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Cues Nursing

Diagnosis
Analysis Goals and Objectives Intervention Rationale Evaluation
Subjective:



Objective:
-weak in
appearance
- Pale
palpebral
conjunctiva
-decrease
leg strength
-Decrease
muscle
strength
-Needs
assistance

















Activity
Intolerance
r/t
immobility
secondary
to hip
fracture

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,
Goal:

After 8 hours of Nursing
Intervention the client will be
able to report measurable
increase in activity
tolerance.




Objective:

After 15mins of Nurse-
patient i nteraction the
cli ent wi l l be able to
report of difficulty
accompl ishing tasks or
desired acti vities.










After 15mins of nursing
intervention, the client will be
to do the planned care with
rest periods between
activities.













Note cl ient reports of difficulty
accompl ishing tasks or desired
acti vities. Evaluate
currentlimitations/degree of
deficit in l ight of usual status
and what the cl ient percei ves
causes,exacerbates, and helps
the problem








Plan care with rest periods
between acti vities
















Provides
comparati ve
basel ine and
influences choice
of intervention and
may reveal causes
that the client is
unaware of
affecting energy,
such as sleep
depri vation,
smoking, poor diet,
depression, or lack
of support.


To reduce fatigue




Was the client
was able to
report
measurable
increase in
activity
tolerance?
Yes_No_
Why?_




Was the client
was able to
report of
difficulty
accompl ishing
tasks or
desired
acti vities?
Yes_No_
Why?_






Was the client
able to do the
planned care with
rest periods
between


side effects of
medications
(e.g., -blockers),
or emotional
states such as
depression or
lack of
confidence to
exert one's self.

(Elsevier,2012)


After 30minutes of nursing
intervention, the client will be
do self-care activities with
assistance.




After 1hour of nursing
intervention, the client will be
able to increase/activity
levels gradually



After 15minutes of
nursing intervention, the
cli ent wi l l be assi sted
with acti viti es and
provide/monitor cl ients
use of assistive devices.





After 30minutes of
nursing intervention, the
cli ent wi l l be referred to
col laborati ve disci pl ines.








Assist with self-care acti vities.
Adj ust acti vities/reduce
intensity level, or discontinue
acti v-iti es that cause
undesired physiological
changes.


Increase exercise/acti vity
levels gradual l y





Assist with acti vities and
provide/monitor cl ients use of
assisti ve devices.








Provide referral to collaborative
disciplines such as exercise
physiologist,
psychologicalcounsel ing/therapy,
occupati onal/physical therapy,
and recreation/leisure




Prevents overexertion







Methods of
conserving energy





Enbl esclient to
maintai n mobi lity
whi le protecting
from inj ury.







May be needed to
devel op
indi vi duall y
appropri ate
therapeutic
regimens
activities?
Yes_No_
Why?_

Was the client
able to do self-
care activities
with assistance?
Yes_No_
Why?


Was the client
able to
increase/activity
levels gradually?
Yes_No_
Why?

Was the client
was able to be
assisted with
acti vities and
provide/monitor
cli ents use of
assisti ve
devices?
Yes_No_
Why?

Was the client
were referred
to collaborati ve
discipl ines?
Yes_No_
Why?

After 30 minutes of
nursing interacti on and
interventi on, the cl ient
wi ll be impl emented
gr aded
exer ci se/ r ehabi l i t at i on
pr ogr am under di r ect
medi cal super vi si on.




After 30 minutes of
health teaching, the
cli ent wi l l be able to
discuss and demonstrate
appropri ate safety
measures




After 15 minutes of
health teaching, the
cli ent wi l l be able to
discuss information
about proper nutrition to
meet metabolic and
energy needs,
obtainingor maintai ni ng
normal body weight.




special ists.

I mpl ement gr aded
exer ci se/ r ehabi l i t at i on
pr ogr am under di r ect
medi cal super vi si on.








Assist cl ient to learn
and demonstrate appropriate
safety measures







Provide information about
proper nutrition to meet
metabol ic and energy needs,
obtainingor maintai ni ng normal
body weight.




Gradual increase
in acti vity avoids
excessi ve
myocardial
workload/excessi ve
oxygen demand.







To prevent inj uries









Energy is improved
when nutri ents are
sufficient to meet
metabol ic demands


Was the client
was able to be
implemented
graded
exercise/
Rehabi litation
program under
direct medical
supervision?
Yes_No_
Why?

Was the client
able to discuss
and
demonstrate
appropri ate
safety
measures?
Yes_No_
Why?

Was the client
able to discuss
information
about proper
nutrition to
meet metabolic
and energy
needs,
obtainingor
maintai ning
normal body
weight?

Yes_No_
Why?