Bulatao, Princess Andrea S.

BSN IV Group B2
Unciano College – Sta. Mesa

NURSING CARE PLAN

Actual Problem: Activity Intolerance

Cues and Data Nursing Diagnosis Goal of Care Interventions/Rationale Evaluation

Subjective:  Activity intolerance After 8 hours of nursing  Obtain vital signs After 8 hours of nursing
of the patient.
 “Hinihingal ako related to interventions, the patient intervention, the patient
Rationale: Health status
kahit wala akong imbalance between will demonstrate a is regulated through has demonstrated a
ginagawa at minsan oxygen supply and decrease in homeostatic decrease in physiological
mechanisms. A change
nahihirapan akong demand as physiological signs of signs of intolerance and
in vital signs might
huminga”, as evidenced by intolerance and will indicate a health change. was able to promote
verbalized by the reports of fatigue, promote good good respiratory
respiratory function.  Observe for function.
client. weakness and
respiratory rate and
exertional dyspnea. rhythm, presence of
Objectives: nasal flaring and
 With oxygen use of accessory
muscles when
support breathing like the
 Pale diaphragm and
coastal muscles.
 Restless
 Rationale: Nasal flaring
and use of accessory
 Emaciated
muscles indicates
 Poor muscle tone increased effort is
required for breathing.
 Place the patient in
semi fowler’s
position.
Rationale: To increase
chest expansion and
alleviate dyspnea.

 Increase fluid
intake.
Rationale: To prevent
dehydration.

 Engage in activities
of daily living base
on capabilities.
Rationale: To avoid
overexertion and to
reduce fatigue.

 Encourage to
maintain good
personal hygiene.
 Rationale: To promote
comfort and prevent
infection.

 Give foods that are

rich in protein and
carbohydrates.
Rationale: For energy
and to build up muscles.

 Enhance familial
support.
Rationale: To relieve
patient’s anxiety and to
assist the patient with all
the things that he/she
needs.

Rainier A. Santos
BSN-IV Group-B2
Unciano College, Sta.Mesa
NURSING CARE PLAN
Impaired Gas Exchange

Cues and Data Nursing Diagnosis Goal of Care Interventions/Rationale Evaluation

Subjective: “medyo  Impaired gas After 2 hours of nursing Assess causative and After 2 hours of nursing
nahihirapan ako exchange related to intervention, the patient contributing factors intervention the patient
huminga” as verbalized ventilation will demonstrate Rationale: helps in was able to demonstrate
by the client perfusion improved ventilation and identifying plan of care improved ventilation and
Objectives: imbalance as decreased symptoms of decreased symptoms of
 Pale evidenced by respiratory distress. Note respiratory rate, respiratory distress.
 Restlessness Increased depth, use of accessory

 Nasal flaring Respiratory rate, muscles.

restlessness, nasal Rationale: Nasal flaring
 Respiratory rate
flaring and and use of accessory
34cpm
dyspnea. muscles indicates
 Dyspnea
increased effort is
 Asthma
required for breathing.

Elevate head part of the

bed (semi fowlers to
high fowlers position).
Rationale: improves
airway and lung
expansion.

Encourage deep
breathing and coughing
exercises
Rationale: promotes
optimal chest expansion
and drainage of
secretions

Encourage adequate rest

and limit activities to
within client tolerance
Rationale: helps limit
oxygen consumption.
Keep environment
allergen free.
Rationale: to reduce
irritant effect of dust and
chemicals in airways.

Emphasize the
importance of proper
nutrition.
Rationale: helps
improve stamina and
may reduce difficulty in
breathing.

 Encourage to
maintain good
personal hygiene.

Rationale: To promote
comfort and to prevent
further infection.