Introduction

Typhoid fever is a bacterial infection transmitted by contaminated water, milk, shellfish or other foods. It is an infection of the Gastrointestinal Tract affecting the lymphoid tissues (Peyers patch) of the small intestines. The disease is caused by an organism Samonella typhosa/typhi. A gram negative, motile and non-spore forming bacteria. It is a hardy organism and easily survives in habitat like water or inorganic materials. It is pathologic to man to man only, through direct and indirect contact with the carrier. The principal vehicles are food and water. Human transmission occurs through the consumption of contaminated food and beverages handled by persons shedding Salmonella typhi from stool (or less common urine) or water from sewage. Shellfish from water polluted by raw sewage and canned meat product using faulty canning process may cause outbreak. Incubation period varies average of 2 weeks, usually ranges 7-14 days. The variability is most likely related to immune status of the host. As long as typhoid bacilli appear in excreta; usually from first week throughout convalescence, it is communicable. The disease has a world wild distribution, & is endemic particularly in areas of low sanitation levels like urban deprived communities. It occurs anytime of the year but especially from May to August. The infection is mostly commonly seen in individual between 16 & 30 years of ages may be affected including the very young.

Patients Profile Name: Mrs. F. M. Address: San Francisco, Gainza,Camarines Sur Age: 64 years old Sex: Female Civil Status: Widow Religion: Roman Catholic Date of Confinement: February 20, 2013 Attending Physician: Dr. Claro Chief complaint: headache with fever Diagnosis: Typhoid Fever Health History A. Reason for seeking Care Fever and Headache B. Present Health History Three days prior to admission, the patient experienced fever followed with headache. The fever is on and off. She consulted Nilo Roa hospital and decided to be confined to St. John Hospital with her preferred doctor. Her admitting vital signs are: BP- 160/90mmHg, RR-20cpm, HR- 80bpm, Temp- 36.5C C. Past Health History Mrs. F. M has no known allergies to foods and drugs. She had received vaccine when she was still preschool and according to her mother, Mrs. F.M. completed the immunization. She had experienced childhood illnesses such as measles, mumps, and chicken pox. She did not experience serious accidents/injuries and surgeries. She doesnt have serious or chronic illnesses and this is her second hospitalization. Mrs. F.M. had 4children but one died because of high blood pressure. She had her first menstruation when she was at the age of 13 years old. Currently, she is not taking any vitamins or supplements.

ADULT FUNCTIONAL HEALTH PATTERN A. Health Perception-Health Management Pattern Usually Mrs. F.M. describes her health as fair but describes her health now as poor. She keeps herself healthy by eating nutritious food and avoiding vices such as tobacco, drugs, and alcohol. Her reason for admission is to get well from her present illness and shes expecting the caregivers to help her with her condition. The anticipated problem she is suffering is about financial problem because of longer stay in the hospital. B. Nutritional-Metabolic Pattern Mrs. F.M. would usually eat 3x a day. She loves to eat vegetables and seldom eat meat and seafoods. For her snacks she would usually eat banana cue or bread and soft drinks. She can consume 2 liters of water a day. Appetite is good without any food restrictions. Weight didnt change for the last 6 months except now. She feels that she lost some weight because of her condition. There are no problems in ability to eat. Skin condition is not that good. She has moist skin but the turgor is poor. No edema or lesion present. C. Elimination Pattern Mrs. F.M would usually urinate 5x in a day but it still depends on her water intake without any assistive device. She would usually defecate once a day every early morning without any problems and assistive devices. D. Activity-Exercise Pattern Mrs. F.M. would usually be in the market to sell banana or any root crops on Thursday and Sunday. If shes not in the market, shes working in their farm. She does the household chores daily. She doesnt exercise. E. Sleep-Rest Pattern The usual sleep pattern of Mrs. F.M. is from 7pm to 4am or 5am. Her routine before going to bed is to take a partial bath. There are no problems in sleeping.

