Jundale G.

Batbatan BSN-III Section: B

NURSING CARE PLAN
Problem: Activity intolerance
Nursing Diagnosis: Activity intolerance related to generalized weakness and fatigue.
Taxonomy: Exercise and Activity
Cause Analysis: Muscle activity, loss of energy results from reduction in the oxygen available in the muscle. Hemoglobin major component of RBC, binds easily with
oxygen necessary for the protection of body from fatigue and activity intolerance. (Reference: Medical-Surgical Nursing 6th ed. By Black et.al, p454)
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objective: Independent:

=Determine cause of activity -Determining the cause of a disease can
After 8 hours of giving intolerance and determine if its cause is help direct appropriate interventions.
The patient verbalizes…
nursing intervention and physical, psychological, or
“Abi nimo luya kaayo akong motivational.
lawas dili ko ganahan health teaching the patient
=Monitor and record client’s ability to -To determine the level of maximum
maglihok-lihok kay kapoy will be able to verbalize an
tolerate activity. performance of activity.
man gud. Diri lang siguro ko understanding of the need to =Teach client the need to pace activity -Rest periods decrease oxygen
sa katri maghigda lang ko gradually increase activity ad rest after meals. consumption.
diri. Unya rako maglakaw based on testing, tolerance, =Observe for pain before activity and, -Pain restricts the client from achieving
lakaw inig maayo na ako and symptoms. And expresses if possible, treat pain before activity. a maximum activity level and is often
paminaw.” an understanding of the need exacerbated by movement.
to balance rest and activity. =Perform passive range of motion -Inactivity rapidly contributes to muscle
exercises if client is unable to tolerate shortening and changes in periarticular
activity. and cartilaginous joint structure.
Objective:
 The patient is Long term objective:
=Encourage client to change position -Immobilization and enforced bedrest in
always lying in bed and from supine to sitting several times the supine position have considerable
always sleeping. After 3 days of giving nursing
daily and to avoid prolonged bedrest. adverse effects on nearly every system
The patient intervention and health
 in the body.
face appears to be teaching the patient will be
Dependent:
generally weak. able to participate in Collaboration with other health care
Administration of medication depends
prescribed physical activity on physicians order. workers will promote the healing
 Appears to be
and demonstrates increased Refer to Physical therapies for further process of the patient.
exhausted
activity tolerance. activity.
 The patient has
a sunken eyeballs.
 Decreased
hemoglobin count. !30-
1609 L Normal, Result is
1209 L
References: Nursing Diagnosis Handbook (A guide to planning care) Ackley & Ladwig 2nd edition. pp. 102-103