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Activity intolerance

Activity intolerance - Assessment Nursing DX/Clinical...

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Assessment Nursing DX/Clinical Problem Client Goals/Desired Outcomes/Objectives Nursing Interventions/Actions/Orders and Rationale Subjective: Client expressed she didn’t want to move “anymore than she has to.” Hx of DM II, CAD Objective: Temp: 101.0 Basilar rales bilaterally Elevated BP (145/86) Elevated HR (110) Client is in atrial fibrillation w/ rapid ventricular response EKG findings of inferior infarction and left axis deviation Decreased grips/weakness on left side Decreased urine output (0 ml/10 hours) Elevated potassium level of 5.3 Elevated BUN (41) Elevated Creatinine (1.73) 2x3, 1 inch depth stage II ulceration on coccyx Unstageable ulceration on right heal Presence of multiple tears on upper extremities Client is NPO Problem Activity intolerance Long Term: Client will meet mutually defined goals of ambulation by [date], 12:00. -Refer client to PT to help increase activity levels and strength. -Provide emotional support and encouragement to the client to gradually increase mobility.
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