ASSESSMENT

Subjective:
madali akong
mapagod. As
verbalized by the
patient
Objective:
Decreased
performance
Irritability
Jittery behavior
V/S
taken as follows:
T: 37.3
P: 89
R: 21
Bp: 120/70

DIAGNOSIS
Fatigue related to
Hypermetabolic
state with increased
energy requirements

SCIENTIFIC
RATIONALE
Thyroid gland
Hypertrophy or
hyperplasia of the
thyroid
Increase t3 and t4
production
Increase amount of
thyroid hormone in
tissue
Neuromuscular
activity
Increased oxygen
consumption
fatigue

PLANNING

INTERVENTIONS

Short-term
outcome:
After 3 hours of
nursing intervention
The client will be
able verbalize about
increasing energy .
.

independent

Monitor vital signs, noting

pulse rate at rest and when active.

Note development of
tachypnea, dyspnea, pallor, and
cyanosis.

Provide for quiet

environment; cool room, decreased
sensory stimuli, soothing colors,
Long Term
quiet music.
Outcome:

Encourage patient to restrict

After the nursing
activity and rest in bed as much as
intervention the
possible.
client will able to

Provide comfort measures:

display improve
touch therapy or massage, cool
ability to participate showers. Patient with dyspnea will
in desired activities be most comfortable sitting in high
Fowlers position.

Provide for diversional

activities that are calming, e.g.,
reading, radio, television.

Avoid topics that irritate or

upset patient. Discuss ways to
respond to these feelings.

Discuss with SO reasons for

fatigue and emotional lability
Collaborative:
Administer medications as indicated:

RATIONALE

Pulse is
typically
elevated and,
even at rest,
tachycardia
(up to 160
beats/min)
may be noted.
O2 demand
and
consumption
are increased
in
hypermetaboli
c state,
potentiating
risk of hypoxia
with activity.
Reduces
stimuli that
may
aggravate
agitation,
hyperactivity,
and insomnia.
Helps
counteract
effects of
increased
metabolism.

EVALUATION
Short-term outcome:
After 3 hours of
nursing intervention
The client will
verbalized about
increasing energy .
.
Long Term
Outcome:
After the nursing
intervention the
client will display
improved ability to
participate in desired
activities

Sedatives: phenobarbital (Luminal),

antianxiety agents: chlordiazepoxide
(Librium)

May decrease
nervous
energy,
promoting
relaxation.
Allows for use
of nervous
energy in a
constructive
manner and
may reduce
anxiety.
Increased
irritability of
the CNS may
cause patient
to be easily
excited,
agitated, and
prone to
emotional
outbursts.

Understanding
that the behavior
is physically
based may
enhance coping
with current
situation and
encourage SO to
respond

positively and
provide support
for patient.
Collaborative:
Combats nervousness,
hyperactivity, and
insomnia.