NURSING CARE PLAN Assessment Subjective: lagi na lang akong nakahiga as verbalized by the patient.

Objective Conscious and coherent body weakness restless poor appetite with limited ROM ambulatory c assistance Nursing Diagnosis Activity Intolerance; Level related to difficulty walking secondary to body weakness Analysis Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., -blockers), or emotional states such as depression Planning Patient will improve mobility participation in the activities of daily living. Interventions - establish rapport - place the client in a comfortable position -take and record vital signs -Determine patient's perception of causes of fatigue or activity intolerance. - Assess patient's level of mobility. Rationale - to facilitate NPI. - to prevent backaches or muscle aches. - to note any significant changes that may be brought about by the disease - These may be temporary or permanent, physical or psychological. Assessment guides treatment. - This aids in defining what patient is capable of, which is necessary before setting realistic goals. - Adequate energy reserves are required for activity. - Difficulties sleeping need to be addressed before activity progression can be achieved. - Depression over inability to perform required activities can further aggravate the Evaluation Patient demonstrated improved mobility participation in activity of daily living in which he is capable of.

- Assess nutritional status. - Monitor patient's sleep pattern and amount of sleep achieved over past few days. - Assess emotional response to change in physical status.

- Encourage

or lack of confidence to exert one's self.

adequate rest periods, especially before meals, other ADLs, and ambulation. - Refrain from performing nonessential procedures. -Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self.

activity intolerance. - Rest between activities provides time for energy conservation and recovery. - Patients with limited activity tolerance need to prioritize tasks. -Assisting the patient with ADLs allows for conservation of energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and selfesteem. -Exercises maintain muscle strength and joint ROM. -These reduce oxygen consumption, allowing more prolonged activity.

-Encourage active ROM exercises three times daily. -Teach energy conservation techniques.

Assessment

Nursing Diagnosis

Analysis

Planning

Interventions

Rationale

Evaluation

Subjective: ang bagal gumaling ng mga sugat ko As verbalized by the patient

Risk for infection related to high glucose levels, decreased leukocyte function.

Objective: -Flushed appearance -Wound at right foot -Alert and coherent

is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (inc reased thirst) and polyphagia (increase d hunger.

After 8 hours of nursing interventions, the patient will identify interventions to prevent or reduce risk of infection

Independent: Observe for signs of infection and inflammation. Promote good handwashing by nurse and patient. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance and site care. Rotate IV sites as indicated. Provide catheter or perineal care. Teach the female patient to clean from front to back after elimination. Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection. Reduces the risk of crosscontamination High glucose in the blood creates an excellent medium for bacterial growth. Minimizes the risk for infection. Peripheral circulation may

After 8 hours of nursing intervention s, the patient was able to identify intervention s to prevent or reduce risk of infection

Provide conscientious skin care, gentl massage bony areas. Keep the skin dry, linens dry and wrinkle free. Place in semi fowlers position. Encourage adequate dietary and fluid intake of 3000 ml per day. Collaborative: Obtain specimen for culture and sensitivities as indicated.

be impaired, placing patient at increased risk for skin irritation or breakdown and infection. Facilitates lung expansion and reduces risk of aspiration. Decrease susceptibility to infection. Identifies organisms so that most appropriate drug therapy can be instituted