Diagnosis Interference Planning Intervention Rationale evaluation

Sub|ective
"bindi ko
magalaw ang
mga kamay at
binti ko"as
verbalized by
tbe patient

Ub|ective
-difficulty in
ambulation.

LUE=J
KUE=J
LEE=J
RLE=J

Potassium level:
=.
Act|v|ty
|nto|erance
re|ated to musc|e
weakness
secondary to
decreased serum
potass|um |eve|

ue to severe
musc|e weakness
a person w||| be
ab|e to have
Insuff|c|ent
phys|o|og|ca| or
psycho|og|ca|
energy to endure
or comp|ete
requ|red or
des|red da||y
act|v|t|es
After 1wee of
nurs|ng
|ntervent|on the
pat|ent w||| be
ab|e to
|ncrease act|v|ty
to|erance thru the
s|gns expressed
pr|mar||y
verba||zat|on
demonstrat|on
of we|| to|erated
act|v|t|es (A%
asses c||ent's
actua| and
perce|ved
||m|tat|ons]degree
of act|on def|c|ts
thru
a test for musc|e
res|stance

ass|sts c||ent to
A's t||| ab|||ty
becomes
dependent to
|ndependent
ass|gn c||ent
s|mp|e act|v|t|es
and cont|nuous|y
add the d|ff|cu|ty
accord|ng to the
capab|||ty of the
c||ent per sess|on

Assessment of
actua| ||m|tat|ons
can g|ve us a
thorough p|cture
about c||ent's
capab|||ty for
act|v|ty


ass|st|ng c||ent
to A's can he|p
|mprove actua|
to|erance

S|mp|e act|v|t|es
w||| be ab|e
musc|es to react
and perce|ved
we|| from
weakness

After 1week of
nurs|ng
|ntervent|on the
pat|ent was ab|e
to Goa| was met
As ev|denced by

acan performed
A

b stated
re|aeaved from
musc|e weakness



Vital signs
Temp: .C
BP:9JmmHg
RR:cpm
PR:bpm.
ncourage pat|ent
to eat food h|gh |n
potass|um ||ke
banana and app|e
Cr adm|n|ster
ka||um duru|e as
ordered by the
doctor

potass|um w|||
be ab|e to
|mprove ske|eta|
and card|ac
musc|e act|v|ty

SSESSMENT DINUSIS INTERFERENCE PLNNIN INTERVENTIUN RTIUNLE EVLUTIUN

"medyo
nabibirapan
akong buminga
as verbalized by
tbe patient


Ub|ectives:
-Nasal Flaring
-Use of
accessory
muscle
-Rapid sballow
breatbing

Vital signs"
Temp:.
Rr:
Pp:9
Bp:9J
Ineffect|ve
breath|ng pattern
re|ated to musc|e
weakness
ue to musc|e
weakness
resp|ratory mus|e
dcreases |ts
funct|on resu|t|ng
to decrease
resp|ratory cyc|e
And caus|ng
|neffect|ve
breath|ng


Sourse bruner
and sudarth
med|ca| nd
surg|ca| nurs|ng
After 1hour of
nurs|ng
|ntervent|on
pat|ent w||| be
ab|e to breathe
norma||y


After 3 weeks of
nurs|ng
|ntervent|on pt
w||| be ab|e to
manage h|mse|f
and now the
proper deep
breath|ng
exerc|se
Assess pat|ents
breath sound and
resp|rat|on




mon|tor v|ta|
s|gn



|evate the bed
of the pat|ent to a
h|gh fow|er's
pos|t|on



*assess|ng
breath|ng pattern
|s a good
|nd|cat|on for
resp|ratory
d|stress or
accumu|at|on of
secret|on

*mon|tor|ng v|ta|
s|gns w||| serve as
the base||ne data
for the
|ntervent|on to
the pat|ent

|evat|ng the bed
and pos|t|on|ng of
the pt w||| he|p
better |ung
expans|on


After nurs|ng
|ntervent|on the
goa| was met
pat|ent can now
breathe norma||y

After 3 weeks of
nurs|ng
|ntervent|on the
goa| was met t
verba||zat|on

ncourage deep
breath|ng
exerc|se


teach and
encourage
d|aphragmat|c
breath|ng


1h|s exerc|se he|p
pat|ent to breath
eas||y and prov|de
comfort

th|s techn|que
w||| he|p the
c||ent to breathe
w|thout fat|gue
and rest|essness

SSESSMENT DINUSIS INTERFERENCE PLNNIN INTERVENTIUN RTIUNLE EVLUTIU

N
Sub|ective
".madalas
akong
magsusuka
ko"as
verbalized by
tbe patient.

Ub|ective
Vital signs
Temp: .C
BP:9JmmH
g
RR: cpm
PR:9bpm


-dry oral
mucosa
-furrowed
ef|c|ent I|u|d
Vo|ume
re|ated
to vom|t|ng

A decrease |n the
|ntravascu|ar
|nterst|a|s
and]or
|ntrace||u|ar f|u|d
due to vom|t|ng t
may affect the
ac|d ]base
ba|ance of the
body and may
resu|t to a f|u|d
vo|ume def|c|t


Sources
8runer and
sudath "med|ca|
and surg|ca|
nurs|ng Vo| 1



After 6 hours of
nurs|ng
|ntervent|on the
pat|ent w||| be ab|e
to ma|nta|n
e|ectro|yte and
ac|d]base ba|anced
as ev|denced by not
comprom|sed
serum e|ectro|ytes
and musc|e
strength

After 3 weeks of
nurs|ng
|ntervent|on
pat|ent w||| be ab|e
to ma|nta|n body
f|u|d homeostas|s
assess the appearance of
the c||ent



mon|tor da||y f|u|d |ntake
and output

mon|tor v|ta| s|gns



encourage to |ncrease f|u|d
|ntake


encourage to |ncrease
|ntake of c|trus fru|ts such as
waterme|on oranges etc
assess|ng the
c||ent's
appearance w|||
g|ve you a p|cture
of sever|ty of
f|u|d def|c|ency
to mon|tor
progress of the
c||ent response to
the |ntervent|on
rov|des
base||ne for
assess|ng and
eva|uat|ng
|ntervent|ons

to rehydrate the
c||ent and to
rega|n what he
|oss

c|trus fru|ts
conta|ns |ots of
f|u|ds that may
After 6 hours
of nurs|ng
|ntervent|on
the goa| was
met as
ev|denced by
not
comprom|sed
serum
e|ectro|ytes
and musc|e
strength

tongue
-cracked lips
-poor skin
turgor
- dry skin



encourage to take crackers
ear|y |n the morn|ng before
gett|ng up



Adm|n|ster med|cat|ons
(metoc|opram|de% as
ordered by the phys|c|an
he|p |n
rehydrat|ng the
c||ent
crackers absorb
excess
hydroch|or|c ac|d
|n the stomach
that cause a
decrease |n GI
|rr|tat|on
metoc|opram|de
|s a n2 b|ocker
thus decrease
gastr|c stat|c