NURSING CARE PLAN

Assessment Nursing Diagnosis Analysis Planning Interventions Rationale Evaluation

Subjective: Activity Intolerance; Most activity Patient will improve
“lagi na lang akong Level related to intolerance is
nakahiga” difficulty walking related to participation in the
as verbalized by the secondary to body generalized activities of daily
patient. weakness weakness and
debilitation
Objective secondary to acute
 Conscious and or chronic illness
coherent and disease. This is
 body weakness especially apparent
 restless in elderly patients
 poor appetite with a history of
orthopedic,
 with limited ROM
cardiopulmonary,
 ambulatory c
diabetic, or
assistance
pulmonary- related
problems. The aging
process itself
causes reduction in
muscle strength and
function, which can
impair the ability to
maintain activity.
Activity intolerance
may also be related
to factors such as
obesity,
malnourishment,
side effects of
medications (e.g.,
-blockers), or
emotional states
such as depression
- establish rapport - to facilitate NPI. Patient
mobility - place the client in a - to prevent demonstrated
comfortable position backaches or muscle improved mobility
-take and record aches. participation in
living. vital signs - to note any activity of daily
significant changes living in which he is
that may be brought capable of.
-Determine patient's about by the disease
perception of causes - These may be
of fatigue or activity temporary or
intolerance. permanent, physical
or psychological.
Assessment guides
- Assess patient's treatment.
level of mobility. - This aids in defining
what patient is
capable of, which is
necessary before
- Assess nutritional setting realistic
status. goals.
- Adequate energy
- Monitor patient's reserves are
sleep pattern and required for activity.
amount of sleep - Difficulties sleeping
achieved over past need to be
few days. addressed before
- Assess emotional activity progression
response to change can be achieved.
in physical status. - Depression over
inability to perform
required activities
can further
- Encourage aggravate the
 or lack of adequate rest activity intolerance.
confidence to exert periods, especially
one's self. before meals, other - Rest between
ADLs, and activities provides
ambulation. time for energy
- Refrain from conservation and
performing recovery.
nonessential - Patients with
procedures. limited activity
-Assist with ADLs as tolerance need to
indicated; however, prioritize tasks.
avoid doing for -Assisting the patient
patient what he or with ADLs allows for
she can do for self. conservation of
energy. Caregivers
need to balance
providing assistance
with facilitating
progressive
endurance that will
ultimately enhance
-Encourage active the patient's activity
ROM exercises three tolerance and self-
times daily. esteem.
-Teach energy -Exercises maintain
conservation muscle strength and
techniques. joint ROM.
-These reduce
oxygen consumption,
allowing more
prolonged activity.

Assessment Nursing Analysis Planning Interventions Rationale Evaluation

Diagnosis
Subjective: Risk for After 8
After 8 hours Independent:
infection is a group of metabolic hours of
“ang bagal related to high diseases in which a of nursing •Observe for signs nursing
Patient may be
gumaling ng mga glucose levels, person has high blood interventions, intervention
of infection and admitted with
sugat ko” decreased sugar, either because the s, the
the patient infection, which
leukocyte body does not produce inflammation. patient was
As verbalized by function. enough insulin, or will identify could have able to
the patient because cells do not interventions •Promote good identify
precipitated the
respond to the insulin to prevent or handwashing by ketoacidotic intervention
that is produced. This s to prevent
reduce risk nurse and patient. state, or may
high blood sugar or reduce
Objective: produces the classical of infection develop a risk of
•Maintain aseptic
-Flushed symptoms nosocomial infection
of polyuria (frequent technique for IV
appearance infection.
urination), polydipsia (inc
insertion
-Wound at right reased thirst) •Reduces the
foot and polyphagia (increase procedure,
risk of cross-
d hunger.
-Alert and coherent administration of
contamination
medications, and
•High glucose in
providing
the blood
maintenance and
creates an
site care. Rotate
excellent
IV sites as
medium for
indicated.
bacterial
•Provide catheter
growth.
or perineal care.
•Minimizes the
Teach the female
risk for
patient to clean
infection.
from front to back
•Peripheral
after elimination.
circulation may
•Provide be impaired,
conscientious placing patient
at increased
skin care, gentl
risk for skin
massage bony irritation or
areas. Keep the breakdown and
skin dry, linens infection.

dry and wrinkle •Facilitates lung

free. expansion and

•Place in semi – reduces risk of

fowler’s position. aspiration.

•Encourage •Decrease

adequate dietary susceptibility to

and fluid intake of infection.

3000 ml per day. •Identifies

Collaborative: organisms so

•Obtain specimen that most

for culture and appropriate

sensitivities as drug therapy

indicated. can be
instituted