Activity Intolerance ● The patient will verbalize decrease in

Objective Data: pain by rating pain less than 4 on 1-10

● Difficulty to engage in activities scale within 24 hours of receiving pain
● Signs of pain (frequent grimace, medication.
reluctancy to initiate activities) ● Display improvement in mood, coping.
● Reduction of pain intensity to a
● EKG changes reflecting strain
manageable level
Expected Outcome:
● Improved ability to perform daily
● The patient will participate in physical
activities
activities with PT and OT
● Enhanced coping strategies for pain
● The patient will achieve an increased
management
conditioned physical state.
Interventions:
Interventions:
1. Administer pain medications as
1. Assess for the cause of the activity
prescribed.
intolerance.
2. Reposition the patient in his/her
2. Assess ability and tolerance to engage
comfortable/preferred position.
in activities.
3. Encourage pursed lip breathing and
3. Assess possible contributing factors to
deep breathing exercises.
intolerance.
4. Ensure uninterrupted bed rest and sleep
4. Assess the patient’s emotional and
in a comfortable position.
motivational status.
5. Assess the patient’s willingness or
5. Encourage activity progressively.
ability to explore a range of techniques
6. Perform range of motion (ROM) as
to control pain.
tolerated.
6. Determine factors that alleviate pain.
7. Encourage the patient to perform active
ROM exercises.
Hyperthermia
8. Coordinate rest periods before straining
Objective Data:
activities such as eating, bathing, and
● Body temperature above normal range
ambulating.
● Flushed skin warm to touch
9. Provide enough time for the patient to
● Increased RR and PR
perform tasks.
Expected Outcomes:
10. Provide opportunities for the patient to
● Patient will maintain core body
express positive and negative feelings.
temperature within normal limits.
11. If the patient is on bed, resting or unable
● Patient will verbalize underlying factors
to sit up, place the patient in an upright
that contribute to hyperthermia.
position several times per day.
● Patient maintains BP and HR within
12. Teach the patient and the
normal limits.
family/caregiver the importance of
continuing activities.
Interventions:
13. Teach the patient and family energy
1. Assess for signs of hyperthermia.
conserving measures.
2. Assess for signs of dehydration as a
Acute Pain result of hyperthermia.
Objective Data: 3. Identify the triggering factors for
● Self-report of intensity using hyperthermia and review the client’s
standardized pain intensity scales history, diagnosis, or procedures.
● Alteration in BP, HR, RR 4. Provide hypothermia blankets or cooling
● Guarding behavior or protecting the blankets when necessary.
body part 5. Apply ice packs to the patient.
● Facial mask of pain (e.g., grimaces) 6. Loosen or remove excess clothing and
● Expression of pain (e.g., restlessness, covers.
crying, moaning) 7. Encourage adequate fluid intake.
Expected Outcomes:
 8. Administer antipyretics (e.g., ibuprofen, dehydration.A client needs to
acetaminophen) as ordered. understand the value of drinking extra
9. Encourage the patient and family to fluid.
have an annual flu vaccination. 8. Encourage the client to drink bountiful
10. Adjust and monitor environmental amounts of fluid as tolerated or based
factors like room temperature and bed on individual needs.
linens as indicated. 9. Provide an adequate, balanced diet as
11. Provide nutritional support or as soon as tolerated.
indicated.
12. Provide mouth care. Application of
water-soluble lip balm can help with Imbalanced Nutrition
dryness and cracks caused by Objective Data:
dehydration. ● Age-related changes in taste, smell, or
appetite
Fluid Volume Deficit (Dehydration & ● Other illness (i.e. cancer, burns)
Hypovolemia) ● Difficulty chewing or swallowing
Objective Data: Expected Outcomes:
● Verbalizations of weakness and thirst ● Patient will maintain weight in desired
that may or may not be accompanied by goal range.
tachycardia or weak pulse ● Patient will recognize factors that are
● Dry mucous membranes, sunken contributing to being under or
eyeballs overweight.
● Decreased skin turgor ● Patient will identify appropriate
● Weak pulse, tachycardia nutritional needs/requirements.
Expected Outcomes: ● Patient will consume adequate nutrition.
● The client demonstrates lifestyle ● Patient will verbalize appropriate
changes to avoid the progression of management of nutrition at home.
dehydration.
● The client verbalizes awareness of Interventions:
causative factors and behaviors 1. Assess the patient’s lab values.
essential to correct the fluid deficit. 2. Determine the patient’s body mass index
● The client explains measures that can (BMI).
be taken to treat or prevent fluid volume 3. Assess the reason for imbalanced
loss. nutrition (i.e. other medical or
environmental conditions).
Interventions: 4. Assess oral care/hygiene.
1. Monitor and document vital signs, 5. Provide nutritional supplements as
especially blood pressure (BP) and heart appropriate or ordered.
rate (HR). 6. Educate the patient on the body’s
2. Assess skin turgor and oral mucous nutritional needs.
membranes for signs of dehydration. 7. Provide the patient with resources
3. Assess alteration in regarding nutrition.
mentation/sensorium, such as 8. If underweight, provide the patient with
confusion, agitation, or slow responses. additional snacks in between meals.
4. Assess color and amount of urine; 9. Ensure a pleasant environment, facilitate
report urine output less than 30 ml/hr proper positioning, and provide good
for two consecutive hours. oral hygiene.
5. Monitor fluid status in relation to dietary 10. Make a selective menu and allow the
intake. patient to choose meals as much as
6. Identify the possible cause of the fluid possible.
disturbance or imbalance. 11. Encourage fluids and fiber.
7. Encourage interventions to prevent or 12. Offer high-calorie drinks and snacks
minimize future episodes of often.