assessment
- Assess lungs by listening for crackles, wheezes or pauses between breaths
- Feel hands and feet to assess for coldness
- Listen to heart beat for one minute before getting out of bed and after (assess the increase by 20 beats per minute after the resting rate, and not returning to pre activity rate within 3 minutes)
- Assess for signs of sweat on body
- Assess for increase in blood pressure
- Assess for chest pains
- Assess for signs of difficulty breathing
nursing diagnosis
- Activity intolerance related to increasing muscle weakness as evidence by sluggish movements and difficult breathing during activity.
plan
- By March 16thth 2014, patient will be able to walk to the dining room and back to bedroom without assistance from caregiver. Patient will walk to dining room with assistance for first six days and return in wheelchair. Patient will walk to dining room from bedroom and return to bedroom with assistance by caregiver the following ten days. By March 16th patient will have increased muscle strength and be able to walk by himself to and from the dining room. Patient will have clear lung sounds and no difficulty breathing.
interventions
- Discuss with patient the need and importance of activity to give patient motivation to begin activity and discuss how they could benefit from it
- Discuss which activities make them the most tired and which ones they feel they will be able to complete to set them up for success, without completely exhausting themselves
- Alternate periods of rest with sleep to prevent patient from getting tired easily
- Allow enough time for patient to rest before beginning activity to prevent patient from making themselves feeling too tired
- Monitor blood pressure, pulse and respirations before and after activity to indicate the level of activity they can handle
- Discuss and set short term and long term goals with patient
evaluation
- By following the Nursing Interventions, patient is walking to and from the dining room without assistance. Patient has understanding of the importance of activity and how they will benefit from it. Patient understands the importance of rest between activities. Patient has clear lung sounds and no difficulty breathing.