NURSING CARE PLAN

Name of Patient:____________________________________________________________________________Age:_____________Civil Status:____________________Religion:_____________________________________________________________

Address:______________________________________________________________________________________Informant:_________________________________Relationship:______________________________________________________________
Chief Complaint:____________________________________________________________________________Medical Diagnosis:______________________________________________________________________________________________________

IMPLEMENTATION
PROBLEM ASSESSMENT PLANNING
LIST (cues & evidences/ (objectives-long Rationale/Justifications
DATE NURSING DIAGNOSIS EVALUATION
(according to objective & term (Nursing Theories of Care,
priority) subjective) & short term) Nursing Interventions Developmental stage, tasks, References
Principles, EBP, Standards of
Nursing Practice)
Insufficient Objective Activity Intolerance  Patient  Note presence of factors  Fatigue affects both the client’s NANDA 14th  Patient
physiological  Patient participates contributing to fatigue (age, frail, actual and perceived ability to Edition participated in
or reporting in necessary acute or chronic illness, heart participate in activities. necessary
psychological weakness or and/or failure, hypothyroidism, cancer and/or
and cancer therapies).
energy to fatigue. desired desired
 Evaluate client’s actual and  Provides comparative baseline and
endure or  Abnormal activities. perceived limitations or degree provides information about needed
activities.
complete heart rate as a  Uses of deficit in light of usual status. education and interventions  Used
required or result of identified  Assess the patient’s response to regarding quality of life. identified
desired daily activity. techniques to activity, noting pulse rate more  The stated parameters are helpful in techniques to
activities.  Exertional enhance than 20 beats per min faster than assessing physiological responses to enhance
discomfort or activity resting rate; marked increase in the stress of activity and, if present, activity
dyspnea. tolerance. BP during and after activity are indicators of overexertion. tolerance.
 Electrocardiog  Reports a (systolic pressure increase of 40  Repored a
measurable mm Hg or diastolic pressure measurable
ram (ECG)
increase of 20 mm Hg); dyspnea
changes increase in increase in
or chest pain; excessive fatigue
reflecting his/her and weakness; diaphoresis;
his/her
ischemia; tolerance for dizziness or syncope. tolerance for
dysrhythmias. activity.  Assess emotional and  Stress or depression may be activity.
 Demonstrates psychological factors affecting increasing the effects of an illness, or  Demonstrated
a decrease in the current situation. depression might be the result of a decrease in
noticeable being forced into inactivity. noticeable
signs of Therapeutic Interventions signs of
intolerance.  Instruct patient in energy-  Energy-saving techniques reduce the intolerance.
conserving techniques (using energy expenditure, thereby
chair when showering, sitting assisting in equalization of oxygen
to brush teeth or comb hair, supply and demand.
carrying out activities at a
slower pace).
 Encourage progressive activity
 Gradual activity progression
 and self-care when tolerated.
Provide assistance as needed.
prevents a sudden increase in
cardiac workload. Providing
assistance only as needed
encourages independence in
performing activities.

Name of Student Nurse and Signature:_____________________________________________________________Year and Section:______________________Date/Duration of Patient Care:__________________________________

Name of Clinical Instructor:_________________________________________________________________________________________Rating:________________________Remarks:________________________________________________________