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