NURSING CARE PLAN

ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:

“Nanghihina ako,kadalasan hindi ko matapos ang mga gawain ko

(I’m feeling weak, I can’t even complete my chores

)” as verbalized by the patient.

Objective:

♦Fatigue.

♦Greater need for sleep and rest.

♦V/S taken as follows: T: 36.9 P: 75 R: 18 BP: 100/80

♦ DIAGNOSIS

Activity intolerance related to imbalance between oxygen supply (delivery) and demand.

objective

Short term:

After 8 hours of nursing interventions the patient will:

♦ Report an increase in activity tolerance including activities of daily living.

♦Demonstrate a decrease in physiological signs of intolerance.

♦Display laboratory

values within acceptable range.

Long term:

After months of nursing interventions, the patient:

♦Is free form weakness and risk for complications has been prevented.

intervention

Independent:

♦Assess patient’s ability to perform normal task or activities of daily living.

♦Note changes in balance/ gait disturbance, muscle weakness.

♦Recommend quiet atmosphere, bed rest if indicated.

♦Elevate the head of the bed as tolerated.

♦Provide or recommend assistance with activities or ambulation as necessary, allowing patient to do as

much as possible.

Plan activity progression with patient, including activities that the patient views essential. Increase
levels of activities as tolerated

Identify or implement energy saving technique like sitting while doing a task.

Collaborative:

♦ Monitor laboratory studies. Hb or Hct and RBC count, arterial blood gases (ABGs).

Rationale

Influences choice of interventions or needed assistance

May indicate neurological changes associated with vitamin B12 deficiency, affecting patient safety or
risk of injury.

♦Enhances rest to lower body’s oxygen requirements, and reduces strain on the heart and lungs.

♦Enhances lung expansion to maximize oxygenation for cellular uptake.

♦Although help may be necessary, self esteem is enhanced when patient does some things for self.

Promotes gradual return to normal activity level and improved muscle tone or stamina without undue
fatigue.

Encourages patient to do as much as possible, while conserving limited energy and preventing fatigue

Identifies deficiencies in RBC components affecting oxygen transport and treatment needs or response
to therapy.

♦evaluation

Patient reveals an increase in activity tolerance, demonstrating a

reduction in physiological signs of intolerance and laboratory values within normal range.