b) Nursing Care Plans

Problem#1: Acute Pain

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S> “Masakit ku Acute Pain related to Acute Pain is the Short term: >Establish rapport >to gain trust and Short term:
salu”, as verbalized increased lactic acid prioritized problem After 4 hours of NI, cooperation After 4 hours of NI,
by the pt. production because it suggests the patient will report the patient shall
secondary to ischemia which is relief of pain. >Assess patient’s >to determine s/sx have verbalized
O> The patient may decreased blood and very fatal. In acute condition methods that
manifest: oxygen supply to myocardial infarction provide relief.
- tachycardia myocardium more commonly >Monitor VS >to obtain baseline
- tachypnea known as heart data
- sleep disturbance attack, a medical
- facial grimaces condition that occurs Long term: >Perform a Long term:
- irritability when the blood After 2 days of NI, comprehensive >to determine After 2 days of NI,
supply to a part of the patient will assessment of pain precipitating the patient shall
>The patient the heart is demonstrate use of factor/s have
manifested: interrupted, most relaxation >Assess demonstrated use
- with oxygen commonly due to techniques and respirations, BP and of relaxation
hooked via nasal rupture of a divertional activities heart rate with each > respirations may techniques and
cannula regulated at vulnerable plaque. as indicated for episodes of chest be increased as a divertional
2 lpm The resulting individual situation. pain. result of pain and activities as
- with ischemia or oxygen associate anxiety. indicated for
condomcatheter shortage causes >Observe nonverbal individual
attached to urine damage and cues >observations situation.
bag potential death of may/may not be
- continuous cardiac heart tissue. congruent with
monitoring Because of verbal reports
decreased blood and indicating need for
oxygen supply to further evaluation
myocardium, shifting
from aerobic to >Provide comfort >to provide non
anaerobic measures such as pharmacological
metabolism happens back rub measures of
thus there is an relieving pain
increase in lactic
134
acid production >Provide adequate
causing irritation to rest periods >to prevent fatigue
the heart muscle. and promote
This mechanism relaxation
causes a feeling of >Maintain bed rest
pain which may during pain, with >to reduce oxygen
activate the position of comfort, consumption and
sympathetic nervous maintain relaxing demand, to reduce
system thus causing environment to competing stimuli
tachypnea and promote calmness. and reduces
tachycardia as a anxiety
response. Due to the
uncomfortable >Prepare for the
sensation, the administration of
patient may be seen medications, and >pain control is a
with facial grimaces monitor response to priority, as it
and irritability. drug therapy. Notify indicates ischemia
physician if pain
does not abate.

>Review ways to
lessen pain
>to promote
wellness
>Provide for
individualized
physical >promotes active,
therapy/exercise not passive role
programs that can
be continued by the
client when
discharged

>Discuss with SO(s)

ways in which they
can assist client and >to promote
reduce precipitating wellness
factors that may
cause or increase
pain

135
 >Instruct
patient/family in
medication effects,
side-effects,
contraindications > to promote
and symptoms to knowledge and
report compliance with
therapeutic regimen
and to alleviate fear
of unknown

Problem#2: Ineffective airway clearance

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S> The patient may Ineffective airway Pneumonia is an Short term: >Establish rapport >to gain trust and Short term:
verbalize: clearance r/t infectious disease After 4 hours of NI, cooperation After 4 hours of NI,
- dyspnea retained characterized by the patient will the patient shall
tracheobronchial inflammatory demonstrate >Assess patient’s >to determine s/sx have verbalized
O> The patient secretions AEB processes affecting behaviors to improve condition methods that
manifested: presence of the lung or maintain airway provide relief.
- productive cough productive cough parenchyma. The patency. >Monitor VS >to obtain baseline
- fuzziness of the invading organism data
lung markings in causes symptoms, in
both lungs part, by provoking an >Auscultate breath > to note presence Long term:
- with oxygen overly exuberant sounds of adventitious After 2 days of NI,
hooked via nasal immune response in Long term: breath sounds the patient shall
cannula regulated at the lungs. After 4 days of NI, have
2 lpm Mucus production is the patient will >Assess respiratory > use of accessory demonstrated use
- with condom increased which demonstrate movements and use muscles to breathe of relaxation
catheter attached to plugs the airway absence/reduction of of accessory indicates and techniques and
urine bag thus further congestion with muscles abnormal increase divertional
- continuous cardiac compromising the breath sounds clear, in work of activities as
monitoring airway clearance of respirations breathing indicated for
the patient. This noiseless and individual
> The patient may event may bring improved oxygen >Observe for signs > to identify situation.
manifest: about cyanosis. In exchange. and symptoms of infectious process
- changes in order to infection and promote timely
respiratory rate or compensate, the interventions
rhythm patient may breathe
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- diminished or rapidly in order to >Monitor chest >to monitor the
adventitious breath bring in more oxygen radiograph reports severity of the
sounds thus manifesting disease
- cyanosis changes in
respiratory rate or >Use positioning by >to facilitate lung
rhythm. placing on a semi- expansion
high fowler’s position

