B.

NURSING MANAGEMENT (Nursing Care Plan) ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME Short term: After 4 hours of nursing intervention the patient shall identify negative factors affecting activity intolerance and eliminate or reduce their effects when possible. Long term: After 2-3 days of nursing intervention the patient shall demonstrate a decrease in physiological

O= Patient manifested the ffg: -weakness -discomfort -fatigue Patient may manifest the ffg: -dysrhythmias -abnormal heart rate/blood pressure -pallor -cyanosis.

Activity intolerance related to body weakness

Short term: -established After 4 hours rapport of nursing oxygen intervention -monitor and carrying the patient taken VS will identify capacity of the negative -note client Hgb. will lead to factors reports of affecting weakness, decrease activity fatigue, pain, nutrition in the intolerance difficulty and eliminate accomplishing cells this will or reduce task, and/or decrease ATP their effects insomnia when production possible. -identify activity since oxygen is needs versus Long term: desires to needed for After 2-3 days evaluate oxidation of of nursing appropriateness intervention CHO/glucose the patient -plan for that will will maximal demonstrate activity within decrease a decrease in the clients energy or physiological ability Decrease

-to gain the pt. trust -for baseline data -symptoms maybe result of/or contribute to intolerance of activity

-to identify causative/ precipitating factors -promotes the idea of normalcy of progressive abilities in this

muscle weakness resulting activity intolerance.

signs of intolerance (e.g., pulse, respiration, blood pressure within normal range clients normal range)

area -plan care to carefully balance rest periods with activities -assists with activities. -to reduce fatigue

-to protect client from injury -to enhance ability to participate in activities -to prevent injuries

signs of intolerance (e.g., pulse, respiration, blood pressure within normal range clients normal range)

-promote comfort measures and provide for relief of pain -assists client in learning and demonstrating appropriate safety measures

ASSESSMENT S: O: The patient may manifest: -weakness -loss of appetite -chest pain -weakness of muscles required in swallowing -poor muscle tone nausea

DIAGNOSIS Altered nutrition: less than body requirements related to loss of appetite as evidenced by weakness

SCIENTIFIC EXPLANATION Because the patient has difficulty of breathing, other manifestations such as chest pain and weakness, this causes the patient to have decrease appetite. Because it requires energy when eating this causes the patient to become exhausted thus increasing the respiratory rate which exacerbate difficulty of breathing. The chest pain felt is also a reason for loss of appetite, the patient

PLANNING Short term: After 4 hours of nursing interventions, the patient will identify nutritional requirements. Long term: After 3 days of nursing interventions, the patient will consume adequate nourishment.

INTERVENTION -Monitor vital signs. -Compare usual food intake to food pyramid noting omitted food groups. -Observe patients ability to eat (time involved, motor skills, ability to swallow various textures of food). -Observe patients relationship to food. Attempt to separate

RATIONALE -To establish baseline data. -Omission of entire food groups increases risk of deficiencies. -In order to come up with the proper interventions.

EXPECTED OUTCOME Short term: The patient shall have identified nutritional requirements Long term: The patient shall have consumed adequate nourishment.

-Refusing to eat may be the only way the patient can express

focuses more on the pain felt rather than on eating. Loss of appetite indicates insufficient intake of nutrients to meet metabolic needs thus weakness is more likely to occur.

physical from physiological causes for difficulty eating. -If patient lacks endurance, schedule rest periods before meals. -Provide companionshi p at mealtime to encourage nutritional intake. -Determine time of day when patients appetite is greatest; offer highest calorie meal

some control and may also be a symptom of depression. -Nursing assistance with ADL will conserve the patients energy for activities. -Mealtime should be a time for social interaction to the patient to increase his appetite. -In order for the patient to have the appropriate amount of calorie needed for energy.

at that time. -Offer small volumes of liquids as an appetizer before meals. -Small volumes of liquids will stimulate GI tract, enhances peristalsis and motility. -This may distract or distress patient, decreasing interest in eating.

-Encourage social interaction during mealtime, but avoid combining mealtimes with other activities. -Prepare the patient for meals, remove unsightly supplies and excretions, and avoid invasive

-A pleasant environment helps to promote intake.

procedures before meals. -Weigh client every day. -To determine the effectivity of interventions provided and to detect patients progress. -Good oral hygiene enhances appetite. -To inform the SO of the nutritional needs of the patient. -In order to provide the necessary specific intake of the patient.

-Provide good oral hygiene before and after meals. -Instruct SO of the proper food that the patient should take. -Monitor food intake. Consult with dietitian for an actual calorie intake.