Nursing Nursing Diagnosis Client Goal Outcome Criteria Nursing Interventions Rationale Actual Evaluation

Assessment
Subjective Cues: Decreased activity The patient will be After 8 hours of nursing Independent: After 6 hours of nursing
“Maglisod kog lihok” tolerance related to able to gain intervention, the patient 1. Monitor vital signs and record. 1. To help determine patient’s current intervention, the patient was
as verbalized by the decreasing oxygen adequate energy will be able to: health status and evaluate able to:
patient. supply to the heart level and perform effectiveness of nursing intervention
Objective Cues: desired activities 1. The patient will be 2. Assist with ADLs while avoiding patient rendered. The patient was able to
Expresses fatigue, with minimal help able to report dependency 2. Allows conservation of energy, increase conditioned of
generalized and supervisions. measurable increase in carefully balance provision of physical state.
weakness, activity tolerance. assistance; facilitation progressive
exertional Scientific Basis: endurance will ultimately enhance the The patient verbalized the
discomfort. Insufficient endurance to 2. The patient will be patient’s activity tolerance and self- ways to improve the activity
Abnormal blood complete required or able to participate esteem. tolerance level.
desired daily activities. willingly in 3. Monitor intake and output as ordered.
pressure response
to activity. necessary/desired 3. To evaluate the proper functioning of The client had no elevation
activities. the patient’s kidney in relation to the in blood pressure above
4. Encourage rest periods.
Vital signs as Nurse’s Pocket Guide, present condition. normal limits and will
16 th
Edition 3. The patient will be maintain blood pressure
follows: 5. Instruct proper breathing exercises 4. Decrease myocardial workload and
T: 36.1 ° C able to demonstrate a increased oxygen distribution. within normal limits.
and relaxation techniques.
decreased in
PR: 83 6. Educate the patient about the gradual 5. To allow an adequate exchange of
O2SAT: 93% physiological signs of oxygen in the body while at rest.
resumption of activities of daily living.
BP:150/100 mmHg intolerance (e.g., pulse, 6. This will help in planning the
RR:24 respiration, and blood Dependent: activities that the patient can tolerate.
pressure remain within 1. Administer supplemental oxygen,
client’s normal range). medications, other treatments, as
1. To improve breathing, myocardial
indicated.
perfusion, and systemic circulation.
Other treatments might include iron
Collaborative: preparations or blood transfusion to
treat severe anemia or use of oxygen
1. Implement a physical therapy/exercise during activities.
program in conjunction with the client
and other team members. 1. A collaborative program with short -
term achievable goals enhance the
likelihood of success and may motivate
the client to adopt a lifestyle of physical
exercise for the enhancement of health.
 Nursing Nursing Diagnosis Client Goal Outcome Criteria Nursing Interventions Rationale Actual Evaluation
Assessment
Objective Cues: Decreased Cardiac The patient will After 8 hours of nursing Independent: After 6 hours of nursing
Expresses fatigue, Output display intervention, the patient 1. Monitor vital signs and record. 1. To help determine patient’s current intervention, the patient was
generalized hemodynamic will be able to: health status and evaluate able to:
weakness, stability. effectiveness of nursing intervention
exertional 1. The patient will be 2. Assist with ADLs while avoiding patient rendered. The patient was able to
discomfort. able to demonstrate dependency 2. Allows conservation of energy, increase conditioned of
Abnormal Scientific Basis:
blood adequate cardiac output carefully balance provision of physical state.
Inadequate
pressure response blood The patient will as evidenced by blood assistance; facilitation progressive
to activity. pumped by the heart to report/demonstrat pressure and pulse rate endurance will ultimately enhance the The patient verbalized the
meet the metabolic e decreased and rhythm within patient’s activity tolerance and self- ways to improve the activity
Vital signs as demands of the body. episodes of normal parameters for esteem. tolerance level.
dyspnea, angina, patient 3. Monitor intake and output as ordered.
follows: and able to
T: 36.1 ° C and dysrhythmias. tolerate activity without 3. To evaluate the proper functioning of The client had no elevation
PR: 83 Nurse’s Pocket Guide, dyspnea, syncope or the patient’s kidney in relation to the in blood pressure above
16 th
Edition 4. Assess for reports of pain of fatigue
O2SAT: 93% chest pain. present condition. normal limits and will
and reduced activity tolerance.
BP:150/100 mmHg 4. Fatigue and exertional dyspnea are maintain blood pressure
2. The patient will remain within normal limits.
RR:24 5. Gradually increase activity with active common problems with low cardiac
free of side effects from range-of-motion exercise in bed, output states.
the medications used to The patient was able to
increasing to sitting and then standing.
achieve adequate 5. Gradual progression of the activity identify signs of cardiac
cardiac output. prevents overexertion. decompensation. Alter
Dependent:
activities and seek help
1. Administer supplemental oxygen,
3. The patient will be medications, other treatments, as appropriately.
able to explain actions indicated. 1. To improve breathing, myocardial
and precautions to take perfusion, and systemic circulation.
for cardiac disease. Other treatments might include iron
Collaborative: preparations or blood transfusion to
treat severe anemia or use of oxygen
1. Implement a physical therapy/exercise during activities.
program in conjunction with the client
and other team members. 1. A collaborative program with short -
term achievable goals enhance the
likelihood of success and may motivate
the client to adopt a lifestyle of physical
exercise for the enhancement of health.