interventions Rationale EvaluationPatient Response

Interventions rationale evaluationpatient response

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Implementation/Nursing intervention(s): Rationale Evaluation/Patient Response Monitor rate and rhythm of the heart / pulse, blood pressure and respiration amount, before / after and during activities as needed. It helps illustrate the level of the heart and pulmonary decompensation. Decreased blood pressure, tachycardia, and tachypnea are indicative of heart activity disorders. Goals met. Assess patient’s ability to perform tasks/ noting reports of weakness, fatigue and difficulty accomplishing task. Influence of choice of Interventions assistance Goals met.
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CONCEPT MAP Recommended quiet atmosphere; bed rest if indicated stress-need to monitor and limit visitors, phone calls and repeated unplanned interruptions Enhance rest to lower body’s Oxygen requirements, and reduces strain on the heart and lungs Goals met. Elevated head of bed as tolerated. Enhances lung expansion to maximize oxygenation for cellular uptake. Goals met. Determine the client’s perception of cause of fatigue or activity intolerance. These may be temporary or permanent, physical, psychological. Patient was able to cope with fatigue as evidenced by verbalization of feelings of comfort and participating in passive ROM Change position often. This distributes work to different muscles to avoid fatigue. Goals met. Organizing a work-rest-work schedule. This reduces strain on energy resources. The client was able to maintain energy and increasing function of her body. Nursing Diagnosis #3: Self-Care Deficit and Desperation Related to (RT ): Musculoskeletal impairment As evident by (AEB): Inability to move purposefully within the physical environment, imposed restriction Planning/Desired Outcome(s): Clients are able to perform self-care activities such as bathing independently self-dressed, eating and defecating / urinating. Implementation/Nursing intervention(s): Rationale Evaluation/Patient Response Provided/recommended assistance with activities/ ambulation as necessary, allowing pt. to do as much as possible Although help may be necessary, self-esteem is enhanced when pt. does things for self Patient was able to do impleads. Assess potential for physical injury with activity. Including safety of the immediate environment Injury may be related to falls, or overexertion. Obstacles which can impede one’s ability to ambulate safely Patient verbalized understanding of the situation, risk factors, and safety. Provide emotional support while increasing activity. Promote positive attitude regarding abilities Clients may be fearful of overexertion. Appropriate supervision during early efforts can enhance confidence. Patient verbalized she felt better and shared her experiences.
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CONCEPT MAP Assist with ADLs as indicated: however, avoid doing for client what they can do for themselves. Assisting the client with ADLs allows for conservation of energy/ caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the client’s activity tolerance and self-esteem.
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