NURSING CARE PLAN

Patient’s Initials: A.C Chief Complaint: Weakness and Fatigue Name of Student Nurse:
Age & Gender: 72 yrs. Old/Male

Birthdate: March 23, 1949 Admitting Diagnosis: Activity intolerance r/t Level/Block/Group:
insufficient energy to complete activities of
daily living secondary to hypertension AEB by
reports of fatigue
Address: Hospital/Area:
Patient’s Home
Date of Confinement: October 21, 2021 Clinical Instructor:
Date: 10/23/2021

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Hypertension is also After nursing  Know the factors  To Goals met. After hours
 “Hindi talaga known as “abnormally interventions, that may determine of nursing intervention,
maganda ang high blood pressure” the patient is contribute to the whether the patient:
pakiramdam ko and it is a state of expected to: presence of the activity
kahit kunting great psychological fatigue such as intolerance - Can now perform basic
galaw ko lang stress. Hypertension - Be able to age, overall is activities without
mahihilo agad is defined as a perform activities physical health, secondary excessive exhaustion or
ako.” as systolic blood of daily living loss of energy
stage of illness. only to the
pressure (SBP) of independently
verbalized by  Observe the illness or
140 mmHg or more, - Can provide positive
the patient. patient when other
or a diastolic blood - Participate in verbal feedback in
pressure (DBP) of 90 self-care activities performing factors to response to the activity
Objective Data:
mmHg or more, or within level of physical activities help in level
 Restlessness
taking tolerance  Monitor vital planning
 Fatigue care.
antihypertensive signs before, - Can now display and
 Weakness  To know
medication. - Report during and after use effective energy
 Loss of increases in activities. what management/conservatio
conscious physical tolerance activities n techniques
 Teach the patient
 Facial Grimace different ways of cause the
- Demonstrate a performing tasks patient - Can now maintain
Vital Signs taken: decrease in regular cardiovascular
 BP- 150/90 such as the use fatigue.
physiological  Changes and respiratory functions
mmHg of chairs during
signs of during activities
  HR- 68 bpm intolerance. showers, carts to in the vital
 RR- 16 cpm push/pull things, signs are
 Temp- 37.5 use of good
degrees Celsius mechanical lifts, indicators
etc. of the
 Allow the patient response
to perform simple of the
tasks before patient.
NURSING DIAGNOSIS progressing to  To reduce
more complex fatigue
 Activity
 Encourage the  To help
intolerance r/t
patient to him
insufficient
continuously sustain an
energy to
perform activities optimum
complete
within the level of level of
activities of daily
tolerance, functioning
living secondary
increasing while
to hypertension
intensity maintainin
AEB by reports
gradually. g safety.
of fatigue