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NURSING CARE PLAN

PROBLEM: Activity intolerance


NURSING DIAGNOSIS: Activity Intolerance related to generalized weakness and pain secondary to sleep deprivation
TAXONOMY: Activity-Exercise Pattern
CAUSE ANALYSIS: Pain and weakness limit patient’s activity. Individual has insufficient physiological or psychological energy to endure or complete required or desired daily activites. Lack of
sleep may cause fatigue thereby affecting the physical activity, and decrease responsiveness to external stimuli.

CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: STO: INDEPENDENT: Demonstrate activity tolerance.


Patient report of fatigue or After 30 mins. of nursing Determine cause of activity Determining the cause of a disease Absence of signs and symptoms.
weakness, discomfort. Patient intervention and management, the intolerance can help direct appropriate
verbalized that he had difficulty in patient will able to: interventions
performing his daily activities due to --identify activities and factors that
the pain she felt over right lower contribute to intolerance Monitor and record client’s ability to
quadrant. He also reports of -- 5 measures to enhance activity tolerate activity; note pulse rate,
inadequate sleep at night due to tha tolerance blood pressure, monitor pattern,
pain she felt. dyspnea, use of accessory muscles,
and skin color before and after
LTO: activity.
After 3 days of nursing intervention
and management, the patient will be Teach client the need to pace activity Rest periods decrease oxygen
able to demonstrate activity and rest after meals consumption
tolerance
Observe for pain before activity and, Pain restricts the client from
if possible treat pain before activity. achieving a maximum activity level
and is often exacerbated by
movement.

Encourage client to change position Immobilization and enforced bedrest


from supine to sitting several times in the supine position have
daily and to avoid prolonged bedrest. considerable adverse effects on
nearly every system in the body.

Perform passive range-of-motion Inactivity rapidly contributes to


exercise if client is unable to tolerate muscle shortening and changes in
activity periarticular and cartilaginous joint
structure. These factors contribute to
contracture and limitation of motion

Implement measures to conserve the Measures to conserve the client’s


client’s energy during activity energy enable the client to increase
activity tolerance

Suggest that the client perform Shorter activity periods performed


activities more slowly and for shorter more slowly and more frequent rest
time periods, resting more often, and periods promote optimal
using more assistance as required. performance and achievement levels.
Appropriate assistance ensure safety
and prevents falling.

Instruct client in energy-conserving Energy-saving techniques reduce the


techniques, e.g., sitting to brush energy expenditure, thereby assisting
teeth or comb hair, carrying out in equalization of oxygen supply and
activities at a slower pace. demand.

Encourage progressive activity/ self-


care when tolerated. Provide Gradual activity progression
assistance as needed. prevents a sudden increase in
cardiac workload. Providing
assistance only as needed encourages
independence in performing
activites.

Referrence: Kozier, et. al .Fundamentals of Nursing, 5th edition.


Doenges, et. al. Nursing Care Plans, 6th edition.

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