NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Patient’s data: Activity intolerance Within 8 hours of nursing Independent: After 8 hours of nursing
Merlinda Saito related to elevation in intervention and treatment, Establish rapport through nurse- Trust between oneself and the intervention and treatment,
62 years old vital signs as the patient will patient interaction (NPI). client is established through the patient was able to
Admission date: evidenced by blood demonstrate blood rapport. Treatment compliance, demonstrate blood
September 6, 2023 at pressure of 150/100 pressure within normal clinical results, and client pressure within normal
1:20 PM mmHg and range and will participate happiness all are improved as a range. From 150/100
patient’s verbalization in rehabilitation program to result. mmHg to 120/80 mmHg.
S: of body weakness and enhance ability to perform. She was able to
“Nanghihina po dahil fatigue participate in desired
Check, document, and During hospitalization,
sa mild stroke,” as activities and increase
continuously monitor vital signs improvement can be tracked by
verbalized by the activity tolerance.
every 4 hours. monitoring vital signs. It aids in
patient.
making a precise diagnosis and
assessing the efficacy of
O:
medical care, particularly the
-body weakness
use of anti-hypertensive
noted
medications.
-fatigue noted
-left facial asymmetry
noted Implement interventions to Continuous monitoring of blood
-discomfort noted regulate patient’s blood pressure pressure helps in identifying
-elevated blood and activity tolerance: how changes in blood pressure
pressure -continuously monitoring of relates to daily activities.
blood pressure
VS: -encourage for gradually This enhances the likelihood of
BP: 150/100 mmHg increasing of physical activity success and to motivate the
T: 36.2 °C and reduce or discontinue client to adopt a lifestyle of
CR: 65 bpm activities that cause undesired physical exercise for
RR: 24 bpm physiological changes to prevent enhancement of health.
Weight: 71 kg overexertion.

Keep clothing and linens dry. Promotes comfort and prevents

bed sores.
Encourage adequate fluid intake Hydration helps in regulating
if not indicated. body temperature, delivering
nutrients in cells and keeping
the organs function properly.

Raise side rails and encourage This ensures patient’s safety

the patient to lay on the left side. and comfort as well as relieve
pressure on the blood vessels
that return blood to the heart.

Note down the patient’s difficulty Evaluate the activity, current

in doing desired activities.
limitations of the client in
performing those activities. It
gives baseline data about
clients activity. It also helps to
plan an effective intervention to
improve clients activity
tolerance levels.

Advise patient to take rest in Rest reduces fatigues. The

between activities, and if
required assist in self-care
activities.
intensity of the activity can also
be reduced or adjusted to
reduce overexertion. Assisting
with activities smooth mobility
and protect the client from
injury.

Provide positive atmosphere Positive reinforcement helps to

while acknowledging the minimize and rechannel energy.
difficulty of situation for the
client. Encourage expression of
feelings contributing to or
resulting from the condition.
Involve the client during the It gives a chance to the client to
planning of activities. perform the activity of their
choice during the peak of their
energy.

Promote comfort measures and This enhances the client’s ability

provide for relief of pain. to participate in activities.

Ask the patient’s guardian to Having a guardian by the

stay with the patient. patient’s side provides safety
and security. Also, they can help
keep track of medication side
effects and unusual symptoms.

Dependent
Infuse intravenous solutions as Intravenous (IV) solutions are
prescribed. specially formulated liquids
that are injected into a vein to
prevent or treat dehydration.

Administer anti-hypertensive Anti-hypertensive medications

medications as ordered. are administered to treat high
blood pressure with the goal of
keeping the heart strong,
preventing from heart failure,
heart attack, kidney failure or
stroke.

FIONA C. SALEN
BSN III