Aquino, Julie Ann

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: Hypovolemia is a decrease in STO: Dx: STO:

the volume of blood in your Within 30 minutes-1 hour of
N/A body, which can be due to effective nursing  Monitor VS every 4 hours (BP,  To assess possible problem (Goal Met)
blood loss or loss of body interventions, the patient will HR,) which can occur, since
Objective: be able to: tachycardia and increased The bleeding
fluids. Blood loss can result
arterial BP are seen in the stopped within
*Excessive bleeding from external injuries,
a) Controlled bleeding early stage to maintain cardiac minutes to an
internal bleeding, or certain
output. after nu
obstetric emergencies.
LTO: intervention
Diarrhea and vomiting are
Nursing Diagnosis:  Accurate measurement is
common causes of body Within 24-48 hours of LTO:
 Monitor the client’s intake and important in detecting negative
fluid loss. Fluid can also be effective nursing
Deficient fluid volume output. fluid balance and guide
lost as a result of large burns, interventions, the patient (Goal Met)
related to hypovolemia therapy.
excessive perspiration, or will:
as evidenced by Within 24-48
diuretics. Inadequate fluid  CVP provides information on
excessive blood loss. a) Maintain fluid of effective nu
intake can also cause  Monitor the client’s central filling pressures of the right
hypovolemia. volume interventions,
venous pressure (CVP), side of the heart; pulmonary
b) The patient is patient was
pulmonary artery diastolic artery diastolic pressure and
normovolemic normovolemic,
pressure (PADP), pulmonary pulmonary capillary wedge
c) Acquired sufficient normal VS, and
At the onset of hypovolemia, capillary wedge pressure, and pressure reflect left-sided fluid
understanding of the learned about
the mouth, nose, and other cardiac output/cardiac index. volumes. Cardiac output
problem and is able knowledge
mucous membranes dry out, provides an objective number
to describe some could use it in
the skin loses its elasticity, to guide therapy.
remedies. real activities.
and urine output decreases.
Initially, the body
compensates for the volume Tx:  To maintain adequate
loss by increasing the heart circulating blood volume
rate, increasing the strength  Administered IVF PLRS1L x 12
of heart contractions, and hours as ordered.
constricting blood vessels in
the periphery while
preserving blood flow to the
brain, heart and kidneys.
With continuing volume
loss, the body loses its ability
to compensate and blood Edx:
pressure drops. At this point,
 Encourage to increase fluid intake  Oral route supports in
the heart is unable to pump
maintaining fluid balance.
enough blood to vital organs  Provide information about the
to meet their needs and problem  To educate them about the dos
tissue damage is likely to and don’ts
occur.
 Advised to report any  To take rapid action in
irregularities, such as severe response to the situation.
bleeding, as soon as possible.
SOURCE/S:

Martin, P. B. (2019, July 11).

4 Hypovolemic

Shock Nursing

Care Plans.

Nurseslabs.

https://nurseslabs.co
 m/hypovolemic-

shock-nursing-care-

plans/

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: as a state in which an STO: Dx: STO:

individual has insufficient
N/A physiological or Within 30 minutes-1 hour of  Assess the patient's ability to  To determine appropriate (Goal Met)
effective nursing stand/walk. intervention for the patient.
psychological energy to
Objective: interventions, the patient will Within 30 minu
endure or complete
be able to:  Motivation and hour of effe
* The patient can hardly necessary or desired daily  Establish guidelines and goals cooperation are enhanced if nursing
perform ADLs activities. of activity with the patient
a) Have adequate knowledge the patient participates in goal interventions,
about activity intolerance. setting. patient gained
* The patient need
adequate know
assistance in walking and b) The patient can provide  This helps the patient to cope.
The following factors that about the pro
moving to bed positive verbal feedback in Acknowledgment that living
lead to activity intolerance  Encourage verbalization of and now verba
may include side effects of response to the activity level feelings regarding limitations with activity intolerance is positive feedba
medication, extended bed both physically and response to ac
Nursing Diagnosis: rest, living a sedentary emotionally difficult. level.
lifestyle, regular restrictions
Activity intolerance to healthy activity levels, LTO: Tx:
related to general improper oxygen  Helps in increasing the LTO:
weakness as evidence by supply/demand balance, Within 24-48 hours of  Have the patient perform the tolerance for the activity
weak range of motion pain, deprived or low-quality effective nursing activity more slowly, in a (Goal Met)
and muscle strength of sleep, depression, lack of interventions, the patient longer time with more rest or
3/5
motivation, and severe will: pauses, or with assistance if Within 24-48
stress. necessary. of effective nu
a) can do activities interventions,
alone such as  Gradually increase activity  Gradual progression of the patient is
walking stand or go with active range-of-motion activity prevents overexertion. independent
SOURCE/S: to bed without exercises in bed, increasing to doing acti
assistance sitting and then standing. without assist
P. (2021b, September 27).
and now
b) The patient can  Dangle the legs from the bed
Activity Intolerance maintain cardio
maintain regular side for 10 to 15 minutes.  Prevents respiratory fun
cardiovascular and
- Nursing Care respiratory orthostatic hypotension. during activities
 Assist with ADLs while
functions during avoiding patient dependence
Plan. Nurse Theory. activities
https://www.nurseth  Assisting the patient with
ADLs allows conservation of
eory.com/activity-
energy. Carefully balance
intolerance/#: provision of
assistance; facilitating
%7E:text=Activity progressive endurance will
ultimately enhance the
%20intolerance patient’s activity tolerance and
self-esteem.
%20is%20a  Gradually progress patient
activity with the following:
%20nursing,necessa  Duration and frequency should
*Range-of-motion (ROM)
be increased before intensity.
ry%20or exercises in bed, gradually
increasing duration and
%20desired frequency (then intensity) to
sitting and then standing.
%20daily
*Deep-breathing exercises
 %20activities.&text three or more times daily.

=Activity *Sitting up in a chair 30

minutes three times daily.
%20intolerance
*Walking in room 1 to 2
%20may%20also minutes TID.
%20be,conditions *Walking down the hall 20
feet or walking through the
%2C%20especially
house, then slowly progressing
%20among walking outside the house,
saving energy for the return
%20elderly trip.

%20patients. Edx:

Vera, M. B. (2017,  Encourage active ROM

exercises. Encourage the
September 24). patient to participate in
planning activities that
Activity Intolerance
gradually build endurance
Nursing Care Plan.  Exercise
maintains muscle strength,
Nurseslabs.
joint ROM, and exercise
https://nurseslabs.co tolerance. Physical inactive
patients need to improve
m/activity- functional capacity through
repetitive exercises over a long
intolerance/ period of time. Strength
training is valuable in
 Teach the patient and/or SO to enhancing endurance of many
 recognize signs of physical ADLs.
overactivity or overexertion.
 Knowledge promotes
 Teach energy conservation awareness to prevent
techniques, such as: the complication of
overexertion.
*Sitting to do tasks
*Frequent position changes
 These techniques reduce
*Pushing rather than pulling
*Sliding rather than lifting oxygen consumption, allowing
*Working at an even pace a more prolonged activity.
*Placing frequently used items
within easy reach
*Resting for at least 1 hour
after meals before starting a
new activity
*Using wheeled carts for
laundry, shopping, and
cleaning needs
*Organizing a work-rest-work
schedule