1.
Lezel M. Laracas
BSN 1-B
Nursing Process
Assessment Subjective data:
- Has complains of generalized body weakness and abdominal cramps
and loose bowel movement
- has been letting out watery stool 3-4 times a day for 2 days
- the patient stated “Namimilipit na ako sa sakit! Bigyan niyo ako ng
gamut.”
Objective data:
- Temperature: 38.5°C
- Pulse Rate: 102 bpm
- Respiratory rate: 24 cycles per minute
- Blood pressure: 90/60 mmHg
Nursing Diagnosis - Risk for electrolyte imbalance related to food and fluid intake as
evidenced by abdominal cramps and loose bowel movement
(diarrhea)
Planning Electrolyte Imbalance can result in excessive amounts of fluids in the body or
dehydration.
Goals:
- Client will display heart rate, blood pressure, and laboratory results within the
normal limit.
The client will also be able to:
- Report increased sense of relaxation.
- Report decreased pain, using a scale of 0 to 10 before and after
therapies.
- Have slower, deeper respirations.
- Maintain an absence of muscle cramping
- Maintain normal serum pH
- Have a decrease in edema
Intervention - Monitor vital signs at least three times a day or more frequently if
needed
- Monitor intake and output and daily weights
- Monitor any abdominal discomfort.
- Monitor the client’s respiratory status and muscle strength (related
to the patient’s abdominal cramps)
- Complete pain assessment or pain scale on patient. Includes the
intensity, onset, location, character, duration, relieving and
aggravating factors.
- Monitor the effects of ordered medications

2.
Evaluation Interventions done by the nurse of the patient should have been met, if
not include it also in the patient’s data. Furthermore, the usage of including
the patient’s environment in his intervention can be assumed as met
because it plays the vital role with patients especially the ones who has
chronic pulmonary diseases.