NCP 2

Assessment


Subjective
“I feel weak”, as verbalized by the patient.
“ I am having discomfort and difficulty of breathing”, as verbalized by the patient

Objective
Temp.: 37.2 degrees Celsius
PR: 140 BPM
RR: 22 breathes/min
BP:140/90 mmHg
Development/severing pallor; excessive coughing

Nursing diagnosis

Activity intolerance related to imbalance between oxygen supply and demand, general weakness possibly evidenced by reports of fatigue,dyspnea,and abnormal ital sign response to activity
Plan
Client will:
Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs either normal patient’s acceptable range.
Plan
*Evaluate patient’s response to activity. Note reports of dyspnea, increase weaknesses/fatigue, and changes in vital signs during and after activities.

*Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.

*Explain importance of rest in treatment plan and necessity for balancing activities with rest. *Establishes patient’s capabilities/needs and facilitates choice of interventions
Rationale


*Reduce stress and excess stimulation, promoting rest.






*Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity intolerance restrictions thereafter are determined by individual patient response to activity and resolution of respiration insufficiency Outcome met. The patient reported and demonstrated a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs were normal.

Evaluation
Outcome met. The patient reported and demonstrated a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs were normal.