Professional Documents
Culture Documents
Fatigue is a
pace activities. contributing
Maintain planned factor to
rest periods. ineffective
Promote energy- coughing.
conservation
techniques.
Patient will
Demonstrate and understand the
teach coughing, rationale and
deep breathing, and appropriate
splinting techniques to
techniques. keep the airway
clear of
secretions.
Smoking
Explain effects of contributes to
smoking, including bronchospasm
second-hand and increased
smoke. mucus production
in the airways.
To treat infection,
Dependent: liquefy secretions
Administer and let the patient
medications. be aware of the
Instruct patient on side effects.
indications for,
frequency, and side
effects of
medications. Chest
physiotherapy
Collaborative: includes the
Consult respiratory techniques of
therapist for chest postural drainage
physiotherapy and and chest
nebulizer percussion to
treatments as mobilize
indicated (hospital secretions in
and home smaller airways
care/rehabilitation that cannot be
environments). removed by
coughing or
suctioning.
Nursing care plan
Patient: Gladys Santos Age: 31 years old CC: cough
• Onset of
chest
discomfort
• Dyspnea
• Palpitations
• Excessive
fatigue
• Lightheadedn
ess,
confusion,
ataxia, pallor,
cyanosis,
nausea, or
any
peripheral
circulatory
insufficiency
• Dysrhythmia
• Exercise
hypotension
(drop in
systolic blood
pressure of
10 mm Hg
from baseline
blood
pressure
despite an
increase in
workload)
• Excessive
rise in blood
pressure
(systolic
>180 mm Hg
or diastolic
>110 mm
Hg) Note:
These are
upper limits;
activity may
be stopped
before
reaching
these values
• Inappropriate
bradycardia
(drop in heart
rate >10
beats/min or
<50
beats/min)
• Increased
heart rate
above 100
beats/min
EditInstruct
the client to stop the
activity immediately
and report to the
physician if the
client is experiencing
the following
symptoms: new or
worsened intensity
or increased
frequency of
discomfort; tightness
or pressure in chest,
back, neck, jaw,
shoulders, and/or
arms; palpitations;
dizziness; weakness;
unusual and extreme
fatigue; excessive air
hunger. These are
common symptoms
of angina and are
caused by a
temporary
insufficiency of
coronary blood
supply. Symptoms
typically last for
minutes as opposed
to momentary
twinges. If symptoms
last longer than 5 to
10 minutes, the
client should be
evaluated by a
physician. Pulse rate
and arterial blood
oxygenation indicate
cardiac/exercise
tolerance; pulse
oximetry identifies
hypoxia (Grimes,
2007; Schmitz,
2007).
EditObserve
and document skin
integrity several
times a day. Activity
intolerance, if
resulting in
immobility, may lead
to pressure ulcers.
Mechanical
pressure, moisture,
friction, and
shearing forces all
predispose to their
development (Fauci
et al, 2008). Refer to
the care plan Risk
for impaired Skin
integrity.
EditAssess
for constipation. If
present, refer to care
plan for
Constipation.
Activity intolerance
is associated with
increased risk of
constipation.
EditRefer the
client to physical
therapy to help
increase activity
levels and strength.
EditConsider
a dietitian referral to
assess nutritional
needs related to
activity intolerance,
provide nutrition as
needed. If client is
unable to eat food,
use enteral or
parenteral feedings
as needed.
EditRecognize that
malnutrition causes
significant morbidity
due to the loss of
lean body mass.
Providing nutrition
early helps maintain
muscle and immune
system function, and
reduce hospital
length of stay
(McClave et al,
2009; Racco, 2009).
EditProvide
emotional support
and encouragement
to the client to
gradually increase
activity. Work with
the client to set
mutual goals that
increase activity
levels. Fear of
breathlessness, pain,
or falling may
decrease willingness
to increase activity.
EditObserve
for pain before
activity. If possible,
treat pain before
activity and ensure
that the client is not
heavily sedated.
Pain restricts the
client from achieving
a maximal activity
level and is often
exacerbated by
movement.
EditObtain
any necessary
assistive devices or
equipment needed
before ambulating
the client (e.g.,
walkers, canes,
crutches, portable
oxygen). Assistive
devices can help
increase mobility
(Yeom, Keller, &
Fleury, 2009).
EditUse a
gait walking belt
when ambulating the
client. Gait belts
improve the
caregiver's grasp,
reducing the
incidence of injuries
(Nelson et al, 2003).
• EditIf the
client is able
to walk and
has chronic
obstructive
pulmonary
disease
(COPD), use
the traditional
6minute walk
distance to
evaluate
ability to
walk. EB:
The 6minute
walk test
predicted
mortality in
COPD
clients
(Pinto-Plata
et al, 2004).
• EditEnsu
re that the
chronic
pulmonary
client has
oxygen
saturation
testing with
exercise. Use
supplemental
oxygen to
keep oxygen
saturation 90
or above or
as prescribed
with activity.
Clients with
COPD may
suffer from
inadequate
gas
exchange.
Oxygen
therapy can
improve
exercise
ability and
ability to
think in
hypoxemic
clients (Celli,
MacNee, &
ATS/ERS
Task Force,
2004).
• EditMoni
tor a
respiratory
client's
response to
activity by
observing for
symptoms of
respiratory
intolerance
such as
increased
dyspnea, loss
of ability to
control
breathing
rhythmically,
use of
accessory
muscles,
nasal flaring,
appearance of
facial
distress, and
skin tone
changes such
as pallor and
cyanosis
(Perme &
Chandrashek
ar, 2009).
• EditInstr
uct and assist
a COPD
client in
using
conscious,
controlled
breathing
techniques
during
exercise,
including
pursed-lip
breathing,
and
inspiratory
muscle use.
EBN: A
systematic
review found
pursed-lip
breathing
effective in
decreasing
dyspnea
(Carrieri-
Kohlman et
al, 2008).
EB: A
systematic
review found
that
inspiratory
muscle
training was
effective in
increasing
endurance of
the client and
decreasing
dyspnea
(Langer et al,
2009).
• EditEval
uate the
client's
nutritional
status. Refer
to a dietitian
if needed.
Use
nutritional
supplements
to increase
nutritional
level if
needed.
Improved
nutrition may
help increase
inspiratory
muscle
function and
decrease
dyspnea.
EBN: A
study found
that almost
half of a
group of
clients with
COPD were
malnourished
, which can
lead to an
exacerbation
of the disease
(Odencrants,
Ehnfors, &
Ehrenbert,
2008).
• EditFor
the client in
the intensive
care unit,
consider
mobilizing
the client in a
four-phase
method if
there is
sufficient
knowledgeab
le staff
available to
protect the
client from
harm. Even
intensive
care unit
clients
receiving
mechanical
ventilation
can be
mobilized
safely if a
multidisciplin
ary team is
present to
support,
protect, and
monitor the
client for
intolerance
to activity
(Perme &
Chandrashek
ar, 2009).
• EditRefer
the COPD
client to a
pulmonary
rehabilitation
program.
EB: A
Cochrane
review found
that
pulmonary
rehabilitation
has been
shown to
relieve
dyspnea and
fatigue
(Lacasse et
al, 2006).
Another
Cochrane
review found
pulmonary
rehabilitation
effective to
decrease
mortality and
rate of
readmission
for the client
who was
recently
discharged
after
treatment for
an
exacerbation
of COPD
(Puhan et al,
2009).
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ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION