ANGELES UNIVERSITY FOUNDATION
COLLEGE OF NURSING
NAME OF STUDENTS:
YEAR/SECTION
GROUP NO.
DATE:
ASSESSMENT
Subjective Cues:
The patient verbalized “I
constantly feel tired and
weak. I don’t have the
energy go play or do
anything else.”
Objective Cues:
Vital Signs:
-Temperature:96.8°F
(36.0°C)
-Heart rate: 123 beats/min -
Respiratory rate: 23/min
-Blood pressure:109/65 mm
Hg
Manifested:
- malaise
- weakness
- persistent fatigue
- irritability
- narrowed focus
NURSING CARE PLAN
Yvette Kristel C. Flores PATIENTS PSEUDONAME: Anton
BSN II-C DIAGNOSIS: Fatigue related to disease process AEB weakness, malaise,
irritability, narrowed focus and persistent fatigue
10 AGE AND SEX: 5-year-old, boy
May 17, 2021
NURSING SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE EXPECTED
DIAGNOSIS OUTCOME
Fatigue related to Rheumatic fever is an autoimmune Short term: Independent Short term:
disease process disease that occurs as a reaction to a After 8 hours of - Examine the patient's -An appropriate quantitative scoring . After 8 hours of
AEB weakness, group A beta-hemolytic streptococcal nursing description of fatigue in scale will assist the patient in nursing interventions,
malaise, irritability, interventions, the terms of severity, changes in determining the level of fatigue they the patient have
infection. The strep bacteria contain a
narrowed focus patient will be able to severity over time, are experiencing. Images or coped up with fatigue
and persistent protein similar to one found in certain cope up with fatigue
aggregating factors, and descriptive language can be used to by verbalization of
fatigue tissues of the body. The body's immune by verbalizing relieving factors. create additional scoring scales. The feelings of comfort.
system, which normally targets infection- feelings of comfort. nurse can compare changes in the
causing bacteria, attacks its own tissue, patient's fatigue level over time using
particularly tissues of the heart, joints, Long term: this system. It's crucial to figure out Long term:
skin and central nervous system. This After 1-2 days of whether the patient's level of fatigue is After 1-2 days of nursing
nursing interventions, constant or fluctuates over time. interventions, the patient
immune system reaction results in
the patient will be able shall have reported an
swelling of the tissues (inflammation). to report an increased increased sense of
The resulting inflammation causes sense of energy by energy by engaging in
symptoms of rheumatic fever like fatigue. engaging in daily - Symptoms of fatigue can show in the daily activities.
Fatigue is a self-recognized state in activities. - Monitor the patient’s vital
patient’s vital signs and become more
which an individual experiences an signs.
prominent as tiring worsens.
overwhelming sustained sense of
exhaustion, typically resulting from
mental or physical exertion or illness. - Assess the patient’s - Fatigue may be a symptom of
Based on the scenario, the patient nutritional intake in terms of protein-calorie malnutrition, vitamin or
manifested malaise, weakness, and adequate energy sources and iron deficiencies.
metabolic demands.
persistent fatigue thus leading to a
diagnosis of fatigue. - Assess the patient's outlook
 for fatigue relief, willingness to - These will encourage the patient to
May Manifest: REFERENCE: participate in fatigue-reduction have an active participation in
- drowsiness Rheumatic fever - Symptoms and strategies, and level of family therapeutic management planning,
- lethargy and social support. implementation, and evaluation.
causes. (2021). Retrieved 18 May 2021,
- Disinterest to surroundings Social support will be essential in
- Alteration in concentration from assisting the patient to implement
- Increased need for sleep https://www.mayoclinic.org/diseases- changes to reduce fatigue.
and rest conditions/rheumatic-fever/symptoms- - Restrict environmental
causes/syc-20354588 stimuli, especially during - In the patient's physical
planned times for rest and surroundings, bright lighting, noise,
sleep. visitors, numerous distractions, and
litter can limit relaxation, disrupt rest
or sleep, and contribute to fatigue.

- Encourage the patient to

maintain a 24-hour fatigue or - Recognizing relationships between
specific activities and fatigue levels
activity log for at least 1 week.
can help the patient and his family
to identify unnecessary energy
outflow. The log could show the times
of day when the person feels the least
tired. This information can assist the
patient's family in making decisions
about how to schedule his activities to
take advantage of periods of high
energy.

- Promote sufficient nutritional - The patient will need properly

intake. balanced intake of fats,
carbohydrates, proteins, vitamins, and
minerals to provide energy resources.
- Provide small frequent
meals with a soft texture. - It takes less energy to consume
several small portions than three full
meals. Soft foods require less
chewing and conserve energy.

- Provide comfort such as

judicious touch or massage, - These may reduce nervous energy
and cool showers. that can lead to relaxation.

- Offer diversional activities

that are soothing.

- Educate the patient and and may lessen anxiety.
family about task organization
methods and time
organization methods.
- Support the patient in
escalating levels of physical
activity and exercise.
- Aid the patient develop
habits to promote effective
rest/sleep patterns.
Dependent
- This method allows the use of
nervous energy in a positive manner
- Organization and management of
time can assist the patient save
energy and avoid fatigue.
- Exercise can reduce fatigue and
assist the patient build stamina for
physical activity.
- Promoting relaxation before sleep
and providing for several hours of
uninterrupted sleep can contribute to
energy restoration.

- Collaborate with the

attending physician about
optimizing medications. - Certain medications such as pain
medications and others can contribute
to fatigue. Adjustments in frequency
and dosing could improve symptoms
of fatigue.
Interdependent

- Teach energy conservation

methods. Collaborate with
occupational therapist as - Patients and caregivers may need to
needed. learn skills for delegating tasks to
others, setting priorities, and
clustering care to use available
energy to complete desired activities.
Organization and time management
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.