F. Cognitive-Perceptual Pattern Mrs. F.M has eye problem particularly her right eye. She finds a hard time reading and studying before because her vision would then be distorted and she would likely to feel pain on her eyes for a long period of reading. No hearing problem. She is able to read and write. Her educational attainment was until second year high school. 3

G. Self-Perception Pattern Mrs. F.M. is most concerned about his health. Her present health goals are to eat healthy foods and to avoid eating in carenderias without knowing its food preparation and also to drink clean water. Being ill make her feel useless and dependent. H. Role-Relationship Pattern No hearing aids use. Language spoken is Bicol. Speech is clear and relevant. She lives with her 4 children. Mrs. F.M. solves problems alone and with praying. I. Sexuality-sexual Functional Pattern Mrs. F.M. is not sexually active because her husband is already dead. J. Coping-Stress Management Pattern When Mrs. F.M. is stressed, she would take a rest or watch TV. She ask for nothing but wellness and good health. K. Value-Belief System Mrs. F.M. is a roman catholic. She attends mass every Sunday and practices rituals. She believed God is the greatest of all.

TEST Hematology 5-06-2010 WBC Hgb Hct Differential Platelet count Segmenters Lymphocytes Monocytes Chemistry Electrolytes 05-06-2010 Potassium Sodium

RESULTS

Diagnostic test NORMAL VALUES

SIGNIFICANCE

6,700/mm3 13.3g/dl 40.0%

5000-10000/mm3 11.7-14.5 g/dl 34.1-44.3 vols%

Normal Normal Normal

220,000/cumm 86% 12% 02%

174000-390000/cumm 43.4-76.2 % 17.4-46.2 % 02-04%

Normal increased- may indicate infection, including typhoid

Normal

2.8 mEq/dL 140 mEq/dL

3.5-5.3 mEq/dL 135-145 mEq/dL

Hypokalemia Normal

Urinalysis Color Transparency Red blood cells Pus cells Epithelial Mucus threads Bacteria Typhoid Tubex Assay 05-08-2010 Yellow Cloudy 42-48/hpf 8-12/hpf Moderate Plenty Few Light straw to dark amber clear Normal values power field Negative Normal Negative Negative infection infection infection Bilirubin or bile pigment Kidney infection

5.0

Negative

Positive

Reference: -Mosby Diagnostic & Laboratory Tests by Pagaria - Fundamentals of Nursing by Taylor et. al., p.1346 - Laboratory & Diagnostic Tests Handbook by Gaedeke

Medicine

Mechanism of action

Ceftriaxone Inhibits bacterial cell T amp IVTT q 2 wall synthesis, ANST (-) rendering cell wall osmotically unstable leading to cell death

Why is it given to the patient? Typhoid fevers causative agent is salmonella, a gram negative bacilli, this medications inhibits this bacteria to multiply by inhibiting cell wall synthesis.

Nursing considerations Assess the patients previous sensitivity reaction to penicillin or other cephalosporins. Cross sensitivity between penicillins & cephalosporins is common. Assess for signs of infection before & during treatment, fever, earache, characteristics of wound, sputum, urine, stool & RBC > 10,000/mm. Instruct patient to take medication as prescribed for the length of time ordered even if he feels better. Advise patient to report bloody, mucoid diarrhea which may indicate pseudomembranous colitis. Assess patients fever or pain (PQRST) Teach patient to

Outcome Absence of signs and symptoms of infection, observed and experienced improvement in symptoms of infection, Absence of drug induced adverse effects.

Paracetamol 500 mg tab q 4 hrs

Decreases fever by inhibiting the effects of pyrogens on the

The patient has fever 37.9 C and reported to have tolerable throbbing

Decrease fever and Pain 7

hypothalamic heat headache 5/10 as scaled regulating centers and on the pain scale. by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

recognize signs of chronic overdose: bleeding, bruising, malaise, fever, sore throat. Inform the patient that urine may become dark brown as a result of phenacetin (metabolite of acetaminophen)

General Appearance The patient is lying on bed with patent IV line D5LR on Right arm with slightly elevated head on a pillow. She is diaphoretic, could walk independently, she appears weak. The skin is moist and the oral mucosa is dry with pale conjunctiva. Nails are dirty. Poor grooming and poor hygiene. System Review of system Physical Assessment Inspection Palpation Percussion Auscultation INTEGUMENTARY Patient claimed that she -(-)lesions -skin is warm to NA NA SYSTEM has no history of skin -pallor touch Skin diseases, problems, -(-)abnormal color -T-38.2C lesions. changes. -moist skin -diaphoretic -*ROSE SPOTS Head/Hair/Face Patient claimed to have -(-)lesions -(+)sensation to NA NA episodes of headache -hairs evenly pain, light touch (P-precipitates when distributed on head and corneal reflex temp rises, Q-throbbing, R-localized, S-5/10, T(-)masses,lesions intermittent) Eyes Patient claimed to have -eyes symmetrical -(-)tenderness on NA NA no instances discharges, and properly both eyes pruritus, lacrimation or positioned pain in eyeball. -eyebrows well She is using assistive aligned and equal device when only hair distribution reading. -eyelashes are evenly distributed -(-) eyelid inflammation and lesion. -pale conjunctiva Pupils are brown, round and symmetrical in size -good extraocular movements Ears Patient claimed to have -both auricles are -(-)edema NA NA 9

