Nursing Care Plan For Hypocalcemia 4f7227

VII. NURSING CARE PLAN

Assessment Diagnosis Planning Subjective: • “madalas mamanhid ang aking mga kamay at paa ko, pati na rin ang aking labi”, as verbalized by the patient named Mr. Sy, 35 yrs.old. Objective: • Anxious • Irritability • Dry, sparse hair • Rough skin BT: 36.7 C PR: 65 bpm RR: 18 m BP: 120/70 mmHg

High Risk for Injury R/T increased neuromuscular irritability resulting from hypocalcemia

Intervention

Short-Term Goal • After 3 hours of nursing intervention, the client will be able to verbalize understanding of individual factors • that contribute to possibility of injury and take steps to correct situations • Long-Term Goal After 7 days of nursing intervention, • the client will be free from injury associated with calcium deficit, as evidenced by no falls or near falls and no pathologic fractures. •

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Rationale

Monitor peripheral • pulses and vital signs, especially the heart rate every hour to every four hours depending on the client’s condition. • Provide information regarding disease/condition that may result in increased risk of injury. Evaluate individual’s response to violence in • surroundings If the client is receiving intravenous calcium, the nurse needs to monitor the IV site for infiltration or phlebitis every hour • Symptomatic hypocalcemia should be assessed by testing of the Chvostek’s and • Trousseaus’ signs. The serum calcium level should be closely monitored and changes reported.

Evaluation

To assess baseline Short-Term Goal After 3 hours of data nursing intervention, the client verbalized understanding of To assist client to individual factors reduce or correct that contribute to possibility of injury individual risk and take steps to factor. correct situations. Goal was met May enhance disregard for own/other’s safety.

Calcium chloride is extremely irritating to the subcutaneous tissue. To check for increased neuromuscular excitability and tetany.

Long-Term Goal After 7 days of nursing intervention, the client had been free from injury associated with calcium deficit, as evidenced by no falls or near falls and no pathologic fractures. Goal was met