Assessment Subjective: Hirap ako maglakad kasi nga namamaga yung mga paa ko pati ang mga kamay

ko kaya madalas nakahiga na lang ako dito sa higaan. As verbalized by the patient. Objective: Edema on both upper and lower extremities. Low Hemoglobin count. Fever with temperature of 39 degrees Celsius

Diagnosis Activity Intolerance related to inflammatory process as manifested by edema on both upper and lower extremities.

Planning After 8 hours of Nursing Intervention the patient will be able to: Objective: Identify techniques that would enhance activity intolerance. Participate willingly in necessary and desired activities

Intervention Establish rapport

Rationale To have a better cooperation from the patient. To promote rest periods. To know if there is an increase in output rather than in input. To be able the express and say what she wanted to say regarding her illness.

Evaluation After 8 hours of Nursing Intervention the patient was able to: Identify techniques that would enhance activity intolerance. Yes __ No __ Participate willingly in necessary and desired activities Yes __ No __

Provide cool and clean environment Monitor patients input and output Encourage the patient to verbalize her feelings

Goal: Promote activities that the patient can do Maintain quality of life.

Give client To promote information about motivation her progress Assist client in his daily needs This is to promote personal hygiene and other things that the patient needed to do.

Assessment Subjective: Bago pa ako maadmit dito sa ospital eh nanghihina na ako kahit hanggang ngayon eh nanghihina pa din ako. As verbalized by the patient. Objective: General Body Weakness. Edema on both upper and lower extremities. Temperature of 39 degrees Celsius. Difficulty standing or even sitting in the bed.

Diagnosis Risk for falls.

Planning After 8 hours of Nursing Intervention the patient will be able to: Objective: Verbalize understanding of individual risk factors that may contribute to injuries. Prevent the possible occurrence of injury. Modify her environment as indicated to enhance safety.

Intervention Establish rapport

Rationale To have a better cooperation from the patient. To promote rest periods. To expect what are the possible things needed to do for the patient. To prevent falls and injuries

Evaluation After 8 hours of Nursing Intervention the patient was able to: Verbalize understanding of individual risk factors that may contribute to injuries. Yes __ No __ Prevent the possible occurrence of injury Yes __ No __

Provide cool and clean environment Encourage the patient to verbalize his needs As much as possible always raise the beds side rails of the patient. When the patient will urinate advise her to use bedpan. Advise the patient to always ask assistance with her relatives or if the relatives is not accessible then with the nurse on duty or student nurse.

To prevent falls and injuries To prevent falls and injuries

Modify her environment as indicated to enhance safety Yes __ No __