ASSESSMENT Explanation of the Problem Objectives Intervention Rationale Evaluation

S : “Nang hihina ako, madali ako Activity intolerance is a state in STO: Dx Sto : Goal was met
mapagod at para kong lagi which an individual has After 8 hours of Nursing >monitor heart rate, rhythm, >changes in VS assist with After 8 hours of Nursing
inaantok“as verbalized by the insufficient physiologic or intervention the patient will respirations and blood pressure monitoring physiologic intervention the patient l
patient psychological energy to endure demonstrate an increase in for abnormalities. Notify responses to increase in activity. demonstrated an increase in
or complete required or desired activity level as manifested by physician of significant changes activity level as manifested by
>Weak in appearance daily activities which may be is gradual tolerance to active in VS. >This may suggest extent of gradual tolerance to active
>Always asleep but easily caused by Increased blood range of motion. >Assess usual daily activities of immobility/ mobility as affected range of motion.
awakens pressure and blood viscosity and patient vs. Tolerated activities by the weakness will also serve
>Shallow respiration RR of that may lead to decreases during complain of patient as data where interventions will
30cpm oxygen supply in the blood be based. LTO:
>With blood pressure of vessels, and then manifests as LTO:
130/100 mmhg body weakness. >Assess muscle strength >Muscle strength may suggest After 72 hours of Nursing
>Slow movements noted After 72 hours of Nursing the extent of weakness of intervention the patient was
>Needs assistance upon intervention the patient will be patient, will also serve as basis able to increased and achieved
changing positions able to increase and achieve for planning of progress. desired activity level,
>Dyspnea noted desired activity level, >Assess laboratory results >Data may serve as baseline progressively, with no
>Pallor noted progressively, with no data for progress of intolerance symptoms noted,
intolerance symptoms noted, interventions, as well as it will such as respiratory compromise
such as respiratory compromise help determine extent of
> Observe and document skin severity of condition.
A: Activity intolerance related to integrity several times a day. > Activity intolerance may lead
imbalance between myocardial to pressure ulcers. Mechanical
oxygen supply and demand as pressure, moisture, friction, and
manifested by body weakness. shearing forces all predispose to
Tx: their development.
> Give assistance to patient
when moving >Since patient feels weak, it
may be best if he will be given
support when changing position
so that occurrence of injury may
be prevented, also, so that
patient will not be exhausted.
>Reposition the patient every 2
hours >To avoid occurrence of
conditions that is caused by
prolong stay in bed like bed
sores and also, Pneumonia.
>Performed active range of
motion intermittently >To promote minimal exercise
for the patient especially that he
>Regulated IVF at ordered rate is not yet able to tolerate heavy
activities
>IVF may help in the regain of
strength since it contains
electrolytes also it is where IV
meds will be given, hence/ also,
it must be regulated accordingly,
to prevent occurrence of cardiac
>Interact with patient overload, hence, aggravating
condition.
>To elicit other more
concerns from patient, hence,
having the ability to plan
>Make a schedule for nursing appropriate nursing care to
time to provide for be performed.
uninterrupted rest periods
>To promote restful sleep,
Edx reduces fatigue, and may
>Discuss with patient the improve cognition.
need for gradual activity
increase and resumption

>Encourage/ Explain to >Education may provide

patient to adhere to advised motivation to increase activity
treatment level even though patient
may feel too weak initially.
>So that patient may easily
>Advice to avoid abrupt recover from condition.
standing and moving

>To prevent orthostatic

>Encourage the use of Bed hypotension that may cause
pan for urinating until falls, injury, or any trauma to
tolerance to walking resumes the patient.

>Since the patient feels

weak, use of bed pan helps
the patient to avoid going in
the bathroom frequently and
also to avoid valsalva
maneuver.