NCP of Activity Intolerance

Assessment

S> Anku maikuti nga nasayaat daytoy sakak isunga marigatan ak nga tumakder.

Explanation of the Problem

The patient was admitted last February 2, 2012 at UC-BCF Hospital with an admitting diagnosis of  O> Weak in appearance. CKD stage 5 secondar se condary y > Cannot perform to CGN on hemodialysis ADLs alone. with a chief complaint of  > With limited range of   joint pain on right lower motion. extremities and also on > Muscle strength: both side of his Left upper extremity=5; abdomen. Because of  Right upper intermittent joint pain extremity=5; he is now having Left lower extremity=4; difficulty walking and Right lower extremity=2. doing ADLs that predispose him to have A> Activity Intoleranc I ntolerance e activity intolerance. related to decreased energy requirements as evidenced by decrease muscle strength.

Objective

STO> After 6 hours of  effective nursing interventions, the patient will be able to do ADLs alone and to participate in self-care activities.

LTO> After 2 days of  effective nursing interventions, the patient will be able to maintain activity level within capabilities as evidenced by normal vital signs during activity, as well as absence of weakness, pain, and difficulty accomplishing accomplishing tasks.

Nursing Intervention

Dx> Monitor vital signs and record.

> Monitor intake and output as order.

> Assess ability to perform ADL. > Assess physical mobility status.

Tx> Assist patient to do ADLs.

> Assist to do active range of motion exercise like flexing of both extremities. > Promote rest and comfort.

Rationale

Evaluation

> To help determine patients current health status and evaluate effectiveness of nursing intervention rendered. > To evaluate the proper functioning of his kidney in relation to his present condition. > To determine the capacity of patient in doing ADLs. > To know if there is any changes on patients condition specifically on physical aspect.

STO> Goal partially met because after 6 hours of  effective nursing interventions, the patient is able to do ADLs but with minimal assistance and participate in selfcare activities.

> To minimize fatigue and to evaluate his capabilities in doing such. > To maximize full strength.

> To conserve energy.

LTO> Goal Fully met because after 2 days of  effective nursing interventions, the patient is able to maintain activity level within capabilities as evidenced by normal vital signs during activity, as well as absence of weakness, pain, and difficulty accomplishing accomplishing tasks.

Reference: (Brunners & Suddarth textbook and  th NANDA book 11 edition)

Edx> Encourage to verbalize feelings and concern regarding his present condition. > Emphasize importance of frequent ambulation. > Encourage active range of motion exercises like flexing of  both extremities. > Emphasize importance of  compliance to treatment and medication. > Encourage adequate rest periods.

> To determine other factors that might contribute to patients present condition. > To promote circulation and. > To maximize full strength.

> To achieve therapeutic effect of medication and for fast recovery. > Rest between activities provides time for energy conservation.