NURSING CARE PLAN ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE: Bakit kaya madalas ako

mahilo? (Why do I always feel dizzy?) as verbalized by the patient. OBJECTIVE: Request for information. Agitated behavior Inaccurate follow through of instructions. vS taken as follows: T: 37.2 P: 84 R: 18 BP: 180/110 Risk for prone behavior related to lack of knowledge about the disease After 8 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment regimen. INDEPENDENT: Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney, and brain. Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. Suggest frequent position changes, leg exercises when lying down. Provides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. These risk factors have been shown to contribute to hypertension. Lack of cooperation is common reason for failure of antihypertensive therapy. Decreases peripheral venous pooling that may be potentiated by vasodilators and After 8 hours of nursing interventions, the patient was able to verbalize understanding of the disease process and treatment regimen. and a blood pressure of 140/90 or above is considered high. An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as end-organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure. Help patient identify sources of sodium intake. Encourage patient to decrease or eliminate caffeine like in tea, coffee, cola and chocolates. Stress importance of accomplishing daily rest periods. COLLABORATIVE: Provide information regarding community resources, and support patients in making lifestyle changes. prolonged sitting or standing. Two years on moderate low salt diet may be sufficient to control mild hypertension. Caffeine is a cardiac stimulant and may adversely affect cardiac function. Alternating rest and activity increases tolerance to activity progression. Community resources like health centers programs and check ups are helpful in controlling hypertension. Nursing Priorities For Care Plan : Improve myocardial contractility/systemic perfusion. Reduce fluid volume overload. Prevent complications. Provide information about disease/prognosis, therapy needs, and prevention of recurrences. Nursing Action or Nursing Intervention : Assess Cardiovascular status including vital signs to detect cardiac compromise. Take an average of two or more blood pressure readings to establish hypertension. Check the client's blood pressure in lying, sitting, and standing position to determine if orthostatic hypotension is present. Also check for pallor, diaphoresis, and vertigo. Assess neurologic static and observe the client for changes that may indicated an alteration in cerebral perfussion (CVA or hemorrhage). Monitor and record intake and output and daily weight to detect fluid volume overload. Administer medications as prescribed to lower blood pressure. Make sure the client maintains a low-sodium, low-cholesterol diet to help minimize hypertention. Encourage the client to express feelings about daily stress to reduce anxity.

Maintain a quiet environment to reduce stress. Planing and Goals of Nursing Care : The client will exhibit a reduction in blood pressure The client will express understanding and acceptance of necessary lifestyle changes. Complications prevented/resolved. Optimum level of activity/functioning attained. Disease process/prognosis and therapeutic regimen understood. Plan in place to meet needs after discharge. Nursing Interventions Assess severity of fatigue on a scale of 0 to 10; assess frequency of fatigue, activities associated with increased fatigue, ability to perform activities of daily living (ADLs), times of increased energy, ability to concentrate, mood, and usual pattern of activity. Evaluate adequacy of nutrition and sleep. Encourage the client to get adequate rest. Refer to Imbalanced Nutrition: less than body requirements or Disturbed Sleep pattern if appropriate. Determine with help from the primary care practitioner whether there is a physiological or psychological cause of fatigue that could be treated, such as anemia, electrolyte imbalance, hypothyroidism, depression, or medication effect. Work with the physician to determine if the client has chronic fatigue syndrome. Encourage client to express feelings about fatigue; use active listening techniques and help identify sources of hope. Encourage client to keep a journal of activities, symptoms of fatigue, and feelings. Assist client with ADLs as necessary; encourage independence without causing exhaustion. Help client set small, easily achieved short-term goals such as writing two sentences in a journal daily or walking to the end of the hallway twice daily. With physician's approval, refer to physical therapy for carefully monitored aerobic exercise program. Refer client to diagnosis-appropriate support groups such as National Chronic Fatigue Syndrome Association or Multiple Sclerosis Association. Help client identify essential and nonessential tasks and determine what can be delegated. Give client permission to limit social and role demands if needed (e.g., switch to part-time employment, hire cleaning service). Refer client to occupational therapy to learn new energy-conserving ways to perform tasks. If client is very weak, refer to physical therapy for prescription and use of a mobility aid such as a walker. Identify recent losses; monitor for depression as a possible contributing factor to fatigue. Review medications for side effects. Certain medications (e.g., beta-blockers, antihistamines, pain medications) may cause fatigue in the elderly. Home Care Interventions Assess client's history and current patterns of fatigue as they relate to the home environment. Fatigue may be more pronounced in specific settings for physical or psychological reason. Assess home for environmental and behavioral triggers of increased fatigue When assisting client with adapting to home and daily patterns, avoid activities of high energy output. Refer to occupational therapy to accomplish this if necessary. Assist client with identifying or creating a safe, restful place within the home that can be used routinely (e.g., a room with familiar, nonthreatening, or nonfrightening belongings). Client/Family Teaching Share information about fatigue and how to live with it, including need for positive self-talk. Teach strategies for energy conservation Teach client to carry a pocket calendar, make lists of required activities, and post reminders around the house. Teach the importance of following a healthy lifestyle with adequate nutrition and rest, pain relief, and appropriate exercise to decrease fatigue. Teach stress-reduction techniques such as controlled breathing, imagery, and use of music. See Anxiety care plan if appropriate; anxiety is correlated with increased fatigue.

