Activity Intolerance r/t imbalance between oxygen supply and demand Reviewed by Momizat on . Cues OBJECTIVE: Initial Vs:T: 35.8 CBP: 95/60 mmHg RR: 18cpm PR: 56 bpm CR: 58 bpm - O2 saturation of 94% - Cold Clammy Skin on lower extremities. - On moderate Cues OBJECTIVE: Initial Vs:T: 35.8 CBP: 95/60 mmHg RR: 18cpm PR: 56 bpm CR: 58 bpm - O2 saturation of 94% - Cold Clammy Skin on lower extremities. - On moderate Rating:
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Activity Intolerance r/t imbalance between oxygen supply and demand

Cues
OBJECTIVE:

Initial Vs:T: 35.8 CBP: 95/60 mmHg

RR: 18cpm

PR: 56 bpm

CR: 58 bpm

- O2 saturation of 94%

- Cold Clammy Skin on lower extremities.

- On moderate high backrest.

- On complete Bedrest

- On bathroom commode as doctors order.

- O2 inhalation 4L PRN

Need

Activity Exercise Pattern

Nursing Diagnosis

Activity Intolerance related to imbalance between oxygen supply and demand

R:   Acute Myocardial Infarction results from the interruption of blood supply to a part of the heart, causing heart cells to die.  Typical symptoms of acute myocardial infarction include sudden chest pain (typically radiating to the left arm or left side of the neck), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety. Women may experience fewer typical symptoms than men, most commonly shortness of breath, weakness, a feeling of indigestion, and fatigue resulting in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities.

Objectives of Care
At the end of 8 hours span of care, the client will be able to maintain her breathing pattern as evidenced by:

Vital Signs within the normal range

Temp: 36.5-37.5C

RR:16-20 cpm

PR: 60-70 bpm

BP:110/70-130/90;

Eupnea (normal breathing);
Regular respiratory rate/ pattern; and
Verbalization of increased energy level.

Nursing Intervention

Vital signs every four hours.

Ò    Changes may indicate complications of oxygen or carbon dioxide imbalance during activity.

Activity level and tolerance, pattern of activity, reasons for tolerance.

Ò    This provides baseline data.

Effect on respirations, work of breathing during activity.

Ò    Exertional dyspnea common and lowers oxygen intake.

Amount of sleep/rest, exercise.

Ò    Rest needed to prevent fatigue exercise to maintain endurance and life-style.

Oxygen for periods of activity.

Ò     Assures proper oxygen level is maintained during activity.

Energy-saving techniques such as placing items within reach, use of arm rests, aids for use in ADL, lifting during exhalation.

Ò       This conserves energy and prevents exertional dyspnea and fatigue.

Provide a quiet and comfortable environment.

Ò    Provides proper rest and stress-free.

Advise the client to avoid conditions that increase oxygen demand, such as smoking, stress.

Ò    These factors increase peripheral vascular resistance, which increases cardiac workload and oxygen requirements.

Teach the client to use pursed-lip and diaphragmatic breathing techniques during activities.

Breathing retraining ensures maximal use of available respiratory functions. Pursed lip breathing leaves positive end –expiratory pressure in the lungs and helps keep airways open.

Evaluation
After 8 hours span of care, the client was able to maintained her breathing pattern as evidenced by:

Vital signs of:

T: 36 C

BP: 110/70 mmHg

RR: 20 cpm

PR: 56 bpm

CR: 58 bpm

O2 saturation of 96%;

Having normal breathing; eupnea
Respiratory rate of 20cpm; and
Verbalized feeling of relief vomiting

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