Leonida, Vince Patrick

BSN 2-2

Assessment Inference Diagnosis Goals and Outcomes Intervention Rationale Evaluation

Subjective Data: Precipitating factor
Patient verbalized that
she feels like she has no
energy. In turn, she
stated that she could Increased metabolic
no longer maintain her
usual routines. She also
added that she has
been irritable because
of the pain in her back.
Objective Data:
Sighing and moaning
observed
Facial grimacing noted
Hand supporting lower
back
She rates pain 6 in a
scale of 1 to 10; 10
being most painful and
1 being least painful.
Vital sings:
 Temp: 36.8oC
 PR: 82 bpm
 RR: 21 cpm
 BP: 110/70
mmHg
Fatigue related to Within our care, the
(lifestyle and hypermetabolic patient will participate in
activities) state secondary to activities that stimulate
I pregnancy and balance physical,
cognitive, affective, and
demand due to social domains as
pregnancy evidenced by the following
I indicators:
Lack of energy,  Discuss the causes
Increased role of fatigue.
demand  Share feelings
I regarding the
Fatigue effects of fatigue
on life.
 Establish priorities
for daily and
weekly activities.
1. Explain the reasons  Fatigue in the first Within our care, the
for fatigue in first and third trimesters client had participated
and third is normal in activities that
trimesters:  Exercise provides stimulate and balance
 Increased basal emotional and physical, cognitive and
metabolic rate physical benefits social domain as
 Changes in  Vivid lighting, noise, evidenced by the
hormonal levels visitors, numerous following indicators:
 Anemia distractions, and  Understand
2. Emphasize the litter in the patient’s how fatigue is
need for naps and physical surroundings acquired and
8 hours of sleep can limit relaxation, what is
each night disturb rest or sleep, causing it.
3. Restrict and contribute to  Express her
environmental fatigue. opinions and
stimuli, especially  Recognizing feelings on
during planned relationships how fatigue is
times for rest and between specific affecting her
sleep activities and levels life.
4. Teach energy of fatigue can aid the  Able to realize
conservation patient recognize her priorities
methods. unnecessary energy for daily and
Collaborate with outflow. The log may weekly
occupational indicate times of day actvities
therapist as when the person
needed. feels the least
5. Promote sufficient fatigued. This
nutritional intake. information can help
6. Assist the patient the patient make
with setting choices about setting
priorities for his or her activities to
preferred take advantage of
activities and role episodes of high
responsibilities energy levels.
 Organization and
time management
Leonida, Vince Patrick
BSN 2-2

can help the patient

conserve energy and
reduce fatigue. The
occupational
therapist can offer
the patient with
assistive devices and
educate the patient
energy conservation
methods.