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ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS
ASSESSMENT NURSINGDIAGNOSIS
SCIENTIFICEXPLANATION
OBJECTIVES NURSINGINTERVENTIONS
RATIONALE EXPECTEDOUTCOME
S:
O: The
patient
manifested:
>poor muscledevelopment
>poor muscle
tone
>unable to
open mouthwide
>weakness
The pt. maymanifest:
>hyperactivebowel sounds
>underweight
>fecal loss ofblood
>prone toinfections
>capillaryfragility
>pale
palpebralconjunctiva
>pale mucus
membrane
AlteredNutrition: less
than body
requirement
r/t inability to
open mouthwide and
muscle
weakness.
Acutedisease
induced by
toxin of
tetanus
bacillusgrowing
anaerobically
in wounds
and at site of
umbilicusamong
infants.
Characterized
by muscularcontraction.
The clientmanifested
weakness due
to severemuscle
contractionand due to
compensatory mechanism
of the body
like increasein
temperature.
The client also
Short Term:After 4 hours
of NI, the
patient will
verbalize
understandingof causative
factors when
known and
necessary
interventions.Patients vital
signs will
decrease/retu
rn to normalrate/ranges.
Long Term:
After 2 days of
NI, the patientwill
demonstratebehaviors,
lifestylechanges to
regain and/or
maintainappropriate
weight and
patients vital
> Establishrapport
> Monitor and
record V/S
>Assess
patients
condition
>Assess skinturgor and
mucousmembranes
>Ascertain
understanding
of individualnutritional
needs
> To gain thetrust and
cooperation
of the pt.
and the SO
> To gain
baseline
data for the
care and
management of the
patient
>This willguide what
interventionsto provide
>To assessany
abnormalities
>To
determinewhat
information
to provide
The patientshall verbalize
understanding
of causative
factors when
known andnecessary
interventions.
Patients vital
signs shall
decrease/return to normal
rate/ranges.
And the
patient shalldemonstrate
behaviors,lifestyle
changes to
regain and/ormaintain
appropriateweight and
patients vital
signs shall
maintain to
normalrates/ranges.
8/4/2019 ncps tetany
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manifested
unable to
open mouthwide due to
muscle spasmcaused by
toxins that
impaires
neurologic
functions.Thus, the
client is
unable to eat
resulting toaltered
nutrition: less
than body
requirements.
signs will
maintain to
normalrates/ranges.
>Assess weight,
age, body
build, strength,activity/rest
level, and soforth
>Discuss eating
habits,
including foodpreferences,
intolerances
>Encouragepatient to
choose foods
which are
appealing
>Emphasize
importance ofwell-balanced,
nutritious intake
>Provides
comparative baseline
>To appeal
to clients
likes/desires
>To stimulateappetite
>To achievewellness and
supplymetabolic
needs
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ACTIVITY INTOLERANCE
ASSESSMENT NURSINGDIAGNOSIS
SCIENTIFICEXPLANATION
OBJECTIVES NURSINGINTERVENTIONS
RATIONALE EXPECTEDOUTCOME
S:
O: The patient
manifested:
> fatigue> weakness
> restlessness
> increased
pulse
> abnormalheart rate to
activity
> low
tolerance ofactivity
>with vitalsigns of:
Temperature-
36.5CPulse rate-
104bpmRespiratory
rate- 20 cpm
The pt. may
manifest:> irritability
> inability to
perform or
ActivityIntolerance
r/t
generalized
weakness
Activity
intolerance isa common
problem since
physical
activity
increases the
demand foroxygen and
heart rhythm.
In tetanus,there is a
spasm in themuscles due
to thespreading of
the toxins of
the clostridiumbacteria that
causes
irritability ofsynapses of
the neurons
making the
individualsaffected
become
physically
weak and
Short Term:After 4 hours of
NI, the patient
will verbalize
and will use
energyconservation
techniques and
management of
fatigue with
increasingactivity level
and effects of
inactivity will be
reduced. Thepatients vital
signs will returnto normal
rates/ranges:
Heart rate of 60-100 bpm
Long Term:After 2-3 days of
NI, the patient
will demonstratemaintenance of
energy and
endurance
> Establishrapport
> Monitor and
record V/S
> Assesstemperature,
respirations,and pulse;
changes in
behavior(irritability,
lightheadedness, short
attentionspan); if easily
fatigued,
unable tosleep, or weak;
ability to
tolerate any
> To gain thetrust and
cooperation
of the pt. and
the SO
> To gain
baseline data
for the care
andmanagement
of the patient
> Providesinformation
about V/Schanges
caused by
hypoxia andabout
behaviorchanges
caused byreduced
oxygenation
of the brain
The patient shallverbalize and
shall use energy
conservation
techniques and
management offatigue with
increasing
activity level
and effects of
inactivity shallhave reduced.
