DATE: July 17, 2009 TIME: 9:15am

ASSESSMENT: Received pt lying on bed, conscious and coherent, with ongoing IVF of D5LR at 700cc level in 40gtts/min regulation intact and infusing well on the
left arm

CUES NX DIAGNOSIS SCI-EXP PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Activity intolerance r/t Increase vascular After 1-2 hrs of > Monitored vs > For baseline data After 1-2hrs of
“Nanghihina ako” generalized weakness permeability in nursing the pt will be > Encouraged pt to > To promote nursing intervention
as verbalized by the associated with plasma able demonstrate an change position q2 venous circulation the pt was able to
pt imbalanced on the ↓ increased in strength and avoid bed sores demonstrate an
supply and demand of Plasma leakage > Kept pt rest and >To conserve increase.
Objective: O2 associated with ↓ avoid fatigue energy
> weak in plasma leakage Decrease platelet > Encouraged pt to > To prevent
appearance ( clotting co-factor) perform isometric muscle atrophy
> poor skin turgor ↓ exercise such as
> Altered ADL Bleeding tendencies stretching
> pallor (Hgb: decreased) > Encouraged pt to > To facilitate
> CR: 4sec ↓ perform deep oxygenation to the
> Hemoglobin Anaerobic breathing exercise vital organs
decreased metabolism (Aarobic
(mitochondria) metabolism) for
↓ ATP synthesis
Lactic acid > Assisted pt in > For support and
formation changing position safety of the pt and
↓ preventing from
Muscle fall
fatigue/weakness > Provided comfort > To relax the
measured such as muscle thereby
soft pillows on both reducing fatigue
sides
> Encouraged pt to > Carbohydrates
eat foods rich in serve as main
carbohydrates such energy source
as bread, oat and converting it to
cereals glucose used by
cells during
metabolism