FOCUS/ NURSING DATA ACTION RESPONSE

DIAGNOSIS

Impaired physical >muscle weakness >start initial exercise >Patient was

mobility related to >verbalizes she easily that requires minimal progressive in her
decreased muscle gets tired strength and exercises and activities
strength >tachypnea coordination >Patient verbalized
>muscle strength of >teach and let the increased energy
3/5 client perform passive >Adequate rests that
>bipedal edema or active assistive ROM normalizes the RR
exercises
>change position for
every 2-4 hrs
>progress to increase
ambulation, movement
and elevation of the
foot
Evaluation
Fully met

FOCUS/ NURSING DATA ACTION RESPONSE

DIAGNOSIS

Non-productive cough >Difficulty of breathing >Educate deep >Patient verbalized

>Fatigue breathing exercises improve breathing
>Crackles in both bases >Elevate head and pattern
of her lungs chest by placing pillows >Adequate rest
>Chest X-ray: fluid in on patient's head >RR: 22 cpm
lower lung field >Limit activity to
>RR: 25 cpm promote adequate rest

Evaluation
Partially met

FDAR

DISCHARGE PLANNING
 FOCUS/ NURSING DATA ACTION RESPONSE
DIAGNOSIS

Evaluation

M Medication instruction Rationale for the

instruction
E Exercise
(activity),environment
T treatment
H Hygiene/ health
teaching
O Out-patient orders
D diet