Problem Identified: body weakness, Nursing Diagnosis: Activity intolerance related to weakness and pain Cause 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 cardiopulmonary, diabetic, or pulmonary-related problems. (Gulanick&Myers (2013) Nursing Care Plans 8th edition.Elsevier: Philadelphia,PA)

Cues Subjective:

Objective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will: 1. Verbalize feeling of less fatigued and weak. Long-term: Within 2 days of nursing interventions, the patient will: 1. Demonstrate an increase tolerance in activities. 2. Perform activities without dizziness or difficulty in breathing.

Intervention

Rationale

evaluation

Problem Identified: +1 edema on all extremities Nursing Diagnosis: Ineffective tissue perfusion related to peripheral edema and decreased albumin levels Cause analysis: It is a general response of the body to injury or inflammation. Edema can be isolated to a small area or affect the entire body. Edema results whenever small blood
vessels become "leaky" and release fluid into nearby tissues. The extra fluid accumulates, causing the tissue to swell. Edema can also result from medical conditions or problems in the balance of substances normally present in blood. Albumin and other proteins in the blood act like sponges to keep fluid in the blood vessels. Low albumin may contribute to edema. When the heart weakens and pumps blood less effectively, fluid can slowly build up, creating leg edema. (WebMD,2013: Edema Overview)

Cues Subjective:

Objective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will: 1. Display absence of pallor or cyanosis. 2. Have palpable peripheral pulses. 3. Exhibit CRT < 3 seconds. 4. Have a urine output of 30ml/hr.

Intervention

Rationale

evaluation

Long-term: Within 2 days of nursing interventions, the patient will: 1. Show a reduction of swelling in edematous areas.

problem Identified: pain Nursing Diagnosis: Acute pain related to gallbladder inflammation and presence of stones Cause analysis: Smaller gallstones tend to block the bile ducts, which causes distension of the tube and spasm of the gall bladder. This manifests clinically as acutepain. The pain is colicky in nature in the right hypochondrium or mid-epigastric area and spreads to the back, between the scapulae, or to the right shoulder. (Viljoen& Uys (2004). General Nursing: Medical and Surgical Nursing Part II. Dieter Zimmerman Ltd:Johanessburg, Cape Town.)

Cues Subjective:

Objective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will: 1. Verbalize a decrease in intensity of pain. 2. Display no significant changes in vital signs.

Intervention

Rationale

evaluation

Long-term: Within 2 days of nursing interventions, the patient will: 1. Perform activities without pain.

Problem Identified: shortness of breath Nursing Diagnosis: Impaired gas exchange related to alveolar-capillary membrane changes secondary to pleural effusion Cause analysis: As pulmonary edema progresses, it inhibits oxygen and carbon dioxide exchange at the alveolar-capillary interface. (Lewis,et.al (2013) MedicaSurgical Nursing) When fluid collects between the visceral and parietal pleura, it produces a pleural effusion. The tissues rub against each other breath after breath, causing inflammation and fluid to accumulate in the space. It may be difficult to hear any breath sounds through the effusion. Because the effusion is filled with fluid, the patients position will affect his or her ability to breathe. ( Nancy L. Carolines Emergency Care in the Streets(2012). Jones & Bartlett Publishers)

Cues Subjective:

Objective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will: 1. Demonstrate no difficulty in breathing. 2. Identify positions that facilitate in breathing. 3. Display adequate oxygen saturation levels.

Intervention

Rationale

evaluation

Long-term: Within 2 days of nursing interventions, the patient will: 1. Maintain usual mental status.

2. Show absence of pallor or cyanosis.

Problem Identified: Nursing Diagnosis: Ineffective breathing pattern related to pressure exerted on the diaphragm secondary to pleural effusion and ascites Cause analysis: Pressure on the diaphragm causes loss of lung volume, resulting in increased work of breathing and compromised oxygenation.(Elliot, et.a;l(2011) ACCCNs Critical Care Nursing . 2nd edition Elsevier Health Sciences) Patients with mild ascites may not be aware of the condition, but as the amount of fluid in the peritoneal cavity builds up, the abdomen becomes increasingly distended and patients will complain of a progressive abdominal heaviness and pressure. They will become increasingly short of breath as the increased pressure impinges on the diaphragm. (Holt, Paula(2009). Diabetes in Hospital: A Practical Approach for Healthcare Professionals. John Wiley & Sons)

Cues Subjective:

Objective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will: 1. Demonstrate decreased difficulty in breathing. 2. Have oxygen saturation levels within normal range.

Intervention

Rationale

evaluation

Long-term: Within 2 days of nursing

interventions, the patient will: 1. Exhibit normal rate and depth of respirations, decreased dyspnea, and symmetrical chest excursion.

Problem Identified: Nursing Diagnosis: Fluid volume excess related to fluid retention secondary to edema, pleural effusion and ascites Cause analysis:

Cues Subjective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will:

Intervention

Rationale

evaluation

Objective:

Long-term: Within 2 days of nursing interventions, the patient will:

Problem Identified: Nursing Diagnosis: Risk for constipation Cause analysis:

Cues Subjective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will:

Intervention

Rationale

evaluation

Objective:

Long-term: Within 2 days of nursing interventions, the patient will:

Problem Identified: Nursing Diagnosis: Fatigue related to decreased RBC and hemoglobin levels Cause analysis:

Cues Subjective:

Objectives Short-term: Within 8 hours of nursing interventions, the patient will:

Intervention

Rationale

evaluation

Objective:

Long-term: Within 2 days of nursing interventions, the patient will: