- Acute Confusion related to Electrolyte imbalance and Impaired metabolism as evidenced by Difficulty initiating goal-directed behavior and Difficulty initiating purposeful behavior
- Ineffective Tissue Perfusion related to Increased hydrogen concentration Hemodynamic instability (shock) and Exposure to toxic chemicals as evidenced by Hypotension and weak peripheral pulses
- Risk for Decreased Cardiac Output related to Increased hydrogen concentration and Alteration in cardiac rhythm as evidenced by alteration in vital signs
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Hallucinations Paranoia Objective data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to Electrolyte imbalance and Impaired metabolism as evidenced by Difficulty initiating goal-directed behavior and Difficulty initiating purposeful behavior | Patient will remain oriented to person, place, time, and situation. Patient will demonstrate alertness and appropriate decision-making. | 1. Orient the patient as needed. Since metabolic acidosis causes confusion, frequent reorientation allows the patient to comprehend the situation and remain aware of the current setting. 2. Closely monitor laboratory results. When initiating treatment for metabolic acidosis, it’s vital that the nurse reviews the results of ongoing lab testing, such as ABGs, electrolyte levels, ammonia levels, and kidney function. 3. Explain procedures and interventions. Patients with metabolic acidosis are often confused and will require explanations about nursing interventions and procedures. An understanding of procedures and treatment promotes adherence and reduces anxiety or agitation. 4. Plan care that allows adequate sleep and rest. Sleep deprivation can aggravate confusion in patients with metabolic acidosis. | Patient remained oriented to person, place, time, and situation. Patient demonstrated alertness and appropriate decision-making. |
| Subjective data: -Altered skin sensations -Claudication -Peripheral pain -Numbness and tingling Objective data: -Weak or absent peripheral pulses -Cool skin temperature -Thickened nails -Skin discoloration: pallor when legs are raised and rubor when dependent | Ineffective Tissue Perfusion related to Increased hydrogen concentration Hemodynamic instability (shock) and Exposure to toxic chemicals as evidenced by Hypotension and weak peripheral pulses | Patient will maintain optimal tissue perfusion as evidenced by the following: SBP >90 mmHg MAP >65 mmHg Pulse rate: 60-100 beats/min Respiratory Rate: 12-20 breaths/min Strong, palpable pulses Warm and dry extremities Capillary Refill Time of <2 secs Patient will not display alterations in alertness or mentation | 1. Administer IV sodium bicarbonate. Sodium bicarb is the treatment of choice to raise the HCO3 level and correct acidosis. 2. Treat hypovolemia and shock. Antibiotics, crystalloids, colloids, and blood products may be necessary depending on the cause of acidosis and hypovolemia. 3. Administer oxygen therapy if indicated. Supplemental oxygen improves tissue oxygenation and perfusion. 4. Administer vasopressors as ordered. In severe cases of metabolic acidosis and impaired tissue perfusion (shock), vasopressors (i.e., vasopressin, norepinephrine, epinephrine, dopamine) may be used to improve blood pressure and perfusion to vital organs. | Patient maintained optimal tissue perfusion as evidenced by the following: SBP >90 mmHg MAP >65 mmHg Pulse rate: 60-100 beats/min Respiratory Rate: 12-20 breaths/min Strong, palpable pulses Warm and dry extremities Capillary Refill Time of <2 secs Patient displayed alterations in alertness or mentation |
| Subjective Data: Verbalizes Strong peripheral pulses Objective Data: -Decreased contractility -Electrolyte imbalances | Risk for Decreased Cardiac Output related to Increased hydrogen concentration and Alteration in cardiac rhythm as evidenced by alteration in vital signs | Patient will manifest adequate cardiac output as evidenced by the following: Blood pressure: SBP: >90 – <140 / DBP: >60 – <90 mmHg Heart rate: 60 to 100 beats/min Urine output 0.5 to 1.5 cc/kg/hour Strong peripheral pulses ECG results will exhibit a normal sinus rhythm. | 1. Review medications. Medications that can cause hyperkalemia, such as angiotensin II receptor blockers, beta-blockers, calcium channel blockers, and potassium-sparing diuretics, should be discontinued 2. Apply EKG. The patient with metabolic acidosis should receive continuous ECG monitoring. 3. Take care in treating renal tubular acidosis type 4. This type of RTA is most common and causes metabolic acidosis because the kidneys cannot excrete potassium effectively. Patients with this condition need a low-potassium diet and may benefit from loop diuretics. 4. Consider dialysis. Patients with severe CNS depression or acute renal injury may benefit from hemodialysis to correct acidosis, remove toxins, and rid the body of excess potassium. | Patient manifested adequate cardiac output as evidenced by the following: Blood pressure: SBP: >90 – <140 / DBP: >60 – <90 mmHg Heart rate: 60 to 100 beats/min Urine output 0.5 to 1.5 cc/kg/hour ECG results exhibited a normal sinus rhythm. |