S > “Oo. Nakakapagod din kasi ang byahe.”
O> Irritability noted
* Weakness noted
* Grimacing noted
* Lying in bed most of the time
* Limited movements noted
* Functional level at 2
* v/s taken as follows:
* BP: 140/80
* T: 37.1 C
* P: 85
* R: 20
* GOALS AND OBJECTIVE
LTO: After 3 days of nursing interventions, the patient will be able to perform ADLs without assistance
STO: Within 8 hours of nursing intervention, the patient will be able to:
> tolerate activities of daily living
> move around the room with assistance
>
NURSING DIAGNOSIS: Activity Intolerance related to fatigue
Interventions | Rationale | Criteria for Evaluation | Evaluation |
Dx> Assess for activity intolerance * Assess rest patterns * Assess skin color before and after an activity * Determined cause of activity intolerance > Monitor vital signs> Observe non verbal cuesTx > Provide comfort measures > Assisted in early ambulation> Use of relaxation technique * Increase fluid intake * Facilitate independence when performing ADLsEd> Encourage enough sleep and rest > Encourage to void freely> Instructed to do activities such as DBE, dorsiflexion of foot | > provides baseline for assessing changes level of activity intolerance and evaluating interventions.> provides baseline for assessing changes level of activity intolerance and evaluating interventions.> Changes in skin color may suggest hypoxia> provides baseline for assessing changes level of activity intolerance and evaluating interventions.> Alterations from normal may indicate signs of infection> Observations may / may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize.> To promote non – pharmacological techniques> To minimize impairment> To distract attention and decrease tension> To prevent constipation and fecal impaction.> To prevent constipation and fecal impaction> To reduce...