Saturday, November 27, 2010

NCP- Activity Intolerance (Click Here)

ASSESSMENT
NURSING DIAGNOSIS
NURSING GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION

SUBJECTIVE:

“Agkakapsuttak ken, marigatanak aggunay”as verbalized by the pt.

OBJECTIVE:

Ø  Weak in appearance
Ø  With Pale skin and conjunctiva
Ø  With fatigability
Ø  Looks thin in appearance
Ø  Dec. Hgb. Level; 12.9 g/dl


Activity intolerance
r/t
Muscle weakness
2o to
Decreased hemoglobin level.

Short Term:

After 8 hours of nursing intervention, the patient will:

a.        Be free from decubitus ulcer/bedsores or hematomas on the most prominent parts of the body such as the back and the buttocks.

Long Term:

Within 2 days of nursing interventions, the patient will:

a.  Be completely independent on all ADLs and without asking assisitance with his S/O
b. Have good skin turgor
c.  Have normal hemoglobin level from 104 g/L to 120g/L Hct. from 31% to 40%.
d.  Reports increased sense of well being

Independent Mgt:

§  Assess patients ability to perform ADLs   noting reports of weakness, fatigue and difficulty in accomplishing task
§  Promote independence in self-care activities as tolerated
§  Encourage alternating activity with rest

§  Explain importance of be rest in treatment.



§  Monitor laboratory results like Hgb. & Hct.


§  Encourage increase intake of iron-rich foods.



§  Influences choice of interventions or needed assistance





§  Mild/moderate activities & improved self-esteem are promoted.
§  Minimized exhaustion & helps balance O2 supply and demand.
§  Bedrest is maintained to decrease metabolic demands thus conserving energy.
§  To identify the extent of deficiency & for better treatment plan.
§  To increase iron supplement of the body.

Short Term:

After 8 hours of nursing intervention, GOAL was met, as evidence by:

a.        Patient’s back and buttocks are free from bedsores/hematomas respectively and free from swelling/redness as well.


Long Term:

Within 2 days of nursing interventions, GOAL was partially met, as evidence by:

a.        The patient Verbalized partial dependence on ADLs with his S/O such as able to feed himself, assistance in toileting & bathing.
b. Demonstrates Improved skin turgor & well being
c. Able to participate in self care activities (grooming dressing)
d.   Hgb and Hct level still needs to be evaluated. 










1 comment:

  1. If you need your ex-girlfriend or ex-boyfriend to come crawling back to you on their knees (even if they're dating somebody else now) you must watch this video
    right away...

    (VIDEO) Get your ex back with TEXT messages?

    ReplyDelete