Nursing Care Plan

Actual Problem: Activity Intolerance (3rd priority)

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective data: Activity Appendicitis LONG TERM Independent LONG TERM
 “Medyo nahihirapan intolerance ↓ GOAL: GOAL WAS
po akong gumalaw related to Pain in the RLQ • Establish • Rapport is MET
dahil sa tahi ko” as presence of ↓ After 2 days of rapport important to gain
verbalized by the surgical incision Appendectomy nursing patient’s After 2 days of
client as manifested by ↓ interventions the cooperation and nursing
limited mobility Surgical Incision client will be reduce anxiety. interventions the
Objective data: on the lower ↓ able to maintain client exhibited
extremities Start of the activity level • Baseline data is a normal range
 Facial grimace inflammatory within • Monitor vital important to help of respiratory
when moved process capabilities, as signs determine pattern of 20
 VS: ↓ evidenced by patient’s current cpm, cardiac rate
o T: 36.6 °C Pain normal heart rate health status and of 79 bpm and
o P: 62 ↓ during activity, evaluate has no shortness
bpm Pain upon moving as well as effiectiveness of of breath and
o R: 20 cpm ↓ absence of nursing fatigue during
Limited mobility shortness of intervention any activity.
o BP:
↓ breath, rendered.
110/80 mmHg
ACTIVITY weakness, and
INTOLERANCE fatigue. • Motivation is
 Pain scale of 8 out
of 10 enhanced if the
• Establish patient
guidelines and participates in
 Burning sensation
goals of activity goal setting.
on incision site
with the patient
and caregiver. • Rest between
 Guarded movement
activities
• Encourage provides time for
 Limited mobility
adequate rest energy
 on lower extremities periods, especially conservation and
before meals, other recovery.
ADLs, exercise
sessions, and
ambulation. • Acknowledgmen
t that living with
• Encourage activity
verbalization of intolerance is
feelings regarding both physically
limitations and emotionally
difficult, aids
coping.

• Promotes rest
and sleep and
• Maintain a prevents anxiety
quiet, comfortable thereby
environment decreasing the
patient’s oxygen
demands

• This promotes
awareness of
• Teach when to reduce
patient/caregivers activity.
to recognize signs
of physical over
activity. • To conserve
energy and
• Teach energy decrease the
conservation need for oxygen
techniques. supply
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