NURSING CARE PLAN
ASSESSMENT
Subjective: ♦ “Nanghihina ako,kadalasan hindi ko matapos ang mga gawain ko
(I’m feeling weak, I can’t even complete my chores)” as
DIAGNOSIS
OBJECTIVE
Short term:
INTERVENTION
Independent: ♦ Assess patient’s ability to perform normal task or activities of daily living. ♦ Note changes in balance/ gait disturbance, muscle weakness.
RATIONALE
EVALUATION
♦ Activity intolerance related to imbalance between oxygen supply (delivery) and demand.
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.
♦ Influences choice of interventions or needed assistance.
verbalized by the patient. Objective: ♦ Fatigue. ♦ Greater need for sleep and rest. ♦ V/S taken as follows: T: P: R: BP: 36.9 75 18 100/80
♦ 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.
♦ Patient reveals an increase in activity tolerance, demonstrating a reduction in physiological signs of intolerance and laboratory values within normal range.
♦ 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.
♦ 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.
Collaborative: ♦ Monitor laboratory studies. Hb or Hct and RBC count, arterial blood gases (ABGs). ♦ Identifies deficiencies in RBC components affecting oxygen transport and treatment needs or response to therapy.