The patients
vital signs shall
return to normalrates/ranges:
Heart rate inbetween 60-
100bpm.
Long term:The patient shall
demonstrate
maintenance ofenergy and
endurance and
will be able to
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begin an
activity
> exertionaldiscomfort or
dyspnea
unable to
engage in
normalphysical
activitywithout
experiencing
profound
fatigue. In very
advancedcases this may
cause parality
of muscles
and otherevidence of
heart failure
may appear.
Patients may
experienceactivity
intolerancebecause of
fatigue,
weakness, andpoor tissue
oxygenationand increased
heart rate.
levels and will
be able to
perform his dailyactivities of life.
activity or ADL
> Assist withactivities that
require exertionand are
beyond
tolerance and
ability
> Provide rest
periods, plan
care and
activitiesaround
rest/sleep
> Provideappropriate
quiet activities,and allow
interaction with
otherindividuals
> Refrain from
performing
nonessential
procedures
> Minimizesphysical
exertion,which
increases
oxygen to
tissues
> Decreases
oxygen
expenditure
to enhancetissue
oxygenation
> Promotesdiversionary
activity andprevents
withdrawal
> Patients
with limited
activity
intoleranceneed to
prioritize tasks
perform his daily
activities of life.
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> Place patient
in semi-Fowler's
or sittingposition
> Administer
transfusion of
blood, packedRBC, platelets
as ordered
> Inform
patient of
measures to
take toconserve
energy andincrease
endurance of
the clientincluding
placing articleswithin reach,
anticipating
needs and
assisting before
client attemptsactivity,
allowing for
rest; remain
> To facilitate
breathing
> Replaces
blood or
blood
componentsdepending
on type of
anemia and
need
> Provides
information to
prevent
fatigue byminimizing
physicalactivity or
exertion,
which utilizesmore oxygen
and lessexertion of
the heart
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with patient as
needed
> Inform
patient to
avoid stressful
situations
> Teach
patient torecognize signs
of physical
overactivity
> Promotes
quiet
environment
for child
>This
promotesawareness of
when to
reduce
activity
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FATIGUE
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVES NURSING
INTERVENTIONS
RATIONALE EXPECTED
OUTCOME
S:
O: The
patient
manifested:
>decreased
performance>weakness
>inability to
restore
energy, even
after sleep>tiredness
>inability to
maintain
usual routines>Vital signs
taken:Temperature-
37.5C
Pulse rate-110 bpm
Respiratoryrate- 64 cpm
The pt. may
manifest:
>lethargic orlistless; drowsy
>compromise
d
Fatigue r/t
muscularweakness and
spasticity
Decreased
The tetanustoxin affects
the site of
interaction
between the
nerve and themuscle that it
stimulates. This
region is
called the
neuromuscular junction. The
tetanus toxin
amplifies the
chemicalsignal from
the nerve tothe muscle,
which causes
the muscles totighten up in
a continuouscontraction or
spasm. Thisresults in
either
localized orgeneralized m
uscle spasms
causing the
Short Term:
After 2-3hours of NI,
the patient
will verbalize
establishmen
t of a patternof sleep/rest
that
facilitates
optimal
performanceof required/
desired
activities.
Patients vital
signs will
return tonormal
rates/ranges.
Long Term:
After 2-3days of NI,
the patientwill achieve
adequate
activitytolerance,
AEB ability to
perform
> Establish
rapport
> Monitor andrecord V/S
>Assess
patients
condition
>Assess current
activity level
>Assess
characteristics
of fatigue:-severity
-changes in
severity over
> To gain the
trust andcooperation
of the pt.
and the SO
> To gainbaseline
data for the
care and
managemen
t of thepatient
>This will
guide whatinterventions
to provide
>Fatigue and
exertionaldyspnea are
characteristic symptoms
of anemia
>Using a
quantitativerating scale
such as 1 to
10 can help
The patient
shallverbalize
establishmen
t of a pattern
of sleep/rest
thatfacilitates
optimal
performance
of required/
desiredactivities.
