Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders
and Rationale
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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
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Problem
Activity intolerance
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Long Term:
Client will meet mutually defined goals of ambulation
by [date], 12:00.
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-Refer client to PT to help
increase activity levels and strength.
-Provide emotional support
and encouragement to the client to gradually increase mobility.
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R/T
Chronic pain, fatigue and weakness secondary to CVA
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Short Term:
Client will increase physical activity by end of shift
today
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-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.
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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.
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