1478 UNIT X / Promoting Physiologic Health
Evaluating
Using the overall goals identified in the planning stage of main-
taining or restoring fluid balance, maintaining or restoring pul-
monary ventilation and oxygenation, maintaining or restoring
normal balance of electrolytes, and preventing associated risks
of fluid, electrolyte, and acid–base imbalances, the nurse col-
lects data to evaluate the effectiveness of interventions. Exam-
ples of desired outcomes for the identified goals are found in
Identifying Nursing Diagnoses, Outcomes, and Interventions on
pages 1451 and 1452.
If desired outcomes are not achieved, the nurse, client, and
support person if appropriate need to explore the reasons before
modifying the care plan. For example, if the outcome “Urine
output is greater than 1,300 mL per day and within 500 mL of in-
take” is not achieved, questions to be considered might include
■Have other outcome measures for the goal of achieving fluid
balance been met?
■Does the client understand and comply with planned fluid intake?
■Is all urinary output being measured?
■Are unusual or excessive amounts of fluid being lost by an-
other route (e.g., gastric suction, excessive perspiration,
fever, rapid respiratory rate, wound drainage)?
■Are prescribed medications being taken or administered as
ordered?
INITIATING, MAINTAINING, AND TERMINATING A BLOOD TRANSFUSION USING A Y-SET continued
SKILL 52-6
EVALUATION
Evaluate the following:
■Changes in vital signs or health status
■Presence of chills, nausea, vomiting, or skin rash
NURSING CARE PLAN Deficient Fluid Volume
ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES*
Nursing Assessment
Merlyn Chapman, a 27-year-old sales clerk, reports weakness,
malaise, and flu-like symptoms for 3–4 days. Although thirsty, she
is unable to tolerate fluids because of nausea and vomiting, and
she has liquid stools 2–4 times per day.
Deficient Fluid Volume related
to nausea, vomiting, and diar-
rhea as evidenced by de-
creased urine output, increased
urine concentration, weakness,
fever, decreased skin/tongue
turgor, dry mucous mem-
branes, increased pulse rate,
and decreased blood pressure
Electrolyte & Acid/Base Bal-
ance [0600] as evidenced by
not compromised:
• Serum electrolytes
• Muscle strength
Fluid Balance [0601] as evi-
denced by not compromised:
• 24-hour intake and output
balance
• Urine specific gravity
• Blood pressure, pulse, and
body temperature
• Skin turgor
• Moist mucous membranes
Physical Examination
Height: 160 cm (5′3′′)
Weight: 66.2 kg (146 lb)
Mild fever: 38.6°C (101.5°F)
Pulse: 86 BPM
Respirations: 24/minute
Scant urine output
BP: 102/84 mm Hg
Dry oral mucosa, furrowed
tongue, cracked lips
Diagnostic Data
Urine specific gravity: 1.035
Serum sodium 155 mEq/L
Serum potassium 3.2 mEq/L
Chest x-ray negative
NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE
Electrolyte Management: Hypokalemia [2007]
Obtain specimens for analysis of altered potassium levels (e.g.,
serum and urine potassium) as indicated.
Administer prescribed supplemental potassium (PO, NG, or IV)
per policy.
Monitor for neurologic and neuromuscular manifestations of hy-
pokalemia (e.g., muscle weakness, lethargy, altered level of con-
sciousness).
Urine and serum analysis provides information about extracellu-
lar levels of potassium. There is no practical way to measure in-
tracellular K⫹.
Low potassium levels are dangerous and Mrs. Chapman may
require supplements.
Potassium is a vital electrolyte for skeletal and smooth muscle
activity.
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