SIGNS AND SYMPTOMS - BODY WEAKNESS

ASSESSMENT NURSING DX PLANNING INTERVENTION RATIONALE EVELUATION

SUBJECT DATA: Activity intolerance & Short-Term Goal: 1. Evaluated client`s 1. This The client has an
The patient complain I fatigue related to an After 5 days of response to activity. establishes the improved sense of
feel extremely over tired imbalance between nursing Note reports of client`s energy and is able to
& weakness over all my oxygen supply & interventions, the increased weakness, capabilities and accomplish some ADLs
body. demand because of client will report an fatigue, and changes in needs and such as eating alone
decreased c/o. as improved sense of vital signs during and facilitates the and walking.
OBJECTIVE DATA: evidenced by energy. after activities. choice of
 Fatigue & verbalization of interventions Partially met.
Malaise overwhelming lack of Long-Term Goal: 2. Explained the
 General energy. After 1-2 weeks of importance of rest in 2. To decrease
Discomfort nursing the treatment plan and metabolic
 Immobility interventions, the the necessity demands, thus
client will be able for balancing activities conserving
VITAL SIGN to perform ADLs with rest energy.
B.P 170/100 mm/hg and participate in
P.R 58 BPM desired activities at 3. Assisted to assume
R.R 26 BPM the level of ability. a comfortable position 3. To promote
O2 89% for rest and sleep. rest.
TEMP 36.8 ‘C
 SIGN AND SYMPTOMS: SWELLING OF BOTH LOWER EXTREMITIES

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVELUATION

Subjective: Fluid Volume Excess Short Term: 1. Established Rapport 1. To Build Nurse- Patient Goal Met.
“My legs are swelling and it related to Sodium (Na) After 12 hours of The patient’s Edema
Trust Relationship
is difficult to move” as retention as evidenced Nursing decreased to Grade 1 ( 2
verbalized by the patient. by the presence of Intervention the mm).
Grade 2 patient’s Edema on
Objectives: Pitting Edema. both lower 2. Assess the patient’s general 2. To Obtain baseline Goal Met:
 Grade 2 Edema, extremities Condition & Vital Signs. Data After 5 days of Nursing
decreased from Care, the patient’s latest
Approximately 3-
Grade 2, (4mm) to 3. Weight patient daily 3. To assess the weight is 97 kg, and no
4mm, on both
Grade 1, (2mm). , (same time, same clothing). degree of the fluid evidence of Edema on both
Lower Extremities
 Weight: 100 Volume Imbalance. lower Extremities.
kg
Long-Term Goal : 4. Helps to Prevent
 Weight gain : After 5 days of
4. Encouraged to decrease
5kgs / week Sodium (Na) Intake to 1500- Fluid Exacerbation.
Nursing Intervention,
 Vital signs as 2000mg/day.
the patient will be able
Follows: to decrease weight by
BP: 170/100 mmHg at least 2 kg and no 5. Monitor intake & Output. 5. To measure the fluid
PR: 58 bpm signs of Edema on retention in the body.
RR: 26 CPM both Lower 6. Encouraged to elevate
Temperature: 36.8 Extremities. lower Extremities by putting 6. To promote venous
2- 3 pillows under the Lower return.
Extremities.

7. Administer Furosemide 7. To reduce excessive fluid

( Lasix) 80 mg P.O O.D. as in the body by increasing
ordered by the physician.
urine output.
 SIGN AND SYMPTOMS: SHORTNESS OF BREATHING

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVELUATION

SUBJECTIVE DATA : Irregular breathing Short term: *. Auscultator breath *. This is to detect or Short term goal:
Patient Verbalize having pattern related to After 8 hrs of nursing sound at least every 4 adventitious breath After 8 hrs of nursing
shortness of breath.
Tachypnea as intervention patient hrs sound. intervention patient
OBJECTIVE DATA: evidenced by will be able to report verbalize his feeling
 TACHYPNEA shortness of feeling comfortable comfortable in
 DYSPNEA breathing. in breathing. *. Utilize pulse *. To detect breathing.
oximetry to monitor alterations in Goal met.
VITAL SIGN Long term: oxygen saturation & oxygenation.
After 12 hrs Patient pulse rate. Long term goal:
B.P – 170/100 mm/hg will be able to After 12 hrs Patient
P.R – 58 BPM improve breathing *. Position the patient *. To allow for better verbalize improve of
R.R – 26 BPM
SpO2 – 89% and will show normal with proper body chest expansion his breathing and
SpO2 95-100, R.R alignment (semi- improving breathing AEB vital sign show
12-20 BPM & H.R fowler position 15-45 by facilitation normal SpO2 > 95,
60-100 BPM. degrees). Oxygenation. R.R 21 BPM & H.R
63 BPM
Partially Goal met…
*. Instruct patients to *. Help to relieves
do deep breathing shortness of breath by
exercises to improve preventing air from
their breathing getting trapped in the
capacity. lungs & help
inhalation.