Anda di halaman 1dari 7

Activity Intolerance r/t generalized weakness inability to perform activity Assessment S: O: The patient manifested: Weakness Pale skin

kin color Fatigue Discomfort Abnormal blood pressure(150/80 ) Poor apetite The patient may manifest: Unusually rapid heartbeat, particularly with exercise Shortness of breath and headache, particularly with exercise Difficulty concentrating Dizziness Pale skin Leg cramps Insomnia Nursing Diagnosis Activity Intolerance r/t generalized weakness inability to perform activity Scientific Explanation Hypertension is a dangerous condition because it can lead to Seriouscomplications.Chronically elevated blood pressure increases the risk of developing heart failure, heart attacks, arterial aneurysm and strokes. Many cases of chronic renal failure have been linked to highbloodpressure.Hypertension is a dangerous condition becauseit can lead toseriouscomplications.Chronicallyelevated blood pressure increases the risk of developing heartfailure, heart attacks, arterial aneurysm andstrokes.Reference: medical-surgical. 790-791 Objectives Short term:: After 3-4 hours of nursing intervention patient will use identified techniques to enhance activity tolerance. Nursing Rationale Intervention 1. Monitor 1. Cardiopulmonary vital sign manifestations (Blood result from Pressure attempts by the , pulse, heart and lungs and to supply respiratio adequate ns) amounts of during oxygen to the and after tissues. activity. Expected Outcome Short term: Patient shall have used identified techniques to enhance activity tolerance.

2. Assess Long term: patient After 2-3 ability to days of perform nursing ADLs intervention patient will 3. Provide able to free or 3. Although help from recomme may be weakness nd necessary, selfand risk for assistanc esteem is complication e with enhanced when been activities client does some prevented and things for self. ambulati on as necessar y,

Long term: Patient shall have free 2. Influences from choice of weakness interventions and and risk for needed complication assistance. been prevented

allowing client to be an active participa nt as much as possible. 4. Suggest client change position slowly; monitor for dizziness . 5. Identify and impleme nt energysaving techniqu es

4. Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.

5. Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.

6. Instruct client to stop activity if palpitatio ns, chest

6. Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary

pain, shortnes s of breath, weaknes s, or dizziness occur.

strain and stress may lead to decompensation and failure.

Problem #2: Imbalance nutrition less than body requirement r/t inability to ingest food Assessment Nursing Scientific Planning Intervention Rationale Diagnosi Explanation s S: O: The patient manifested: Weakness Pale skin color Fatigue Discomfort Abnormal blood pressure(1 50/80) Poor appetite The patient may manifest: Unusual ly rapid heartbeat, particul arly with exercis e Shortne ss of breath and headac Imbalance nutrition less than body requireme nt r/t inability to ingest food Intake of nutrients insufficient to meet metabolic needs. Adequate nutrition is necessary to meet the bodys demands. Nutritional status can be affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or Short Term: After 2 hours of NI, the pt will be able to demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight. Long Term: After 1 -2 days of NI, the pt will be able to display normalization of laboratory values and be free of signs of malnutrition as reflected bin Defining Characteristic s. 1. Establish rapport > to relieve anxiety to achieve compliance


2. monitor and record VS 3. Determine client inability to swallow food, chew or taste food. 4. Discuss to the SO the eating habits, including food preferences, intolerance/a versions. 5. assess drug interactions, adverse effects, laxatives,

Short Term: Patient shall have demonstrated behaviors, lifestyle changes to > to establish regain and/or baseline data maintain appropriate > it maybe affect weight. ingestion and digestion of Long Term: nutrients Patient shall have displayed >to appeal normalization clients ;likes of laboratory and dislikes values and be free of signs of malnutrition as reflected bin Defining Characteristic s. > it may affect appetite, food intake, or absorption

he, particul arly with exercis e Difficult y concent rating Dizzine ss Pale skin Leg cramps Insomni a

psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an important role in healing and recovery. Cultural and religious factors strongly affect the food habits of patients. Women exhibit a higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and selfconstructed fad dieting. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources, cognitive

allergies. 6. determine the psychologica l factors/perfo rm psychologica l assessment 7. >assess weight > it may indicate protein-energy 8. >observe for malnutrition absence of subcutaneou s fat/muscle wasting. >to reveal possible cause 9. note age, of body build, malnutrition/cha strength, nges that could activity/rest be made in level clients intake > it helps to determine nutritional needs > to asses body image and congruency

> to establish parameter

10. promote pleasant, relaxing environment

11. >promote adequate/

>to reduce possibility of early satiety

impairments causing them to forget to eat, physical limitations that interfere with preparing food, deterioration of their sense of taste and smell, reduction of gastric secretion that accompanies aging and interferes with digestion, and social isolation and boredom that cause a lack of interest in eating. This care plan addresses general concerns related to nutritional deficits for the hospital or home setting.

timely intake


>to monitor 12. >weigh at effectiveness of regular dietary plan intervals and document results