Colleen S.

De la Rosa
BSN III
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Evaluation

NSG. Action Rationale
Subjective Data: Activity After the nursing After the nursing
Ng hihina na ako 1. Note presence of factors 1. Fatigue affects both the clients
intolerance r/t interventions, the interventions, the
at hindi gaano contributing to fatigue (age, frail, actual and perceived ability to
Imbalance client will have no acute or chronic illness, heart participate in activities. client had no
nakakahinga as between elevation in blood failure, and cancer therapies). elevation in blood
verbalized by the oxygen supply pressure above 2. Instruct patient in energy- 2. Energy-saving techniques pressure above
pt. and demand normal limits and conserving techniques reduce the energy expenditure, normal limits and
will maintain thereby assisting in equalization of maintains blood
Objective Data: blood pressure oxygen supply and demand. pressure within
- Weak in within acceptable 3. Encourage progressive activity 3. Gradual activity progression acceptable limits.
appearance and self-care when tolerated. prevents a sudden increase in
limits.
- Warm to Provide assistance as needed. cardiac workload. Providing
assistance only as needed
touch
encourages independence in
- Flushed skin performing activities.
- Temp: 37.2 4. Assess emotional and 4. Stress or depression may be
- RR: 30 psychological factors affecting the increasing the effects of an illness,
- PR: 89 current situation. or depression might be the result
- BP: 160/100 of being forced into inactivity.
5. Encourage relaxation 5. It helps reduce stressful stimuli,
techniques like guided imagery thereby decreases blood pressure.
and distractions
6. Implement dietary sodium, fat, 6. These restrictions can help
and cholesterol restrictions as manage fluid retention and, with
indicated. associated hypertensive response,
decrease myocardial workload.