You are on page 1of 3

CUES Subjective: Hindi ko magawa yung mga gusto kong gawin mabilis kasi akong mapagod ngayon at nagiingat

din ako kasi baka sumakit na naman dibdib ko, as verbalized by the patient. Objective: Tired facial expression Weakness, Fatigue Pallor Hgb: 133 Vital Signs: BP: 130/90 RR: 30 PR: 96

PROBLEM/ HEAD NURSING DIAGNOSIS Activity Intolerance related to imbalance between supply and demand of oxygen

NURSING OBJECTIVE After 2 weeks of nursing intervention, the patient will be able to:

NURSING INTERVENTION 1. Determine patient's perception of causes of fatigue or activity intolerance. 2. Assess patients level of mobility.

RATIONALE 1. These may be temporary or permanent, physical or psychological. Assessment guides treatment. 2. This aids in defining what patient is capable of, which is necessary before setting realistic goals.

EVALUATION After 2 weeks of nursing intervention, the patient was able to: Maintain activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue. Verbalized and uses energy- conservation techniques.

Maintains activity level within capabilities, as evidenced by normal 3. Assess patient's heart cardiopulmonary status rate and blood pressure before activity using the during activity, as following measures: well as absence of shortness of breath, weakness, and fatigue. Heart rate Verbalizes and uses energy- conservation techniques.

Need for oxygen with increased activity

4. Observe and document response to activity. 5. Establish guidelines and goals of activity with the patient and caregiver.

Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. This number will change depending on the intensity of exercise the patient is attempting. Supplemental oxygen may help compensate for the increased oxygen demands 4. Close monitoring serves as a guide for optimal progression of activity. 5. Motivation is enhanced if the patient participates in goal setting.

6. Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation.

7. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self.

8. Encourage verbalization of feelings regarding limitations.

9. Encourage verbalization of feelings regarding limitations.

10. Implement graded cardiac rehabilitation/ activity program

6. Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of arrest period. 7. Assisting the patient with ADLs allows for conservation of energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and selfesteem. 8. Acknowledgment that living with activity intolerance is both physically and emotionally 9. Acknowledgment that living with activity intolerance is both physically and emotionally difficult aids coping. 10. Strengthens and improves cardiac function under stress, if cardiac

dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption.