Fatigue related to hyper metabolic state with increased energy requirements, Irritability of central nervous system (CNS); altered body chemistry as evidenced by Verbalization of overwhelming lack of energy to maintain usual routine, decreased performance.
Goal: Verbalize increase in level of energy and Display improved ability to participate in desired activities.
Interventions: Monitor vital signs, noting pulse rate at rest and when active. Rationale: Pulse is typically elevated and, even at rest, tachycardia (up to 160 beats/min) may be noted.
Interventions: Note development of tachypnea, dyspnea, pallor, and cyanosis. Rationale: O2 demand and consumption are increased in hyper metabolic state, potentiating risk of hypoxia with activity.
Interventions: Provide for quiet environment; cool room, decreased sensory stimuli, soothing colors, quiet music. Rationale: Reduces stimuli that may aggravate agitation, hyperactivity, and insomnia.
Interventions: Encourage patient to restrict activity and rest in bed as much as possible. Rationale: Helps counteract effects of increased metabolism.
Interventions: Provide comfort measures: touch therapy or massage, cool showers. Rationale: Patient with dyspnea will be most comfortable sitting in high Fowler’s position. May decrease nervous energy, promoting relaxation.
Evaluation: Client will report improved sense of energy and ability to participate in activities.