F.E.M.

, 51 years old, male, overfatigue T

+ fever

CUES

+ cough +colds

+ fatigue; tiredness + muscle weakness + restlessness

CONCEPT MAP

NURSING DIAGNOSES Impaired gas exchange related to increased pulmonary vascular resistance Activity intolerance related to imbalance oxygen supply and demand Imbalanced nutrition: less than body requirements related to loss of appetite Fatigue related to inadequate energy production Impaired physical mobility related to chest pain Mild to Moderate anxiety related to change in health status Altered tissue perfusion related to increase body temperature

OUTCOME CRITERIA Gas exchange: Correct breathing exercises Well-rested Cardiac output: Demonstrate an increase in activity tolerance Relax and participate in activities that reduce workload of the heart Nutrition: Demonstrate progressive weight gain Plan and implement a healthy balanced diet for age and energy and calorie needs Fatigue: Report improved sense of energy Well-rested and adequate sleep Pain and discomfort: Report that pain is relieved/controlled Follow prescribed pharmacologic regimen Identify and demonstrate non-pharmacologic methods that provide relief such as distraction through reading, watching television, listening to guided imagery audios, etc. Mobility: Plan and participate in ADLs and desired activities Plan and participate in non-strenuous exercises (e.g. walking) Anxiety: INTERVENTIONS Verbalize awareness of feelings of anxiety Report anxiety is reduced to a manageable level Appear relaxed Self-esteem and self-efficacy Verbalize acceptance of disease condition and symptoms, and relief of anxiety Monitoring Teaching

Vital signs: TPR BP q 4hours: note depth, rate, and rhythm of RR; note rate, rhythm and sounds of heart; note change in sudden increase or decrease in systole; T every 1 hour after administra tion of antipyretic drug;

Pain level in a scale of 0-10 with 0 as no pain and 10 as severe hourly; and every 15 minutes for 1-2 hours after administ ration of antiinflamm atory drug: PQRS of Pain: location of pain

daily food intake and amount of calories taken;

Periods of rest and sleep: amount of exercise s in hours q8h

Readines s to open up or verbalize feelings of anxiety and lowselfesteem daily;

Correct pursed-lip breathing exercises and its purpose

Distraction through reading books or magazines, watching television, and guided imagery as nonpharmacol ogic techniques in coping with pain

Encourage adequate rest balanced with moderate activity

Encourage socializatio n, coordinati on and personal involveme nt to perform health tasks.

The average daily intake based on BMI; average caloric intake; nutrition deficiencies and food preferences

The importance of exercise and how it helps with the normal functioning of the body through improving blood circulation; the effects of strenuous activities; the importance of sleep and rest

Improvement of coping with anxiety;

INTERVENTIONS

Medication

Vigocid