1)can ambulate 15 feet with assistance by D/C2)verbalizes an understanding of the need to gradually increase activity by end of shift3)client will report increased tolerance to activity by D/C4)verbal report of pain level 1-2 with ambulation (patient verbalizes can tolerate pain level 1-2) by D/C5)Client will be able to perform ADLs independently by D/C6) Client will eat at least 75% of food tray once NPO status has been discontinued.Strict I&O 2. Daily weights 3. Monitor pulse, RR, BP, and pulse ox 4. CBC 5. Basal metabolic profile 6. Walking test (measure in ft how far pt walks)Outcome StatePresent State1)Only able to ambulate 5 ft with assistance2)Patient shows lack of motivation to exercise by verbalizing “I do not want to walk today because I’m not ready”3)Gait is weak, slow and uncoordinatedPatient verbalizes fatigue4)Verbal report of pain at level 5 after ambulating5)Requires assistance to maintain proper alignment, reposition, ambulate and stand and bathe6) Inadequate nutrition: patient is currently NPOInterventions on next pageExit Framing: 83 y/o black female admitted for renal failure and perf ulcer in bed w/ HOB 30 deg; no visitors; able to ambulate 5 ft with assistance; IV catheter in rt forearm; indwelling urinary catheter draining yellow urine; PCA pump; clamped NGT in rt. Nare; patient usually sleepingReflective SRL Journal promptsCue LogicRisk for infectionRisk for fallsRisk for impaired skin integrityAcute confusionAcute painImbalanced nutritionFatigueImpaired urinary eliminationKeystone Issues: Activity intolerancePatient-in-Context StoryPt A is a 83 y/o black female admitted 2/28/10 for renal failure and perf. Ulcer with a h/o arthritis, GERD, HTN, and NSAID use. Temperature is 98.9 orally. Radial pulse is 76 bpm. Heart rate is regular and no presence of murmurs. Extremities warm, smooth, and dry to touch. Medial abdominal wound (stapled) draining serosanguinous fluid into Jackson Pratt. BP is 148/78 in upper left arm. Denies pain when at rest, but reports pain level 5 with ambulation described as dull and in her adb radiating to her rt shoulder. Respirations 22 bpm, unlabored, breath sounds equal bilaterally, no supplemental O2 with a pulse ox of 100%. Denies cough. No signs or symptoms in eyes and ears, and PERRLA. NPO. NGT in rt nare is clamped. Disoriented to time and place. Oriented to self. Speech is clear and understandable. Movement in extremities equal bilateral. Normal sensations. She is currently on Protonix, Fentanyl, Lovenox. She is on Fentanyl (PCA), Ondasentron HCL, Diphenhydramine HCL, Hydralzine, Cepacol, Chloraseptic PRN. WBC 14.5, RBC 3.14, HGB 9.0, HCT 27.0, RDW 15.4. Creatinine 1.4, Na 135, Mg 1.5, Cl 110.She is not married and is a retired 6th grade teacher. Most of her family lives in NY and she talks to them everyday on the phone. They also sent her flowers. She has a niece who visited her. She was transported via helicopter from Elizabethtown 2/28/10 where she lives by herself in her own home.Judgments1)partially met; pt able to ambulate 10 ft with assistance; use of walker was helpful 2) partially met; verbalizes disinterest in ambulating, but asked to get into chair twice; appropriate response when I told her walking will help her heal faster and get better; she liked the positive feedback after ambulating3)partially met; pt still lethargic and verbalizing fatigue, but able to ambulate a little further4)partially met; pt verbalizes pain level of 3 after ambulating5)partially met: pt required minimal assistance to reposition in bed and helped with bathing herself6) not met: pt remains NPO.Interventions1.Obtain any necessary assistive devices or equipment needed before ambulating the client.2. Normalize the client’s activity intolerance; encourage progress with positive feedback.3. Refer the client to physical therapy for resistance exercise training as able, including leg press, leg extension, leg curl, calf press and more.4. Before activity, observe for and if possible treat pain. Ensure that the client is not over sedated.5. When appropriate gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation.6. Educate client on the importance of maintaining adequate nutrition and protein intake for healing process Rationales1. Assistive devices can increase mobility by helping the client overcome limitations (Ackley, p. 120).2. The client’s experience should be validated as within expected norms. Recognition of progress enhances motivation (Ackley, p. 122).3. This systematic review suggests that older adults with different levels of abilities can improve their functional performance by regular exercise training (Chin A Paw et al., p.792).4. Pain limits mobility and is often exacerbated by movement (Ackley, p. 552).5. Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension. These methods can prevent falls (Ackley, 119).6. Nutrition is a major prognosticator of healing (Chin A Pat et al., p. 672).Reference:Ackley, B.J. and Ladwig, G.B., (Eds.). (2008). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (8th ed.). Missouri: Mosby.Chin A Paw, M., van Uffelen, J., Riphagen, I., & van Mechelen, W. (2008). The functional effects of physical exercise training in frail older people: A systematic review. Sports Medicine, 38(9), 781. Retrieved from Academic Search Premier database.Renal FailurePerf. UlcerActivity Intolerance 8Only able to ambulate 5 ft with assistancePatient shows lack of motivation to exercise by verbalizing “I do not want to walk today because I’m not ready”Gait is weak, slow and uncoordinatedPatient verbalizes fatigueVerbal report of pain at level 5 after ambulatingRequires assistance to maintain proper alignment, reposition, ambulate and stand and batheRisk for impaired skin integrity 5Braden score-16Recent surgical wound draining (medial abd)Mostly in bedNPOSkin is dry and thingNGT in rt nare showing drying Fatigue 7Verbalizes “I am just so tired all the time now”LethargicAnemia (HGB 9.0)Always coldMalnutritionVerbalization of overwhelming lack of energyAcute confusion 4 On narcotics83 yrs oldLethargicH/O dementiaFrequently forgets has PCA and how to use itDisoriented to time and placeImbalanced nutrition 5NPO Nausea and vomitingI&O off balanceUnable to hold food or liquids