characterized by the expression of fatigue and weakness, abnormal response to activities such as discomfort and dyspnea.
Goals:
- Clients can maintain the normal function of the musculoskeletal, shown by the distance of motion in all joints of the body within the limits of normal, muscle mass and strength can be maintained.
- Minimize cardiovascular events shown by vital signs are still within normal limits and signs of venous blood flow adequate (absence of edema, inflammation, venous distention, skin changes).
- Respiratory function in normal circumstances characterized by normal breath sounds on auscultation, normal chest expansion and the absence of chest pain, fever, or other respiratory signs, indicator of the lung damage, embolism or atelectasis.
- Maintaining the granting of proper nutrition and fluids, which can be shown by weight, adequate tissue turgor, balance fluid inputs and outputs, and the value of serum proteins in normal limits.
- Maintaining normal elimination patterns, which can be seen clearly through the urine output of at least 1500 ml per day, the absence of signs of urinary retention, urinary tract infection.
- Maintaining the integrity of the skin that can be seen through the skin clean, intact, good skin hydration, lack of emphasis marks on the skin.
- Maintaining the stability of the emotional, social and intellectual, which can be seen from the active participation of the client, consulted in determining the action, able to maintain good relationships with others.
Interventions
1. Do proper exercise program (isotonic, exercise active or passive) for at least 4 hours at a time, on hands, feet, and neck as indicated.
Rationale: isotonic exercises to prevent contractures and muscle atrophy, isometric maintain muscle strength, passive exercises maintain joint movement.
2. Motivation active participation in self-care.
Rationale: self-care, can move the joints and muscles of the body active.
3. Compare the size and muscle strength as baseline data on each side of the body every day.
Rationale: Early detection of muscle atrophy and decreased muscle strength can facilitate early intervention anyway.
4. Position the client in accordance with body alignment.
Rationale: By positioning the client in accordance with body alignment can prevent contractures and maintain structural integrity of muscles and joints.
5. Assist clients moving wherever possible or help clients stand beside the bed.
Rationale: By moving to prevent disuse osteoporosis.
6. Monitor vital signs according to the client's needs.
Rationale: Monitoring routine allows the nurse to detect early alterations.
7. Teach clients how to avoid the Valsalva maneuver.
Rationale: Valsalva menauver may put more pressure on the heart.
8. Use the client anti-embolism stockings as indicated.
Rationale: The use of anti-embolism stockings can prevent the formation of thrombus, venous engorgement, edema, and orthostatic hypotension.
9. At some time the foot is lifted for about 20 minutes every day.
Rationale: With the elevation adds to the peripheral circulation.
10. Assess the state of the skin lower limbs and measure the circumference of the calf as indicated.
Rationale: Inspection and routine measurement can enable nurses to detect changes early.
11. See also musculuskletal intervention to function.
Rationale: All these measures also stimulates blood circulation and prevent cardiovascular complications.
12. Assess breath sounds and chest expansion of at least 8 hours per day.
Rationale: This action is performed by a nurse to detect abnormalities of breathing and inadequate chest expansion.
13. Teach client to take a deep breath and cough every waking hour.
Rational: Breath in and cough can effectively augment alveolar expansion, preventing the secretion stasis, improving gas exchange, and maintain a patent airway.
14. Create a schedule change in position, and clients are encouraged to change position every 2 hours, help clients to move if possible or reseat the client in the chair.
Rationale: Changes in position to provide free lung area for expansion, and help move and then discharged through secretions during coughing.
15. Monitor weight clients, tissue turgor, the input and output of fluid and serum protein value.
Rational: Normal on data found, indicating adequate hydration and nutrition inputs.
16. Monitor the color, clarity, acidity number, and urine specific gravity, color and stool characteristics, frequency of defecation. Ask if the client feel pain when urinating.
Rationale: Decreased urine output, gloom / not clear urine and pain during urination is an indication of infection and urinary retention, constipation can be associated with the occurrence of immobilization.
17. Encourage clients to choose foods that contain high fiber.
Rationale: High-fiber foods may improve intestinal peristaltic and defecation.
18. Instruct the client to make a decision as much as possible, such as: moving parts to private property, planning daily activities, to use clothing.
19. Plan spare time is right for the client.
Rationale: Fostering mutual trust with the client very well done because it can motivate the client to express his feelings.
20. Assess the activities that make the client happy, and freely plan their daily activities.
Rationale: everyday activities that please the clients can stave off boredom on the client and motivate clients to look and think ahead.