Name of Patient: Vicente Agbuya

Age: 30 Sex: Male

Diagnosis: T/C PTB Pneumonia with Congestion

PROBLEM # 3: Body weakness

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
S: “Mahina ang katawan Activity intolerance LTO: After 1 week of 1. Obtained resting vital signs. 1. Baseline data is important to Goals met.
ko, madali akong related to fatigue, nursing intervention, the help determine patient’s degree of - patient participated
mapagod”, as verbalized altered nutritional patient will be able to activity intolerance. willingly in ADLs and
by the patient. status, and fever. tolerate prescribed 2. Assessed patient’s ability to 2. Determines nursing verbalizes ways to
physical activities, such perform ADL’s, providing interventions needed to assist conserve energy and
O: as ADL. assistance as necessary especially patient; ensures patient safety. prevent fatigue.
- weak and pale in during tasks requiring ambulation. - patient demonstrated
appearance STO: After 8 hours of 3. Noted changes in balance/gait 3. Patients with Vitamin B12 tolerance to activities
- shallow, rapid nursing intervention, the disturbance, muscle weakness. deficiency often manifest as evidenced by
respiration (RR = 39 patient will: neurologic changes. decrease in RR to 26
cpm) - participate willingly in 4. Monitored BP, pulse, respirations 4. Increase in BP, HR, RR, and cpm and PR to 100
- weak, rapid pulse (PR necessary activities of and skin color during and after changes in skin color result from bpm.
= 120 bpm) daily living. activity. the attempts of the heart and
- BP = 110/80 mmHg - demonstrate a decrease lungs to supply adequate amounts
(within patient’s in physiologic signs of of oxygen to the tissues.
baseline BP) activity intolerance as 5. Instructed patient to change 5. Postural hypotension may
- slowness of movement evidenced by PR and position slowly. cause dizziness and increased risk
- restlessness RR within normal of injury.
range. 6. Provided adequate rest and sleep 6. Rest lowers the body’s oxygen
- verbalizes ways to periods especially between requirements.
conserve energy and activities.
prevent fatigue. 7. Elevated head of bed as tolerated. 7. Promotes lung expansion for
maximum oxygenation.
8. Encouraged patient to eat a well 8. To provide adequate strength
balanced diet. and improve general body
condition.
9. Provided health teachings on the 9. Promotes adequate rest and
importance of prioritization of maintains energy level.
activities, relaxation techniques,
spacing, and DBE.