ASSESSMENT SUBJECTIVE: 0 OBJECTIVE: Weak in appearanc e With pink skin and conjunctiv a With easy fatigabilit y Dec. Hgb.

Hgb. Level; 138 g/l

NURSING DIAGNOSIS Activity intolerance r/t Muscle weakness 2o to Decreased hemoglobin level.

SCIENTIFIC EXPLANATION Dec. oxygen carrying capacity of Hgb would result to a decreased nutrition in cells which would decrease ATP production since oxygen is needed for oxidation of CHO/glucose resulting to decrease energy or muscle weakness which would cause Activity intolerance

NURSING GOAL Short Term: After 3-4 hours of nursing intervention, the patient will demonstrate participation in ADLs without undue fatigue Long Term: Within 2 days of nursing interventions, the patient will be completely independent on all ADLs ,without asking assistance with his S/O

NURSING INTERVENTION Establish therapeutic relationship Assess patients vital signs Assess patients ability to perform ADLs noting reports of weakness, fatigue and difficulty in accomplishing task Promote independence in self-care activities as tolerated Encourage alternating activity with rest Explain importance of be rest in treatment.

RATIONALE To gain the trust and cooperation of the patient This serves as a baseline data Influences choice of interventions or needed assistance

EVALUATION Short Term: The patient shall have been able to demonstrate participation in ADLs without undue fatigue Long Term: The pt shall have been able to become completely independent on all ADLs without asking assistance with his SO

Mild/moderate activities & improved selfesteem are promoted. Minimized exhaustion & helps balance O2 supply and demand. Bedrest is maintained to decrease metabolic demands thus

Monitor laboratory results like Hgb. & Hct. Encourage increase intake of iron-rich foods.

conserving energy. To identify the extent of deficiency & for better treatment plan. To increase iron supplement of the body.

Problem #2: Impaired gas exchange related to ventilation-perfusion imbalance

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION ACS

OBJECTIVES

NURSING INTERVENTIONS 1. Monitor vital signs.

RATIONALE

EXPECTED OUTCOME

S:

Impaired gas In exchange related

with Short term: After 4 hours of nursing intervention, patient will be able participate treatment regimen as to in

1. To obtain baseline Short term: data

Dilated to Cardiomyopathy, there decreased is

O: the patient ventilationmanifested: Capillary refill testy of less than seconds 3 perfusion

2. Monitor respiratory rate, effort, muscles, flaring abnormal depth and 2. Increased respiratory muscles, of panic in including nasal and

The shall

patient have in as by of

imbalance as contractility of the evidenced by myocardial dyspnea and muscle fatigue there fibers. would be Because of this,

rate, participated nasal regimen the utilization

use of accessory

use of accessory treatment flaring and a look evidenced

 Slightly lips

pale

altered myocardial

evidenced utilization

by of

breathing patterns.

patients eyes may breathing be seen with exercises, effective coughing and use of oxygen. hypoxia.

Untrimmed finger and and color Limited movements observed With cugh Rales upon auscultation With easy heard nonnails toenails pale in

function or there breathing is failure in the exercises, pumping effective and mechanism of the coughing atrium hypertrophy. Because atrium hypertrophy there would and be loss of elasticity, backflow of blood in the left atrium then blood would regurgitates to the pulmonary circulation causing pooling of blood lungs. in the in the This lungs of left Long term: After 3 days of nursing intervention, patient will be able demonstrate improved ventilation adequate oxygenation tissues evidenced absence symptoms respiratory distress. of as by of of and 4. Monitor behavior onset restlessness, agitation, confusion. patients and of to 3. Auscultate breath sounds hours. every 4

heart causing left use of oxygen.

Long term: 3. Presence of patient have crackles may alert the student nurse The to may an lead airway shall to or improved and adequate oxygenation of tissues 4. Changes behavior in evidenced and absence as by of of obstruction

productive

that demonstrated

exacerbate existing ventilation hypoxia.

fatigability

mental status for

mental status can symptoms be early signs of respiratory impaired exchange. gas distress.

pooling of blood the patient may manifest: causes pulmonary

 diaphoresis inability move secretions cyanosis confusion restlessness irritability to

congestion. Because pulmonary congestion, oxygen could not easily diffuse to the pulmonary circulation causing decreased oxygen supply. 6. Encourage breathing hours. deep and 6. Clear airways and facilitates delivery. oxygen of 5. Observe especially color of for 5. Central cyanosis in tongue mucosa indicative serious emergency. and oral is of hypoxia note tongue

cyanosis in skin;

and oral mucous membranes.

and is a medical

coughing every 2

7. Provide rest and 7. Hypoxic patient has minimize fatigue. limited activity reserves; can

inappropriate increase hypoxia.

8. Reduces

oxygen

consumption/

demands 8. Position patient in a Semi-Fowlers or sitting position. lung inflation.

and

promotes maximal

9. To help the patient increase oxygenation times 9. Teach patient how to perform pursedlip breathing. 10. Turning important prevent complications 10. Turn the client immobility. of is to dyspnea of in acute

every 2 hours. 11. Increases alveolar oxygen concentration which may consent or reduce tissue hypoxemia.

11. Administer humidified oxygen through cannula, indicated. nasal as 12. The during therapy. patient may

hypoventilate oxygen

12. Watch for onset of hypoventilation as evidenced increased somnolence after initiating oxygen. by