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Implementation/Nursing intervention(s):Rationale Evaluation/Patient ResponseMonitor 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 bloodpressure, 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 assistanceGoals met.
CONCEPT MAPRecommended quiet atmosphere; bed rest if indicated stress-need tomonitor and limit visitors, phone callsand repeated unplanned interruptionsEnhance rest to lower body’sOxygen requirements, and reduces strain on the heart and lungsGoals met.Elevated head of bed as tolerated.Enhances lung expansion tomaximize 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 participatingin passive ROMChange 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 DesperationRelated to (RT): Musculoskeletal impairmentAs evident by (AEB): Inability to move purposefully within the physical environment, imposed restrictionPlanning/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 ResponseProvided/recommended assistance with activities/ ambulation asnecessary, allowing pt. to do as much as possibleAlthough help may be necessary, self-esteem is enhanced when pt. does things for selfPatient was able to do impleads.Assess potential for physical injury with activity. Including safety of the immediate environmentInjury may be related to falls, or overexertion. Obstacles which can impede one’s ability to ambulate safelyPatient verbalized understanding of the situation,risk factors, and safety.Provide emotional support while increasing activity. Promote positive attitude regarding abilitiesClients may be fearful of overexertion. Appropriate supervision during early efforts can enhance confidence.Patient verbalized she felt better and shared her experiences.
CONCEPT MAPAssist 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 endurancethat will ultimately enhance the client’s activity tolerance and self-esteem.