NURSING CARE PLAN

Clients name: Slave, Martin Arrisgado Age: 52 Sex: Male Civil Status: Married Religion: Roman Catholic Allergies: Food: None Drug: none Diet: Nutren Diabetes 4 scoops + 110cc of water every 4hours per NGT Date of Admission: September 16, 2011 ; 1:42pm Diagnosis: Brain Metastasis secondary to small cell non-Hodgkins lymphoma S/P chemotherapy with new recurrence Patient Care Classification: (Please Check) ______*____ Wholly Compensatory: Pts. therapeutic self-care is accomplished by nurse __________ Partially Compensatory: Pts. performs some self-care measures __________ Supportive Educative: Pts. accomplishes self-care measures TH Clinical Division and Bed No: 4 FLOOR room 403 Name of Physician: Dr. Ellie May Villegas M.D. and Dr. Ann Co M.D. Name of Nurse: Gaspe, Karen Joyce C.

ASSESSMENT
Subjective: No verbal cues necessary for nursing diagnosis Objective: > seen lying on bed, restless. > weakness noted on lower extremities >pale in appearance observed

SCIENTIFIC REFERENCE Weakness is a lack of Activity physical or muscle Intolerance strength and the related to generalized feeling that extra weakness effort is required to secondary to move your arms, infectious process legs, or other muscles. If muscle weakness is the result of pain, the person may be able to make muscles work, but it will hurt.

NURSING DIAGNOSIS

GOAL
SHORT TERM: After 8 hours of effective nursing intervention: - The caregiver can identify negative factors affecting activity tolerance and and reduce their effects as possible. LONG TERM: After 5 days of comprehensive nursing intervention: - the primary caregiver will report increase in activity tolerance

INTERVENTION INDEPENDENT: Establish guidelines and goals of activity with the patient and caregiver. Promote adequate rest periods

RATIONALE - Motivation is enhanced if the patient participates in goal setting. - Rest between activities provides time for energy conservation and recovery. - Promotes rest and sleep and prevents anxiety thereby decreasing the patients oxygen demands - This promotes awareness of when to reduce activity.

EVALUATION

Maintain a quiet, comfortable environment

Fatigue is a feeling of tiredness or exhaustion or a need to rest because of lack of energy or

Teach caregivers to recognize signs of physical over activity.

strength. Fatigue may result from overwork, poor sleep, worry, boredom, or lack of exercise. It is a symptom that may be caused by illness, medicine, or medical treatment such as chemotherapy. Anxiety or depression can also cause fatigue. These two are presenebt in activity tolerance because due to exhaustion patient can't tolerate activities of daily living. SOURCE: http://www.webmd.c om/a-to-zguides/weakness-andfatigue-topicoverview

Teach energy conservation techniques.

- To conserve energy and decrease the need for oxygen supply