Medical Diagnoses: Activity Intolerance, Weakness and fatigue Assessmen Nursing Client Nursing *I t DX/Clinical Goals/Desired Interventions/Actions/Or Problem Outcomes/Objectiv ders and Rationale es Subjective Problem Long Term: *Evaluate medications the client is taking to Pt states Activity Pt will see if they could be that he Intolerance demonstrate causing activity cannot increased intolerance.

Evaluation Goals Goal met. Pt demonstrated increased tolerance to activity. Pt

Interventions Continue interventions as listed. Continue to evaluate the

walk any farther than the bathroom or the chair without experienci ng shortness of breath. Pt states that he was admitted because he was experienci ng unusual shortness of breath

tolerance to activity by discharge.

Rationale: Medications such as beta-blockers, lipidlowering agents, which can damage muscle, and some antihypertensives such as Clonedine and lowering the blood pressure to normal in the elderly can result in decreased functioning. (Ackley & Ladwig, 2008, p 121) *Assess nutritional needs associated with activity intolerance. Rationale: The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers. (Ackley & Ladwig, 2008, p 120) *Provide emotional support and encouragement to the client to gradually increase activity. Rationale: Fear of breathlessness, pain, or falling may decrease willingness to increase activity. (Ackley & Ladwig, 2008, p 120)

was able to ambulate to the room door and back to the bed without any abnormal changes in vitals. Pt stated that he felt stable after ambulating.

pts medications to see if they could be causing the activity intolerance. Continue to assess pts nutritional needs. Continue to provide emotional support and encouragement so that the pt may feel more confident about resuming activity.

Objective Chart states chief complaint as shortness of air Diagnosis of congestive heart failure Pt demonstra tes dyspnea upon exertion and acitivty.

R/T Weakness and fatigue

Short Term:

AEB Pt states that he cannot ambulate far without experienci ng shortness of breath.

* Monitor vitals before and after any activity, Pt will participate noting any abnormal in physical activity changes. with appropriate changes in heart Rationale: rate, blood This can be caused by a pressure, and temporary insufficiency respirations within of blood supply (Ackley three days, by & Ladwig, 2008, p 119) [date]. *Assess for pain before activity. Rationale: Pain restricts the client from achieving a maximal activity level and if often exacerbated by movement. (Ackley & Ladwig, 2008, p 120) *Obtain any necessary assistive devices or

Goal met. Pt was able to participate in physical activity with appropriate vitals changes. His vitals were checked before and after activity and there were no indications of unstable vitals.

Continue interventions as listed. Continue to monitor vitals before and after activity. Continue to assess for pain before activity. Continue to obtain any assistive devices before activity.

Diagnosis of congestiv e heart failure Chief complaint of shortness of breath

equipment needed before assisting in ambulation Rationale: Assistive devices can increase mobility by helping the client

NURSING CARE PLAN GUIDE NURSING DIAGNOSIS: FATIGUE NANDA Definition: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level SUBJECTIVE, OBJECTIVE CHARACTERISTICS:EXPECTED OUTCOMES: Inability to restore energy, even after sleep Lack of energy or inability to maintain usual level of physical activity Increased rest requirements Tired Verbalization of an unremitting and overwhelming lack of energy Inability to maintain usual routines Lethargic or listless Increased physical complaints Perceived need for additional energy to accomplish routine tasks Compromised concentration Feelings of guilt for not keeping up with responsibilities Patient verbalizes having sufficient energy to complete desired activities. RELATED FACTORS: Psychological: o Boring lifestyle o Stress o Anxiety o Depression Environmental: o Humidity o Light o Noise o Temperature Situational: o Negative life event o Occupation Physiological: o

