- Acute Confusion Related to Severe dehydration and electrolyte imbalances as evidenced by Decreased level of consciousness and Seizures
- Decreased Cardiac Output related to electrolyte imbalances, Alteration in heart rate and rhythm and decreased myocardial contractility as evidenced by arrhythmia and Hypotension/hypertension
- Deficient Fluid Volume related to electrolyte imbalances and dehydration as evidenced by Dry mucous membranes and Increased urine concentration
| 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 Severe dehydration and electrolyte imbalances as evidenced by Decreased level of consciousness and Seizures | Patient will remain oriented to person, place, and time. Patient will maintain a normal level of consciousness without tremors or muscle weakness. Patient will not experience a seizure. | 1. Provide reality orientation. Keeping the patient oriented as needed can help reduce confusion and encourage cooperation with the treatment regimen. 2. Use therapeutic communication and reassurance. This promotes a trusting relationship with the patient. Reassure family members that confusion is temporary and explain why it is occurring. 3. Limit exposure to stimuli and keep the environment free from excess noise. Excessive stimulation can aggravate confusion and irritability in patients with metabolic alkalosis. 4. Provide safety against seizures. Seizures are a risk with metabolic alkalosis. Keep the patient safe in the event of a seizure by preventing injury or aspiration and maintaining a patent airway. | Patient remained oriented to person, place, and time. Patient maintained a normal level of consciousness without tremors or muscle weakness. Patient not experienced seizure. |
| Subjective data: Verbalizes Chest tightness and increasing Body weight Objective data: -Tachycardia -Arrhythmia -Hypotension/hypertension -Decreased peripheral pulses -Abnormal heart sounds -Orthopnoea -Crackles -Jugular vein distension -Edema -Weight gain -Oliguria | Decreased Cardiac Output Related to electrolyte imbalances, Alteration in heart rate and rhythm and Decreased myocardial contractility as evidenced by Arrhythmia and Hypotension/hypertension | Patient will manifest adequate cardiac output as evidenced by the following: Blood pressure: SBP >90 to <140 mmHg / DBP >60 to <90 mmHg Heart rate: 60 to 100 beats/min with a regular rhythm Respiratory rate: 12 to 20 breaths/min Urine output 0.5 to 1.5 cc/kg/hour Absence of abnormal heart sounds Patient will adhere to their diuretic regimen to prevent hypokalemia and fluid overload. | 1. Administer medications as ordered. Heart failure therapy necessitates a complex therapeutic regimen. The cornerstone of treatment includes angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and diuretics. Aldosterone antagonists, digoxin, and vasodilators may also be prescribed as necessary. Polypharmacy is a challenge for patients with heart failure, but adhering to their treatment plan is crucial to prevent volume overload. 2. Assist in the conduct of diagnostic modalities. 12 lead ECG: ST-segment depression and T- wave flattening can develop due to hypokalaemia Chest x-ray: Cardiomegaly and pulmonary congestion may be observed 3. Take caution with IV fluids. With CHF, use potassium chloride instead of normal saline to correct alkalosis and hypokalaemia and prevent fluid overload. IV HCl can be administered for severe metabolic alkalosis to correct cardiac arrhythmias. 4. Replace with potassium-sparing diuretics. Thiazide and loop diuretics may need to be replaced with potassium-sparing diuretics to prevent hypokalaemia. | Patient manifested adequate cardiac output as evidenced by the following: Blood pressure: SBP >90 to <140 mmHg / DBP >60 to <90 mmHg Heart rate: 60 to 100 beats/min with a regular rhythm Respiratory rate: 12 to 20 breaths/min Urine output 0.5 to 1.5 cc/kg/hour Absence of abnormal heart sounds Patient adhered to their diuretic regimen to prevent hypokalaemia and fluid overload. |
| Subjective data: Verbalizes urine colour changes and increased thirst Objective data: -Decreased blood pressure -Decreased urine output -Increased body temperature -Increased heart rate -Increased urine concentration -Altered mental status -Sunken eyes -Thirst -Weakness | Deficient Fluid Volume related to electrolyte imbalances and dehydration as evidenced by Dry mucous membranes and Increased urine concentration | Patient will remain free from signs of dehydration, with vital signs within normal limits. Patient will demonstrate interventions to manage vomiting and correct fluid loss. | 1. Monitor and evaluate electrolyte levels. Fluid loss in metabolic alkalosis is associated with electrolyte imbalance (hypokalaemia and hypochloraemia) and will require correction. 2. Administer fluid replacement IV or orally. If oral fluid intake is difficult due to excessive vomiting, intravenous fluid replacement may be necessary to correct and manage fluid loss in metabolic alkalosis. 3. Monitor the patient’s intake and output. Decreased urine output can indicate kidney dysfunction, further aggravating metabolic alkalosis if the kidneys cannot reabsorb hydrogen or excrete bicarbonate. 4. Administer medications to treat symptoms. If severe vomiting or diarrhoea is causing hypovolemia and subsequent metabolic alkalosis, administer antiemetics or antidiarrheals to prevent fluid loss. | Patient remained free from signs of dehydration, with vital signs within normal limits. Patient demonstrated interventions to manage vomiting and correct fluid loss. |