NURSING CARE PLAN

ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: Short term: Independent:

♦ “Nanghihina ♦ Activity After 8 hours of ♦ Assess patient’s ♦ Influences choice of ♦ Patient reveals
ako,kadalasan intolerance nursing interventions ability to perform interventions or an increase in
hindi ko related to the patient will: normal task or needed assistance. activity
matapos ang imbalance activities of daily tolerance,
mga gawain ko between oxygen ♦ Report an living. demonstrating a
(I’m feeling weak, I supply (delivery) increase in reduction in
can’t even
complete my
and demand. activity tolerance ♦ Note changes in ♦ May indicate physiological
including balance/ gait neurological signs of
chores)” as
activities of daily disturbance, muscle changes associated intolerance and
verbalized by
living. weakness. with vitamin B12 laboratory
the patient.
deficiency, affecting values within
Objective: ♦ Demonstrate a patient safety or risk normal range.
decrease in of injury.
♦ Fatigue.
physiological
signs of ♦ Recommend quiet ♦ Enhances rest to
♦ Greater need
intolerance. atmosphere, bed rest lower body’s oxygen
for sleep and
if indicated. requirements, and
rest.
♦ Display laboratory reduces strain on
values within the heart and lungs.
♦ V/S taken as
acceptable range.
follows:
♦ Elevate the head of ♦ Enhances lung
Long term: the bed as tolerated. expansion to
T: 36.9
maximize
P: 75
After months of oxygenation for
R: 18
nursing interventions, cellular uptake.
BP: 100/80
the patient:
♦ Provide or ♦ Although help may
♦ Is free form recommend be necessary, self
weakness and assistance with esteem is enhanced
risk for activities or when patient does
complications has ambulation as some things for self.
been prevented. necessary, allowing
patient to do as much
as possible.
♦ Plan activity ♦ Promotes gradual
progression with return to normal
patient, including activity level and
activities that the improved muscle
patient views tone or stamina
essential. Increase without undue
levels of activities as fatigue.
tolerated.

♦ Identify or implement ♦ Encourages patient

energy saving to do as much as
technique like sitting possible, while
while doing a task. conserving limited
energy and
preventing fatigue.

Collaborative:

♦ Monitor laboratory ♦ Identifies

studies. Hb or Hct and deficiencies in RBC
RBC count, arterial components
blood gases (ABGs). affecting oxygen
transport and
treatment needs or
response to therapy.