Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

Subjective:

Client expressed she didn’t want to move “anymore than she has to.”

Hx of DM II, CAD

Objective:

Temp:  101.0

Basilar rales bilaterally

Elevated BP (145/86)

Elevated HR (110)

Client is in atrial fibrillation w/ rapid ventricular response

EKG findings of inferior infarction and left axis deviation

Decreased grips/weakness on left side

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

2x3, 1 inch depth stage II ulceration on coccyx

Unstageable ulceration on right heal

Presence of multiple tears on upper extremities

Client is NPO

Elevated blood glucose (185)

Post-CVA

Problem

Activity intolerance

Long Term:

Client will meet mutually defined goals of ambulation by [date], 12:00.

-Refer client to PT to help increase activity levels and strength.

-Provide emotional support and encouragement to the client to gradually increase mobility.

R/T

Chronic pain, fatigue and weakness secondary to CVA

Short Term:

Client will increase physical activity by end of shift today

-Determine the cause of activity tolerance to determine whether the cause is physical, emotional or motivational.  Determining the cause will help guide management (Ackley & Ladwig, 2008).

-Minimize cardiovascular deconditioning by positioning the client upright several times a day as condition allows.

-Perform ROM exercises if the client is unable to tolerate activity.

-Monitor and record the patient’s ability to tolerate activity:  note pulse rate, blood pressure, respiratory pattern, dyspnea, and skin color before and after activity.  If s/s of cardiac decompression develop, stop activity immediately.

-Provide emotional support and encouragement to the client to gradually increase mobility.

-Move client to the chair as ordered and monitor tolerance.

AEB:

Left side extremity weakness, right side hemiparesis, dysrhythmias, altered respiratory rate (24) and presence of 2x3, 1 inch depth stage II ulceration on coccyx, unstageable wound on the right heal, presence of multiple skin tears on the upper extremities, decreased Hgb (10.2), decreased albumin (2.0), elevated blood glucose (185) and client is NPO.