(^430) Medical-Surgical Nursing Demystified
NURSING DIAGNOSES
- Ineffective breathing pattern
- Decreased cardiac output
- Impaired urinary elimination
NURSING INTERVENTION
- Monitor vital signs for changes.
- Monitor cardiovascular status for irregularity of heart rhythm, pulse deficit.
- Monitor intake and output.
- Assess muscle strength—hand grips, foot pushes bilaterally for strength and
equality. - Assess abdomen for bowel sounds, distention, and pain.
- Encourage mobilization, assist with ambulation if necessary to decrease bone
resorption due to immobility. - Assist with range-of-motion exercises.
- Low-calcium diet to reduce intake.
- Strain urine for stones.
- Explain to patient:
- High calcium foods.
- Avoid calcium supplements.
- Avoid calcium-based antacids.
- Weight-bearing exercise is important to avoid bone resorption.
Hypokalemia
WHAT WENT WRONG
Hypokalemia is a lower-than-normal level of potassium in the blood. A balance
between the amount of potassium within the cell (intracellular) and outside the cell
(extracellular) is necessary. This allows the resting potential of the cell membrane
to be maintained. When there are low potassium levels, a greater-than-normal stim-
ulus is needed to depolarize the cell membrane. Many cells become more sluggish,
especially nerve cells. However, cardiac cells become more excitable. Fluid losses
due to diuretics or diarrhea, endocrine disorders (such as hyperthyroidism, hyper-5