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Subjective
Pt states that he cannot walk any farther than the bathroom or the chair without
experiencing shortness of breath.
Pt states that he was admitted because he was experiencing unusual shortness of
breath
Objective
Chart states chief complaint as “shortness
of air”
Diagnosis of congestive heart failure
Pt demonstrates dyspnea upon exertion and acitivty.
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Problem
Activity Intolerance
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Long Term:
Pt will demonstrate increased tolerance to activity by discharge.
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*Evaluate medications the client is taking
to see if they could be causing activity intolerance.
Rationale:
“Medications such as beta-blockers, lipid-
lowering agents, which can damage muscle, and some antihypertensives such as Clonedine
and lowering the blood pressure to normal in the elderly can result in decreased
functioning.” (Ackley & Ladwig, 2008, p 121)
*Assess nutritional needs associated with activity
intolerance.
Rationale:
“The decline in body mass, with physical weakness,
inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers.”
(Ackley & Ladwig, 2008, p 120)
*Provide emotional support and encouragement
to the client to gradually increase activity.
Rationale:
“Fear of breathlessness, pain, or falling may
decrease willingness to increase activity.” (Ackley & Ladwig, 2008, p 120)
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Goal met. Pt demonstrated increased tolerance
to activity. Pt was able to ambulate to the room door and back to the bed without
any abnormal changes in vitals. Pt stated that he felt stable after ambulating.
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Continue interventions as listed. Continue
to evaluate the pt’s medications to see if they could be causing the activity intolerance.
Continue to assess pt’s nutritional needs. Continue to provide emotional support
and encouragement so that the pt may feel more confident about resuming activity.
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R/T
Weakness and fatigue
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Short Term:
Pt will participate in physical activity with appropriate changes in heart rate,
blood pressure, and respirations within three days, by [date].
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* Monitor vitals before and after any activity, noting any abnormal changes.
Rationale:
“This can be caused by a temporary insufficiency of blood supply” (Ackley &
Ladwig, 2008, p 119)
*Assess for pain before activity.
Rationale:
“Pain restricts the client from achieving a maximal activity level and if often
exacerbated by movement. (Ackley & Ladwig, 2008, p 120)
*Obtain any necessary assistive devices or equipment needed before assisting in
ambulation
Rationale:
Assistive devices can increase mobility by helping the client overcome limitations.”
(Ackley & Ladwig, 2008, p 120)
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Goal met. Pt was able to participate in physical activity with appropriate vitals
changes. His vitals were checked before and after activity and there were no indications
of unstable vitals.
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Continue interventions as listed. Continue to monitor vitals before and after activity.
Continue to assess for pain before activity. Continue to obtain any assistive devices
before activity.
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