NURSING CARE PLAN University of Iloilo Phinma Education Network College of Nursing Rizal Street, Iloilo City Name

of Patient: Ms. L.P Age: 40 ___ Attending Physician:__Dr. D.__________________ Chief Complaint: _weakness of upper and lower extremities Diagnoses: t/c hypokalemia Plan/ Goal Outcome Criteria

Nursing Diagnoses >impaired mobility

Nursing Intervention

Rationale

Evaluation

Short Term: >Within 8 hours of nursing intervention patient will be regained body strength & loss of appetite will be relieved. Long Term: >After 2 days of duty patient will be demonstrate improvement in appetite & proper nutrition.

Independent: >Encouraged to eat adequate nutritious food like green leafy vegetables, fishes and fruits rich in vitamin C. >Advised to have adequate rest & sleep, it helps to regained body strength.

To boost immune system.

>Goals met Short Term: >After 8 hours of nursing intervention patient regained body strength & loss of appetite is

related to decreased muscle strength as manifested by limited ROM

To regained body strength.

relieved. Long Term: >After 2 days of duty patient demonstrates improvement in appetite & proper nutrition.

Students Name: Leana Rae B. Siel Year & Section: 4- C

Clinical Instructor:Mr. Roger John Baguio, R.N Date Submitted: July 18, 2011_________

NURSING CARE PLAN University of Iloilo Phinma Education Network College of Nursing Rizal Street, Iloilo City Name of Patient: Ms. L.P Age: 40___ Attending Physician:__Dr. D_______________ Chief Complaint: weakness of upper and lower extremities Diagnoses: t/c hypokalemia Plan/ Goal Outcome Criteria

Nursing Diagnoses

Nursing Intervention

Rationale

Evaluation

Deficient Fluid Volume related to nausea, vomiting, and diarrhea as evidenced by decreased urine output, increased urine concentration, weakness, fever, decreased skin/tongue turgor, dry mucous membranes, increased pulse rate and decreased

Within 8 hours of nursing intervention the patient will be able to compromised: Serum electrolytes Muscle strength

Obtain specimens for analysis of altered potassium levels (e.g., serum and urine potassium) as indicated. Monitor for neurologic and neuromuscular manifestations of hypokalemia (e.g., muscle weakness, lethargy, altered level of consciousness).

Urine and serum analysis provides information about extracellular levels of potassium. There is no practical way to measure intracellular K Potassium is a vital electrolyte for skeletal and smooth muscle activity. Many cardiac rhythm disorders can result from hypokalemia. It is critical to monitor cardiac function with hypokalemia.

After 8 hours of nursing intervention the patient was able to compromised Serum electrolytes Muscle strength

Monitor for cardiac manifestations of hypokalemia (e.g., hypotension, tachycardia, weak pulse, rhythm irregularities)

blood pressure

Students Name: Leana Rae B. Siel Year & Section: 4- C

Clinical Instructor: Mr. Roger John Baguio R.N. Date Submitted: July 18, 2011________

NURSING CARE PLAN University of Iloilo Phinma Education Network College of Nursing Rizal Street, Iloilo City Name of Patient: L.P Age: 40 Attending Physician: Dr. D Chief Complaint: weakness of upper and lower extremities Diagnoses: t/c hypokalemia Plan/ Goal Outcome Criteria

Nursing Diagnoses

Nursing Intervention

Rationale

Evaluation

Imbalance nutrition: less than body requirements related to inadequate diet as evidenced by poor appetite.

After 8 hours of nursing intervention the patient will demonstrate behaviors to maintain proper nutrition.

Independent: 1. Measure dietary intake by calorie count.

Provides information about intake, needs and deficiencies.

Goal met. After 8 hours of nursing intervention the patient was able to demonstrate behaviors to maintain proper nutrition.

Improved nutrition is vital to recovery. 2. Encourage patient to eat. Explain reasons for types of diet. Consider preferences in food status. 3. Recommend small frequent meals. Aids in reducing gastric irritation and abdominal discomfort that may impair oral intake. 4. Restrict intake of caffeine, gas forming, or spicy and excessively hot or cold foods. Poor tolerance to larger meals may due to increased intra-abdominal pressure.

Students Name: Leana Rae B. Siel Year & Section: 4- C

Clinical Instructor: Mr. Roger John Baguio, R.N Date Submitted: July 18, 2011