Nursing Care Plan

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Medical Diagnoses: Fatigue, Disease process,Poor physical condition

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt states a new person comes into his room every five minutes and he is not getting normal rest.

 

Pt states that he feels tired and worn out.

 

Objective

         

Pt demonstrates facial expressions of irritation when a staff member enters the room.

         

Pt was found sleeping or in a drowsy state when a staff member entered the room throughout the day.


Problem:

         

Fatigue

Long Term:

 

Pt will verbalize increased energy and improved well being by discharge.


 

         

*Evaluate adequacy of nutrition and sleep patterns.

 

Rationale: “A commonly suggested treatment for fatigue is rest, although excessive sleep can aggravate fatigue. Inadequate nutrition can also contribute to fatigue.”  (Ackley & Ladwig, 2008, p. 359).

 

*Review medications for side effects.

 

Rationale: “Certain medications (e.g., antihistamines, pain medications, anticonvulsants, chemotherapeutic agents) may cause fatigue, particularly in the elderly.” (Ackley & Ladwig, 2008, p. 360).

 

*Teach strategies for energy conservation (e.g. sitting instead of standing during showers, store items at waist level)

 

Rationale: “Energy conservation strategies can decrease the amount of energy used.” (Ackley & Ladwig, 2008, p. 360).

 

 

         

ü            

Goal met.  Pt verbalized feelings of increased energy and improved well being. He stated that he felt refreshed and more energized once he was able to identify the problems and they were fixed. Pt demonstrates a more positive and happier attitude than before the interventions were applied.

Continue interventions as listed. Continue to evaluate the pt’s adequacy of nutrition and sleep patterns. Continue to review medications for side effects that may cause fatigue or drowsiness. Continue to teach the pt energy conservation methods.

R/T:

         

Disease process

         

Poor physical condition

      

Short Term:

 

Pt will identify potential factors that aggravate and relieve fatigue within two days, or by [Month] 26, [Year].

      

*Assess severity of fatigue on a scale of 0-10 q 4 hours or PRN.

 

Rationale: “These assessments have all been shown to have good internal reliability.” (Ackley & Ladwig, 2008, p. 359)

 

*Encourage the client to keep a journal of activities, symptoms of fatigue, and feelings, including how fatigue affects the client’s normal activities and roles.

 

Rationale:  “The journal can increase the client’s awareness of symptoms and sense of control and facilitate communication with healthcare practitioners.”  (Ackley & Ladwig, 2008, p. 359)

ü           

      

Goal met. Pt was able to identify factors that aggravate and relieved his fatigue. He was first assessed and rated his fatigue 8/10. He then was able to record aggravating factors that led to determining relieving factors. He stated factors such as the unit’s noise levels and constantly having someone in his room.


 

Continue interventions as listed. Continue to assess the pt’s fatigue level q 4 hours or PRN using the 10 point scale. Continue to have the pt journal aggravating and relieving factors of his fatigue.

AEB

 

Pt statement about not being able to rest because he is constantly being bothered by the staff.

 

Pt facial expressions of irritation when a staff member enters his room

 

Pt demonstrates tiredness and fatigue by dozing off during the day, taking frequent naps, and appearing drowsy.

 

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*I = Implementation.  Check those interventions/actions/orders that were implemented.

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.


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