>Elevate head of > to take

bed or change advantage of
position every 2 gravity decreasing
hours and prn pressure on the
diaphragm and
enhancing
drainage or
ventilation to
different lung
segments

>Maintain adequate >to aid in the

hydration when mobilization of
possible secretions

> Perform >to loosen

nebulization and secretions
CPT as indicated

>Institute suctioning > to clear airway

as needed when secretions
are blocking the
airway

>Use naso- > to have patent

pharyngeal / oro- airway through
pharyngeal airway artificial means
as needed

>Administer >to provide

medication as pharmacological
prescribed management to
treat condition
137
 >Administer >to maximize
analgesics as cough when pain is
prescribed inhibiting effort

>Refer to > to promote

appropriate support continuity of care
groups

Problem#3: Impaired Gas Exchange

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S> The patient may Impaired Gas Pneumonia both Short term: >Establish rapport >to gain trust and Short term:
verbalize: Exchange r/t affects ventilation After 4 hours of NI, cooperation After 4 hours of NI,
- dyspnea collection of and diffusion. An the patient will the patient shall
secretions affecting inflammatory demonstrate >Assess patient’s >to determine s/sx have
O> The patient oxygen exchange reaction can occur in behaviors to improve condition demonstrated
manifested: across alveolar the alveoli, or maintain airway behaviors to
- productive cough membrane producing exudates patency. >Monitor VS >to obtain baseline improve or
- fuzziness of the that interfere in the data maintain airway
lung markings in diffusion of oxygen patency.
both lungs and carbon dioxide. >Auscultate breath >to note presence
- with oxygen White blood cells, sounds of adventitious
hooked via nasal mostly neutrophils, breath sounds
cannula regulated at also migrate into the Long term:
2 lpm alveoli and fill the Long term: >Assess respiratory >use of accessory After 4 days of NI,
- with condom normally air- After 4 days of NI, movements and use muscles to breathe the patient shall
catheter attached to containing spaces. the patient will of accessory indicates and have
urine bag Areas of the lungs demonstrate muscles abnormal increase demonstrated
- continuous cardiac are not adequately absence or in work of absence or
monitoring ventilated because reduction of breathing reduction of
of secretions and congestion with congestion with
> The patient may mucosal edemathat breath sounds clear, >Observe for signs >to identify breath sounds
manifest: cause partial respirations and symptoms of infectious process clear, respirations
- confusion occlusion of the noiseless and infection and promote timely noiseless and
- lethargy bronchi or alveoli, improved oxygen interventions improved oxygen
- abnormal ABG’s with a resultant exchange. exchange.
138
- cyanosis decrease in alveolar >Monitor chest >to monitor the .
oxygen tension. An radiograph reports severity of the
imbalance in oxygen disease
and carbon dioxide
exchange may be >Evaluate pulse >to assess
evident in the oximeter to respiratory
patient’s arterial determine insufficiency
blood gases. A oxygenation
decrease in oxygen
supply may cause >Use positioning by >to facilitate lung
confusion and placing on a semi- expansion
lethargy. high fowler’s position

>Elevate head of > to take

bed or change advantage of
position every 2 gravity decreasing
hours and prn pressure on the
diaphragm and
enhancing
drainage or
ventilation to
different lung
segments

>Maintain adequate >to aid in the

hydration when mobilization of
possible with secretions
precautions on fluid
overload

>Perform >to loosen

nebulization and secretions
CPT as indicated

>Institute suctioning > to clear airway

as needed when secretions
are blocking the
airway

>Use naso- > to have patent

pharyngeal / oro- airway through
139
 pharyngeal airway artificial means
as needed
>Encourage > helps limit oxygen
adequate rest and needs/consumption
limit activities to
within client
tolerance

