Question

1) Mr. Johnson, 68-year-old, has been vomiting and has had diarrhea for 2 days. He complains of being dizzy. The nurse assesses his physiologic status and notes that his muscles are weak, his abdomen is distended, and bowel sounds are absent.

a. Develop one care plan for this case study.. It should contain a NANDA nursing diagnosis, one goal, and at least four nursing interventions. Nursing interventions are not doctor’s orders

Answer 1

The client is having hypokalemia evidence by the diminished bowel sounds, abdominal distension, dizziness, and generalized weakness.

Hypokalemia is due to overall depletion of the potassium ion or from maximum intake by the muscles.

Assessment	Diagnosis	Goal	Planning	Interventions	Evaluation.
Subjective data: The client is complaining of vomiting and diarrhea for 2 days Objective data: Client look lethargic, dizzy due to hypotension and abdomen is distended.	Risk for electrolyte imbalance related to vomiting and diarrhea	Goal is to restore normal electrolyte balance.	1.to monitor heart rate 2. to monitor breathing rate 3. to encourage coughing exercise. 4. to auscultate bowel sound. 5.to encourage food intake rich in potassium 6. to maintain record to intake and output. 7. to assess for sign of metabolic alkalosis.	1. heart rate monitored for assessment of changes associated with hypokalemia. 2. breathing rate, death and efforts monitored 3. patient was encouraging for coughing exercise to prevent respiratory arrest due to muscle weakness. 4. auscultation of bowl sound done and noting changes in it. 5. patient was encouraging to take potassium rich food such as banana, leafy vegetables, orange, pea, bakes potato etc. 6. assessment of metabolic alkalosis done to prevent any further complication.	Display of laboratory test within normal limits and absence of muscle weakness and diarrhea vomiting

you can add doctors order also in interventions.

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