Patients vital
signs shall
return tonormal
rates/ranges.And the
patient shall
achieveadequate
activitytolerance,
AEB ability toperform
activities of
daily livingand
verbalization
of return to
http://www.medicinenet.com/script/main/art.asp?articlekey=101231http://www.medicinenet.com/script/main/art.asp?articlekey=101231http://www.medicinenet.com/script/main/art.asp?articlekey=101231http://www.medicinenet.com/script/main/art.asp?articlekey=1012318/4/2019 ncps tetany
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concentratio
n
>disinterest insurroundings
> increasedrest
requirements
>increased
physical
complaints
client to be
paralyzed
and becomeweakened or
fatigued.
activities of
daily living
andverbalization
of return tonormal/near-
normal
activity
levels.
time
-aggregating
factors-alleviating
factors
>Monitor serum
electrolytes
and urine
osmolality andreport
abnormal
values
>Assess
patients
emotional
response tofatigue
the patient
describe the
amount offatigue
experienced.Other rating
scales can
be
developed
using picturesor descriptive
words. This
method
allows thenurse to
compare
changes in
the patients
fatigue levelover time. It is
important todetermine if
the patients
level offatigue is
constant or ifit varies over
time.
>Anxiety and
depressionare the more
common
emotional
normal/near-
normal
activitylevels.
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>Assess the
patients
expectations
for fatigue
relief,
willingness toparticipate in
strategies to
reduce
fatigue, and
level of familyand social
support
>Evaluate the
patients sleep
patterns for
quality,quantity, time
taken to fall
asleep, and
feeling upon
awakening
>Assist the
patient to
responses
associated
with fatigue.These
emotionalstates can
add to the
persons
fatigue level
and create avicious cycle
>Social
support willbe necessary
to help the
patient
implement
changes toreduce
fatigue
>Thispromotes
interest in
drinking
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develop a
schedule for
daily activityand rest
>Help thepatient to set
priorities for
desired
activities and
roleresponsibilities
>Minimizeenvironmental
stimuli,especially
during planned
times for rest
and sleep
>A plan that
balancesperiods of
activity withperiods of
rest can help
the patient
complete
desiredactivities
without
adding to
levels offatigue
>To conserve
energy and
this canimprove the
patients
mood and
sense of
emotionalwell-being
>Bright
lighting,
noise, visitors,
frequent
distractions,and clutter in
the patients
physical
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>Teach the
patient and
family task
organization
techniques
>Help the
patientdevelop habits
to promote
effective
rest/sleep
patterns
>Provide
diversional
activities
environment
can inhibit
relaxation,interrupt
rest/sleep,and
contribute to
fatigue
>Organization can help
the patient
build
endurancefor physical
activity
>Promoting
relaxationbefore sleep
andproviding for
several hours
ofuninterrupted
sleep cancontribute to
energy
restoration
>Impairedconcentratio
n can limit
ability to
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>Encourage
the patient toverbalize
feelings aboutthe impact of
fatigue
block
competing
stimuli/distractions
>Fatigue can
have a
profound
negative
influence onfamily
processes
and social
interactions
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Impaired swallowing
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVES NURSING
INTERVENTIONS
RATIONALE EXPECTED
OUTCOME
S:
O: The
patient
manifested:
>poor muscle
development>poor muscle
tone
>unable to
open mouth
wide>weakness
>dysphagia
>incomplete
lip closure
The pt. maymanifest:
>aspiration
>coughing>adventitious
breathsounds
>productivecough
>acidic
smellingbreath
>vomiting
>dry mucous
Impaired
swallowingrelated to
nueromascul
ar
impairment
Acute
diseaseinduced by
toxin of
tetanus
bacillus
growinganaerobically
in wounds
and at site of
umbilicus
amonginfants.
Characterized
by mascular
contraction.Muscle spasm
is caused bytoxins
because it
affectsimpulses that
stimulatesmuscle
contrationand rigidity.
The client
manifesteddysphagia
due to spasm
of muscles in
Short term:
After 3-4 hoursof nursing
interventions,
the client will
be able to
pass food andfluid from
mouth to
stomach
safely
Long term:
After 2-3 days
of nursing
interventions,the client will
be able tomaintain
desired body
weight
> Establish
rapport
> Monitor andrecord V/S
>Assess
patients
condition
>Determine
ability toinitiate/sustain
effective suck
>Note for
hyperextensionof head
> To gain the
trust andcooperation
of the pt.
and the SO
> To gainbaseline
data for the
care and
manageme
nt of thepatient
>This will
guide whatinterventions
to provide
>To assess
for impairedability to
swallow
>It suggests
inability tocomplete
swallowing
process
The patient
shall verbalizeunderstanding
of causative
factors when
known and
necessaryinterventions.
