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O: - weak and pale in appearance - shallow, rapid respiration RR = 29 bmp PR = 87 bpm BP = 110/80 mmHg - slowness of movement - restlessness
DIAGNOSIS Activity intolerance related to fatigue, altered nutritional status.
PLANNING After 8 hours of nursing intervention, the patient will be able to tolerate prescribed physical activities, such as ADL. After 8 hours of nursing intervention, the patient will: - participate willingly in necessary activities of daily living. - demonstrate a decrease in physiologic signs of activity intolerance as evidenced by PR and RR within normal range. - verbalizes ways to
INTERVENTION Independent: 1. Obtained resting vital signs.
RATIONALE 1. Baseline data is important to help determine patient·s degree of activity intolerance.
EVALUATION Goals met. - patient participated willingly in ADLs and verbalizes ways to conserve energy and prevent fatigue. - patient demonstrated tolerance to activities
2. Assessed patient·s ability to perform ADL·s, providing assistance as necessary especially during tasks requiring ambulation. 3. Noted changes in balance/gait disturbance, muscle weakness.
2. Determines nursing interventions needed to assist patient; ensures patient safety.
3. Patients with Vitamin B12 deficiency often manifest neurologic changes.
4. Monitored BP, 4. Increase in pulse, BP, HR, RR, and respirations changes in skin
Encouraged 8. 6.conserve energy and prevent fatigue. Educative: 8. Elevated head of bed as tolerated. Rest lowers the body·s oxygen requirements. 6. Instructed patient to change position slowly. 7. To provide . and skin color during and after activity. 7. 5. 5. Promotes lung expansion for maximum oxygenation. Provided adequate rest and sleep periods especially between activities. Postural hypotension may cause dizziness and increased risk of injury. color result from the attempts of the heart and lungs to supply adequate amounts of oxygen to the tissues.
Promotes adequate rest and maintains energy level 9. Provided health teachings on the importance of prioritization of activities. adequate strength and improve general body condition. and DBE.patient to eat a well balanced diet. relaxation techniques. . 9. spacing.