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Medical Diagnoses: Activity Intolerance, Weakness and fatigue

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt states that he cannot walk any farther than the bathroom or the chair without experiencing shortness of breath.

 

Pt states that he was admitted because he was experiencing unusual shortness of breath

 

 

 

 

Objective

     

Chart states chief complaint as “shortness of air”

     

Diagnosis of congestive heart failure

     

Pt demonstrates dyspnea upon exertion and acitivty.

Problem

    

Activity Intolerance



Long Term:

 

Pt will demonstrate increased tolerance to activity by discharge.

*Evaluate medications the client is taking to see if they could be causing activity intolerance.

     

Rationale:

“Medications such as beta-blockers, lipid- lowering 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)

     

     

     

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

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

R/T

 

Weakness and fatigue

 

 

 

 

 

Short Term:

 

Pt will participate in physical activity with appropriate changes in heart rate, blood pressure, and respirations within three days, by [date].

* Monitor vitals before and after any activity, noting any abnormal changes.

 

Rationale:

“This can be caused by a temporary insufficiency of blood supply” (Ackley & Ladwig, 2008, p 119)

 

*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 equipment needed before assisting in ambulation

 

Rationale:

Assistive devices can increase mobility by helping the client overcome limitations.” (Ackley & Ladwig, 2008, p 120)

 

 

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.

AEB

 

Pt states that he cannot ambulate far without experiencing shortness of breath.

 

Diagnosis of congestive heart failure

 

Chief complaint of shortness of breath

 

 

 

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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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