ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Activity
intolerance
After 4 hours
of nursing
Evaluate
patient’s
NURSING CARE PLAN
Establishes
patient’s
After 4 hours of
nursing
“Hindi ako related to interventions the response to capabilities interventions
makatulog exhaustion patient will activity or needs and the patient was
dahil sa ubo associated demonstrate facilitates able to
ko” as with interruption a measurable choice of demonstrate a
verbalized by in usual sleep increase in interventions measurable
the patient. pattern tolerance in increase in
because of activity with Reduces tolerance in
Objective: discomfort, absence of Provide a quiet stress and activity with
-Fatigue. environment and excess
excessive dyspnea and absence of
-Dyspnea
coughing excessive fatigue. limit stimulation, dyspnea and
- With productive
cough, scanty in and dyspnea visitors during promoting excessive
amt. whitish in acute phase rest fatigue.
color
-no crackles upon These measures
auscultation promotes maximal
- V/S taken Elevate head and inspiration,enhanc
as follows: encourage frequent e
position changes, expectoration of
BP: 90/70 mmHg
deep secretions to
T: 37.3◦ C
P: 71 bpm breathing and improve
R: 20 bpm effective ventilation.
coughing.

Facilitates healing
Encourage process and
adequate rest enhances
balanced with natural resistance
moderate activity
Promote adequate
nutritional intake
Fluids especially
Force fluids to warm liquids aid in
at least 3000 ml mobilization and
per day and expectoration of
offer warm, secretions.