Able to maintain / improve ambulation / activity.
Expected Outcomes :
- Reported an increase in activity tolerance (including daily activities).
- Indicates decrease in physiological signs of intolerance, such as pulse, respiration, and blood pressure is still within the normal range.
- Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity.
Rational : Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues.
- Assess patient ability to perform ADLs
Rational : Influences choice of interventions and needed assistance.
- Provide or recommend assistance with activities and ambulation as necessary, allowing client to be an active participant as much as possible.
Rational : Although help may be necessary, self-esteem is enhanced when client does some things for self.
- Suggest client change position slowly; monitor for dizziness.
Rational : Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
- Identify and implement energy-saving techniques
Rational : Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.
- Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.
Rational : Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary strain and stress may lead to decompensation and failure.
Risk for infection related to an inadequate secondary defenses (decreased hemoglobin leucopenia, or a decrease in granulocytes (inflammatory response depressed)).
Infection does not occur.
Expected Outcomes :
- Identify the behaviors to prevent / reduce the risk of infection.
- Improving wound healing, free of purulent drainage or erythema, and fever.
- Increase of good hand washing; by care givers and patients.
Rational: to prevent cross-contamination / bacterial colonization. Note: patients with severe anemia / aplastic can be risky due to the normal flora of the skin.
- Maintain strict aseptic technique in the procedure / treatment of injuries.
Rational: reducing the risk of colonization / infection of bacteria.
- Provide skin care, perianal and oral carefully.
Rational: reducing the risk of damage to the skin / tissue and infection.
- Motivation changes in position / ambulation frequently, coughing and breathing exercises that deep.
Rational: to improve the ventilation of all lung segments, and help mobilize secretions to prevent pneumonia.
- Increase adequate fluids.
Rational: to assist in the dilution of respiratory secretions to facilitate the spending and prevent stasis of body fluids such as respiratory and kidney.
- Monitor / limit visitors. Provide insulation if possible.
Rational: to limit exposure to the bacteria / infection. Protection of insulation required in aplastic anemia, when the immune response is disrupted.
- Monitor body temperature. Note the chills and tachycardia with or without fever.
Rational: the process of inflammation / infection require evaluation / treatment.
- Observe erythema / wound fluid.
Rational: indicators of local infection. Note: the formation of pus may not exist when granulocytes depressed.
- Take specimens for culture / sensitivity as indicated (collaboration)
Rational: differentiate an infection, identify the specific pathogen and affect treatment options.
- Give a topical antiseptic; systemic antibiotics (collaboration).
Rational: propilaktik may be used to reduce colonization or for the treatment of local infection process.