5 Key Nursing Diagnoses:
Deficient fluid volume related to inadequate fluid intake
and vomiting
Impaired skin integrity related to hyperbilirubinemia from
jaundice
Imbalanced nutrition; less than body requirements related to
loss of appetite and vomiting
Activity intolerance related to muscle and joint aches,
headache, and fever
Risk of delirium and altered mental status related to organ
ischemia
Problem
|
Related To
|
Plan
|
Outcome
|
Nursing Intervention
|
Activity intolerance
|
Fever
Headache
Nausea and vomiting
Muscle and joint aches
|
Assess nutritional status
Monitor patient’s sleep pattern and amount of sleep
achieved over past few days
Assess potential for physical injury with activity
Assess emotional response to change in physical status
|
Patient maintains activity level within capabilities, as
evidenced by normal heart rate and blood pressure during activity, as well as
absence of shortness of breath, weakness, and fatigue
Patient verbalizes and uses energy-conservation techniques
|
Encourage adequate rest periods
Refrain from performing nonessential procedures to promote
rest
Progress activity gradually
Encourage verbalization of feelings regarding limitations
Provide emotional support
|
References:
Gulanick, M. (2012). Activity intolerance – Weakness;
deconditioned; sedentary. Elsevier.
Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick01.html
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