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Cues SO-Muscle grade of 2 Dyspnea upon exertion Vital signs taken as follows:

Nursing Diagnosis Activity intoleranc e related to imbalance between oxygen supply and demand as evidenced by muscle grade of 2

Scientific Explanation

Objectives After 6 hours of nursing intervention, the patient will be able to maintain activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.

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

Rationale -Medications such as betablockers, lipidlowering 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) -The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers. (Ackley & Ladwig, 2008, p 120) -Fear of breathlessness, pain, or falling may decrease willingness to increase activity. (Ackley & Ladwig, 2008, p 120)

Evaluation What are the medications of the patient?

-Assess nutritional needs associated with activity intolerance.

What is the diet of the patient?

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

What does the patient feel regarding his/her condition?

-Monitor vital signs before and after any activity, noting any abnormal changes.

-This can be caused by a temporary insufficiency of blood supply (Ackley & Ladwig, 2008, p 119) -Pain restricts the client from achieving a maximal activity level and if often exacerbated by movement.

What is the vital signs of the patient?

-Assess for pain before activity

Did the patient manifest pain?