NURSING MANAGEMENT (NCP)

CUES	NURSING DIAGNOSIS	SCIENTIFIC EXPLANATION	PLANNING	INTERVENTIONS	RATIONALE	EVALUATION
S> O O>conscious    >appears     weak   >(+)dyspnea   >looks pale   >irritable at   times   >with lab   results of: Serum K= 1.75 mmol/min   >with VS as   follows:    BP- 160/100    T- 35.9    P- 87    R-15	Activity intolerance related to generalized muscle weakness secondary to decreased levels of potassium and sodium in the blood	Potassium and sodium are needed for muscle function and a decreased in its level can cause weakness. Hypertension can cause deprivation of body cells of O2 secondary to decrease blood flow resulted from vasoconstriction. This can in turn causes weakness of the muscles and dizziness	After 8 hours of nursing interventions, patient will be able to deal with contributing factors of intolerances and manage activities within individual limits.	1.        Establish rapport 2.        Assess general conditions 3.        Monitor VS 4.        Reduce intensity level or discontinue activities that cause undesired physiological changes 5.        Provide supplemental O2 6.        Plan care to carefully balance rest periods with activities 7.        Provide positive atmosphere, while acknowledging difficulty of the situation for the client 8.        Encourage expression of feelings 9.        Assist with activities and provide use of assistive devices 10.     Provide comfort measures 11.     Assist client in learning and demonstrating appropriate and safety measures 12.     Administered medicines as ordered	1.        To gain trust 2.        For baseline data 3.        To determine alterations which may indicate a need for interventions 4.        To prevent overexertion 5.        To assist client with O2 need 6.        To reduce need for O2 7.        This helps client to minimize frustration and rechannel energy 8.        To gain pertinent data 9.        To protect client from injury 10.     To enhance ability to participate activities 11.     To prevent injuries 12.     For compliance to medication regimen	Goal met, patient was able to deal with contributing factors of intolerances and managed activities within individual limits.