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Nursing Care Plan : Activity intolerance related to compromised oxygen transport secondary to congestive heart failure

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Alteration in Nurtition: More Than Body Requirements

Alteration in Nurtition: More Than Body Requirements

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Altered satiety patterns (_) Medications (steroids) (_) Lack of knowledge (_) Decreased activity (_) Decreased metabolic needs (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)	(_) Overweight (weigh 10% to 20% over ideal for height and frame. (_) Obese (weigh over 20% of ideal).
Minor: (May be present)	(_) Reported undesirable eating patterns. (_) Intake in excess of metabolic requirements. (_) Sedentary activity patterns.

Date & Sign.	Plan and Outcome [Check those that apply]	Target Date:	Nursing Interventions [Check those that apply]	Date Achieved:
	The patient will:(_) Decrease total calories ingested. (_) Increase activity level. (_) Loose weight: (_____ pounds by discharge). (_) Other:		(_) Assess and document patient's dietary history, patterns of ingestion, activity patterns.(_) Discuss with patient potential causative factors for weight gain. (_) Assess motivation to correct overweight. (_) Consult with dietician regarding balanced plan for weight loss. Reinforce teaching. Discuss realistic weight loss of not more than 2 pounds per week. (_) Provide positive reinforcement for weight loss. (_) Record intake. (_) Weigh q ___ days at ____ am/pm. (_) Other:________________ ________________________ ________________________ ________________________

Alteration in Health Maintenance

Alteration in Health Maintenance

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Loss of independence (_) Changing support systems (_) Change in finances (_) Lack of knowledge (_) Poor learning skills (illiteracy) (_) Crisis situation (_) Inadequate health practice (_) Substance abuses:_______ __________________________

(_) Lack of accessibility to health care services (_) Health beliefs (_) Religious beliefs (_) Cultural/folk beliefs (_) Alterations in self image (_) Age related conditions (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)

(_) Reports or demonstrates an unhealthy practice or life style. (_) Reckless driving of vehicle. (_) Substance abuse. (_) Overeating. (_) Reports or demonstrates frequent alterations in health. eg: _________________________________________________

Date & Sign.	Plan and Outcome [Check those that apply]	Target Date:	Nursing Interventions [Check those that apply]	Date Achieved:
	The patient will:(_) Incorporate principles of health promotion into lifestyle: (_) Other:		(_) Assess for factors that contribute to the promotion and maintenance of health or that result in alterations in health.(_)Provide pertinent information concerning screening for: breast cancer, BP, other:______________________ (_) Explore health promotion behaviors that patient is willing to incorporate into lifestyle. (_) Initiate health teaching and referrals as indicated: review daily health practices dental care food intake fluid intake exercise use of tobacco, alcohol, and drugs knowledge of safety practices, fire prevention, water safety, automobile safety, bicycle safety, and poison control other: (_) Other:________________ ________________________ ________________________ ________________________

Alteration in Family Processes

Alteration in Family Processes

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Illness of a family member:_____________________ (_) Loss/gain of family member due to:______________ ____________________________________________ (_) Change in family roles:_______________________ (_) Conflict:___________________________________ (_) Financial crisis:_____________________________ (_) Other:____________________________________ ____________________________________________ ____________________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)	(_) Family system cannot or does not adapt constructively to crisis or family system cannot or does not communicate openly and effectively between family members.
Minor: (May be present)	(_) Family system cannot or does not: meet physical needs of all its members meet emotional needs of all its members meet spiritual needs of all its members express or accept a wide range of feelings seek or accept help appropriately

Assess ment	Plan and Outcome [Check those that apply]	Target Date:	Nursing Interventions [Check those that apply]	Date Achieved:
	The family member or patient will:(_) Frequently verbalize feelings to professional nurse and each other. (_) Maintain functional system of mutual support for each member. (_) Seek appropriate external resources when needed. (_) Other:		(_) Assess causative and contributing factors.(_) Meet with patient/family to identify: strengths/weaknesses resources available needs priorities alternative arrangements Other: (_) Encourage verbalization of guilt, anger, hostility, etc. and subsequent recognition of these feelings to: nursing staff family members (_)Direct family to hospital/community agencies: home health care nurse discharge planners social workers other: (_) Other:________________ ________________________ ________________________ ________________________

Alteration in Comfort: Pain

Alteration in Comfort: Pain

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Musculoskeletal disorder (_) Visceral disorder (_) Cancer (_) Information (_) Trauma (_) Diagnostic test

(_) Immobility/improper positioning (_) Pressure points (_) Pregnancy (_) Fear (_) Anxiety/stress (_) Overactivity (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)	(_) Pt. reports or demonstrates discomfort.
Minor: (May be present)	(_) Autonomic response to acute pain: increased BP, P, R diaphoresis dilated pupils guarding facial mask of pain crying/moaning abdominal heaviness cutaneous irritation

