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Cues Needs Nursing Objective of Care Nursing Rationale Evaluation

Diagnosis Intervention

Subjective: P Activity After 8 hours of Independent: Goal partially met.


intolerance nursing
“Di ako related to intervention, the After 8 hours of
H patient will be  To assess factors
nakakagalaw ng generalized  Assess presence nursing
able to: of factors affecting current
maayos dahil sa weakness intervention, the
Y contributing to situation
nararamdaman secondary to patient was able to
GENERAL: fatigue
kong Muscular increase activity
S
panghihina ng Dystrophy  Assess if tolerance but still
- Increase in  To prevent injury to
aking katawan” activity tolerance assistance is patient needs assistance
I needed from when doing a
Objective: another person certain task.
SPECIFIC:
O Rational: - Identify  To maintain muscle
- With  Encourage
negative factors strength and joint range
active ROM
limited L In muscular affecting of motion
ROM exercises
activity
- Unable to dystrophy,
O tolerance
ambulate abnormal
- Body genes  Note patient’s  Symptoms may be
weakness G (mutations) report of result or contribute to
noted interfere weakness, intolerance of activity
- Unable to fatigue, pain and
I with the
flex and any difficulty of
production accomplishing
extend
knees C of proteins task
freely needed to
- Decreased form
lower healthy
extremity  Monitor vital  To baseline data and to
muscle,
strength N signs assist patient to deal
thus, it with contributing factors
causes and manage activities
E
progressive within individual limits.
weakness
E and loss of
V/S taken as  Assess
muscle  Adequate energy
follows: nutritional status
D mass reserves are required for
activity
resulting to
BP: S alteration  Ascertain ability  To determine current
110/80mmHg of one’s to stand and status and needs
mobility move about and associated with
T: 37.0 C degree of participation in desired
assistance activities
(Ackley,
necessary
PR: 90bpm 2011, p.
558).  Assist with
 To protect patient from
activities and
RR: 19cpm provide/monitor
injury
client’s use of
assistive devices
such as
crutches,
walker, or
wheelchair

 Promote
wellness  To indicate the need to
- Instruct alter activity level
client/ SO in
monitoring
response to
activity

- Assist patient  To prevent injuries


in learning
and
demonstrating
appropriate
safety
measures

Encourage patient To enhance sense of


to maintain well-being
positive attitude