NURSING CARE PLAN

Assessment Nursing Scientific Planning Interventions Rationale Evaluation

Diagnosis Explanation
S: “lagi na lang Activity Most activity Patient will  establish rapport  to facilitate NPI. Patient
akong nakahiga” Intolerance; intolerance is improve mobility  place the client in  to prevent demonstrated
as verbalized by Level I r/t related to aeb participation a comfortable backaches or muscle improved
position aches.
the patient. difficulty walking generalized in the activities  take and record  to note any
mobility aeb
secondary to weakness and of daily living. vital signs significant changes participation in
O: body weakness debilitation ADL in which he
that may be brought
 Conscious and secondary to about by the disease is capable of.
coherent acute or chronic  Determine  These may be
 c body patient's perception temporary or
illness and
of causes of fatigue permanent, physical
weakness disease. This is or activity or psychological.
 restless especially intolerance. Assessment guides
 c poor apparent in treatment.
appetite; elderly patients  This aids in
consumed ¼ of with a history of  Assess patient's defining what patient
level of mobility. is capable of, which
the food served orthopedic, is necessary before
 c limited ROM cardiopulmonary setting realistic
 ambulatory c , diabetic, or goals.
assistance pulmonary-  Assess nutritional  Adequate energy
related status. reserves are required
for activity.
problems. The
 Monitor patient's  Difficulties
aging process sleep pattern and sleeping need to be
itself causes amount of sleep addressed before
reduction in achieved over past activity progression
muscle strength few days. can be achieved.
and function,  Assess emotional  Depression over
response to change inability to perform
which can impair in physical status. required activities
the ability to can further
maintain activity. aggravate the
Activity activity intolerance.
 Encourage
intolerance may
adequate rest  Rest between
also be related periods, especially activities provides
to factors such before meals, other time for energy
as obesity, ADLs, and conservation and
malnourishment, ambulation. recovery.
side effects of  Refrain from  Patients with
performing limited activity
medications nonessential tolerance need to
(e.g., - procedures. prioritize tasks.
blockers), or  Assist with ADLs  Assisting the
emotional states as indicated; patient with ADLs
such as however, avoid allows for
doing for patient conservation of
depression or what he or she can energy. Caregivers
lack of do for self. need to balance
confidence to providing assistance
exert one's self. with facilitating
progressive
endurance that will
ultimately enhance
the patient's activity
tolerance and self-
 Encourage active esteem.
ROM exercises three  Exercises maintain
times daily. muscle strength and
 Teach energy joint ROM.
conservation  These reduce
techniques. oxygen consumption,
allowing more
prolonged activity.