: Less than Body Requirements related to anorexia,metabolic imbalance
related to fatigueAssess patient's level of mobility.
This aids in defining what patient is capable of,which is necessary before setting realistic goals.
Encourage adequate rest periods, especially before meals, other ADLs, exercisesessions, and ambulation.
Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period.
Risk for Impaired Skin Integrity
related to edema, immobility, pruritis,hypoproteinem
Ineffective Breathing Patterns
related to ascites Risk for Injuryrelated to impaired coagulation
Disturbed Thought Processes
related to elevated blood ammonia
Ineffective airway clearance
Assess respirations: note quality, rate, pattern, depth, and breathing effort.
Bothrapid, shallow breathing patterns and hypoventilation affect gas exchange.Shallow, "sighless" breathing patterns postsurgery (as a result of effect of anesthesia, pain, and immobility) reduce lung volume and decrease ventilation.
Avoid high concentration of oxygen in patients with COPD.
Hypoxia stimulatesthe drive to breathe in the chronic CO
retainer patient. When applying oxygen,close monitoring is imperative to prevent unsafe increases in the patient’s PaO
,which could result in apnea.
NOTE: If the patient is allowed to eat, oxygen still must be given to the patientbut in a different manner (e.g., changing from mask to a nasal cannula).
Eating isan activity and more oxygen will be consumed than when the patient is at rest.Immediately after the meal, the original oxygen delivery system should bereturned.
Impaired Physical Mobility
Evaluate the safety of the immediate environment.
Obstacles such as throw rugs, children’s toys, and pets can further impede one’s ability to ambulatesafely.