>Administer >to provide

medication as pharmacological
prescribed management to
treat condition

>Administer >to maximize cough

analgesics as when pain is
prescribed inhibiting effort

>Refer to > to promote

appropriate support continuity of care
groups

Problem#4: Ineffective tissue perfusion (cardiac) r/t myocardial cell wall injury

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S> The patient may Ineffective tissue Ineffective tissue Short term: >Establish rapport >to gain trust and Short term:
verbalize: perfusion (cardiac) perfusion is a After 4 hours of NI, cooperation After 4 hours of NI,
- sense of impending r/t myocardial cell decrease in Oxygen the patient will the patient shall
doom wall injury resulting in the verbalize >Assess patient’s >to determine s/sx have
failure to nourish the understanding of condition demonstrated
O> The patient tissues and condition and >to obtain baseline behaviors to
manifested: capillaries. therapy regimen and >Monitor VS data improve or
- dilated left Myocardial Infarction demonstrate lifestyle maintain airway
ventricle with occurs when changes to improve >Review baseline > to note degree of patency.
segmental wall insufficient blood circulation. ABGs, electrolytes, impairment/organ
motion abnormalities supply reaches the BUN/Cr, cardiac involvement
- severely depressed heart thus causing enzymes
left ventricular damage to the heart Long term:
systolic function with muscle. Possible Long term: > Assess for > Early detection of After 4 days of NI,
140
at least grade 3 left contributing factors After 4 days of NI, possible causative cause facilitates the patient shall
ventricular diastolic include dilation of the patient will factors related to prompt, effective have
dysfunction the left ventricle demonstrate temporarily impaired treatment. demonstrated
- elevated CK–MB which inhibits its increased perfusion arterial blood flow absence or
levels (47.4 ng/dl) normal pumping as individually reduction of
- hgb levels below ability, thus reducing appropriate. > Maintain optimal > This ensures congestion with
normal (124 g/dl) the blood supply that cardiac output adequate perfusion breath sounds
- hct levels below the heart and tissues of vital organs. clear, respirations
normal (0.39 g/dl) demand. Also, in Support may be noiseless and
- chest pain cases of low required to facilitate improved oxygen
- with oxygen hemoglobin and peripheral exchange.
hooked via nasal hematocrit levels, circulation (e.g., .
cannula regulated at the tissues would not elevation of
2 lpm receive the adequate affected limb,
- with condom amount of oxygen antiembolism
catheter attached to they need, and if left devices)
urine bag untreated would
- continuous cardiac result to ischemia > Encourage quiet, > to conserve
monitoring which may lead to restful atmosphere energy and lowers
an infarction. Certain tissue O2 demands
> The patient may cardiac markers may
manifest: be used to diagnose > Caution patient to > to maximize
- confusion an infarction such as avoid activities that tissue perfusion
- lethargy CK-MB. Such would increase cardiac
- abnormal ABG’s confirm an infarction workload.
- cyanosis if levels are seen Encourage early
elevated. ambulation, if
possible

> Explain possible > To impose

factors that may awareness on the
boost the occurrence patient and SO
of ineffective tissue
perfusion

> Identify changes r/t > To evaluate if

systemic or further complications
peripheral alterations will occur
in circulation

>Administer >Drugs that improve

141
 medications with perfusion also carry
caution the risk of adverse
response

>Discuss individual >Information

risk factors necessary for client
to make informed
choices about
remedial risk factors
and commitment to
lifestyle changes, as
appropriate, to
prevent
complications or
manage symptoms
when present

>Instruct in blood >Facilitates

pressure monitoring management of
at home hypertension which
is a major risk factor
in the damage of
blood vessels or
organ dysfunction.