no earaches, infections, discharges. No history of hearing loss.

RESPIRATORY SYSTEM Nose and Sinuses

Patient claimed to have no sinus pain, nasal obstruction,nosebleeds, or any change in smell.

aligned with outer cantus of the eyes -(-)redness, discharges,lumps -both ears are able to hear whispers four steps away from the patient . -nose symmetrical -(-) deformities ,lesions -pink nasal mucosa -(-) discharges -patent nasal airways -able to distinguish different smells -*(+) NOSEBLEED -teeth and gums are intact -symmetrical lips -dry and crack lips -36 teeth. Some have dental caries and tartar. -(+) tongue movement -altered taste sensation -tongue has few whitish spots -*LOSS OF APPETITE -(-)lesions -(+)head

-(-)masses -pinna recoils after it is folded. -(-)tenderness

-(-)tenderness

-(-)tenderness

NA

Mouth and Pharynx

Patient claimed to have no incidence of frequent sore throat, bleeding gums. PTA, pt had six episodes of vomiting

-(+)gag, swallowing reflex -(-)lesions on tongue

NA

NA

Neck

Patient claimed to have no limitations of motion,

-(-)masses -nonpalpable

NA

-No bruit heard 1

Thorax and Lungs

Breast and Axilla

CARDIOVASCULA R SYSTEM GI SYSTEM Abdomen

Genitourinary

movement, flexion, lateral rotation and hyperextension -(-)jugular vein distention Patient claimed to have -symmetrical on no history of lung posterior and lateral diseases. She views. experiences shortness of -RR-26-30 cpm breath when she is -*(+)COUGH overworked Patient claimed to have -symmetrical no lumps, pain on breast, well breasts. No history of contoured breast diseases or -(-)lesions undergone any surgeries -(-)discharges on the breasts. No -nipples are dark axillary tenderness, lump or swelling. Patient claimed to have -jugular pulsation=2 no family history of htn cm -*SLOW HEARTBEAT Patient claimed to have -(+) epigastric pain incidence of vomiting 2 (P-unpredictable, days PTA. Q-piercing, R-whole Patient stated that PTA epigastrium, Sshe ate at a restaurant 5/10, T-intermittent) beside a highway and -abdominal girth= she drunk water from a 61 cm jar. Patient claimed to have -color=yellow urinated at least 5x a day with a minimum of transparency=cloud 30ml/urination. She y was14 years old when -RBC=42-48/hpf

lumps, swelling or goiter. No history of DM or thyroid diseases.

thyroid gland -trachea is centrally placed on neck -(+)vocal fremitus -(-)lumps, masses, tenderness -(-)masses NA -(-)rales,wheezes, and crackles on all lobes

-CRT=<2 sec -Brachial pulse=96 bpm -(-)masses -(-)epigastric tenderness

-BP= 100/80mmhg

-bowel sounds: RUQ 12 RLQ LLQ 10

LUQ 13

9 NA

NA

she had her menarche. Has no history of UTI.

MUSCOLOSKELET AL SYSTEM Motor and Lower Extremities

Patient claimed to have no history of arthritis or gout. No joint pain, stiffness, swelling.

