Wednesday, September 15, 2010


DATE: 09/01/09
S> O
   >appears weak
   >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
A> Activity intolerance related to generalized muscle weakness secondary to decreased levels of potassium and sodium in the blood
P> After 8 hours of nursing interventions, patient will be able to deal with contributing factors of intolerances and manage activities within individual limits
I> Established rapport
 >Assessed general conditions
 >Monitored VS
 >Reduced intensity level or discontinued activities that cause undesired physiological changes
 >Provided supplemental O2
 >Planned care to carefully balance rest periods with activities
 >Provided positive atmosphere, while acknowledging difficulty of the situation for the client
 >Encouraged expression of feelings
 >Assisted with activities and provide use of assistive devices
 >Provided comfort measures
 >Assisted client in learning and demonstrating appropriate and safety measures
 >Administered medicines as ordered
E> Goal met, patient was able to deal with contributing factors of intolerances and managed activities within individual limits.


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