NURSING NEED DESIRED NURSING RATIONALE EVALUATIION INTERVENTION RATIONALE

DIAGNOSIS OUTCOME INTERVENTION MODIFICATION MODIFICATION

3. Activity Within two

Intolerance r/t P (2) days of Independent:

Goal not met. Continue nursing This is done
disease H nursing  Encourage  Rest between
intervention until to meet the
Mrs. Misty’s is
process as Y intervention, adequate rest activities
the patient will optimal state
still able to
manifested by S the patient periods, provides time for
be able to report of well-being
report of signs
generalized I will be able especially before energy
relief or control of the
of muscle
body O to report meals, other conservation
of signs of patient.
weakness.
weakness and L control or ADLs, and and recovery.
muscle
pain. O relief of ambulation. Heart rate
weakness.
G muscle recovery

I weakness. following activity

C is greatest at the

beginning of a

Subjective N rest period.

110
Cues: E

E  Provide bedside  This reduces

“Sakit kaayo
D commode as energy
ilihok mao na
S indicated. expenditure.
hinay-hinay
NOTE: A bedpan
lang ko kung
requires more
mulihok.
energy than a
Sunod dili pud
commode.
ko kalingkod
 Instruct client in  Energy-saving
ug katindog
energy- techniques
kay sakit
conserving reduce the
kaayo.” As
techniques; eg.,, energy
verbalized by
CBB or complete expenditure,
Mrs. Misty.
Bed bath thereby assisting

in equalization of

Objective: oxygen supply

and demand.

111
*report of  Encourage to  To increase

fatigue and increase intake of muscle strength.

weakness. CHON for tissue

repair.
*limited body
 Encourage  Acknowledgment
movement
verbalization of that living with
*needs
feelings activity
support in
regarding intolerance is
eating,
limitations. both physically
changing
and emotionally
clothes,
difficult aids
bathing,and
coping.
urinating

*irritable

 Teach  This promotes

*body malaise
patient/caregiver awareness of
* lying on bed.
to recognize when to reduce

112
*respiration signs of physical activity.

slightly over activity.

labored
 These conserve
 Teach
Vital signs:
energy and
appropriate use
BP: 90/60 prevent injury
of environmental
from fall.
RR: 24Bpm aids (e.g., bed

rails, and
Background
elevating head of
Knowledge:
bed while patient

Insufficient gets out of bed).

physiological

or

psychological

energy to

endure or

complete

113
required or

desired daily

activities.

Most activity

intolerance is

related to

generalized

weakness and

debilitation

secondary to

acute or

chronic illness

and disease.

Our patient

suffers from a

severe pain for

114
almost 2 years

and because

of that she

cannot do

anything she

wants such as

standing,

walking and

sitting. She

cannot

performed her

daily activity

living.

Reference:

 Gulanick

and Myers,

115
Nursing Care

Plans:

Nursing

Diagnosis

and

Intervention

116