NERVOUS SYSTEM Neurolgic

Patient claimed to have no history of seizure, stroke and fainting. No mental health dysfunction or hallucinations

-Pus cells=8-12/hpf Epithelial=moderate -Mucus threads= plenty Bacteria=few -muscle coordination: rapid alternating supination and pronation on hands, and point to point testing. -fair grip -(-)gait problem -(+) cranial nerves: OLFACTORY -with closed eyes, she was able to differentiate smells. OCULOMOTOR -able to follow six ocular movements TROCHLEAR -able to follow the six ocular movements TRIGEMINAL -(+) blink reflex -able to distinguish between a sharp and blunt. FACIAL -able to smile, raise eyebrows, frown, close eyes tightly

-muscle strength=+3 on both arms +2 on lower extremities

-DTR= +3 on biceps, triceps, patellar,achilles

NA

NA

NA

-less able to identify taste AUDITORY -able to hear whispers GLOSSOPHARYN GEAL -able to move tongue from side to side movement against resistance HYPOGLOSSAL -able to protrude tongue at midline then move it side to side. -*(+)DELIRIUM Legend: *CAPITAL LETTERS=Book based manifestations

Nursing Diagnosis: Risk for Imbalance Nutrition: Less than body requirements r/t loss of appetite & altered absorption of nutrients NANDA Definition: Intake of Nutrients Insufficient to meet metabolic needs Cause Analysis: Lack of appetite is a common symptom of many diseases. Brief periods of anorexia are life threatening but can cause temporary nutrition. Prolonged anorexia may lead to serious consequences such as malnutrition. During reduced food consumption, people use up their stored glycogen w/c provides energy through glycogenolysis. Prolonged reduced food consumption may minimize, reduce, and consume the stored glycogen thus malnutrition occurs. (Timby&Smith. MedicalSurgical. P. 741) Defining Characteristics Subjective: Pt verbalized wala kayo ko gana anoing mga panahuna maam Intervention Nutrition monitoring Assessment 1. Obtained nutritional hx; include family, significant others, or caregiver in assessment. 2. Monitored & explored attitudes toward eating & food. Rationale Expected Outcomes Nutritional Status: Nutrient Intake 1. The pts perception of actual intake may differ. (Gulanick. MET AEB 2007. NCP 6th ed. P. 135) 2. Many psychological, psychosocial, & cultural factors determine the type, amount, and appropriateness of food consumed. . (Gulanick. 2007. NCP 6th ed. P. 135) 3. Indicates health status & effect illness w/c require an increased nutritional needs & appetite that is affected by illness & may result in malnutrition. (Delmars. NCP. P.137) 4. Attention to the social aspects of eating is important in both the Consumed lunch food Able to consume 1400 cc of fluids

Objectives Weight= 35kg Bowel sounds

3. Assessed for appetite changes, presence of illness & dx, effect of nutrition on skin, hair, eyes, mouth, head muscles & behavior. poor skin turgor Comfort Measures 4. Provided companionship pale during meal time. conjunctiva

diaphoretic

5. Administered D5LR 1 liter @ 50 gtts/min 6. Suggested liquid drinks for supplemental nutrition. Health Education 7. Discouraged beverages that are caffeinated or carbonated. 8. Encouraged exercise.

hospital & home settings. . (Gulanick. 2007. NCP 6th ed. P. 136) 5. Maintain hydration status. . (Gulanick. 2007. NCP 6th ed. P. 135) 6. Such supplements can be used to increase calories and protein without interfering with voluntary food intake.(Gulanick. 2007. NCP 6th ed. P. 135) 7. These may decrease appetite and lead to early satiety. . (Gulanick. 2007. NCP 6th ed. P. 137) 8. Metabolism and utilization of nutrients are enhanced by activity. (Gulanick. 2007. NCP 6th ed. P. 137) 9. Maintains and promotes health status. . (Gulanick. 2007. NCP 6th ed. P. 13)

9. Encouraged to eat foods high in calories & protein that will promote weight gain & nitrogen (e.g., small frequent meals of foods high in calories & proteins)

Care Plan Evaluation: care plan was effective. Pt was able to consumed her lunch and able to drink a lot of fluids. Continuous implementation is needed to treat the risk for imbalance nutrition. Nursing Diagnosis: Hyperthermia r/t infection of systemic effects of endotoxins & bacterial products 2 typhoid fever NANDA Definition: Body temperature elevated above normal range

Cause Analysis: fever is not a failure of the body to regulate temperature; rather, body temperature is regulated at a higher level than normal. Body temperature is regulated by nervous system feedback to the hypothalamus, which functions as a central thermostat. A large number of agents (pyrogens) can produce fever. (Porth. 2004. Understanding Pathophysiology. P. 199) Defining Characteristics Subjective: Pt verbalized sige nako hilanat maam gikan pa adtong Sunday gabalikbalik Complained of tolerable throbbing headache in a scale of 5/10. Intervention Temperature Regulation Assessment 1. Assessed v/s, especially axillary temperature. 2. Measured input and output Rationale Expected Outcomes Thermoregulation MET AEB

