DATE & TIME

CUES

NURSING DIAGNOSIS

OBJECTIVE

INTERVENTIONS

EVALUATION

N O V E M B E R

Subjective: Lain akong pa paminaw, na maluya luya ko Objective: Vital Signs: T RR: CR:

Imbalance Nutrition: less than body requirements related to hypokalemia Elderly client may be eating empty calories rather that nutritious food, eating alone or suffering from chronic diseases that affect food

Within my 3 days span of nursing care, patient will be nutrition as evidenced by: a. Normal laboratory results in the potassium level within the normal range of 3.5-5.1mmol/L b. Demonstrate behaviors, lifestyle changes to meet the bodys nutritional requirements such as

1.) Obtain the nutritional history, include caregiver the family, significant others, assessment R Patients perception of actual intake may differ 2.) Monitor or explore

November , 2011 @ 3:00 pm

able to improve body or

in After my 3 days span of nursing care, my patient was able to improve body nutrition as evidenced by:

attitudes toward eating a. //11 serum potassium and food R many psychological, and result is mmol/L. b. patient demonstrated behaviors to meet her bodys nutritional requirement like taking her medications/supplement s c. Absence of signs

psychosocial,

2011

PR: BP:

cultural factors determine the type, amount, and appropriateness of food consumed 3.) Review indicated

body intake and metabolism. weakness They

-serum result : -

K frequently have dietary deficiencies of Vitamin A, B, C and D. and the minerals of iron, calcium and potassium that lead them having imbalance

complying to the diet and medications ordered by the physician c. Absence of signs and symptoms of hypokalemia such as fatigue ,weakness and etc.

laboratory data (e.g., serum albumin, serum potassium leveletc.) to evaluate degree of deficit 4. Monitor for signs and symptoms hypokalemia such of as

and symptoms of hypokalemia such as fatigue ,weakness, decrease cardiac rate and etc.

Kalium

Durule i tab

TID - Piperacillin sodium and Tazobactam sodium 2.25 gms. q6

fatigue, weakness, and decrease cardiac rate R Potassium is an

IVTT nutrition. hours

ANST (-)

electrolyte that compose of 65 75 percent in the muscle and maintains electrical excitability 5.) Evaluate total daily food intake. Obtain diary of calorie intake, patterns and times of eating To reveal possible

cause of malnutrition and changes that could be

made in clients intake. 6.) companionship mealtime R Attention of in and to social is the Provide during

aspects important hospital settings

eating both

home

7.) Eat foods rich in potassium fish and etc. R Help to replenish or normalize the potassium level in the body 8.) Administer agents such as banana, oranges, carrots,

pharmaceutical

such as vitamin, mineral, electrolytes supplements as indicated

 To meet the clients nutritional needs. 9.) importance balanced, intake. information individual these needs Emphasize of wellProvide regarding nutritional within nutritious

needs and ways to meet financial constraints. To promote wellness to the patient and help her to understand her condition. 10.) Encourage regular exercise and stress reduction program. Metabolism by and activity

utilization of nutrients are enhanced and to promote wellness.

11.) Consult dietitian or nutritional indicated To implement team team as

interdisciplinary management.