Assessment Nursing Planning Interventions Rationale Evaluations

Diagnosis
SUBJECTIVE: Activity intolerance After 8 hours of Check vital signs before Orthostatic After 8 hours of
related to generalized nursing intervention and immediately after hypotension can occur nursing intervention
weakness and client will Participate activity, especially if with activity because client have participate
prolonged bed rest or in desire activities; patient is receiving of medication effect in desired activities;
OBJECTIVE: immobility. meet own self-care vasodilators, diuretics, (vasodilation), fluid meet own self-care
needs, and achieve or beta-blockers. shifts (diuresis), or needs, and achieve
 Weakness measurable increase compromised cardiac measurable increase
 Fatigue in activity tolerance, pumping function. in activity tolerance,
 Change in vital evidence by reduce evidenced by reduced
signs fatigue and weakness fatigue and weakness
 Dyspnea and by vital signs Compromised and by vital signs
within acceptable Document myocardium and/or
 Pallor within acceptable
limits during activity. cardiopulmonary inability to
 Diaphoresis limits during activity.
response to activity. increase stroke volume
 Dysrhythmias Note tachycardia, during activity may
 Chest pain dysrhythmias, dyspnea, cause an immediate
diaphoresis, pallor. increase in heart rate
Vital Sign: and oxygen demands,
TEMP: 36.0 c thereby aggravating
PR: 160 bpm weakness and fatigue.
RR: 27 cpm Assess for other causes
BP: 150/80 mmHg Fatigue is a side effect
of fatigue (treatments,
of some medications
pain, medications).
(beta-blockers,
tranquilizers, and
sedatives). Pain and
stressful regimens also
extract energy and
produce fatigue.
Assess patient’s general
condition To note for any
abnormalities and
deformities present
within the body.

Evaluate accelerating
activity intolerance.
May denote increasing
cardiac
decompensation rather
than over activity.
Provide assistance with
self-care activities as Meets patient’s
indicated. Intersperse personal care needs
activity periods with rest without undue
periods. myocardial stress and
excessive oxygen
Assist patient with demand.
ROM exercises. Check
regularly for calf pain
and tenderness. To prevent deep vein
thrombosis due to
vascular congestion.
Adjust client’s daily
activities and reduce
intensity of level. Prevents straining and
Discontinue activities overexertion which
that cause undesired may aggravate
psychological changes symptoms

Provide the patient with

a calm and quiet
environment Provides relaxation

Assist the client in

ambulation
Prevents risk for falls
that could lead to
injury