NURSING CARE PLAN

Client Initials: Mrs. M. R Age: 84 years Initiation Date of Nursing Care Plan: 05/11/11 Admitting Diagnosis: FAILURE TO COPE
ASSESSMENT

y y y y y y y y y y

Her vital signs are stable. She is awake, alert and oriented X 3 (person, place and time). Able to communicate verbally Requires visual aid/glasses and no hearing aid is required All lung fields clear with good air entry. Bowel sounds hypoactive, abdomen is soft and not distended She has no pain. But feeling very tired She is bedridden Minimal ROM on lower extremities Scars on bottom of both legs with small amount of drainage

NURSING DIAGNOSIS

GOALS (EXPECTED OUTCOMES)

NURSING INTERVENTIONS

EVALUATION

Fatigue related to The client will: disease process and poor y Verbalize increased energy physical and improved well being condition

The nurse will: y Evaluate adequacy of nutrition and sleep patterns. Review medications for side effects. y Teach strategies for energy conservation Encourage client to express feelings about fatigue; use active listening techniques and help identify sources of hope. Assist client with ADLs as necessary; encourage independence without y y Patient verbalized feelings of increased energy and improved well being. Patient demonstrates a more positive and happier attitude than before the interventions were applied Patient is able to identify factors that aggravate and relieved her fatigue. Patient is able to record aggravating factors that led to determining

y y

causing exhaustion.

relieving factors.

Identify potential factors that aggravate and relieve fatigue

Assess severity of fatigue on a scale of 0-10 q 4 hours or PRN. Encourage the client to keep a journal of activities, symptoms of fatigue, and feelings, Encourage patient to participate in Physical therapy