Problem#5: Decreased Cardiac Output

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S> the patient may Decreased cardiac The hypoxic tissue in Short term: >Establish rapport > to gain trust and Short term:
verbalize: output r/t altered myocardial infarction After 4 hours of NI, cooperation After 4 hours of NI,
- shortness of breath stroke volume within the border the patient will the patient shall
/dyspnea zone may become a participate in >Assess patient’s > to determine have participated
- fatigue site for generating activities that condition signs and in activities that
- anxiety arrhythmias. decrease the symptoms decrease the
Infracted tissue does workload of the heart workload of the
O> The patient not contribute to such as stress >Monitor VS > to obtain baseline heart such as
manifested: tension generation management data stress
- dilated left during systole, and or therapeutic management
ventricle with therefore can alter medication regimen >Monitor ECG for > decrease in or therapeutic
142
segmental wall ventricular systolic program dysrrhythmias, cardiac output may medication
motion abnormalities and diastolic function conduction defects result in changes in regimen program
- severely depressed and disrupt electrical and for heart rate cardiac perfusion
left ventricular activity within the causing
systolic function with heart. Without dysrhythmias Long term:
at least grade 3 left improvement, the Long term: After 4 days of NI,
ventricular diastolic heart muscles may After 4 days of NI, >Monitor cardiac > to note for the patient shall
dysfunction undergo remodeling the patient will rhythms effectiveness of have displayed
- with oxygen such as hypertrophy, display continuously medicines hemodynamic
hooked via nasal losing its normal hemodynamic stability AEB
cannula regulated at pumping ability, thus stability AEB >Encourage patient > caffeine is a normalization of
2 lpm may cause normalization of to decrease intake of cardiac stimulant ECG tracings and
- with inadequate blood to ECG tracings and caffeine, cola and and may adversely blood pressure
condomcatheter meet the needs of blood pressure chocolates affect cardiac readings
attached to urine the body’s tissues. readings function
bag Cardiac output and
- continuous cardiac tissue perfusion are >Observe skin color, > peripheral
monitoring interrelated, thus a temperature, vasoconstriction
decrease in cardiac capillary refill time may result in pale,
output may bring and diaphoresis cool, clammy skin,
The patient may about cyanosis, with prolonged
manifest: pallor and prolonged capillary refill time
- dysrhythmias capillary refill. There due to cardiac
- ECG changes may also be fatigue dysfunction and
- cyanosis and shortness of decreased cardiac
- pallor breath as there is output
- prolonged capillary not enough oxygen
refill supplied to the >Monitor intake and > to maintain
- decreased tissues. output and calculate adequate nutrition
peripheral pulses 24 hour fluid balance and fluid balance
- variations in blood
pressure readings >Administer > to provide for
supplemental adequate
oxygen as indicated oxygenation

>Administer > to promote

medicines as wellness
prescribed by the
physician

>Promote adequate > to decrease

143
 rest by decreasing oxygen
stimuli providing consumption
quiet environment

>Encourage > to prevent

changing positions occurrence of
slowly, dangling legs orthostatic
before standing hypotension

>Instruct client & > restrictions can

family on fluid and assist with
diet requirements decrease in fluid
and restrictions of retention and
sodium hypertension,
thereby improving
cardiac output

> instruct client and > promotes

family on knowledge and
medications, side compliance with
effects, drug regimen
contraindications
and signs to report

Problem#6: Risk for Aspiration

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S> O Risk for Aspiration r/t Pneumonai is a Short term: >Establish rapport >to gain trust and Short term:
presence of retained serious infection that After 4 hours of NI, cooperation After 4 hours of
O> the patient secretions affects the airsacs the patient will be NI, the patient
manifested: with accompanying free from aspiration >Assess patient’s >to determine signs shall be free from
- with productive secretions that may AEB having a patent condition and symptoms aspiration AEB
cough be expectorated. airway having a patent
- with presence of Sudden coughing >Monitor VS >to obtain baseline airway
crackles on lower may mobilize the data.
lobe of the right lung secretions and may
- with oxygen reach the airway > Monitor level of > A decreased level
hooked via nasal which may cause consciousness of consciousness is
cannula regulated at distress to the Long term: a prime risk factor
144
2 lpm patient’s breathing After 2 days of NI, for aspiration Long term:
- with condom which is fatal. the patient will After 2 days of NI,
catheter attached to Usually when experience no > Keep suction > This is necessary the patient shall
urine bag someone aspirates aspiration AEB setup available and to maintain a patent have
- continuous cardiac they cough in an noiseless use as needed airway experienced no
monitoring attempt to clear the respirations and aspiration AEB
food or fluid out of clear breath sounds > Notify the physician > Early intervention noiseless
>the patient may their lungs. or other health care protects the patient’s respirations and
manifest: provider immediately airway and prevents clear breath
- respiratory distress of noted decrease in aspiration sounds
cough and/or gag
reflexes or difficulty
in swallowing

>Assist with postural >to mobilize

drainage thickened secretions
which may cause
impairment in
swallowing

>Provide a rest >the rested client

period prior to may have less
feeding time difficulty in
swallowing

>Minimize use of >these agents can

sedatives/hypnotics impair coughing or
whenever possible. swallowing

>Provide information >severe coughing

on the effect of and cyanosis
aspiration on the associated with
lungs eating or drinking or
changes in vocal
quality after
swallowing indicates
onset of respiratory
symptoms
associated with
aspiration and
requires immediate
145
 interventions.

