Students Name: Ramos, Shelly Mae A.
Patients Initials: M.T.
                                                    NURSING CARE PLAN
 ASSESSMENT       DIAGNOSIS       BACKGROU           PLANNING         INTERVENTIO        RATIONALE          EVALUATION
                                     ND                                    N
                                  KNOWLEDG
                                      E
                                                                      INDEPENDENT
Subjective:        Activity       One of the        After 2-3 hours                                         GOAL
                  Intolerance:    bodys main       of nursing        >Noted             Body               PARTIALLY
 Di ako          Inability to    electrolytes is   intervention      presence of        Weakness           MET
nanghihina,       perform         the potassium     the client will   factors            affects both
pero              ADLs           (K). It is        be able to:       contributing to    the clients       After 2-3 hours
nahihirapan pa    unassisted      necessary for                       body weakness      actual and         of nursing
rin akong         related to      muscle            >perform                             perceived          intervention
kumilos as       decrease in     contraction       simple ADLs                         ability to         the patient
verbalized by     electrolyte.    and therefore     unassisted.       >Evaluated         participate in
the client        (K+)            for                                                                        was not
                                                                      clients actual     activities
                                  movement.         >Use                                                      able to
                                                                      and perceived
Objective:                        Deficiency in     identified                                                perform
                                                                      limitations, and   Provides
                                  potassium         techniques to                                             simple
                                                                      severity of        comparative
>K+ level: 2.37                                     enhance                                                   ADLs
                                  may result in                       deficit in light   baseline and
                                  generalized       activity                                                  unassisted
>Appears Weak                                                         of usual status    information
                                  body              intolerance                                              was able to
                                                                                         about needed
                                  weakness.                                              education or         identify
> Lying on bed                                      >Report
                                                                                         interventions        techniques
                                                    measurable                                                to enhance
                                                                      >Noted clients    regarding
                                                    increase in                                               activity
                                                                      report of          quality of life.
                                                    performing                                                intolerance
                                                                      weakness and
                                                    ADLs
                                                                      fatigue
                                                    >Demonstrate                         Symptoms
                                                    an increase to    >Adjusted          may be result
Students Name: Ramos, Shelly Mae A.
Patients Initials: M.T.
                                       NURSING CARE PLAN
                                                       activities to     of intolerance
                                       normal range    prevent           of activity
                                       of K+           overexertion
                                                                         Reduce
                                                                         intensity level
                                                       > Monitored       of activities
                                                       the potassium     that
                                                       levels of the     contributes to
                                                       patient           body
                                                                         weakness
                                                                         To assess the
                                                       >Plan care to     patients
                                                       carefully         status and to
                                                       balance rest      serve as basis
                                                       periods with      for the
                                                       activities        patients
                                                                         mobility
                                                       COLLABORATI       capacities.
                                                       VE
                                                       >Administered
                                                       and monitored     To reduce
                                                       incorporated      factors that
                                                       potassium         may
                                                       chloride via IV   anticipate
                                                       as prescribed     fatigue to the
                                                                         patient
                                                       >Administer
                                                       Kalium Durule
                                                       500mg PO OD
                                                                         To promote
Students Name: Ramos, Shelly Mae A.
Patients Initials: M.T.
                                       NURSING CARE PLAN
                                                           electrolyte
                                                           balance
                                                           To help
                                                           replenish the
                                                           lost
                                                           potassium.