Nursing Care Plan #6

Cues Nursing Dx Objectives Intervention Rational Evaluation

Subjective:


Objective:
-generalized body
weakness noted.
- seeks help in ADL
-ECG reflecting atrial
fibrillation with pattern of
ischemia and tissue
necrosis
Activity Intolerance
related to generalized
weakness.
Short term:
At the end of 30 minutes of
nursing interventions, the patient
will be able to:

a. Identify negative factors
affecting activity tolerance.

b. Verbalize understanding of
techniques to enhance activity
tolerance.


Long term:

At the end of 24 hours of nursing
intervention the patient will be
able to:

a. Participate willingly in
necessary activities.

b. Report measurable increase in
activity tolerance.

c.Demonstrate a decrease in
physiologic signs of intolerance
(PR, RR, and BP within patients
normal range).






Independent:

1. Assess cardiopulmonary
response to physical activity,
including vital signs before,
during and after activity.

2. Reduce intensity level or
discontinue activities that
cause undesired
physiological changes.

3. Assist with ADLs as
indicated; however, avoid
doing for patients what
they can do for
themselves.

4. Encourage active ROM
exercises; if further
reconditioning is needed,
confer with rehabilitation
personnel.


Dependent:
1. Administer O2 inhalation
as prescribed.






-Assessing
cardiopulmonary notes
progression or accelerating
degree of fatigue.

-Adjust activities to prevent
overexertion.



-Assisting the patient with
ADLs allows for
conservation of energy.



-Exercise maintains
muscle strength and joint
ROM.





-Providing oxygenation
reduces fatigue and
anxiety for patient.

After 30 minutes, the
patient:
a. identified the factors
that affected her
activities of daily
living.
b. used identified
techniques to
enhance activity
tolerance.


Long Term:

After 16 hours, the patient
a. particated willingly in
necessary or desired
activities.
b. reported increase in
activity tolerance