL doesn’t fall to the bottom. Should be prepared by pharmacist under laminar flow hood.

• Provide measures to prevent metabolic alkalosis……

• Reduce K depleting problems: collaborate with MD for antiemetics and K sparing diruretics

Teaching

• Provide a list of foods that are high in potassium which include: apricots, artichokes, avacados, bananas, carrots, dried fruits, mushrooms, nuts…..

• Explain to client that low K potentiates the effects of digoxin and that they could develop an irregular heart rate.

• Teach client how to take a pulse and to recognize a regular pulse vs irregular.

Outcomes

• By noon on Tuesday, client will not have any signs of hypokalemia AEB:

• A) serum K of 3.5 – 5.0

• B) PR of .12 to .20, QRS of .04 - .10, upright T wave, non-depressed ST seg, no PVC’s, HR between 60 – 100 and regular

• C) no complaint of nausea, cramps, or decreased reflexes

Outcomes

• D) No vomiting (with loss of K rich gastric juices)

Evaluation

• Day one: A) 3.5 B) PR .18 QRS .08 ST not depressed, T wave upright and rounded, HR-80 regular, no PVC’s C)no nausea, cramps, or decreased reflexes D) no vomiting.

• Day two: results

Revision Statement

• Although on day one of care the hypokalemia was the main concern, however on day two the client began to experience respiratory failure and had to be intubated and so the number one diagnosis on day two was impaired gas exchange.

Resources

• http://www.rncentral.com/nursing-library/careplans

• http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

• http://www.ltcsbooks.com/care_plan_resources.html

• http://www.medi-smart.com/carepl10.htm