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Activity and Rest
- inadequate sleep for past 3 nights (I)
- slow and unsteady gait (I)
- able to perform simple ADLs such as brushing hair (A)
- very shaky when moving from a lying position to a sitting position (I)
Focal: difficulty tolerating physical activity
Contextual: pain
Residual: loss of motivation
- health teaching
- encourage pt to stand up and walk around his room
- manage pain (assess pain every hour)
- encourage food intake for energy
- preform ROM on pt
Evaluation
NANDA statement
Oxygenation
- O2 sat: 96% room air (A)
- symmetrical lung expansion (A)
Elimination
- <50mL in 3hrs (I)
- no bowel movement (I)
- hematuria (I)
- on a CBI and drainage was serous-sang; almost clear (A)
Nutrition
- ate less than half his breakfast (I)
- drinking plenty of water (A)
- mucous membrane moist (A)
Activity and Rest
- inadequate sleep for past 3 nights (I)
- slow and unsteady gait (I)
- able to perform simple ADLs such as brushing hair (A)
- very shaky when moving from a lying position to a sitting position (I)
Senses
- pain 9/10 (I)
- reoccurring bladder spasms (I)
- Constant right flank pain (I)
Protection
- bruising and redness around coccyx (I)
Activity intolerance r/t inadequate motivation secondary to pain
- Pt will show knowledge of health teaching as evidenced by answering questions adequately on the importance of physical activity
- Pt will show improvement of physical activity as evidenced by walking around the room for >5min
- Pt will show improvement by pain as evidenced by a self-report of pain that is <5/10
- Pt will show improvement of food intake as evidenced by a consumption of >3/4 of meal
- Pt will show an increased motivation in activity tolerance as evidenced by active participation in ROM sessions
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PRIORITY
Reflects nursing interventions
Client Health Profile
Name: Mr. P.
Age: 60
Gender: M
Admitting Diagnosis: Atrial fibrillation
Health History: Radical prostatectomy, diabetes, hypertension, sleep apnea
Level of Risk for Falls: Moderate
Care providers: doctor, nurse, pain management nurse
Rovustatin
Pantoprazole
Medication:
Tylenol #3
Opium-Belladonna
Metoprolol