Nsg. Dx # 3: Activity intolerance related to weakness on Nsg.

Dx # 4: Risk for fall related to periodic episodes of

both lower extremities as evidence by patient’s paralysis and weakness on the both lower extremities
verbalization of weakness upon accomplishing activities of Subjective cues:
daily living – On August 24, 2009 (1000H ) patient verbalization
Subjective cues: “Nanghihina ako agad kahit konti lang ang ikinikilos
– August 24, 2009 (1000H ) patient verbalization ko kahit magtoothbrush nakakapagod na.:
“Kahit magtoothbrush nakakapagod na.” Objective cues:
– Upon admission, patient’s description of calf and – Age 32 y/o
G2P1 (1001) HYPOKALEMIA PERIODIC
thigh cramp, having an extra effort to get up from – Activity as tolerated
PARALYSIS AND GESTATIONAL DIABETES
sitting position. – Positive risk for fall
Focus Assessment
Objective cues: – Myopathic changes over upper and lower extremities
 Age
– Activity as tolerated muscle upon EMG-NCV.
 Weight and Height
– Positive risk for fall – Methycobal 500 mcg 1 tablet 2x/day
 Vital Signs
– Myopathic changes over upper and lower
– Respiratory rate
extremities muscle upon EMG-NCV.
– Methycobal 500 mcg 1 tablet 2x/day – Heart Rate
– KCl 20 mcg incorporated into IVF  Pain Scale
– Kalium durule medication 750 mg 1 durule 3x/day  Physical Examination
– Methycobal 500 mcg 1 tablet 2x/day – Nutritional Status
– Neurologic Assessment
– Thorax and Lung Assessment
– Cardiovascular Assessment
 Activity Level
Nsg. Dx # 2: Fatigue related weakness on both lower  Diet
extremities secondary to hypokalemia.  Risk for Fall Nsg. Dx # 5: Deficient knowledge regarding the client’s
Subjective cues:  OB History choice of food related to unfamiliarity with information
– August 24, 2009 (1000H ) patient verbalization  Laboratory and Diagnostic Exams about appropriate food intake as evidenced by verbalization
“Nanghihina ako agad kahit konti lang ang ikinikilos – Congenital Anomaly Scan of “Ang hirap naman pumili ng appropriate food to take na
ko kahit magtoothbrush nakakapagod na.: – Electromyography and Nerve high in potassium pero hindi dapat high in sugar ”
Objective cues: Conducting Studies Subjective cues:
– Serum K=1.5 meq/L on August 21, 2009 – Serum K, Na, Ca – August 25, 2009 (0830H), patient verbalization “Ang
– Serum K=2.3 meq/L on August 24, 2009 – Routine Urinalysis hirap pumili ng food na high in potassium pero hindi
– KCl 20 mcg incorporated into IVF – Capillary Blood Glucose high in sugar.”
– Kalium durule medication 750 mg 1 durule 3x/day – Arterial Blood Gases Objective cues:
– Methycobal 500 mcg 1 tablet 2x/day – Thyroid Function Test – Client was observed taking Gatorade and Anmum
– Activity as tolerated – Lipid Profile despite knowing both are high with sugar
– Myopathic changes over upper and lower extremities – Creatinine
muscle upon EMG-NCV. – BUN
– SGPT/SGOT
 Medications
 Mood and Affect
 Contraptions (IVF, nasal cannula)
 Input and Output
 Room environment

20
Nsg. Dx # 1: Imbalanced nutrition: less than body Nsg. Dx # 6: Readiness for enhanced nutrition related to
requirements related to restriction to food high in choice of food as evidence by patient’s request for lecture on
carbohydrates and serum potassium level of 1.5 meq/L her diet, “Sana maibigay na yung lecture sa diet ko. Ang
(N,V. 3.5-5.1) secondary to hypokalemia. hirap kasi kapag kakain ako ng rich in potassium like
Subjecting cues: Gatorade, mataas na man sa sugar. Dapat mag-ingat ako sa
– August 25, 2009 (0830H), patient verbalization sugar intake ko.”
“Ang hirap pumili ng food na high in potassium Subjective cues:
pero hindi high in sugar.” – On August 25, 2009 at 0830H verbalization of client
– August 24, 2009 (1000H), patient verbalization “Sana maibigay na yung lecture sa diet ko. Ang hirap
eating more than 3x/day and preference to sweets kasi kapag kakain ako ng rich in potassium like
(cakes and chocolates) Gatorade, mataas na man sa sugar. Dapat mag-ingat
Objective cues: ako sa sugar intake ko.”
– Serum K=1.5 meq/L on August 21, 2009 Objective cues:
– Serum K=2.3 meq/L on August 24, 2009 – Age 46 y/o
– DM diet – Manifestation of compliance with the prescribed diet.
– Large for gestational age fetus upon Congenital
Anomaly Scan
– Lipid profile result: high triglyceride=1.97 mmol/L
(N.V. 0.17-1.70)
– High Fasting Blood Sugar (FBS)=6.15 mmol/L
(N.V. 3.85-6.05)
– CBG monitoring pre breakfast and 1 hour post
meals
– Humulin N 100 U/ml 4 units at bedtime.

CONCEPT MAP
Patient’s Initials: Mrs. L.S.A. Medical Diagnosis: G2P1 (1001) Hypokalemic Periodic Paralysis and Gestational Diabetes
Age: 32 y/o Gender: Female Basis for Prioritization: Maslow’s Hierarchy of Needs
Category: Room no.: 518 Date of Admission: August 21, 2009 Student Nurse: Group 2 III-B
(1255H)