Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Assessment

1. Physical examination:

• Musculoskeletal: decreased tone, strength, muscle size and endurance; range of motion of joints and skeletal strength.
• Cardiovascular: the formation of thrombosis, thrombophlebitis signs include: erythema, edema, tenderness and signs of positive Humans.
• Respiration: atelectasis and pneumonia symptoms, early signs include an increase in temperature and heart rate.
• Integument: ischemia injury against the first tissue is inflammatory, early changes seen on the surface of the skin as an irregular area of erythema.
• Urinary function: physical signs such as urinating a little and often, lower abdominal distension and bladder limits that can be touched.
• Gastrointestinal: constipation and faecal going small, hard and dry.
• Environment: bathroom without handles, loose rugs, lighting is not adequate, a high ladder, slippery floor and toilet seat that lowers the client mobility.

2. Assessing the skeletal body: The deformity and alignment. Abnormal bone growth due to bone tumors. Shortening of limb, amputation and body parts that are not in anatomical alignment. Abnormal angulation of the long bones or movement at a point other than the joints usually indicate the presence of fractures.

3. Assessing the spine:

• Scoliosis (curvature of the lateral deviation of the spine)
• Kyphosis (curvature of the spine increase the chest)
• Lordosis (quack, the curvature of the lumbar spine over)

4. Assessing joint system: Broad movement was evaluated both active and passive, deformity, stability, and the lumps, the joint stiffness.

5. Assessing muscle system: The ability to change the position, muscle strength and coordination, and the size of each muscle. Limb circumference to mementau or atropfi edema, muscle pain.

6. Assessing how patients walk: The irregular movements are not considered normal. If one limb shorter than the other. A variety of neurological conditions associated with abnormal gait (eg walking spastic hemiparesis way - stroke, patients go step by step - lower motor neuron disease, patients walked vibrate - Parkinson's disease).

7. Assessing the skin and the peripheral circulation: palpation of the skin can indicate a temperature hotter or colder than others and the edema. Peripheral circulation was evaluated by assessing peripheral pulses, color, temperature and capillary refill time.

8 . Assessment of functional status :

• Baths : Told independent when in client activity just need help to scrub or clean up a certain portion of the body member , said the dependent if the client requires assistance to more than one body part .
• Dress : Independent if unable to take his own clothes in a closet or drawer .
• To the toilet : Independent when the elderly can not afford to own a toilet , getting out of the toilet and hem itself . Dependent when it need a bed pan or pot .
• Transferring : Independent themselves when able to climb down from a bed or wheelchair . Dependent if always require assistance for activities above or unable to perform one or more activities of transferring .
• Continence : Independent shitting themselves when able ( urinary and defecation ) . When dependent on one or both of micturition or sefekasi require enema or catheter .
• Eating : Independent if it is able to bribe their own food , take away from the plate .

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis : Impaired Physical Mobility related to depression

Goal : Depression can be resolved and activities to do.

Outcomes:

Clients can perform daily activities , and depression disappeared .

Intervention :

1. The prevention of osteoporosis , either through medical intervention , nutrition , as well as lifestyle adjustments .
2. The prevention of falls in accordance with the results of the assessment of the environmental factors as well as risk factors does surgery on the risk of environmental factors .
3. Maintenance of strength and resilience of the musculoskeletal system , which includes daily exercise conditioning program both isometric and isotonic muscle contraction , strengthening and aerobic activity , nutrition and protein anabolism to increase bone formation and attitude of commitment to exercise .
4. Maintaining the flexibility of the joints involved in range of motion exercises , proper positioning and activities of daily living .
5. Maintenance of normal ventilation and hyperinflation include mobilization and eliminate secretions .
6. Maintenance of adequate circulation include supporting measures to maintain vascular tone , compression stockings to put external pressure on the limbs and adequate fluid intake to prevent dehydration effect on blood volume .
7. Maintenance of urinary and bowel function were normal relies on nutritional support and environmental structure and routines to facilitate elimination .