NURSING CARE PLAN

Defining Characteristics Nursing diagnosis: Activity intolerance : level II related to imbalance between oxygen supply and demand secondary to valvular damage S: dali lage ko kapuyon?? as verbalized O:>received sitting on bed,awake, coherent >hair unkempt >diaphoresis noted >dark undereyes noted >pulsating and distended jugular veins >reports f fatigue after activity >hesitancy to do activities >generalized weakness
T=37.8 P=100 bpm R=28cpm, Bp=90/40

Expected Outcome (Ideal)

Intervention and Rationale

Behavioral Outcome (Actual)

Short term: After 8 hours of nursing interventions client will identify activity intolerance and eliminate or reduce the effects when possible Be able to use identifies techniques to enhance activity tolerance

Long term : After 5 days of nursing interventions client will participate willingly in necessary or desired activities

I: Determine patient's perception of causes of fatigue or activity intolerance R: These may be temporary or permanent, physical or psychological. Assessment guides treatment. S:Gulanick et.al. Nursing Care Plans p.78 I:evaluate current limitations , degree of deficit in light of usual status R: provides comparative baseline S: Doenges et.al. Nurses Pocket Guide p.66-67 I: assess nutritional status R: adequate energy reserves are required for activity S: Gulanick et.al. Nursing Care Plans p.7

Defining Characteristics Laboratory Results:

Expected outcome (Ideal)

Intervention and Rationale I: Establish guidelines and goals of activity with the caregiver and patient R: motivation is enhanced if the patient participates in goal setting S: Gulanick et.al. Nursing Care Plans p.78 I: elevate head of bed as tolerated R: enhances lung expansion to maximize oxygenation for cellular uptake S: Doenges et.al. Nursing Care Plans p. 503 I:encourage adequate rest periods R: rest between activities provides time for energy conservation and recovery S: Gulanick et.al. Nursing Care Plans p.78 I: assist patient and SO to plan for activities for times when she or he has more energy R: not all self care activities need to be completed in the morning S: Gulanick et.al. Nursing Care Plans p.78 I:encourage verbalization of feelings regarding limitations R: acknowledgement that living with activity intolerance is both physically and emotionally difficult S: Black and Hawaks, Medicalsurgical nursing p.503 I: provide assistance as necessary R: although help is enhanced when client does some things for itself S: Doenges at.al. Nursing Care Plans p.503-504 Collaborative: Sources:

Behavioral Outcome (Actual)

Theoretical Basis: A few patients with rheumatic fever become critically ill with intractable heart failure, serious dysrhythmias, and pneumonia. These patients are treated in an intensive care unit. Most patients recover quickly. However, although the patient is free of symptoms, certain permanent residual effects remain that often lead to progressive valvular deformities. The extent of cardiac damage, or even its existence, might not have been apparent in clinical examinations during the acute phase of the disease. Eventually, however, the heart murmurs that are characteristic of valvular stenosis, regurgitation, or both become audible on auscultation and, in some patients, even detectable as thrills on palpation. Usually, the myocardium can compensate for these valvular defects very well for a time. As long as the myocardium can compensate, the patient remains in apparently good health. With

Doenges et.al. NursingCAre Plans: Individualizing Client Care Across the Life Span, F.A. Davis Company, 7th edition, 2006 Gulanick et.al. Nursing Care Plans: Nursing diagnosis and Interventions, Elsvier Saunders, 6th ed. 2006 Doenges et.al. Nurses Pocket Guide: Diagnoses, Prioritized Interventions and rationales, F.A. Davis Company, 10th ed. 006 Black and Hawaks, MedicalSurgical Nursing: Clinical Management for Positive Outcomes, Elsvier Saunders, 7th ed. 2004 Brunner and Suddarth, Medical-Surgical Nursing, 10th edition, 2008

I: monitor laboratory studies R:identifies deficiencies S: Doenges et.al. Nursing Care Plans p.503-504

continued valvular alterations, the myocardium is unable to compensate , as evidenced by signs and symptoms of heart failure, The decrease in the ejected ventricular volume causes the sympathetic nervous system to increase the heart rate (tachycardia), often causing the patient to complain of palpitations. The pulses become weak and thready. Without adequate CO, the body cannot respond to increased energy demands, and the patient is easily fatigued and has decreased activity tolerance. Fatigue also results from the increased energy expended in breathing and the insomnia that results from respiratory distress, coughing, and nocturia. - Brunner and Suddarth, MedicalSurgical Nursing p.881

I:provide supplemental oxygen as indicated R: maximizes oxygen transport to tissues and improve ability to function S: Doenges et.al. Nursing Care Plans