1. V/S provided more accurate

indication of core temperature. (Gulanick. 2007. NCP 6th ed. P.105)

T- 36.5C at 2pm T-36.7C at 3pm

2. Fluid resuscitation may be

necessary to correct dehydration. The pt that is significantly dehydrated is no longer able to sweat, w/c allows for evaporative cooling. (Gulanick. 2007. NCP 6th ed. P.105)

Comfort Measures 3. Removed excess clothing and covers. 4. Administered Paracetamol 500mg PRN for fever.

Objectives: Temperature T- 38.2C 8am T- 38.7C 9:45 am Crack lips Intake of 1400cc Output of 500 cc

3. This decreases warmth and

increases evaporative cooling. (Gulanick. 2007. NCP 6th ed. P.105) 4. Decreases fever inhibiting the effects of pyrogens by a hypothalamic action leading to sweating and vasodilation. (Gulanick. 2007. NCP 6th ed. P.105) 1

5. Provided ample of fluids by mouth or intravenously. D5LR 1 liter @ 50gtts/min.

Lab results 05-06=10 Segmenters: 86%= infection WBC= 6,700 mm3

6. Provided tepid sponge bath; avoid alcohol.

5. If pt is dehydrated or
diaphoretic, fluid loss contributes to fever. (Gulanick. 2007. NCP 6th ed. P.105)

Health Education 7. Informed precipitating factors and preventive measures including maintenance of adequate fluid intake and taking medications as prescribed. 8. Provided information regarding normal temperature and control. 9. Promote adequate rest.

6. May help reduce fever.

Note: use of ice water/alcohol may cause chills, actually evaluating temperature. In addition, alcohol is very drying to skin. (Doenges.2000. NCP. P.677)

05-08-10 Typhoid tubex test assay : 5.0 = positive

Urinalysis Mucus threadsplenty Bacteria- few

7. Pts & families need to learn

how to prevent future episodes of hyperthermia. (Gulanick. 2007. NCP 6th ed. P.105)

8. This is especially necessary

for pt with conditions or in situations putting them at risk for hyperthermia. (Gulanick. 2007. NCP 6th ed. P.106) 9. To reduce fatigue & improve the childs ability and desire to eat. (Gulanick. 2007. NCP 6th ed. P.105)

Care Plan Evaluation: care plan was effective because pts temperature returned to normal state. Monitoring of the temperature needs to be continued to affect a good result.

Nursing Diagnosis: Risk for spread of infection(spread to other systems) related to inadequate secondary defense(agranulocytopenia, neutropenia) NANDA Definition: An increase risk for being invaded by pathogenic organisms. Cause Analysis: Leukocytes provide protection from infection. These Protective functions depend on maintaining normal numbers and ratio of different mature, circulating WBCs when one type of WBC is present in either abnormally high or abnormally low amounts, immune function is altered to some degrees, placing client at risk for many complications. (Ignatavicius & Workman (2006) Medical-surgical nursing.5 th edition.897) Defining Intervention Rationale Expected Outcomes Characteristics Subjective: NIC: Infection protection NOC: Infection Control Siige nako hilanat Assessment maam gikan pa 1. Assessment temperature, 1. Provides information pt remains free of adtong Sunday s/s and laboratory test about infection in child infection, AEB gabalikbalik indicating infectious nade susceptible b steroid normal VS process, irritability and and globulin therapy, malaise, swelling in soft particularly in aplastic Objectives: tissue or nodes. anemia or pneumococcal Temperature and salmonella infections 8am- 32.2C in child. Luxner (2005) 9:45am- 38.7C Delmars Pediatric NCP. 10am- 38.9C 2. Assess lab results for 336) 2pm- 36.5C infection (elevated WBC). 2. TO prevent and treat Lab results: infection. Luxner (2005) Segmenters- above Delmars Pediatric NCP. 86-infection 3. Assessed nutritional 188) Potassium-below2.8status, including weight hypokalemia history of weight loss and 3. Patients with poor serum albumin. nutritional status may be 5-8-2010 unable to respond to 1

