Pneumonia - created from Mind Map

AssessmentFatigue

Diagnosis

Intervention

Planning or Goals and Outcome

Evaluation

Fatique, weakness, insomnia, prolonged immobility and bed rest. Loss of appetite, n/v, lethargy, decreased tolerance to activity, tachycardia, neurosensory changes such as confusion, somnolence(drowsiness), ineffective neuro ck response  on the left foot. Small lesion on the left lower arm. Patient on contact precaution.

Ineffective airway clearance, may be related to tracheal bronchial inflammation possibly evidenced by changes in rate and  depth of respiration. Impaired gas exchange maybe related to altered oxygen- carrying capacity of blood, possible evidenced by dyspnea  hypoxia. Activity intolerance maybe related to inbalance between oxygen supply and demand, general weekness. Exhaustion associated with interruption in usual sleep pattern because of discomfort , coughing possibly evidenced by verbal report of weakness, fatigue, tachypnea, tachycardia in responce to activity.Pt. on contact precaution due to  MRSA. 

Patient will be evaluated about  response to activity. Report of dyspnea, increased weakness and fatigue, changes in vital signs during and after activities will be noted. Pt. will be assisted with self care activities as necessary.

Patient will report and demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue with vital signs within patient's acceptable range. Patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within clients acceptable range and absence of symptoms of respiratory distress. Patient will identify and demonstrate behavior to achieve airway clearance by elevating the head of bed to fowler position, turning regularly and using flow meter at intervals.

Patient did not verbalized understanding of condition, disease process and prognosis.  Pt. demonstrated  a small measurable increase in tolerance activities with less noted  sob, fatigue and VS within normal range. Overall the goals were not completely made, however patient has been helped around the clock by family members rotating between mother and daughter.

Pneumonia

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