Saturday, November 27, 2010

NCP- Activity Intolerance (Click Here)



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


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
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. 

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