Assessment

Explanation of the Problem

Objective

Nursing Intervention

Rationale

Evaluation

S> Anku maikuti nga nasayaat daytoy sakak isunga marigatan ak nga tumakder .

The patient was admitted last February 2, 2012 at UC-BCF Hospital with an admitting diagnosis of O> Weak in appearance. CKD stage 5 secondary to CGN on hemodialysis > Cannot perform with a chief complaint of ADL s alone. joint pain on right lower > With limited range of extremities and also on motion. both side of his > Muscle strength: Left upper extremity=5; abdomen. Because of intermittent joint pain Right upper he is now having extremity=5; difficulty walking and Left lower extremity=4; Right lower extremity=2. doing ADL s that predispose him to have activity intolerance. A> Activity Intolerance related to decreased energy requirements as evidenced by decrease muscle strength.

STO> After 6 hours of Dx> Monitor vital signs effective nursing and record. interventions, the patient will be able to do ADL s alone and to participate in self-care activities. > Monitor intake and output as order.

LTO> After 2 days of effective nursing interventions, the patient will be able to maintain activity level within capabilities as evidenced by normal vital signs during activity, as well as absence of weakness, pain, and difficulty accomplishing tasks.

> Assess ability to perform ADL. > Assess physical mobility status.

> To help determine patient s current health status and evaluate effectiveness of nursing intervention rendered. > To evaluate the proper functioning of his kidney in relation to his present condition. > To determine the capacity of patient in doing ADL s. > To know if there is any changes on patient s condition specifically on physical aspect. > To minimize fatigue and to evaluate his capabilities in doing such. > To maximize full strength.

STO> Goal partially met because after 6 hours of effective nursing interventions, the patient is able to do ADL s but with minimal assistance and participate in selfcare activities. LTO> Goal Fully met because after 2 days of effective nursing interventions, the patient is able to maintain activity level within capabilities as evidenced by normal vital signs during activity, as well as absence of weakness, pain, and difficulty accomplishing tasks.

Tx> Assist patient to do ADL s.

> Assist to do active range of motion exercise like flexing of both extremities. > Promote rest and comfort.

> To conserve energy.

Reference: (Brunner s & Suddarth textbook and NANDA book 11th edition)

Edx> Encourage to verbalize feelings and concern regarding his present condition. > Emphasize importance of frequent ambulation. > Encourage active range of motion exercises like flexing of both extremities. > Emphasize importance of compliance to treatment and medication. > Encourage adequate rest periods.

> To determine other factors that might contribute to patient s present condition. > To promote circulation and. > To maximize full strength.

> To achieve therapeutic effect of medication and for fast recovery. > Rest between activities provides time for energy conservation.