Sleep deprivation o Pregnancy o Poor physical condition o Disease states o Increased physical exertion o Malnutrition o Anemia ASSESSMENT GUIDELINES RATIONALE Assess characteristics of fatigue: Severity Changes in severity over time Aggregating factors Alleviating factors Using a quantitative rating scale such as 1 to 10 can help the patient describe the amount of fatigue experienced. Other rating scales can be developed using pictures or descriptive words. This method allows the nurse to compare changes in the patients fatigue level over time. Itis important to determine if the patients level of fatigue is constant or if it varies over time. Assess for possible causes of fatigue: Recent physical illness Emotional stress Depression Medication side effects Anemia Sleep disorders Imbalanced nutritional intake Increased responsibilities and demands at home or work Identifying the related factors with fatigue can aidin determining possible causes and establishing acollaborative plan of care. Assess the patients ability to perform activitiesof daily living (ADLs), instrumental activities ofdaily living (IADLs), and demands of daily living(DDLs). Fatigue can limit the persons ability to participate in self-care and perform his or her role responsibilities in the family and society. Assess the patients emotional response to

fatigue. Anxiety and depression are the more common emotional responses associated with fatigue. These emotional states can add to the persons fatigue level and create a vicious cycle. Evaluate the patients routine prescription and over-the-counter medications. Fatigue may be a medication side effect or an indication of a drug interaction. The nurse should give particular attention to the patients use of blockers, calcium channel blockers, tranquilizers, alcohol, muscle relaxants, and sedatives. Assess the patients nutritional intake of calories, protein, minerals, and vitamins. Fatigue may be a symptom of protein-calorie malnutrition, vitamin deficiencies, or iron deficiencies. Evaluate the patients sleep patterns for quality, quantity, time taken to fall asleep, and feeling upon awakening. Changes in the persons sleep pattern may be a contributing factor in the development of fatigue. Assess the patients usual level of exercise and physical activity. Both increased physical exertion and limited levels of exercise can contribute to fatigue. Evaluate laboratory/diagnostic test results: Blood glucose Hemoglobin/hematocrit BUN Oxygen saturation, resting and with

activity Changes in these physiological measures can be compared with other assessment data to understand possible causes of the patients fatigue. Assess the patients expectations for fatigue relief, willingness to participate in strategies to reduce fatigue, and level of family and social support. The patient will need to be an active participant in planning, implementing, and evaluating

therapeutic interventions to relieve fatigue. Social support will be necessary to help the patient implement changes to reduce fatigue. NURSING INTERVENTIONS RATIONALE Encourage the patient to keep a 24-hour fatigue/activity log for at least 1 week. Recognizing relationships between specific activities and levels of fatigue can help the patient identify excessive energy expenditure. The log may indicate times of day when the person feels the least fatigued. This information can help the patient make decisions about arranging his or herEncourage the patient to keep a 24-hour fatigue/activity log for at least 1 week. Recognizing relationships between specific activities and levels of fatigue can help the patient identify excessive energy expenditure. The log may indicate times of day when the person feels the least fatigued. This information can help the patient make decisions about arranging his or her activities to take advantage of periods of high energy levels. Assist the patient to develop a schedule for daily activity and rest. A plan that balances periods of activity with periods of rest can help the patient complete desired activities without adding to levels of fatigue. Refer the patient to an occupational therapist. The occupational therapist can provide the patient with assistive devices and teach the patient energy conservation techniques. Encourage the patient to use assistive devices for ADLs and IADLs: Long-handled sponge for bathing Long shoehorn Sock-puller Long-handled grabber The use of assistive devices can minimize energy expenditure and prevent injury with activities. Help the patient set priorities for desired activities and role responsibilities.

Setting priorities is one example of an energy conservation technique that allows the patient to use available energy to accomplish important activities. Achieving desired goals can improve the patients mood and sense of emotional wellbeing. Monitor the patients nutritional intake foradequate energy sources and metabolicrequirements. The patient will need adequate intake of carbohydrates, protein, vitamins, and minerals to provide energy resources. Encourage the patient to identify tasks that can be delegated to others. Delegating tasks and responsibilities to others can help the patient conserve energy. Minimize environmental stimuli, especially during planned times for rest and sleep. Bright lighting, noise, visitors, frequent distractions, and clutter in the patients physical environment can inhibit relaxation, interrupt rest/sleep, and contribute to fatigue. PATIENT TEACHING RATIONALE Teach the patient and family task organization techniques and time management strategies. Organization and time management can help the patient conserve energy and prevent fatigue. Help the patient engage in increasing levels of physical activity and exercise. Exercise can reduce fatigue and help the patient build endurance for physical activity. Monitor the patients energy expenditure with activity. Changes in oxygen saturation, respiratory rate, and heart rate will reflect the patients tolerance for activity. Using MET (metabolic equivalent) activity levels can help evaluate energy