Javier, Darryl O. Assessment Subjective: hirap ako tumayo ng walang alalay as verbalized by the client.

Objective: -Conscious and coherent -Body weakness. -Poor appetite -Limited ROM -Ambulatory with assistance. Nursing Diagnosis Activity intolerance related to difficulty ambulating secondary to body weakness. Analysis Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of

Nursing Care Plan Planning Goals: After the shift the client will be able to improve mobility participation in the activities of daily living. Objectives: After 2 hours of nursing interventions the client will be able to use and identify techniques to enhance activity tolerance. Establish rapport Place the client in a comfortable position Take and record vital signs To facilitate NPI. To prevent backaches or muscle aches. To note any significant changes that may be brought about by the disease These may be temporary or permanent, physical or psychological. Assessment guides treatment. This aids in defining Interventions Rationale

BSN307-26 Evaluation Does the client client able to improve mobility participation in the activities of daily living? Yes__No__Why? Does the client able to use and identify techniques to enhance activity tolerance? Yes__No__Why?

Determine patient's perception of causes of fatigue or activity intolerance.

Assess patient's level

medications (e.g., blockers), or emotional states such as depression or lack of confidence to exert one's self.

of mobility.

what patient is capable of, which is necessary before setting realistic goals. Adequate energy reserves are required for activity. Difficulties sleeping need to be addressed before activity progression can be achieved. Depression over inability to perform required activities can further aggravate the activity intolerance. Rest between activities provides time for energy conservation and recovery. Patients with limited activity tolerance need to prioritize

Assess nutritional status. Monitor patient's sleep pattern and amount of sleep achieved over past few days. Assess emotional response to change in physical status.

Encourage adequate rest periods, especially before meals, other ADLs, and ambulation. Refrain from performing nonessential

procedures. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self.

tasks. Assisting the patient with ADLs allows for conservation of energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and selfesteem. Exercises maintain muscle strength and joint ROM. These reduce oxygen consumption, allowing more prolonged activity.

Encourage active ROM exercises three times daily. Teach energy conservation techniques.

Objective: -Presence of grade 3 bedsore at the sacral area. -Skin loss involving damage of subcutaneous tissue. -GCS = 3

Impaired skin integrity related to bed sore at the sacral area secondary to prolonged immobility.

Skin is the primary defence of the body; it protects the body against infections and diseases brought about by the invasion of microbes in the body. A normal skin is moist and intact; dryness of the skin is more prone to friction that may result to impairment of the skin integrity as compared with a moist skin. Pressure on soft tissues between bony prominences Compresses capillaries & occludes blood flow Pressure not relieved Micro thrombi formation

Goal: After 5 -7 days of nursing interventions, the client will be able to regain skin integrity (reduce size of ulcer). Objective: After 2 days of nursing interventions, the client will be able to display timely healing of bed sores without complications within the hospital stay. Protect the skin from trauma and prolonged pressure The peripheral circulation of pad places the patient at high risk for injury To prevent infection Scratching can cause lesions and open sores

Does the affected area display timely healing of bed sore without complications? Yes__ No__Why? Does the the client regain skin integrity (reduce size of ulcer)? Yes__ No__Why? Keep the affected area dry always Note for scratching skin and of keeping finger nails short and clean

Put mittens on hand if Mittens prevent necessary excessive scratching Note the patients ability to move Position the patient in the non-affected area Immobility is greater risk for skin breakdown To avoid pressure on the affected area

+ occlusion in capillaries & blood flow Formation of blister Rupture of blister + open wound

causing for severity. Ensure adequate dietary intake. Review dieticians recommendations. Prevent the ulcer from being exposed to urine & feces. Use indwelling catheters, bowel containment systems, & topical creams or dressings. Supplement the diet with vitamins & minerals. Vitamins C and zinc are commonly prescribed. Provide oral supplementations, tube-feedings or hyper alimentation to achieve positive nitrogen balance. Remove devitalized tissue from the wound bed, except in To prevent malnutrition & delayed healing To prevent contamination/spread of infection

To promote wound healing on clients who do not have adequate calories.

Pressure ulcers cannot heal in clients with severe malnutrition.

To promote faster healing & reduce infection

the avascular tissue or on the heels. Began by cleansing the ulcer bed with normal saline, then use appropriate technique for debridement. Once the ulcer is free of devitalized tissue, apply dressing the keep the wound bed moist & the surrounding skin dry. Do not use occlusive dressings on ulcer.