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Activity Intolerance

The nursing care plan assessed a patient experiencing right flank pain and difficulty moving due to pain. The patient reported pain levels of 9/10 and had dyspnea, guarding, grimacing and slow movement. The nursing diagnosis was activity intolerance related to flank pain. Goals were for the patient to demonstrate pain relief and resumption of activities within 3 hours. Nursing interventions included vital sign monitoring, positioning instructions, splinting during movement, pain assessments every two hours, and encouraging self-care. After 3 hours the patient reported a reduced pain level of 5/10 and could change positions with minimal assistance, meeting the goals.

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Jenny Pearl Pasal
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5K views

Activity Intolerance

The nursing care plan assessed a patient experiencing right flank pain and difficulty moving due to pain. The patient reported pain levels of 9/10 and had dyspnea, guarding, grimacing and slow movement. The nursing diagnosis was activity intolerance related to flank pain. Goals were for the patient to demonstrate pain relief and resumption of activities within 3 hours. Nursing interventions included vital sign monitoring, positioning instructions, splinting during movement, pain assessments every two hours, and encouraging self-care. After 3 hours the patient reported a reduced pain level of 5/10 and could change positions with minimal assistance, meeting the goals.

Uploaded by

Jenny Pearl Pasal
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

ASSESSMENT DATA
(Subjective & Objective Cues)

NURSING DIAGNOSIS
(ProbIem and EtioIogy)
GOALS AND
OBJECTIVES
NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
Subjective:
"Galisod ko og lihok kay sakit
ang tuo na bahin sa ako tiyan"
as verbalized by the patient.



Objective:
-dyspnea
-pain scale of 9/10
- guarding behavior
-grimacing face
-slow movement
- assisted ADL's




Activity intolerance: level V
(dyspnea, fatigue at rest) related
right flank pain.

























Within 3 hours of
nursing interventions the
patient will be able to
demonstrate
techniques/behaviors
that enable resumption
of activities and will
experience pain relief.

















ndependent nursing interventions:
1. Monitor vital signs.

R: baseline data of the patient's
condition

2. nstruct the use of side rails.

R: for position changes and transfer.

3. Splint affected body parts during
movement.

R: to maintain position of function
and alleviate pain

4. TTS every two hours.

5. Encourage participation in self
care

R: to enhance self-concept and
sense of independence.





Goals met. After 3
hours of nursing
intervention, the
patient stated pain
scale of 5/10 and
demonstrated position
changes and transfer
with minimal
assistance.









Dependent nursing interventions:

1. Administer Acalka, 1 tab, once a
day as prescribed by the doctor for
treatment in potassium depletion.

2. Gave supplemental oxygen as
ordered (2LPM via nasal cannula)

R: helps in giving adequate oxygen
to the client

Collaborative nursing interventions:
1. Consult with the
physical/occupational therapist as
indicated.

R: to develop individual
exercise/mobility program and
identify appropriate mobility devices.

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