Assessment Subjective cues: According to the grandson: Ang laki ng pinayat ni lola, lalo na nung una niyang naexperience

yang sakit na yan last month. Simula nun nawawalan na siya ng gana kumain, tsaka ngbawas talga yung food intake niya. Objective cues: -weight loss (approximatel y 2-4 kg) -weakness of muscles -pale mucous membrane - electrolyte imbalance (Hypokalemia)

Background knowledge Some symptoms of hypokalemia are directly related to its underlying cause. For example, vomiting and increased urination can cause the disorder and also indicate that it is present. The patient may exhibit a lack of appetite and weight loss associated with the vomiting, therefore causing dietary potassium deficiencies. (Medical surgical Nursing pp. 904)

Nursing Diagnosis Imbalanced Nutrition: less than body requirements related to inability to ingest food as evidenced by weight loss and poor appetite

Goals and objectives Goal: Within 8 hours of duty, the patient and the family will gain knowledge on how to manage the clients condition resulting to the improvement of clients nutritional status Objectives: After 15 minutes, the nurse will able to assess the patient. After 5 minutes, the clients family will be assessed for their level of understan ding After 30min, the client together with the family will gain knowledg e on how to improve

Nursing Intervention Assess the patient

Rationale

Evaluation

To assess

Monitor
clients vital signs

the causative/ contributi ng factors. (Nurses pocket guide by Doenges pp.410)

Changes
in clients vital signs may indicateco mplication. (Nurses pocket guide by Doenges pp.410)

Assess the level of understa nding of the client and the family

To have a

Educate the patient about the disease, Hypokale mia since it is the underlyin

baseline data in performing health teaching(N urses pocket guide by Doengespp .410)

This will

help the client and the family understan d the clients condition which can