TIME NURSING GOAL OF

AND CUES NEED DIAGNOSIS CARE INTERVENTIONS EVALUATION

DATE
SUBJECTIVE: A Activity Within 2 hours 1. Monitor vital signs GOAL MET:
“ C intolerance span of ®To provide baseline comparison
F T related to interaction with >Patient is now
E OBJECTIVE: I decrease the patient, the 2. Determine cause of activity intoler- able to walk and
B > Decrease mobility V energy level patient will be ance do ADL without
R >Drowsy I able to: ® Determining the cause of a disease the assistance of
U >Body malaise/ Weakness T ® can help direct appropriate interventions significant others.
A >Needs assistance in doing Y > Demonstrate
R ADL - activity 3. Teach client the need to pace activity
Y >Change in mental-confused/ E tolerance as and rest after meals
disoriented X evidenced by ® Rest periods decrease oxygen
14, E walking and consumption
R doing ADL
2 C without 4. Observe for pain before activity and,
0 I assistance. if possible treat pain before activity
1 S ® Pain restricts the client from achieving
2 E a maximum activity level and is often
exacerbated by movement
@ P
1:00 A 5. Encourage to change position from
PM T supine to sitting several times daily
T and to avoid prolonged bed rest
E ® Immobilization and enforced bed rest
R in the supine position have considerable
adverse effects on nearly every system
in the body

6. Perform passive range-of-motion ex-

ercise if client is unable to tolerate
activity