NURSING CARE PLAN

ASSESSMENT
Subjective:
Nanghihina
ako,kadalasan
hindi ko matapos
ang mga gawain
ko
(Im feeling weak,
I cant even
complete my
chores
) as verbalized
by the patient.
Objective:
Fatigue.
Greater need
for sleep and
rest.
V/S taken as
follows: T: 36.9
P: 75 R: 18
BP: 100/80

DIAGNOSIS

Activity
intolerance
related to
imbalance
between oxygen
supply (delivery)
and demand.

OBJECTIVE

INTERVENTION

Short term:
After 8 hours of
nursing
interventions the
patient will:

Independent:
Assess patients
ability to perform
normal task or
activities of daily
living.

Report an
increase in
activity tolerance
including
activities of daily
living.
Demonstrate a
decrease in
physiological
signs of
intolerance.
Display
laboratory
values within
acceptable
range.

Long term:
After months of
nursing

Note changes in
balance/ gait
disturbance,
muscle
weakness.
Recommend
quiet
atmosphere, bed
rest if indicated.
Elevate the
head of the bed
as tolerated.
Provide or
recommend
assistance with
activities or
ambulation as
necessary,
allowing patient

RATIONALE

Influences
choice of
interventions or
needed
assistance.
May indicate
neurological
changes
associated with
vitamin B12
deficiency,
affecting patient
safety or risk of
injury.
Enhances rest to
lower bodys
oxygen
requirements,
and reduces
strain on the
heart and lungs.
Enhances lung
expansion to
maximize
oxygenation for
cellular uptake.

EVALUATION

Patient reveals
an increase in
activity
tolerance,
demonstrating a
reduction in
physiological
signs of
intolerance and
laboratory values
within normal
range.

NURSING CARE PLAN

interventions, the
patient:
Is free form
weakness and
risk for
complications
has been
prevented.

to do as much as
possible.

Plan activity
progression with
patient, including
activities that the
patient views
essential.
Increase levels of
activities as
tolerated.
Identify or
implement
energy saving
technique like
sitting while
doing a task.
Collaborative:
Monitor
laboratory
studies. Hb or
Hct and RBC
count, arterial

Although help
may be
necessary, self
esteem is
enhanced when
patient does
some things for
self.

Promotes
gradual return to
normal activity
level and
improved muscle
tone or stamina
without undue
fatigue.
Encourages
patient to do as
much as possible,
while conserving
limited energy
and preventing
fatigue.
Identifies
deficiencies in

NURSING CARE PLAN

blood gases
(ABGs).

RBC components
affecting oxygen
transport and
treatment needs
or response to
therapy.