Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective cues: Altered electrolyte At the end of -Monitor vital signs -Respiratory muscle After doing the
imbalance related to the shift after weakness may necessary nursing
hypokalemia effective progress to paralysis interventions and
Objective: nursing -Monitor Intake and leading to teachings, the client:
-Temp 36.5 C intervention, output and IV fluids respiratory arrest.
BP 132/82mmhg the client will -achieved
PR 102 bpm exhibit the signs appropriate urine
RR 29 cpm -Assess respiratory -To reduce the output
of improvement muscle weakness dryness of the
SpO2 100% in hydration
Potassium <3.5 mucosa Demonstrated use of
status.
mmol/l -Monitor level of relaxation skills to
-Muscle weakness consciousness and -Tetany, reduce anxiety
-Restlessness neuromauscular paresthesia, apathy,
-Decreased skin function, noting drowsiness,
turgor movement, strength irritability and coma
and sensation may occur

-To monitor if IV
-Keep a quiet fluid and electrolyte
environment and replacement is
calm activities needed

Collaborative -To reduce anxiety

- ask the attending and stress
physician for an
order for high
potassium diet -for potassium
assistance
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective cues: Activity intolerance Patient will -Establish guidelines -Motivation and After intervention,
related to immobility exhibit and goals ofactivity cooperation are the nurse had
Objective cues: tolerance with patient and enhanced if the helped optimize the
-Long term stay in during physical relatives patient participates patients autonomy
bed due to activity as in goal setting and independence in
immobility evidenced by ADL
normal -Evaluate the need
- Inability to feed self flunctuation of for additional help -Coordinated efforts
independently vital signs at home are more
during physical meaningful and
- Inability to dress activity, will effective in assisting
self independently report ability to -Have the patient the patient in
perform perform the activity conserving energy
- Inability to bathe required more slowly, in a
and groom self activities of longer time with
independently daily living more rest or pauses, -Helps increasing
or with assistance if the tolerance for
- Incapable for toilet necessary the activity
privileges
-Refrain from -Patient with limited
- Inability to performing activity tolerance
ambulate nonessential need to prioritize
independently activities or important tasks first
procedure

-Duration and
-Gradually progress frequency should be
patient activity with increased before the
 Range-of-motion intensity
exercises in bed,
gradually increasing
duration and
frequency then
intensity to sitting
then standing

Discharge planning

Medication Instruct patient to take all the prescribed medications at the proper time and dosage for the
specific duration as the doctor has ordered.

Environment/Exercise Walking Exercise: Is most basic and best exercise to help get fresh air, and to maintain body
regularly.

Environment:

- Get out of direct sunlight and lie down in a cool spot, such as in the shade or an air-
conditioned area.

Treatment - Walking Exercise.

Health Teaching - Explain the Dehydration to the Patient.
- Inform them to do walking exercise to help get fresh air, and to maintain their body
regularly.
- Instruct patient to take all the prescribed medications at the proper time and dosage for
the specific duration.
- Tell to them to get out of the direct sunlight.
- Make sure that they can engage physical exercise, and advise them to eat foods that a lots
of vitamins and minerals to enhance body immunity.

Out Patient (follow up - Instruct the patient to return to the Attending Physician for follow up check-up and for
consultation) emergency medical assistance.

Diet - Diet as Tolerated

- Increase oral fluid intake: To prevent the dehydration.
- Avoid juices and coffee, To prevent abdominal pain
Spiritual - Advise the patient to encourage praying to God as the Family does every day and to
strengthen their faith.
Course in the ward

July 31, 2017

The patient was on bed, awake with an endotracheal tube to ventilation set up of with nasogastric tube, with folley catheter, side
drip of Norepinephrine at 3 mcg/kg/hr. vital signs was taken and recorded, suctioning was done, feeding was done.

August 1, 2017
The patient is with nasogastric tube, suctioning was done, CXR was repeated