Assessment

S: Sabi ng doctor ko
kelangan ko daw
magpacheck up dito
kasi daw mababa daw
ung potassium ko sa
dugo.

O:
Potassium level at 2.3
Muscle weakness at
lower extremities

Diagnosis
Risk for electrolyte
imbalance related to
excessive loss of
potassium

Planning
Short Term Goal:
After 4 6 hours of NI,
patient will be free of
complications resulting
from electrolyte
imbalance

Interventions
Independent
Assess specific client
risk

Rationale

Note clients age and

developmental level

Risk may increase with

age group

Long Term Goal:

After 5 days of NI,
patient will identify
individual risks and
engage in appropriate
behaviors or lifestyle
changes to prevent or
reduce frequency of
electrolyte imbalance

Assess mental status

Can be associated with

altered electrolyte
balance

Monitor heart rate and

rhythm

Alterations can be
associated with
potassium imbalances
(and other electrolytes)

Auscultate breath
sounds (assess rate,
depth and ease)

Hypokalemia can cause

or exacerbate
respiratory
insufficiency

Evaluate motor strength

and function

Provides clues to
electrolyte imbalance

To note processes that

may lead to electrolyte
imbalances

Provide or recommend
balanced nutrition.
Monitor intake, weight
and bowel function.

Measure and report all

fluid losses

Loss of fluids rich in

electrolytes can lead to
imbalance

Evaluation
After 6 hours of NI,
clients responses to NI
were favorable and was
free from complications

Instruct client in
reportable symptoms
Dependent:
Administer drugs as
prescribed (Klyte)

Collaborative:
Consult with dietician
or nutritionist for
specific teaching needs
(diet in K+)

Assessment
S: Nahihirapan ako
gumalaw. Hirap ako sa
position ko. Kahit
anong position parang
ang hirap.

O:
Patient has facial
grimace whenever
theres movement
O2 Saturation at 95
96%
Shallow respirations
Muscle weakness at
lower extremities

Diagnosis
Risk for activity
intolerance related to
lower extremity
muscle weakness

Planning
Short Term Goal:
After 4 6 hours of NI,
patient will
demonstrate a decrease
in physiological signs
of intolerance
(e.g., pulse,
respirations, and blood
pressure remain
within
clients normal range).
Long Term Goal:
After 5 days of NI,
patient will report
measurable increase in
activity tolerance.

Interventions
Independent
Note presence of factors
contributing to fatigue
Evaluate current
limitations/degree of
deficit in light of usual
status.
Assess
cardiopulmonary
response to physical
activity, including vital
signs before, during,
and after activity.

Assess
emotional/psychologica
l factors affecting the

Rationale

Provides comparative
baseline

Notes progression of
intolerance

Evaluation
After 6 hours of NI,
clients responses to NI
were favorable and has
attained favorable
outcome to
interventions

current situation
Monitor vital/cognitive
signs

To watch out for

sudden changes

To avoid overexertion
Reduce intensity
level or discontinue
activities that cause
undesired physiological
changes
Plan care with rest
periods between
activities to reduce
fatigue
Provide positive
atmosphere, while
acknowledging
difficulty of the
situation for the client.

Help minimize
frustration and manage
or rechannel their
energy

Promote comfort
measures and provide
for relief of pain

Dependent:
Provide/monitor
response medications
and changes in
treatment regimen.
Collaborative:
Provide referral to other
disciplines as indicated

To develop individually
appropriate therapeutic
regimens.

(e.g., exercise
physiologist,
psychological
counseling/therapy,
occupational/
physical therapists,
and recreation/leisure
specialists)