Date

Cues

Need

Nursing Diagnosis

Goal of Care

Intervention Plan

Evaluation

07/06 /10 @ 7:00 AM

Subjective: “Dili nako maka-tindog ug ako ra,” stated by the client. Objective: -creatinine levels of: • 272.8 (06/26/10) • 359 (07/01/10) • 389 (07/02/10) -needs assistance -PT 2 sessions -complained of pain in pelvic area

A C T I V I T Y A N D E X E R C I S E P A T T E R N

Activity intolerance r/t muscular weakness as evidenced by high serum creatinine level ® Creatinine can cause dehydration and fatigue. medicinenet.com

At the end of 2 days of care, Mr. S. will be able to demonstrate a decrease in physiological signs of intolerance as evidenced by: a) able to perform a specific task with improved strength;

1.

2.

3.

b) able to seek help in performing activities of daily living; c) verbalize acceptance of decreased activity level and;

4.

d) experience less discomfort when transferring, or performing other activities.

5.

6.

Establish guidelines and goals of activity with the patient and the caregiver ® Motivation is enhanced if the patient participates in goal setting. Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation ® Rest between activities provides time for energy conservation and recovery. Refrain from performing nonessential procedures ® Patients with limited activity tolerance need to prioritize tasks. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self ® 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 self-esteem. Assist patient to plan activities for times when he has the most energy ® Not all self-care and hygiene activities need to be completed in the morning. Likewise, not all housecleaning needs to be completed in 1 day. Improvise in adapting environment ® Appropriate aids will enable the patient to achieve optimal independence for self-care.

“GOAL MET” @ 07/07/10 12:00 nn At the end of 2 days of care, Mr. S was able to demonstrate a decrease physiological signs of intolerance as evidenced by: a. had great strength on lower extremities; observed during draping for removal of catheter b. asked help from student nurse or watcher in changing positions; c. “Ana jud ng mutiguwang ka,” he joked. d. “Nagasakit gihapon diri dapita (arthritis) pag mulihok, pero gamay gamay na lang.”

82

Sign up to vote on this title
UsefulNot useful