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Date

Cues

Need

Nursing Diagnosis

Goal of Care

Intervention Plan

Evaluation

07/06 /10 @ 7:00 AM

Subjective: Dili nako maka-tindog ug ako ra, stated by the client. Objective: -creatinine levels of: 272.8 (06/26/10) 359 (07/01/10) 389 (07/02/10) -needs assistance -PT 2 sessions -complained of pain in pelvic area

A C T I V I T Y A N D E X E R C I S E P A T T E R N

Activity intolerance r/t muscular weakness as evidenced by high serum creatinine level Creatinine can cause dehydration and fatigue. medicinenet.com

At the end of 2 days of care, Mr. S. will be able to demonstrate a decrease in physiological signs of intolerance as evidenced by: a) able to perform a specific task with improved strength;

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b) able to seek help in performing activities of daily living; c) verbalize acceptance of decreased activity level and;

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d) experience less discomfort when transferring, or performing other activities.

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Establish guidelines and goals of activity with the patient and the caregiver Motivation is enhanced if the patient participates in goal setting. Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation Rest between activities provides time for energy conservation and recovery. Refrain from performing nonessential procedures Patients with limited activity tolerance need to prioritize tasks. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self Assisting the patient with ADLs allows for conservation of energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patients activity tolerance and self-esteem. Assist patient to plan activities for times when he has the most energy Not all self-care and hygiene activities need to be completed in the morning. Likewise, not all housecleaning needs to be completed in 1 day. Improvise in adapting environment Appropriate aids will enable the patient to achieve optimal independence for self-care.

GOAL MET @ 07/07/10 12:00 nn At the end of 2 days of care, Mr. S was able to demonstrate a decrease physiological signs of intolerance as evidenced by: a. had great strength on lower extremities; observed during draping for removal of catheter b. asked help from student nurse or watcher in changing positions; c. Ana jud ng mutiguwang ka, he joked. d. Nagasakit gihapon diri dapita (arthritis) pag mulihok, pero gamay gamay na lang.

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