Nursing Diagnosis for Addison's Disease : Fluid and Electrolyte Imbalances
related to:
lack of sodium and fluid loss through the kidneys, sweat glands, GI tract (for lack of aldosteron)
Outcomes:
Nursing Intervention for Addison's Disease
1) Monitor TTV, record blood pressure changes in a change in position, the strength of the peripheral pulse.
R /: Hypotension is part of hypovolemia due to lack aldosteron.
2) Measure weight client.
R /: fast weight gain caused by fluid retention and availability of sodium in relation to the treatment of steroids.
3) Study of patients on thirst, fatigue, rapid pulse, capillary filling lengthwise, ugly skin turgor, dry mucous membranes, skin color and the temperature record.
R /: Identifying the influence of hypothermia and volume needs replacement.
4) Check the status of mental and sensory.
R /: Dehydration weight decrease cardiac output, tissue perfusion, especially weight and brain tissue.
5) Auskultasi noisy bowel (peristalsis specific) record and report of nausea, vomiting and diarrhea.
R /: Damage functions intestinal tract, increasing the loss of fluids and electrolytes.
Collaboration:
6. Provide fluids and medications as prescribed.
7. Replace / maintain urinary catheters and NG hose as indicated.
R /: To facilitate accurate measurement of output with both urine and stomach, gastric decompression and provide limiting vomiting.
11) Monitor the results of the laboratory:
a) hematocrit (Ht)
R /: Increased levels of blood hematocrit is an indication of the occurrence of hemoconcentration will return to normal in accordance with the occurrence of dehydration in the body.
b) urea / creatinine
R /: Increased blood urea and creatinine levels is an indication of the level of cell damage due to dehydration / attack sign of heart failure.
c) Sodium
R /: Hyponatremia is an indication of excessive loss through urine katena impaired reabsorption in the renal tubules.
d) Potassium
R /: Decreased levels of aldusteron resulted in a decrease in sodium and water.
related to:
lack of sodium and fluid loss through the kidneys, sweat glands, GI tract (for lack of aldosteron)
Outcomes:
- Adequate urine output (1 cc / kg / hour)
- Vital signs (within normal limits).
- Elastic skin turgor.
- Capillary rise of less than 3 seconds.
- Mucous membranes moist.
- Pale skin tone.
- Ideal weight.
Nursing Intervention for Addison's Disease
1) Monitor TTV, record blood pressure changes in a change in position, the strength of the peripheral pulse.
R /: Hypotension is part of hypovolemia due to lack aldosteron.
2) Measure weight client.
R /: fast weight gain caused by fluid retention and availability of sodium in relation to the treatment of steroids.
3) Study of patients on thirst, fatigue, rapid pulse, capillary filling lengthwise, ugly skin turgor, dry mucous membranes, skin color and the temperature record.
R /: Identifying the influence of hypothermia and volume needs replacement.
4) Check the status of mental and sensory.
R /: Dehydration weight decrease cardiac output, tissue perfusion, especially weight and brain tissue.
5) Auskultasi noisy bowel (peristalsis specific) record and report of nausea, vomiting and diarrhea.
R /: Damage functions intestinal tract, increasing the loss of fluids and electrolytes.
Collaboration:
6. Provide fluids and medications as prescribed.
7. Replace / maintain urinary catheters and NG hose as indicated.
R /: To facilitate accurate measurement of output with both urine and stomach, gastric decompression and provide limiting vomiting.
11) Monitor the results of the laboratory:
a) hematocrit (Ht)
R /: Increased levels of blood hematocrit is an indication of the occurrence of hemoconcentration will return to normal in accordance with the occurrence of dehydration in the body.
b) urea / creatinine
R /: Increased blood urea and creatinine levels is an indication of the level of cell damage due to dehydration / attack sign of heart failure.
c) Sodium
R /: Hyponatremia is an indication of excessive loss through urine katena impaired reabsorption in the renal tubules.
d) Potassium
R /: Decreased levels of aldusteron resulted in a decrease in sodium and water.
