Assessment Diagnosis Planning Intervention Rationale Evaluation

Objectives:
>Ambulatory with
assistance
>limited motion
>restlessness
>body weakness

Vital signs
BP140/90 mmHg
-RR - 32 bpm
-CR - 105 bpm
-Temp.- 38.2
degrees Celsius

Decrease
Hgb-= 114
Hct= .32


Activity Intolerance
related to
imbalance oxygen
supply and demand
as evidenced by
Decrease in
Hgb=114
Hct= .32
Body
weakness
After 8 hours of nursing
interventions, the
patient will demonstrate
a decrease in
physiological signs of
intolerance.


Monitor vital signs




Assess patients
ability to perform
tasks.



Plan for activity
within the clients
ability

elevate head of bed
as tolerated and
encourage deep
breathing exercise


Bed Rest


Promote quiet
environment.

recommend
assistance with
activities or
ambulation

provide oxygen as
needed
to note changes
that may be
brought by the
disease

activity that is
done without
urgency is less
physically
demanding.

Maintains client
energy level.


Promotes lung
expansion to
maximize
oxygenation for
cellular uptake.

to decrease
oxygen demand

Promotes rest.


prevents further
injury


Increase oxygen
transport to
tissues improves
ability to function.
Goal Met
After 8 hours of
nursing
interventions, the
patient was able to
demonstrate a
decrease in
physiological signs
of intolerance.