NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

DATA
Activity Insufficient physiologic or After 8 hours of After 8 hours of
SUBJECTIVE: Intolerance r/t psychological energy to nursing 1. Assess general 1. To obtain nursing
generalized endure or complete required interventions the condition. baseline data. interventions the
“Diri gud ako weakness as or desired daily activities patient will be able patient was able to:
nakakakiwa. Gin evidenced by results to activity intolerance. to: 2. Assess the patient’s 2. In normal adults,
bubuligan la ako hit reports of feeling This is mostly observed in baseline HR should not
akon asawa kun weak older patients with a history of a) Participate in cardiopulmonary increase more a) Participate in
malingkod, maihi, orthopedic, cardiopulmonary necessary and status (e.g., heart than 20 to 30 necessary and
tapos mauro.” as or diabetic problems. It also desired rate, orthostatic BP) beats/min above desired
verbalized results from obesity, activities. before initiating resting with activities.
malnourishment, anemia, and activity. routine
OBJECTIVE: side effect medications. b) Report a activities. Older b) Report a
measurable patients are measurable
- General body Source: Nursing Care Plans increase in more susceptible increase in
weakness (9th Edition) pg. 136 activity to orthostatic activity
- Verbalizations of tolerance. drops in BP with tolerance.
weakness position
- Cannot perform c) Demonstrate a changes. c) Demonstrate a
ADLs alone decrease in decrease in
-Muscle strength 3 physiological 3. Assess ability to 3. To determine the physiological
signs of perform ADL capacity of signs of
intolerance. patient in doing intolerance
ADLs.

4. Assess physical 4. To know if there

mobility status. are any changes
on patients
condition
specifically on
physical aspect.

5. Assess nutritional 5. Adequate energy

status. reserves are
required for
activity
6. Assess emotional 6. Depression over
response to the inability to
limitations in perform
physical activity. activities can be
a source of stress
and frustration.

7. Determine functional 7. Determines

ability using a scale strengths or
of 0 to 4 and reasons insufficiency
for impairment. and may give
0 – completely information
dependent regarding
1 – requires use of recovery.
equipment or device Currently, the
2 – requires help patient is in level
from another person 3.
for assistance,
supervision or
teaching.
3 – requires help
from another person
and equipment or
device
4 – is dependent,
does not participate
in activity

8. Check for skin 8. This will allow

integrity for signs of prevention or
redness and tissue early recognition
ischemia. and treatment
pressure ulcers.

9. Use portable pulse 9. May determine

oximetry to assess the use of
for oxygen supplemental
oxygen to help
 desaturation during compensate for
activity. the increased
oxygen demands
during physical
activity.

10. Present a safe 10. These measures

environment: bed promote a safe,
rails up bed in down secure
position, important environment and
items close by. may reduce risk
for falls.

11. Execute passive or 11. Exercise

active assistive ROM enhances
exercises to all increased venous
extremities. return, prevents
stiffness and
maintains
muscle strength
and stamina.

12. Promote and 12. Early mobility

facilitate early increases self-
ambulation when esteem about
possible. reacquiring
independence

13. Instruct client in 13. Energy-saving

energy-conserving techniques
techniques, such as reduce the
using chair when energy
showering, sitting to expenditure,
brush teeth or comb thereby assisting
hair, and carrying out in equalization
activities at a slower of oxygen
pace. supply and
demand.
14. Encourage 14. Gradual activity
progressive activity progression
and self-care when prevents a
tolerated. Provide sudden increase
assistance as needed. in cardiac
workload.

15. Encourage to 15. To determine

verbalize feelings other factors that
and concern might contribute
regarding his present to patient’s
condition. present
condition.

16. Encourage adequate 16. Rest between

rest periods activities
provides time
for energy
conservation