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ASSESSMENT

Nursing Diagnosis

Scientific Basis

Objectives

Implementation

Rationale

I.

Physiologic

Objective cues: - Fatigue - Dyspnea - Cyanosis - Dizziness - Chest pain - Tachycardia Subjective Cues: Day ako anak ba malipong lagi if magbarog siya og dugay din magsakit pud daw iya dughan as verbalized by the mother
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Activity Intolerance: fatigue related to imbalance between oxygen supply and demand

When PS is present, resistance to blood flow causes right ventricular hypertrophy. If right ventricular develops, right atrial pressure increase and this may resulting in reopening of foramen ovale, shunting of unoxygenated blood into the left atrium, and systemic cyanosis. An associated defect such as patent ductus arteriousus partially compensates for the obstruction by shunting blood from the aorta to the pulmonary artery into the lungs. Wongs Nursing care of infants and childres by Hockenberry /

After 8 hours of holistic nursing care, the patient will be able to achieve measurable increase in activity tolerance as evidenced by reduced fatigue and by vital signs within acceptable limits during activity

1.

Wilson p. 1464