NURSING CARE PLAN

Assessment Nursing Analysis Planning Interventions Rationale Evaluation

Diagnosis
Subjective: Activity Most activity Patient will - establish rapport - to facilitate NPI. Patient
“lagi na lang Intolerance; Level intolerance is improve mobility - place the client in - to prevent demonstrated
akong nakahiga” related to related to participation in a comfortable backaches or improved mobility
as verbalized by difficulty walking generalized the activities of position muscle aches. participation in
the patient. secondary to body weakness and daily living. -take and record - to note any activity of daily
weakness debilitation vital signs significant changes living in which he
Objective secondary to that may be is capable of.
 Conscious and acute or chronic brought about by
coherent illness and -Determine the disease
 body weakness disease. This is patient's - These may be
 restless especially perception of temporary or
 poor appetite apparent in causes of fatigue permanent,
elderly patients or activity physical or
 with limited
with a history of intolerance. psychological.
ROM
orthopedic, Assessment guides
 ambulatory c
cardiopulmonary, treatment.
assistance
diabetic, or - Assess patient's - This aids in
pulmonary- level of mobility. defining what
related problems. patient is capable
The aging process of, which is
itself causes necessary before
reduction in - Assess nutritional setting realistic
muscle strength status. goals.
and function, - Adequate energy
which can impair - Monitor patient's reserves are
the ability to sleep pattern and required for
maintain activity. amount of sleep activity.
Activity achieved over past - Difficulties
intolerance may few days. sleeping need to
also be related to - Assess emotional be addressed
 factors such as response to before activity
obesity, change in physical progression can be
malnourishment, status. achieved.
side effects of - Depression over
medications (e.g., inability to perform
-blockers), or required activities
emotional states - Encourage can further
such as adequate rest aggravate the
depression or lack periods, especially activity
of confidence to before meals, intolerance.
exert one's self. other ADLs, and
ambulation. - Rest between
- Refrain from activities provides
performing time for energy
nonessential conservation and
procedures. recovery.
-Assist with ADLs - Patients with
as indicated; limited activity
however, avoid tolerance need to
doing for patient prioritize tasks.
what he or she can -Assisting the
do for self. patient with ADLs
allows for
conservation of
energy. Caregivers
need to balance
providing
assistance with
facilitating
-Encourage active progressive
ROM exercises endurance that will
three times daily. ultimately enhance
-Teach energy the patient's
conservation activity tolerance
techniques. and self-esteem.
 -Exercises
maintain muscle
strength and joint
ROM.
-These reduce
oxygen
consumption,
allowing more
prolonged activity.

Assessment Nursing Analysis Planning Interventions Rationale Evaluation

Diagnosis
Subjective: Risk for After 8 hours Independent: After 8
infection is a group of metabolic hours of
“ang bagal of nursing •Observe for
related to high diseases in which a Patient may be nursing
gumaling ng glucose levels, person has high blood interventions, intervention
signs admitted with
mga sugat ko” decreased sugar, either because the the patient s, the
of infection and infection, which
As verbalized by leukocyte body does not produce will identify patient was
could have
the patient function. enough insulin, or interventions inflammation. able to
because cells do not precipitated the identify
to prevent or •Promote good ketoacidotic
respond to the insulin intervention
reduce risk handwashing by state, or may
that is produced. This s to prevent
Objective: high blood sugar of infection nurse and develop a or reduce
-Flushed produces the classical nosocomial risk of
symptoms patient. infection
appearance infection.
of polyuria (frequent •Maintain aseptic
-Wound at right urination), polydipsia (inc •Reduces the
foot technique for IV
reased thirst) risk of cross-
-Alert and and polyphagia (increase insertion
contamination
coherent d hunger. procedure,
•High glucose in
administration of
the blood
medications, and
creates an
providing
excellent
maintenance and
medium for
site care. Rotate
bacterial
IV sites as
growth.
indicated.
•Minimizes the
•Provide catheter
risk for
or perineal care.
infection.
Teach the female
•Peripheral
patient to clean
circulation may
from front to be impaired,
back placing patient
at increased
after elimination.
risk for skin
•Provide irritation or
conscientious breakdown and
skin care, gentl infection.

massage bony •Facilitates lung

areas. Keep the expansion and

skin dry, linens reduces risk of

dry and wrinkle aspiration.

free. •Decrease

•Place in semi – susceptibility to

fowler’s position. infection.

•Encourage •Identifies

adequate dietary organisms so

and fluid intake that most

of appropriate

3000 ml per day. drug therapy

Collaborative: can be

•Obtain specimen instituted

for culture and

sensitivities as
indicated.
Pandac, Tara Angela M.
N314 C1