FATIGUE Nursing Care Plan

This is a nursing care plan sample about fatigue of Mr. Ong, 29 years old, civil engineer. Mr. Ong is very hardworking, he even work almost 18 hours straight without even napping. Just few eats and drinks and he will back to work again. For almost two weeks of doing this kind fo routine, Mr. Ong felt something different with him and it is not good. He immediately went to the hospital for check-up.

ASSESSMENT

Subjective:
“I’m so tired, I need some rest,” as verbalized by the patient.

Objectives:
The patient is lethargic and drowsy. He/she is not interested to his/her environment and he/she didn't want to socialize with others. Vital signs are taken and noted as follows: Body temperature is 36.5 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, and pulse rate of 88 beats per minute.

DIAGNOSIS

Fatigue related to lethargy as manifested by lack of energy and disinterest in the surroundings. (Lethargy is a condition when a person is irritable, can't stay still and can't find his/her comfort).

PLANNING

After 8 hours of nursing intervention, the patient will report improve sense of energy.

INTERVENTION

- Ascertain Mr. Ong's belief of about what is causing his fatigue. Assess Mr. Ong's vital signs to evaluate his fluid status and cardiopulmonary response to activity. Determine presence of sleep disturbances because his fatigue can be a consequences of sleep deprivation. Interview Mr. Ong's parent or relatives regarding specific changes. Note daily energy patterns. Measure physiological response to activity: changes in blood pressure, heart rate and respiratory rate. Evaluate need for individual assistance. Established realistic activities with the Mr. Ong and encourage forward movement.

- Instruct Mr. Ong in methods to conserve his energy such as sitting instead of standing during daily care, carry several small leads instead of big one, combine and simplify activity. Take frequent short rest breaks during activities and delegate task for assistance. Encourage Mr. Ong the use of activities device to conserve energy for his other tasks. Avoid exposure to extreme temperature and humidity which can negatively impact his energy level. Provide pleasurable activities. Discuss to Mr. Ong routines to promote restful sleep. Promote his overall health measures: nutrition, adequate fluid intake and appropriate vitamin supplementation.

Note the age, gender and developmental stage, although, some studies show a prevalence of fatigue in working adult, the condition may be present in any person at any age. Identify presence of Mr. Ong's physical and psychological conditions such as factors said above. Review his medication regimen or use. Certain medications, including prescription (especially beta - adrenergic blockers), over-the-counter, herbal supplements, and combinations of drugs or substances, are known to cause and exacerbate his fatigue. Note Mr. Ong recent lifestyle changes, including his conflicts (expanded responsibilities or job related conflicts); maturational issues such as adolescent with eating disorder); and developmental issues such as new parenthood, loss of spouse. Assess psychological and personality factors that may affect reports of fatigue level. Evaluate aspect of "learned helplessness" that may be manifested by giving up. This can perpetuate a cycle of fatigue, impaired functioning, and increased anxiety and fatigue. Obtain Mr. Ong descriptions of fatigue like lacking energy or strength, tiredness, weakness lasting over length of time. Note presence of additional concerns such as irritability, lack of concentration, difficulty making decisions, problems with leisure, relationship difficulties. These assist in evaluating impact on Mr. Ong's life. Rate his fatigue from 1-10 and note its effects on his ability to participate in desired activities. Discuss his lifestyle changes or limitations imposed by his fatigue state. Interview Mr. Ong's parent regarding specific changes observed in his child or elder, Mr. Ong may not be able to verbalize feelings or relate meaningful information.

EVALUATION

After 8 hours of nursing intervention, the patient reported improved sense of energy.

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