Activity intolerance care plan PDF

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Summary

care plan...

Description

Torrie Bell Priority #2

THE NURSING PROCESS: NURSING CARE PLAN NURSING DIAGNOSIS

PLANNING

(Problem; Etiology; Signs and Symptoms) Client Goal: WIMC client will demonstrate increased Activity Tolerance Activity Intolerance Related to: Right-sided HF. As evidenced by: SOB, fatigue

Outcome Criteria (Measurable evidence that will demonstrate that the client goal was met) WIMC client will: 1. demonstrate increased tolerance to activity. 2.

3.

Nursing Interventions (Assess; Do; Teach) Assess: 1. Assess the level of assistance needed by the client and express in terms of amount of effort needed from the person assisting the client.

maintain intact skin, normal pulmonary function, and maintain normal bowel and bladder function. participate in prescribed physical activity with appropriate changes in heart rate, blood pressure, and breathing rate.

2.

Assess skin condition daily using the Baden scale.

3.

Assess the client for orthostatic hypotension.

4.

Encourage client to incorporate bed exercises such as active and passive ROM exercises.

Rationale for Nursing Interventions (Author and page number) 1.

2. 3.

4.

Do:

5.

Help the client out of bed and ambulating as soon as possible.

6.

Monitor bowel function daily (provide increased fluids, fiber, and laxatives prn)

5.

6.

Teach: 7.

Teach client the use of specialized boots to prevent pressure ulcers on the heels and foot drop

7.

8.

Educate client on appropriate exercises/activities that should be able to be done within client’s condition.

8.

9.

Educate client about medical alert necklaces that can be worn in case of fall.

9.

Level of assistance acts as a guideline on how to determine the amount of care the client will need (Ackley & Ladwig). Use of a risk assessment tool is effective to predict the risk of developing a pressure ulcer/other skin issues (Ackley & Ladwig). Orthostatic hypotension is important to note when changing positions and exercising to decrease the risk for falls. (Ackley & Ladwig) ROM exercises can provide supplemental therapy to a current physical therapy program (Ackley & Ladwig). Early mobilization reduces risk of atelectasis, pneumonia, venous thromboembolism, pulmonary embolism, and reduces orthostatic hypotension; as well as reducing risk of muscle atrophy, and joint contractures (Ackley & Ladwig). Constipation is common in immobilized clients because of decreased activity and fluid and food intake. (Ackley & Ladwig) Boots can help keep the foot in the normal anatomical alignment to prevent foot drop and prevent pressure ulcer formation on the heel (Ackley & Ladwig) Daily exercise is still important to overall health and there are activities that can be done within a client’s health status. (Ackley& Ladwig) Decreased activity intolerance puts patients at higher risk for falls, medical alert jewelry can be especially helpful to those who live alone. (Ackley & Ladwig)

IMPLEMENTATION

EVALUATION

(Which were not done? Explain why planned interventions were not done)

(Was the client goal met? partially met? Unmet? What evidence (actual outcome criteria) support your evaluation? What would you do differently next time?

Simulation, unable to determine Simulation, unable to determine...