>Refer >to promote

continuity of care

Problem#7: Anxiety

Nursing Nursing
Cues Scientific Explanation Objectives Rationale Evaluation
Diagnosis Interventions
S= O Anxiety r/t Coping with the pain Short term: >Establish rapport >To gain trust and Short term:
O= pt. manifested perceived /actual and emotional trauma is cooperation
threat of death, difficult. Patient may fear After 3-4 hours of After 3-4 hours
-with good skin turgor pain, possible death and or be anxious nursing >Assess patient’s >To monitor of nursing
-with pale palpebral lifestyle changes about immediate intervention pt will condition physiologic intervention pt
conjunctiva by restlessness environment. Ongoing identify healthy condition shall have
-with capillary refill 2 anxiety (related to ways to deal with identified healthy
seconds concerns about impact and express >Monitor vital signs >To have baseline ways to deal with
- Cold clammy skin of heart attack on future anxiety. data and express
-with oxygen hooked lifestyle, matters left anxiety.
via nasal cannula unattended/unresolved
regulated at 2 lpm and effects of illness on >Observe for >to help pt. regain
-with condom family) may be present verbal/non-verbal control of own
catheter attached to in varying degrees for signs of anxiety, and behavior
urine bag some time and maybe stay with the pt.
-continuous cardiac manifested by Intervene if pt.
monitoring symptoms of depression displays destructive Long term:
such as sleep Long term: behavior.
disturbance and After 3 days of
restlessness. After 3 days of >Maintain confident >honest nursing
Pt. may manifest: nursing manner (without false explanation can intervention pt.
intervention pt. will reassurance) alleviate anxiety shall have
-Sleep disturbance appear relaxed appeared
-Restlessness and report anxiety >Orient pt/SO to >predictability and relaxed and
-Tachycardia is reduced to a routine procedures participation can reported anxiety
-Tachypnea manageable level. and expected activities decrease anxiety is reduced to a
manageable
>Provide privacy for >Allows needed level.
pt. and SO. time for personal
expression of
146
 feelings, may
enhance mutual
support and
promote more
adaptive behaviors.

>Provide rest >Conserves energy

periods/uninterrupted and enhances
sleep, quiet coping abilities.
surroundings.
>to provide safety
>Raise side rails
> To maintain
>Emphasize general good
importance of health.
adequate nutritional
intake.
>To promote fluid
>Regulate and monitor management.
IV fluid.
>For optimum
>Administer wellness
medications as
ordered

Problem#8: Fatigue

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S > “agad ako Fatigue r/t decrease Fatigue is an Short term: >Establish rapport >to gain the trust Short term:
napapagod, tulad oxygenation and overwhelming After 3 hours of and cooperation of After 3 hours
pag maglalakad at perfusion 2º sustained sense of nursing interventions the patient. nursing
maliligo ako” pulmonary exhaustion and patient will be able to interventions
congestion decreased capacity perform ADLs and >Assess patient’s >to have a general patient shall have
O> The patient for physical and participate in desired condition health status of the performed ADLs
manifests: mental work at usual activities at level of patient. and participate in
• cold clammy level. Insulin is ability. desired activities
skin secreted by beta > Monitor vital signs >to obtain baseline at level of ability.
• dry skin cells, which are one data
• weakness of four types of cells Long term:
147
 even with in the islets of After 1 day of > Instruct patient to > a source of energy Long term:
simple Langerhans in the nursing interventions increase fluid intake and After 1 day of
activities pancreas, insulin is a patient will report up to 8- 10 glasses to prevent nursing
• capillary storage hormone, improve sense of of water dehydration interventions
refill < 3 sec. when a person eats energy. patient shall have
• crackles on a meal, insulin > Instruct to sit > to conserve reported improve
the right secretion increases instead of standing energy sense of energy.
lung field and move glucose to during activities or
• v/s taken the blood, into shower
and muscle, liver, and fat
recorded as cells. Due to DM >Instruct patient to > to promote overall
follows: type 2 there is increase intake of health measures.
T=36ºC, RR=21 insulin resistance or vitamin or iron
cpm, PR=65 bpm, impaired insulin supplementation like
BP=130/80 mmHg. secretion which juice
results in the
inhibition of the >Stretch linens >to provide comfort
transport and
metabolism of >Assist with self- >To conserve
glucose into energy care needs like keep energy
leading to easy bed in low position
The patient may fatigability AEB by
manifests: pt. weakness even >Stress proper hand >to prevent infection.
• restlessness doing activities of washing
• tachypnea daily living.
>Administer drugs > for optimum
as ordered. wellness

