ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

PROBLEM/ pathophysiology

S: “my breasts are Risk for activity intolerance as GOAL: DX:

sore and tender but defined by NANDA is vulnerable
there is no milk to experiencing insufficient >Note presence of acute or chronic >. Many factors can
illness, , pregnancy-induced cause or contribute to
coming out and Im physiological or psychological STO: STO:
also in pain due to energy to endure or complete hypertension, and acute and chronic fatigue, having
After 6 hours pain potential to interfere
uterine cramping ” required or desired daily
as verbalized by the activities, which may of effective nursing with client’s ability to
perform at a desired Goal met if patient,
patient. compromise health. interventions, the
patient will be able to level of activity.
will be able to do ADL’s
As for the condition of the do ADL’s alone and to However, the term
alone and to participate
patient, one of her main concern participate in self-care “activity intolerance”
in self-care activities
is pain because there is a qi and activities implies that the client
blood deficiency that causes cannot endure or adapt
weak body, blood loss, blood and to increased energy or
O: T=36.5 , qi weakening and blood that oxygen demands Goal partially met if
BP=110/80, LTO: patient,
cannot move causing poor blood caused by an activity
RR=14, flow and lack of nourishment After 2 days of effective >Ask client/significant other (SO) >to identify potential Will be able to do some
O2 Sat= 94% that brings up pain and the qi nursing interventions, about usual level of energy problems and/or ADL with the help of
PR=78 deficiency opens the blood the patient will be able
client’s/SO’s significant others.
chamber and receives cold – to maintain activity
>edematous perception of client’s
blood clotting, obstructed level within capabilities Goal not met if patient,
perineum , as energy and ability to
placental membranes in the as evidenced by normal
examined perform needed or Will not be able to do
uterus, emotional disorders- liver vital signs during
qi stagnation leading to blood desired activities. ADL’s alone and to
>Cannot perform activity, as well as
stasis and blocking that causes participate in self-care
ADL’s alone absence of weakness,
general activation of immune activities
pain, and difficulty
> facial grimacing system leading to signs and >Note client reports of weakness, >Symptoms may be a
accomplishing tasks
symptoms such as pain , uterine fatigue, pain, difficulty accomplishing result of or contribute
>irritability cramping ,fever, chills, chest tasks, and/or insomnia. to intolerance of
pain , fatigue, and muscle activity
constrain and if this
>to determine current
manifestation wouldn’t be given >Ascertain the client’s ability to stand LTO:
appropriate nursing intervention status and needs
and move about and the degree of associated with
Nursing Diagnosis: it will lead to risk for activity assistance necessary or use of
intolerance. A risk diagnosis is participation in
 Risk for Activity equipment needed/desired GOAL met if patient,
not evidenced by signs and
Intolerance related activities.
symptoms as the problem has will be able to maintain
to decreased energy
not yet occurred; rather, nursing activity level within
requirements as
interventions are directed at capabilities as evidenced
evidenced by
prevention. > Determine the client’s current >This provides a by normal vital signs
decrease muscle baseline for
strength activity level and physical condition during activity, as well
with observation, exercise-capacity comparison and an as absence of weakness,
testing, or use of a functional-level opportunity to track pain, and difficulty
classification system (e.g., Gordon’s), changes accomplishing tasks.
as appropriate

GOAL partially met if

TX: >to prevent patient,

>Reduce intensity level or discontinue overexertion Will be able to maintain

activities that cause undesired activity level within
physiological changes capabilities as evidenced
>This helps to minimize by normal vital signs
> Provide positive atmosphere while
frustration and during activity, but still
acknowledging the difficulty of the
situation for the client. rechannel energy. have presence of
weakness, mild pain,
and difficulty
 >to enhance ability to accomplishing tasks.
>Promote comfort measures and participate in activities
provide for relief of pain . GOAL not met if patient,

Will not be able to

>to conserve energy maintain activity level
>Instruct client in proper performance and promote safety within capabilities as
of unfamiliar activities and in alternate evidenced by normal
ways of doing familiar activities vital signs during
activity, as well as
Edx: presence of weakness,
>Understanding this pain, and difficulty
> Discuss with client/SO(s) the relationship can help accomplishing tasks.
relationship between illness or with acceptance of
debilitating condition and the ability limitations or reveal
to perform desired activities opportunity for
changes of practical
value

>This promotes the

>Plan for maximal activity within the idea of normalcy of
client’s ability progressive abilities in
this area.

>To promote wellness

> Instruct client/SO(s) in monitoring

response to activity and in recognizing
signs/symptoms that indicate need to
alter activity level.

>Both activity tolerance

 and health status may
> Plan for progressive increase of improve with
activity level/participation in exercise progressive training.
training, as tolerated by client.
> to sustain motivation

>Give client information that provides

evidence of daily/ weekly progress