ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:
“I had been feeling very Fatigue related to After 1-2 hours of 1. Monitor vital signs, noting pulse rate 1. Pulse is typically elevated After 1-2 hours of proper
tired and had little Hypermetabolic proper nursing at rest and when active. and, even at rest, nursing intervention the client
energy for cleaning the state with intervention the client 2. Note development of tachypnea, tachycardia (up to 160 displays improved ability to
house or family increased energy will display improved dyspnea, pallor, and cyanosis. beats/min) may be noted. participate in desired activities.
activities.” As requirements as ability to participate in 3. Provide for a quiet environment; 2. O2 demand and
verbalized by the evidenced by desired activities. cool room, decreased sensory consumption are increased GOAL MET
patient verbalization of stimuli, soothing colors, quiet music. in the hypermetabolic state,
overwhelming 4. Encourage patient to restrict activity potentiating the risk of
OBJECTIVE: lack of energy to and rest in bed as much as possible. hypoxia with activity.
 Tire easily maintain the 5. Provide comfort measures: touch 3. Reduces stimuli that may
 Feel cold usual routine, therapy or massage, cool showers. aggravate agitation,
despite warmer decreased Patient with dyspnea will be most hyperactivity, and
environmental performance. comfortable sitting in high Fowler’s insomnia.
temperatures. position. 4. Helps counteract effects of
 Struggle with 6. Avoid topics that irritate or upset increased metabolism.
constipation. patient. Discuss ways to respond to 5. May decrease nervous
these feelings. energy, promoting
7. Administer medications as indicated: relaxation.
Sedatives such as phenobarbital 6. Increased irritability of the
(Luminal); antianxiety agents; CNS may cause the patient
chlordiazepoxide (Librium) to be easily excited,
8. Assess client’s knowledge of agitated, and prone to
contributing causes, treatment plan, emotional outbursts.
specific medications, and therapeutic 7. Combats nervousness,
actions. hyperactivity, and
insomnia.
8. To avoid any kinds of
complications.