Alynna Cherise T.

Valbuena N4A

NURSING CARE PLAN

ASSESSMENT
Subjective: The patient complaints of easy fatigability. Objective: BP: 160/90 Protruding abdomen with purple striae over the abdomen and buttocks Round face Develoment of facial hair Numerous bruises on the skin Thin lower extremities Difficulty climbing from one stair to another Diagnostic tests reveal the ff: Glucose: 186 mg/dl Na: 152 mEq/L K: 3.2 mEq/L Ca: 4.3 mEq/L Cortisol: 35 ug/dl

DIAGNOSIS
Activity Intolerance r/t muscle weakness and fatigues as manifested by inability to maintain usual routines.

PLANNING
After 8 hours of nursing intervention, the patient will achieve slight increase in activity tolerance evidenced by acceptable level of fatigue/weakness.

INTERVENTIONS
Assess sleep patterns and note changes in thought processes/behaviors.

RATIONALE
Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of medication, and progression of disease process. Prevents overexertion, allows for some activity within patient ability.

EVALUATION
After 8 hours of nursing intervention, the patient has achieved slight increase in activity tolerance evidenced by acceptable level of fatigue/weakness.

Recommend scheduling activities for periods when patient has most energy. Adjust activities as necessary, reducing intensity level/discontinuing activities as indicated. Encourage patient to do whatever possible, e.g., self-care, sit in chair, visit with family/friends. Instruct patient/family/caregiver in energy conservation techniques. Stress necessity of allowing for frequent rest periods following activities. Demonstrate proper performance of ADLs, ambulation/position changes. Identify safety issues, e.g., use of assistive devices, temperature of bath water, keeping travel-ways clear of furniture. Encourage nutritional intake/use of supplements as appropriate.

Provides for sense of control and feeling of accomplishment.

Enhances performance while conserving limited energy, preventing increase in level of fatigue.

Protects patient/caregiver from injury during activities.

Necessary to meet energy needs for activity.