1. Pt. reports fatigue (Hgb=10.5, Hct=34.0)2. Dyspnea, SOB on exertion3. Diminished sensations to lower extremities4. Pain level 8/105. Decreased food intake (5-10% of meals) 1. Pt. will report decreased periods of fatigue by discharge.2. Pt. will verbalize no difficulty in breathing following mealtime/OOB to chair by discharge.3. Maintains skin integrity with no further decrease in lower extremity pulse strength by end of shift.4. Pt. will state pain level is a 2/10 or less by discharge.5. Pt. will eat 75% of meals by discharge.Testing1. Complete Blood Count2. Borg scale, O2 sats, VS, ADL’s3. Peripheral pulses, Doppler, Braden scale4. Pain scale (1-10), VS5. Bowel movements, calorie count Outcome StatePresent StateInterventions on next pageExit Framing: 70 year old pt. admitted for popliteal endarterectomy r/o PAD complications; in bed with limited mobility due to surgery and pain level 8/10; restless; surgical wound lower R. leg, draining by JP wound vac; 2 IV lines, 20 gauges, L. and R. hands; indwelling urinary catheter; married with 3 children, 3 grandchildren, 2 great grandchildren; wife and daughter at bedside.Reflective SRL Journal promptsCue Logic-Acute pain-Deficient fluid volume-Fatigue-Risk for infection-Risk for injury-Risk for impaired skin integrity-Decreased cardiac output-Altered tissue perfusionKeystone Issues: Activity IntolerancePatient-in-Context Story70 year old man admitted to hospital for a R. popliteal endarterectomy with angioplasty and stent r/o PAD complications. History of PAD, COPD, A-fib, asthma, sleep anea, and GERD. Incision wound on lower R. leg. C/o SOB and weakness. Wheezes in lower lobes of lungs. Pt. reports “burning” pain, a level 8/10. Decreased sensation to lower legs, with diminished posterior tibialis and pedal pulses. R. pedal pulse absent. Sluggish cap refill (greater than 3 seconds). VS checked ever 4 hours. VS are T=97, P=68, R=24, BP ranges from 98/56 to 124/106. O2 sat = 94% with nasal cannula at rate of 3 L/min. Pt. is anemic (Hgb=10.5, Hct=34.0). Other out-of-range lab values are: RBC = 3.74, WBC=14.3, Glucose= 152, CO2=34. Meds are ASA, lovenox, Lopressor, Oxycontin and Protonix. Pt. married with 3 children, 3 grandchildren, and 2 great grandchildren. Is visited by wife and youngest daughter on a daily basis. Lives at home with wife. Works at a golf coarse part-time, likes to play golf with friends and grandchildren.Judgments1. Not met. Pt. c/o of weakness and fatigue.2. Not met. Pt. remains SOB and c/o of dyspnea on exertion.3. Met. Skin integrity and peripheral pulses maintained.4. Not met. Pt. c/o pain level of 8/10.5. Partially met. Pt. ate 75% of lunch before end of shift.Interventions1. Encourage pt. to keep a journal of activities, symptoms of fatigue, and feelings, including how fatigue affects the client normal activities and roles (Ackley & Ladwig, 2008, p. 359).2. Encourage daily inspiratory muscle training (IMT ). 3. Provide warmth (i.e. blankets, socks) and instruct patient on factors that interfere with circulation (Lewis, 2007, p. 905).4. Teach and implement nonpharmacological interventions (i.e. music, television, massage, relaxation therapy).5. Will schedule rest periods before meals, open packages, and cut up food for the patient (Ackley & Ladwig, 2008, p. 577).Rationales1. The journal can increase the client’s awareness of symptoms andsense of control and facilitate communication with the healthcare team (Ackley & Ladwig, 2008, p. 359). 2. With a training intensity of at least 30% of the PImax for 20-30 minutes per day, inspiratory muscle training results in a decrease in dyspnea at rest and during physical activity, as well as improves inspiratory strength and endurance by 10-12 weeks (Padula & Yeaw, 2006, p, 300-301).3. Providing warmth promotes vasodilation and increased circulation. Instruct patient on factors that interfere with circulationto prevent worsening peripheral perfusion and to decrease ischemic pain (Lewis, 2007, p. 905).4. Nonpharmacological interventions should be used to supplementpharmacological interventions (Ackley & Ladwig, 2008, p. 607).5. Nursing assistance will conserve the client’s energy for eating (Ackley & Ladwig, 2008, p. 577).ReferencesAckley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis handbook. St. Louis, Missouri: Mosby, Inc.Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P. G., & Bucher, L. (2007). Vascular Disorders. Medical-Surgical Nursing (pp.892-924). St. Louis, Missouri: Mosby, Inc. Padula, C. A., & Yeaw, E. (2006). Inspiratory muscle training: Integrative Review. Research and Theory for Nursing Practice: An InternationalJournal, 20(4), 300-301.PADActivity Intolerance (10)-Surgical wound R. leg-C/o of weakness-Anemia (Hgb=10.5, Hct=34.0)-SOB on exertion (eating, OOB to chair)-Pain level 8/10 R. leg-Diminished sensations to lower extremities\-Decreased food intake (5-10% of meals)-Dyspnea-Asthma,COPD, PADRisk for Impaired Skin Integrity (5)-Surgical wound R. leg-Braden score of 17-PAD-Diminished sensations to lower extremities-Altered mobility/deconditioningRisk for Infection (4)-Surgical wound R. leg-JP wound vac-Indwelling catheter-Decreased hemoglobin (Hgb=10.5)-Increased exposure to environmental pathogensAltered Tissue Perfusion (8)-Sluggish cap refill (>3sec)-Diminished lower extremity pulses (using Doppler)-Absent R. pedal pulse-Pallor (L. lower leg)-Thick, brittle toenails-Diminished lower extremity sensationsDeficient Fluid Volume (6)-Skin turgor > 3 seconds-Dry mucous membranes-Dry skin-Decreased blood pressure (98/56)-Weak/thready pulsesDecreased Cardiac Output (8)-Irregular heart rate-PAD-Dyspnea-Decreased peripheral pulses-Restlessness-Weak/thread pulsesRisk for Injury (5)-Reported difficulty swallowing food-Altered mobility/deconditioning-Diminished lower extremity sensations-Pain level of 8/10-C/o weaknessAcute Pain (6)-Pain level 8/10-Surgical wound R. leg-Pt. states, “My leg is burning.”-Frequent groans and grimaces-Frequent use of PCA-Reports pain radiating up and down R. legFatigue (6)-Anemia (Hgb=10.5, Hct=34.0)-Lethargic -Reports not being able to sleep in uncomfortable hospital bed-Wife reports restlessness when