Assess ment	Plan and Outcome [Check those that apply]	Target Date:	Nursing Interventions [Check those that apply]	Evaluation
	The patient will:(_) Experience relief of pain A.E.B. verbal reports of relief of pain less autonomic responses to pain (_) Other:		(_) Asses characteristics of pain: location, severity on a scale of 1-10, type, frequency, precipitating factors, relief factors.(_) Eliminate factors that precipitate pain: eg.:__________________ ________________________ (_) Offer analgesics q___ hrs prn (according to physician order). (_) Teach patient to request analgesics before pain becomes severe. (_) Explore non-pharmacological methods for reducing pain/promoting comfort: back rubs slow rhythmic breathing repositioning diversional activities such as music, TV, etc. (_) Other:________________ ________________________ ________________________ ________________________

Alteration in Bowel Elimination: Diarrhea

Alteration in Bowel Elimination: Diarrhea

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Inflammation of bowels (_) Colon mucosa ulceration (_) Fecal impaction (_) Gastric bypass (_) Infant - breast fed (_) Decreased sphincter reflexes (_) Allergies

(_) Medications_______________________ ____________________________________ (_) Stress/anxiety (_) Tube feedings (_) Decreased tolerance to dietary program: ____________________________________ ____________________________________ (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)	(_) Loose liquid stools and/or: (_) Frequency
Minor: (May be present)	(_) Urgency (_) Cramping/abdominal pain (_) Hyperactive bowel sounds (_) Increase of fluidity or volume of stools

Assess ment	Plan and Outcome [Check those that apply]	Target Date:	Nursing Interventions [Check those that apply]	Evaluation
	The patient will:(_) Have stool/elimination pattern that closer resembles that of patient's normal stool/pattern. (_) Patient and/or significant other will verbalize methods for preventing and/or treating diarrhea. (_) Other:		(_) Assess abdomen for distention, bowel sounds, pain q___ hours.(_) Identify factors that contribute to diarrhea:________________ _______________________ _______________________ _______________________ (_) Record color, odor, amount and frequency of stool. (_) Instruct patient in: diet medication usage S/S of diarrhea to watch for requiring medical attention discontinuing solids offer clear liquids. (_) Other:________________ ________________________ ________________________ ________________________

Alteration in Bowel Elimination: Constipation

Alteration in Bowel Elimination: Constipation

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Malnutrition (_) Metabolic and endocrine disorders (_) Sensory/motor disorders (_) Stress (_) Immobility (_) Inadequate diet (_) Irregular evacuation pattern

(_) Drug side effects (_) Pain (upon defecation) (_) Pregnancy (_) Surgery (_) Lack of privacy (_) Dehydration (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)	(_) Hard formed stool and/or defecation occurs fewer than three times per week.
Minor: (May be present)	(_) Decreased bowel sounds. (_) Reported feeling of rectal fullness or pressure around rectum. (_) Straining and pain on defecation. (_) Palpable impaction.

Assess ment	Plan and Outcome [Check those that apply]	Target Date:	Nursing Interventions [[Check those that apply]	Evaluation
	The patient will:(_) Have soft formed stool by _____ and q ___ day(s). (_) Patient and/or significant other will verbalize an understanding of method for preventing and/or treating constipation.		(_) Assess abdomen for distention, bowel sounds q ___ hours.(_) Assess bowel elimination q ___ hours. (_) Asses factors responsible for constipation: stress discomfort sedentary lifestyle laxative abuse debilitation lack of time/privacy drug side effect (_) Promote corrective measures: review daily routine provide privacy/time provide comfort encourage adequate exercise (_) Promote adequate dietary/fluid intake. Patient likes: Fluids:_______________ ____________________ Fiber foods:___________ ____________________ (_) Initiate bowel program to promote defecation. (_) Consult dietitian. (_) Other:________________ ________________________ ________________________ ________________________

Activity Intolerance

Activity Intolerance

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Alterations in O2 transport (_) Chronic disease:____________ ____________________________ (_) Depression (_) Diabetes Mellitus (_) Fatigue (_) Lack of motivation (_) Malnourishment

(_) Pain (_) Prolonged immobility (_) Stressors (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)

(_) _____________________________________________________ ________________________________________________________ ________________________________________________________

	Plan and Outcome [Check those that apply]		Nursing Interventions [Check those that apply]	Evaluation
	The patient will:(_) Identify factors that reduce activity tolerance. (_) Progress to highest level of mobility possible. Describe: (_) Exhibit a decrease in anoxic signs of increased activity. (eg: BP, pulse, resp.) (_) Other:		(_) Reduce or eliminate contributing factors by: Assess patient's schedule. Allow rest periods between all activities. Encourage person to note daily progress. Evaluate patient's pain and the present treatment regimen. Check pulse rates resting and after activity to avoid danger of too great an increase. Assess skin color (hands, nails, circumoral) before and after activity. Relaxation training (work with pulmonary rehab.) Cough/deep breathe. Encourage fluid intake, roughage. Teach inhaler use. Sit when conversing with patient. Progress the activity gradually. (_) Other:________________ ________________________ ________________________ ________________________

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