Name of Student: Velarde__________________________ Section and Group number: _BN3F Group 4 (Case Scenario 3)_____
Assessment Nursing (Rationale) Desired Nursing Intervention Justification Evaluation
Cues Diagnosis Pathophysiologic / Outcome
Schematic Diagram
Subjective: Activity Intolerance After 8 hours of Independent: After a series of
related to insufficient nursing intervention, nursing care, the
“Gapang luya ko Predisposing factors:
physiologic energy as the patient is patient is able to:
kag sakit akon evidenced by > Female expected to: Assess the patient’s vital signs To serve as baseline data and
lawas. Budlayan generalized body at least every 4 hours. assist in creating an accurate
weakness. > 47 years old
ko mag giho kag diagnosis and monitor
effectiveness of medical
nalipong man ko Achieve normal
treatment.
sang ligad nga Precipitating factors: Increase serum laboratory values,
adlaw.” as calcium levels to 9-10 especially calcium and
>History of smoking and mg/dl. phosphorus levels.
verbalized by the alcohol drinker past 5 yrs An extremely low calcium
client. Activity Intolerance level may cause tingling, GOAL MET
Monitor calcium (normal 8.6 muscle aches, spasms of the
Definition: to 10.0 mg/dL) and phosphate muscles in the throat,
>Generalized body weakness
levels (normal 2.7 to 4.5 stiffening and spasms of
State in which an Display physiological
mg/dL) muscles (tetany), seizures, and
individual has no improvement and use
Objective: abnormal heart rhythms. effective energy
physiological or >Muscle cramps in upper
Achieve an increased management
Patient is awake, psychological energy and lower extremities
enough to resist or conditioned physical techniques.
alert, and
complete required or state.
responsive to GOAL MET
desired daily activities. >Fainting episode Due to increased risk of tetany
both verbal and
and seizures. A trach tray
painful stimuli.
needs to be easily accessible
> GCS score= 15 Evaluate the airway and have for this.
Source/Reference: emergency equipment at
> Facial grimace
Nurse’s Pocket Guide:
↓ bedside. ensure that a trach
After 3 days of nursing tray is easily accessible.
> Abdominal Diagnoses, Prioritized Perform basic
Decrease in gland function interventions, the
guarding Interventions, and Nutritional needs are activities without
patient will be able to: important because they
Rationales Edition 12 excessive exhaustion
> Stiffening of Assess nutritional status. provide an energy source to or loss of energy.
upper and lower ↓ Exhibit an increased
engage in activities.
GOAL MET
extremities Resistance to PTH action tolerance to perform
activities.
> Pallor
↓ ROM exercises increase
Demonstrate
behaviors & lifestyle
circulation and help prevent changes to reduce risk
Inadequate PTH secretion
Vital signs: Perform range of motion contractures. factors and improve
and increased reabsorption Identify changes in
(ROM) as tolerated. well-being.
BP- 110/80 mmHg of Ca in GI tract lifestyle necessary to
Temp.- 37.1 improve and maintain
Prolonged immobility may
degrees Celsius ↓ health.
lead to the development of
pressure ulcers.
RR- 18 cpm Increase in calcium level in Monitor skin integrity several
blood times per day.
PR- 69 bpm
Weight- 65 kgs
Source/Referenc Collaborative: To determine effectiveness of
e ↓ therapy or presence of side
effects.
Laboratory Muscular hyper irritability
NANDA After establishing that the
values: patient has no drug allergies,
Calcium=4 ↓ administer antibiotics as
ordered and note the client's
mg/dL response.
Muscle cramps in
Phosphorous= 6.1 extremities, hypocalcemic
mg/dL tetany To improve patient education
and medication adherence.
↓ Educate patient on the impact
of hypoparathyroidism and
Activity Intolerance related treatment on physiologic
to weakness and apathy as functioning.
evidenced by generalized
body weakness.
Strength:
She has someone
watching over her,
emotional support
Reference:
Weakness:
Patient lacks
Michels, T. C., & Kelly, K. M.
knowledge on (2013, August 15). Parathyroid
hypoparathyroidism disorders. American Family
or any endocrine Physician.
disorder. https://www.aafp.org/afp/2013
/0815/p249.html.
Ratheesh R Follow. (n.d.).
Hypoparathyroidism.
SlideShare.
https://www.slideshare.net/Rat
heeshR9/hypoparathyroidism-
88169324.
Name of CI: Ms. Maita Monfort RN, MN_______________________________ Area of Exposure: Medical Ward_____________________
