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Activity Intolerance

The patient reported staying in bed most of the time due to immobility from a fresh surgical incision. On examination, the patient had a surgical incision, was sleeping often, and reported weakness and 4/10 pain. The nursing diagnosis was activity intolerance related to impaired skin integrity from the fresh surgical incision. The goal was for the patient to be able to use techniques to enhance activity tolerance after 8 hours of nursing interventions including encouraging ambulation, exercises, adjusting activities to prevent overexertion, assisting with activities, and providing comfort measures for pain relief. After 8 hours, the goal was met as the patient could use techniques to enhance activity tolerance.
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0% found this document useful (0 votes)
1K views

Activity Intolerance

The patient reported staying in bed most of the time due to immobility from a fresh surgical incision. On examination, the patient had a surgical incision, was sleeping often, and reported weakness and 4/10 pain. The nursing diagnosis was activity intolerance related to impaired skin integrity from the fresh surgical incision. The goal was for the patient to be able to use techniques to enhance activity tolerance after 8 hours of nursing interventions including encouraging ambulation, exercises, adjusting activities to prevent overexertion, assisting with activities, and providing comfort measures for pain relief. After 8 hours, the goal was met as the patient could use techniques to enhance activity tolerance.
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Cues/needs Subjective Data: Hindi ako masyado nagkikilos dito, lagi ako nasa kama as verbalized by the patient

Objective Data: -immobility(stays in bed most of the time) -Presence of fresh surgical incision -sleeps most of the time -weakness -pain scale of 4/10

Nursing diagnosis Activity intolerance related to impaired skin integrity or fresh surgical incision.

Rationale Insufficient physiological energy to endure or complete required or desired activity due to pain and distress with chest tube movement or removal

Goals and objectives After 8 hours of nursing intervention, patient will be able to use appropriate techniques to enhance activity intolerance

Nursing Intervention -Encourage ambulation.

Rationale

evaluation After 8 hours of nursing intervention: Goal was met as evidence by patients ability to use appropriate techniques to enhance activity intolerance

-to restore movement and prevent painful -Begin patients arm stiffening and shoulder exercise -to prevent overexertion -Adjust activities. Reduce intensity level of the activities that cause undesired physiological changes -assist with activities and provide/monitor clients use of assistive device -Promote comfort measures to provide for relief of pain

-to protect client from injury

-to enhance ability to participate in activities

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