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NURSING CARE PLAN Problem: Body Malaise Nursing Diagnosis: Activity Intolerance

NURSING CARE PLAN Problem: Body Malaise Nursing Diagnosis: Activity Intolerance

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Published by: LaGlaGan Group on Oct 02, 2009
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07/20/2013

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NURSING CARE PLAN
Problem: Body malaiseNursing diagnosis: Activity intolerance related to general malaise secondary to DMTaxonomy: Activity- Exercise PatternCause analysis: Fatigue and general malaise are common symptoms of DM patient which can interfere with an individual’s ability to initiate ADLs[Medical Surgical Nursing By Smeltzer and Bare, pp. 679]CUESOBJECTIVESINTERVENTIONSRATIONALEEVALUATIONSubjective:“Dii man niya kayamagtindog na siya lang” asverbalized by the SOObjective:
appeared weak
pale
patient is lethargic
unable to performADLs
dependent on otherscare
always lying on bedSTO:After 4 hours of givingeffective nursinginterventions, the patientwill be able to cope withfatigue as evidenced byverbalized feelings of comfort and increaseactivity participationLTO:Within 3 days of givingnursing interventions, thepatient will be able todemonstrate an increase inactivity tolerance asevidenced by doing simpleADL’sIndependent:1.Assessed patient’sability to perform tasks/noting reports of weakness, fatigue anddifficulty accomplishingtask.2.Recommended quietatmosphere; bed rest if indicated stress-need tomonitor and limitvisitors, phone callsand repeatedunplanned interruptions3.Elevated head of bedas tolerated.4.Provided/recommendedassistance withactivities / ambulationas necessary, allowingpt to do as much aspossible]5.Assisted pt to prioritizeADLs/desired activities.1.Influence of choiceof interventionsassistance2.Enhance rest tolower body’s oxygenrequirements, andreduces strain onthe heart and lungs3.Enhances lungexpansion tomaximizeoxygenation for cellular uptake.4.Although help maybe necessary, self esteem is enhancedwhen pt does thingsfor self.5.promotes adequaterest energy level,and alleviates strainon the cardiac andrespiratory systems.After 4 hours of givingeffective nursinginterventions, the patientwas able to cope withfatigue as evidenced byverbalization of feelings of comfort and participating inpassive ROMWithin 3 days of givingnursing intervention, thepatient was not able to dosimple ADLsRef: Nursing Care Plans by Doenges p 492-493

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