CARE OF CLIENTS ACROSS THE LIFESPAN WITH PROBLEMS ININFLAMMATORY AND IMMUNOLOGIC REACTIONS, CELLULARABERRATIONS, ACUTE BIOLOGIC CRISIS, INCLUDING EMERGENCYAND DISASTER NURSING
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NURSING CARE PLAN Client Initials: Initials: Mrs. M. R
Age: 84 years Initiation Initiation Date of Nursing Care Plan: 05/11/11 Admitting Diagnosis: FAILURE TO COPE ASSESSMENT
y
Her
y
She
y y y y y y y y
vital signs are stable. is awake, alert and oriented X 3 (person, place and time). Able to communicate verbally Requires visual aid/glasses and no hearing aid is required All lung fields clear with good air entry. Bowel sounds hypoactive, abdomen abdo men is soft and not distended She has no pain. But feeling very tired She is bedridden Minimal ROM on lower extremities Scars on bottom of bot h legs wit h small amount of drainage
NURSING DIAGNOSIS
Fatigue related to disease process and poor physical condition
GOALS (EXPECTED OUTCOMES)
The client will w ill:: y
Verbalize
increased energy and improved well being
NURSING INTERVENTIONS
EVALUATION
The nurse will: y
y
Evaluate adequacy of nutrition and sleep patterns.
y
Review medications for side effects. y
y
y
y
Teach strategies for energy conservation Encourage client to express feelings about fatigue; use active listening techniques and help identify sources of hope. Assist client wit h ADLs as necessary; encourage independence without
causing exhaustion.
y
Identify potential factors that aggravate and relieve fatigue
y
y
y
Assess severity of fatigue on a scale of 0-10 q 4 hours or PRN. Encourage the client to keep a journal of activities, symptoms of fatigue, and feelings, Encourage patient to participate in Physical therapy
y
y
Patient verbalized feelings of increased energy and improved well being. Patient demonstrates a more positive and happier attitude t han before t he interventions were applied Patient is able to identify factors that aggravate and relieved re lieved her fatigue. Patient is able to record aggravating factors t hat led to determining determining
relieving factors.
causing exhaustion.
y
Identify potential factors that aggravate and relieve fatigue
y
y
y
Assess severity of fatigue on a scale of 0-10 q 4 hours or PRN. Encourage the client to keep a journal of activities, symptoms of fatigue, and feelings, Encourage patient to participate in Physical therapy