Patients vital
signs shall
decrease/retu
rn to normalrate/ranges.
And the
patient shall
demonstratebehaviors,
lifestylechanges to
regain and/or
maintainappropriate
weight andpatients vital
signs shallmaintain to
normal
rates/ranges.
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membrane
>poor skin
turgor
the oral
cavity.
Neuromascular system is
afftected thatresults to
severe
contraction of
muscles. Thus,
results toimpaired
swallowing.
>Auscultate for
breath sounds
>Keep Head of
Bed
>Suction oral
cavity PRN
>Encourage arest period
before meals
>to evaluate
presence ofaspiration
>To reduce
risk of
regurgitation
/aspiration
>To clear
secretionsand
promotes
airway
safety
>To minimize
fatigue
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Risk for aspiration
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVES NURSING
INTERVENTIONS
RATIONALE EXPECTED
OUTCOME
S:
O: The
patient
manifested:
>poor muscle
development>poor muscle
tone
>unable to
open mouthwide
>weakness
>dysphagia
The pt. maymanifest:
>coughing>adventitious
breath
sounds>productive
cough
Risk for
aspirationrelated to
impaired
swallowing
Acute
diseaseinduced by
toxin of
tetanus
bacillus
growinganaerobically
in wounds
and at site of
umbilicusamong
infants.
Characterized
by mascular
contraction.Muscle spasm
is caused bytoxins
because it
affectsimpulses that
stimulatesmuscle
contrationand rigidity.
The client
manifesteddysphagia
due to spasm
of muscles in
Short term:
After 1-2 hoursof nursing
interventions,
the client will
be able to
identifycausative/risk
factor
Long term:
After 2-3 days
of nursing
interventions,
the client willbe able to
demonstratetechniques to
prevent and
correctaspiration
> Establish
rapport
> Monitor andrecord V/S
>Assess
patients
condition
>Assess clients
ability toswallow and
strength ofgag/cough
reflex
>Note for
administration
of enteral
> To gain the
trust andcooperation
of the pt.
and the SO
> To gainbaseline
data for the
care and
management of the
patient
>This will
guide whatinterventions
to provide
>To
determinepresence/eff
ectiveness ofprotective
mechanisms
>Because ofpotential for
regurgitation
and or/
Short term:
The client shallhave
identified
causative/risk
factor
Long term:
the client shall
have
demonstratedtechniques to
prevent and
correct
aspiration
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the oral
cavity. Thus,
resulting toaspiration that
may causecomplications
like aspiration
pneumonia.
feedings
>Ascertain
lifestyle habits
such as use of
alcohol,
tobacco, andother CNS
>Keep wire
cutter/scissorswith client at
all times when
jaws arewired/banded
>Suction as
needed
>Avoid
keeping client
in supineposition when
enteral
feedings.
misplaceme
nt of tube.
>because it
affectawareness
and muscle
of
gag/swallow
.
>To facilitateclearing
airway inemergency
situations
>To clearsecretions
while
reducingpotential for
aspiration ofsecretions
>To
decrease
potential riskfor
aspiration.
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C. diet
Type of Diet Date ordered,
performed,changed
Description Indication/Purpose Specific foods
taken
Clients
response/reaction
DAT with SAP 8/14/11 This type of diet is
usually ordered
for patients with
respiratory
problems.
The patient
manifests difficulty
of swallowing and
unable to open
mouth wide
Soft foods such as
porridge, kamote,
mashed potato,
soup.
The client has not
experienced
aspiration. The
patient is
compliant with
regards to the diet
ordered.
Before During after
Explain to the patientand the patients relativesthe need of the diet.
Encourage deepbreathing exercises
Instruct patient to be onhigh fowlers positionwhile eating or drinking .
Instruct patient to eatfood that are easy to
chew and swallow.
Instruct patient to avoid
Instruct patient to drinkwater to flush down food
Instruct patient tomaintain high fowlers
position for 10 minutes
after eating
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certain foods (eg,
caffeine, fatty meals,
carbonated beverages,
peppermint, citrus)
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