Typhoid tubex assay5.0-positive Urinalysis: Bacteria-few WBC-6700m

4. Assessed for exposure to individual with active infection.

Comfort Measures 5. Administer antibiotic therapy as ordered.

pathogens and are therefore more susceptible to infection. (Gulanick (2007). NCP.110) 4. This provides warning for potential infection. (Gulanick (2007). NCP.133

6. Performed Hand washing medical surgical asepsis during procedures on care as appropriate. 7. Avoided allowing those with infection to have contact with the patient. 8. Monitored urine output for adequacy of amount color and presence of foul odor TEACHING 9. Informed patients of s/s of infection. To report. 10. Instructed family members and patient to avoid

5. Interferes with protein synthesis in bacterial cell by binding to ribosomal sub unit, causing misreading of genetic code; inaccurate peptide sequence forms in protein chain causing bacterial death. (PPD. (2007)Nursing Drug Guide.152) 6. Prevent transmission of microorganisms to patient. (Luxner(2005).NCP.188) 7. Prevent transmission of microorganisms. Luxner(2005)NCP.41) 8. May identify presence of infection. (Luxner(2005).Delmars NCP.156) 1

exposure to infectious things. 11. Taught patient of possible source of infection and risk for spread or transmission and infection. 12. Reinforced completion of course of antibiotic therapy.

9. Allows for early intervention of infection is present. Luxner (2005) Delmars NCP. 220) 10. Provide understanding of susceptibility to infectious agents. Luxner (2005) Delmars NCP. 204) 11. Promotes understanding and cooperation in treatment and procedure, prevent spread of infection. Luxner (2005) Delmars NCP. 330) 12. Prevent recurrence of infection. Luxner (2005) Pediatric NCP. 212)

Care Plan Evaluation: This care plan was applicable to the patients case to prevent the spread of infection, but needs more diagnostic test and days to observe the improvement of health of the patient.

Nursing Diagnosis: Activity intolerance related to muscle weakness NANDA Definition: Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to factors such as malnourished and emotional states such as depression or lack of confidence. Cause Analysis: Decrease ability to tolerate activity often accompanies impaired mobility. Activity intolerance is when a person has inadequate physiologic or psychologic energy to endure or to complete an activity. Symptoms associated with activity intolerance are dyspnea, tachycardia, discomfort weakness and fatigue. Reduction in muscle cells size result from the alterations on the metabolism that occurs during immobility breakdown muscle lass to obtain energy (catabolic energy) Craves & Hirnle (2003) Fundamental of nursing.766 Defining Intervention Rationale Expected Outcomes 2

Characteristics Subjective: The pt. verbalized headache P-when temperature rises Q- Throbbing R- Localized S- 5/10 T-Intermittent Objective: T- 38.2C

NIC: exercise therapy & Muscle control Assessment 1. Assess the patient level of mobility

Noc: Activity tolerance 1. This aids in defining what the patient is able which is necessary before setting realistic goals.(Gulanick (2007) NCP.8) 2. Adequate energy reserves are required for activity (Gulanick (2007). NCP.8 3. Difficulties sleeping need to be addressed before activity progress can be achieve. (Gulanick. (2007).NCP.8) 4. Depression resulting from the inability to perform required activities can further aggravated activity intolerance. (Gulanick. (2007).NCP.8) 5. Patient with limited activity tolerance need to prioritize task. (Gulanick. (2007).NCP.8) 6. This reduces the energy expenditure. (Gulanick. (2007).NCP.8) 7. To reduce risk for falling while reaching. (Gulanick. (2007).NCP.8) 8. This distributes work to different muscles to avoid 2

To be able to do some activities but with assistance.

2. Assess nutritional status 3. Monitor the patients sleep pattern and amount of sleep achieved over the most few days. 4. Assess emotional response to change in physical status. Comfort Measures 5. Refrain from performing nonessential procedures. 6. Provide bedside commode as indicated 7. Anticipate the patients needs TEACHING 8. Teach energy conservation technique even as the

following -changing position often -Placing frequently use items within reach 9. Teach appropriate use of items or environmental aid.

fatigue. (Gulanick. (2007).NCP.8) 9. This conserve energy and prevent injury from each. (Gulanick. (2007).NCP.8)

Care Plan Evaluation: Care plan was not effective, So, it needs more interventions to improve condition.