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activity intolerance related to decrease blood flow

activity intolerance related to decrease blood flow

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Published by DarkCeades
Nursing Care plan for Activity Intolerance
Nursing Care plan for Activity Intolerance

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Categories:Types, School Work
Published by: DarkCeades on Apr 14, 2009
Copyright:Attribution Non-commercial

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07/19/2013

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Nursing Care Plan
Cues NursingDiagnosisAnalysis Goal and Objectives Interventions Rationale Evaluation
Subjective:The clientverbalized:-“Nahihirapantalaga akomaglakad lalo nadito sa kaliwangpaa ko”-“mga 5 out of 10parin yung sakitna ramdam kopag naglalakadako” Objective:-In the nursingchart, the client isdiagnosed tohaveIntracerebralHemorrhage atthe ® upper medial frontallobe-there is (+)difficulty inambulation-during theinterview there isslight slurring of speech.Measurement:BP: 150/90RR: 26ActivityIntolerancerelated todecreaseblood flowA stroke is therapidly developingloss of brainfunction(s)due toadisturbanceintheblood supplytothe brain.This can be duetoischemia(lack of blood supply)causedbythrombosisor e mbolismor due toahemorrhage.As a result, theaffected area of thebrain is unable tofunction, leadingtoinability to moveone or more limbson one side of thebody, inabilitytounderstandor formulatespeechor inability toseeone side of thevisual fieldIn the past, strokewas referred to ascerebrovascular accident or CVA,but the term"stroke" is nowGoal:After 8 hours of proper nursing interventions,the client will be able toenhance activitytolerance.Objectives:After 30 minutes of nursing interventionand health teachings:-The client willunderstand theimportance of ROMexercises.-The client will be ableto learn at least 3 out of Developmental:-Explain to the clientthe importance andgood effect of ROMexercises.-Teach anddemonstrate 5Range of motionexercises help keepyour joints andmuscles as healthy aspossible. Withoutthese exercises, bloodflow and flexibility(moving and bending)of your joints candecrease. Joints, suchas your knees andelbows, could becomestiff and lockedwithout range of motion exercises.
 
To enhanceGoal was met.The client wasable tounderstand theimportance of the ROMexercises.The client wasable to learn 3
 
PR: 80preferred.
5 ROM exercises.-The client will be ableto demonstrate andparticipate in the ROMexercises.-Client’s safety will beensured.-Client’s response willbe monitored.-Client’s vital signs willbe monitored.appropriate ROMexercises.-Instruct client todemonstrateappropriate ROMexercises to theclient.Supplemental:-
 
Take safetyprecautions-Monitor the patientregularly for anysigns of distressduring the exercise.-Monitor anddocument vital signs.knowledge.To prevent or limitdeterioration.
(NANDA, page64 )
To be able to evaluatethe acquiredknowledge and skillson the givensituational scenario.-To avoid injury
.
(NANDA, page64)
To preventoccurrence of accidents and other complications.
(www.scribd.com/doc/2432 886/Cardiovascular-Exercise-Safety-Precaution)
To preventoverexertion.
(NANDA, page63)
Vital signs aremeasures of variousphysiological statisticsoften taken byhealthprofessionalsin order to assess the mostbasic body functions.Also to establishout of 5 ROMexercises.The client wasable todemonstratead participatein theexercises.The client’ssafety wasensured.The client’sresponse wasmonitored.The client’svital signs wastaken andrecorded.

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