Cues Nsg Dx Analysis Planning Interventions Rationale Evaluation

Objective Cues: Stem: Scientific Short-Term Goal: The client

Activity Analysis: After 2 hours of manifested/showe
Vital signs intolerance Hemoglobin is a nursing d
(insufficient major component intervention, the Met: ✓
BP: 90/60 of red blood cells, patient will Partially met:__
physiological or
PR: 89 the predominant demonstrate Unmet: __
psychological cell present in relaxation and
RR: 15
energy to endure or blood. Because of improvement of Effectiveness
Temp: 37.2
complete required hemoglobin’s her vital signs. 1. The patient
O2 stat: 98%
or desired daily importance in ability to get verbalized relief
Weight: 49.89 kg oxygen sufficient sleep, from discomfort
activities)
Height: 162 cm transportation, and enough (weakness,
Related to: anemia (too few tolerance to dizziness,
Facial Grimace red blood cells that perform activities headache, fatigue).
Insufficient sleep
Pallor contain too little or appropriately. Y ✓ N__
and rest periods
abnormal
The patient has hemoglobin) Long-Term Goal: 2. The patient
AEB: interferes with After 1 day of identified factors
been diagnosed
headache oxygen delivery to nursing that cause stress
with Iron facial grimace
Deficiency Anemia the tissues, leading intervention, the and fatigue.
dizziness to fatigue and patient will be able Y ✓ N__
in 2014. fatigue activity to increase and
weakness intolerance. achieve desired 3. The patient
abnormal (Berman, 2020) activity level verbalized and
Subjective Cues: (lowered) blood progressively with demonstrated
pressure no intolerance energy-conservatio
The patient Situational symptoms noted n techniques and
verbalized, Analysis: such as headache, healthy lifestyle
“Nanghihina po facial grimace, practices.
ako at nahihilo. Activity dizziness fatigue, Y ✓ N__
Napapagod po intolerance is weakness, and
ako agad sa mga defined as the lack abnormal blood 4. The patient was
gawain sa bahay at of sufficient pressure. able to maintain
online classes.” physiological or activity levels
psychological within capabilities.
The patient gave a energy to complete Y ✓ N__
pain rating of 4/10 required or desired
for the headache daily activities. 5. The patient
she was Activity Objectives: exhibited an
experiencing. intolerance is also improvement in
often related to 1. After 1 Independent: - Dramatic changes her vital signs and
generalized hour of - Taking the vital in heart rate and ability to
weakness and sleep nursing signs of the patient rhythm, changes in accomplish
or rest deprivation. intervention usual blood activities.
(Simple Nursing, , the patient pressure, and Y ✓ N__
2020) will progressively
In this specific verbalize worsening fatigue Efficiency
case, the patient relief from result from an The strategies were
reported that she discomfort imbalance of suitable for the
has not been (weakness, oxygen supply and given time -frame
getting sufficient dizziness, demand. Y ✓ N___
sleep and rest due headache,
to her daily fatigue). - Asking the client - Asking the Appropriateness
activities and about her usual client’s potential The selected
routines. These level of energy. problems, energy strategies/intervent
factors are likely to level, and ability to ions were
be the root causes perform needed or appropriate to the
of activity desired activities is patient’s needs
intolerance that she crucial in Y ✓ N___
is experiencing. identifying
potential problems. Adequacy
Dependent: The specific
- Administering learning objectives
medication for pain and its content
relief and were enough to
maintenance for meet the client’s
lowered blood needs
pressure Y ✓ N__

Acceptability
2. After 30 Independent: The
minutes of - Assess usual - Many factors can strategies/intervent
nursing daily activities of cause or contribute ions were
intervention the patient to fatigue, having acceptable for the
, the patient potential to patient
 will interfere with Y ✓ N__
identify client’s ability to
factors that perform at a
cause stress desired level of
and fatigue. activity. This
provides a
comparative
baseline and
information about
needed education
or interventions
regarding quality
of life.
- Position the client - Reducing
comfortably intensity level or
discontinuing
activities that cause
undesired
physiological
changes will
prevent
overexertion.

3. After 30 Independent: - Providing

minutes of - Advise client information about
health about the the effect of
teaching, importance of lifestyle on activity
the patient taking medication tolerance will be
will for maintenance on helpful in reducing
verbalize time risk factors by
and - Encourage proper modifying them.
demonstrat nutrition, adequate
e fluid intake, and
energy-cons getting sufficient
ervation rest and sleep
techniques
and - Instruct client to - Proper
healthy avoid activities that performance of
lifestyle may trigger unfamiliar
 practices. discomfort activities in
‘ alternate ways of
doing familiar
activities will
conserve energy
and promote safety.

4. After a day Independent:

of nursing - Encourage - Ascertain the
intervention progressive client’s ability to
, the patient activity/self-care stand and move
will be able when tolerated. about and the
to maintain Provide assistance degree of
activity if needed. assistance
levels necessary or use of
within equipment to
capabilities. determine current
status and needs
associated with
participation in
needed/desired
activities.

5. After a day Independent:

of nursing - Reassessment of - Reassessment or
intervention the patient’s check-ups provide
, the patient condition and vital a baseline for
will exhibit signs comparison and an
an opportunity to
improveme track changes.
nt in her Dependent:
vital signs - Advice client to - Identifying and
and ability consult a doctor for discussing
to evaluation and symptoms for
accomplish medicinal which the client
activities. counselling if needs to seek
symptoms recur medical
assistance/evaluati
on will help in
 providing timely
intervention.

(NANDA
International &
Herdman, T. H.,
2012)

References

T Heather Herdman, Shigemi Kamitsuru, & North. (2014). NANDA International, Inc. Nursing Diagnoses : Definitions & Classification
2015-2017. Wiley Blackwell.

Berman, A. T. (2020). Kozier & Erb’s Fundamentals of Nursing : concepts, process and practice. Prentice Hall.

Activity Intolerance. (2020). Simple Nursing.

https://simplenursing.ph/nursing-intervention-for-activity-intolerance/#:~:text=Activity%20intolerance%20is%20a%20common