Problem#9: Risk for Infection

Scientific
Cues Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation
Explanation
S> O Risk for Infection r/t Upper airway Short term: >Establish rapport >to gain trust and Short term:
inadequate primary characteristics After 2 hours of cooperation After 2 hours of
O> The patient defenses normally prevent nursing intervention NI, the patient
manifested: (decreased ciliary potentially infectious patient will identify >Assess patient’s >to determine s/sx shall have
- productive cough action) particles from interventions to condition identified
148
- with oxygen reaching the sterile prevent/reduce interventions to
hooked via nasal lower respiratory risk/spread >Monitor VS >to obtain baseline prevent/reduce
cannula regulated tract. Pneumonia of/secondary data risk/spread
at 2 lpm involves the infection. of/secondary
- with condom inflammation of the >Obtain appropriate >for observation for infection..
catheter attached to lung parenchyma tissue/fluid specimens culture and
urine bag which eventually sensitivity testing
- continuous leads to a Long term:
cardiac monitoring decreased ciliary After 4 days of NI, >Stress proper hand > it is a first line Long term:
action and may the patient will washing techniques by defense against After 4 days of NI,
> The patient may further lead to stasis achieve timely all care givers between nosocomial the patient shall
manifest: of respiratory resolution of current therapies and client infection or cross have achieved
- fever secretions the client infection without contamination timely resolution
- chills is at risk for the complications. of current infection
- DOB spread of infection >Encourage coughing >for mobilization of without
- increase in RR, since the continuous &, position change respiratory complications
PR production of mucus secretions
- increase in WBC secretions is a
levels and perfect breeding >Monitor client’s >to limit exposures,
neutrophils place for visitors or caregivers thus reduce cross
microorganisms. for presence of contamination
And if the body does respiratory illnesses.
not cope well the Offer masks/tissues to
infection may spread client/visitors who are
to the rest of the coughing or sneezing
body.
>Encourage deep >for mobilization of
breathing, coughing secretions and
and frequent position prevention of
changes aspiration or
respiratory
infection

> Encourage adequate > Facilitates healing

rest balanced with process and
moderate activity. enhances natural
Promote adequate resistance.
nutritional intake

>Administer or monitor >to determine

medication regimen effectiveness of
149
and note client’s therapy and
response presence of side
effects

>Administer >to correct nor

prophylactic antibiotic reduce existing risk
as indicated factors

> Investigate sudden > Delayed recovery

changes/deterioration or increase in
in condition, such as severity of
increasing chest pain, symptoms
extra heart sounds, suggests
altered sensorium, resistance to
recurring fever, antibiotics or
changes in sputum secondary infection
characteristics

>Review individual >to promote

nutritional needs, wellness
appropriate exercise
program and need for
rest

>Emphasize needs for >Premature

taking antiviral or discontinuation of
antibiotics as directed treatment when
client feels well
may result in return
of infection and
may potentiate
drug-resistant
strains

>Provide information or >to increase

involve in appropriate awareness of and
community and national prevention of
education programs aommunicable
diseases

