Assessment Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation

Subjective: Activity Intolerance auto immune Short Term Goal: Independent: After 8 hours of
“Di ako makatayo dahil related to response  Monitor vital  To have nursing intervention
may manas sa paa ko.” inflammation on After 8 hours of nursing signs baseline data the goal was met by
As verbalized by the connective tissues. destroys connective intervention, the patient  Check for the patient identifying
patient. tissues would identify palpitaions techniques that would
techniques that would  Note presence  To know what increase ctivity
“masakit nga ung inflammatory increase activity of factors aggravates the tolerance and willing
kasukasuan ko” response tolerance and willingly contributing to situation of to participate in
p- walking participate in necessary fatigue the patient necessary or desired
q- release of chemical or desired activities as  Provide rest  To prevent activities as evidenced
r-from bone end point mediators evidenced by: fatigue by:
to muscles  Functional Level  Avoid  To increase  Functional
s-5/10 vascular response Classification of strenuous rest activities level
time- intermittent. level 1 (can walk activities classification
vasodilatation in regular pace  Assist with  To promote of level 1 (can
Objective: on level activities and safety and walk in regular
 Pedal edema increase blood flow to indefinitely; 1 provide/monit support pace on level
(grade 3) the injury flight or more or clients use indefinitely; 1
 Fatigue but lesser short of assistive flight or more
 Muscle increase capillary of breath) devices but lesser
weakness permeability  Promote  To prevent short of
 Guarding comfort further breath).
behavior. swelling measures and complications
 Slowed provide for
movement relief of pain
 Pallor
 BP: 140/110
 Functional
level
Classification:
Level 4
(dyspnea and
fatigue at rest
Assessment Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation
Subjective: Excess fluid volume Short Term Goal:
“Napansin ko na related to After 8 hours of nursing
biglang nagkaroon ng compromised intervention the patient
manas dito sa paa ko regulatory mechanism would verbalize dietary
at sa bandang mata as decreased plasma fluid restrictions and
ko.” As verbalized by proteins (connective demonstrate behaviors
the patient tissue destruction). and monitor I/O as
evidenced by:
Objective:  Self- monitoring
>BP-140/100 and restricting.
>pulse- 62 bpm, weak  Verbalization of
and bounding diet
> edema (pedal, peri –
orbital),grade 3
>dyspnea
>decreased Hb/Hct
>restlessness