150
Problem#10: Activity Intolerance

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S> The pt. may Activity Intolerance The underlying Short term: >Establish rapport >to gain trust and Short term:
verbalize: r/t cardiac mechanism of a After 4 hours of NI, cooperation After 4 hours of NI,
- exertional dyspnea dysfunction, heart attack is the the patient will use the patient shall
or discomfort imbalance in oxygen destruction of heart identified techniques >Assess patient’s >to determine signs have used
- reports of fatigue or supply and muscle cells due to a to increase activity condition and symptoms identified
weakness consumption as lack of oxygen. If tolerance. techniques to
evidenced by these cells are not >Monitor VS >changes in VS increase activity
O> the patient shortness of breath supplied with assist with tolerance.
manifested: upon exertion sufficient oxygen by monitoring
- need for assistance the coronary arteries physiologic
upon movement to meet their responses to
- limited range of metabolic demands, Long term: increase in activity.
motion they die by a After 4 days of NI, Long term:
- with oxygen process called the patient will be >Identify causative >alleviation of After 4 days of NI,
hooked via nasal infarction. The able to increase and factors leading to factors that are the patient shall
cannula regulated at decrease in blood achieve desired intolerance of activity known to create have increased
2 lpm supply may bring activity level, intolerance can and achieved
- with about necrosis of the progressively, with assist with desired activity
condomcatheter heart muscle which no intolerance development of an level,
attached to urine would make it symptoms noted, activity level progressively, with
bag weaker as a pump. such as respiratory program no intolerance
- continuous cardiac As a result, the compromise. symptoms noted,
monitoring pumping mechanism >Encourage patient > to help give the such as
of the heart will be to assist with patient a feeling of respiratory
The patient may ineffective thus planning activities, self-worth and well- compromise
manifest: giving the individual with rest periods as being
- tachypnea and an insufficient supply necessary
increased blood of blood, bringing
pressure upon about an inefficient >Instruct patient in > to decrease
performance of supply of oxygen to energy conservation energy expenditure
activities the tissues thus techniques and fatigue

151
- pallor leading to easy
- cyanosis fatigability upon >Assist with active > to maintain joint
- ischemic ECG simple exertions. If or passive ROM mobility and muscle
changes the condition exercises tone
becomes severe, the
patient may have >Assist patient with > to gradually
inability in ambulation, as increase the body
performing activities ordered, with to compensate for
and show changes progressive the increase in
in vital signs upon increases as overload
performance of patient’s tolerance
activities. Also, there permits
could be changes in
the ECG showing >Adjust activities > to prevent
signs of ischemia. according to overexertion
patient’s tolerance

>Plan care with rest > to reduce fatigue

periods between
activities

>Provide positive > helps to minimize

atmosphere, while frustration,
acknowledging rechannel activities
difficulty of the
situation for the
patient

>Assist patient with > to protect client

activities and from injury
monitor use of
assistive devices

>Promote comfort > to enhance ability

measures and to participate in
provide for relief of activities
pain

>Provide referral to > to develop

other disciplines as individually
indicated appropriate
152
 treatment regimen

> Instruct client/SO > may indicate a

in monitoring need in alteration of
response to activity activities
and recognizing
signs and symptoms

Problem#11: Self Care Deficit r/t weakness

Scientific Nursing
Cues Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions
S>Ø Self care deficit The nurse may Short term: >Establish rapport >to gain the trust Short term:
O> The patient related to weakness encounter the After 3 hours of and cooperation of After 3 hours
manifests: or tiredness. patient with self - nursing interventions the patient. nursing
care deficit in the patient will be able to interventions
• cold clammy hospital. The deficit verbalize >Assess patient’s >to have a general patient shall have
skin may be a result of understanding on condition health status of the verbalized the
• good skin transient limitations, the importance of patient. importance of self-
turgor such as those one self-care. care.
• capillary might experience > Monitor vital signs >to obtain baseline
refill < 3 sec. while recovering Long term: data
• irritability from surgery or the After 1 day of
• weakness result of the nursing interventions >Assist with > to encourage and
when taking progressive patient will safely necessary build on successes Long term:
a bath deterioration that perform self-care adaptations to After 1 day of
erodes the activities. accomplish ADLs nursing
• easy
individual’s ability or interventions
fatigability
willingness to > Arrange for > to prevent injury patient shall have
even only
perform the activities assistive devices as performed safely
doing ADLs
required to care for necessary (seat/grab self-care activities.
himself. Careful bars)
examination of the
patient’s deficit is >Instruct patient to > to prevent
required in order to increase fluid intake dehydration and a
The patient may
be certain that the up to 8- 10 glasses source of energy
manifests:
patient is not failing of water
self-care because of
• restlessness
lack of materials with >Encourage food > to increase energy
arranging the choices reflecting
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environment to suit individual likes and
the patient’s physical abilities that meet
limitations. nutritional needs

>Stretch linens >to provide comfort

>Stress proper hand >to prevent infection.

washing

>Instructed patient >To relieve patient

to perform good and provide comfort
hygiene

>Administer drugs > for optimum

as ordered. wellness

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