Activity Intolerance r/t generalized weakness inability to perform activity

Nursing Nursing
Objective Expected
Assessment Diagnosi Scientific Explanation Interventi Rationale
s Outcome
s on
S: Ø Activity Hypertension is a dangerous Short 1. Monito 1. Cardiopulmon
Intoleran condition because it can lead to term:: r vital ary Short
O: The patient ce r/t Seriouscomplications.Chronically After 3-4 sign manifestation term:
manifested: generaliz elevated blood pressure increases hours of (Blood s result from Patient
 Weakness ed the risk of developing heart failure, nursing Pressu attempts by shall have
 Pale skin weaknes heart attacks, arterial aneurysm and interventio re, the heart and used
color s inability strokes. Many cases of chronic renal n patient pulse, lungs to identified
 Fatigue to failure have been linked to will use and supply technique
 Discomfort perform highbloodpressure.Hypertension is a identified respira adequate s to
 Abnormal activity dangerous condition becauseit can technique tions) amounts of enhance
blood lead s to during oxygen to the activity
pressure(150 toseriouscomplications.Chronicallyel enhance and tissues. tolerance.
/80) evated blood pressure increases the activity after
 Poor apetite risk of developing heartfailure, heart tolerance. activity Long
The patient may attacks, arterial aneurysm . term:
manifest: andstrokes.Reference: medical- Long Patient
surgical. 790-791 term: After 2. Influences shall have
 Unusually
2-3 days choice of free from
rapid
of nursing 2. Assess interventions weakness
heart-
interventio patient and needed and risk
beat,
n patient ability assistance. for
particularl
will able to to complicati
y with
free from perfor on been
exercise
weakness m 3. Although help prevented
 Shortness
and risk ADLs may be
of breath
for necessary,
and
complicati 3. Provid self-esteem is
headache
on been e or enhanced
,
prevented recom when client
particularl
mend does some
y with
assista things for self.
exercise
nce
 Difficulty with
concentra activiti
ting es and
 Dizziness ambula
 Pale skin tion as
 Leg necess
cramps ary,
 Insomnia allowin
g client
to be
an
active
particip 4. Postural
ant as hypotension
much or cerebral
as hypoxia may
possibl cause
e. dizziness,
4. Sugge fainting, and
st increased risk
client of injury.
change
positio
n 5. Encourages
slowly; client to do as
monito much as
r for possible,
dizzine while
ss. conserving
limited energy
5. Identify and
and preventing
implem fatigue.
ent
energy
-saving
 techniq
ues 6. Cellular
ischemia
potentiates
risk of
infarction,
6. Instruct and
client excessive
to stop cardiopulmon
activity ary strain and
if stress may
palpitat lead to
ions, decompensati
chest on and
pain, failure.
shortn
ess of
breath,
weakn
ess, or
dizzine
ss
occur.

Problem #2: Imbalance nutrition less than body requirement r/t inability to ingest food
Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosi
 s Explanation

S: Ø Imbalance Intake of Short Term: 1. Establish > to relieve Short Term:

nutrition nutrients After 2 hours rapport anxiety to Patient shall
O: The patient less than insufficient to of NI, the pt achieve have
manifested: body meet metabolic will be able to compliance demonstrated
 Weakness requireme needs. demonstrate behaviors,
 Pale skin nt r/t Adequate behaviors, lifestyle
color inability to nutrition is lifestyle 2. monitor and changes to
 Fatigue ingest necessary to changes to record VS > to establish regain and/or
 Discomfort food meet the body’s regain and/or baseline data maintain
 Abnormal demands. maintain 3. Determine appropriate
blood Nutritional status appropriate client > it maybe affect weight.
pressure(1 can be affected weight. inability to ingestion and
50/80) by disease or swallow digestion of Long Term:
 Poor injury states Long Term: food, chew nutrients Patient shall
appetite (e.g., After 1 -2 days or taste food. have
The patient gastrointestinal of NI, the pt displayed
may manifest: [GI] will be able to 4. Discuss to >to appeal normalization
malabsorption, display the SO the client’s ;likes of laboratory
 Unusua
cancer, burns); normalization eating and dislikes values and be
lly rapid
physical factors of laboratory habits, free of signs of
heart-
(e.g., muscle values and be including malnutrition as
beat,
weakness, poor free of signs of food reflected bin
particul
dentition, activity malnutrition as preferences, Defining
arly
intolerance, pain, reflected bin intolerance/a Characteristics
with
substance Defining versions. .
exercis
abuse); social Characteristic
e
factors (e.g., lack s. 5. assess drug > it may affect
 Shortne
of financial interactions, appetite, food
ss of
resources to adverse intake, or
breath
obtain nutritious effects, absorption
and
foods); or laxatives,
headac
psychological allergies.
he,
factors (e.g.,
particul
depression, 6. determine > to asses body
arly
 with boredom). the image and
exercis During times of psychologica congruency
e illness (e.g., l
 Difficult trauma, surgery, factors/perfo
y sepsis, burns), rm
concent adequate psychologica
rating nutrition plays an l assessment > to establish
 Dizzine important role in parameter
ss healing and 7. >assess
 Pale recovery. weight
skin Cultural and > it may indicate
 Leg religious factors protein-energy
cramps strongly affect 8. >observe for malnutrition
 Insomni the food habits of absence of
a patients. Women subcutaneou
exhibit a higher s fat/muscle
incidence of wasting. >to reveal
voluntary possible cause
restriction of food 9. note age, of
intake secondary body build, malnutrition/cha
to anorexia, strength, nges that could
bulimia, and self- activity/rest be made in
constructed fad level client’s intake
dieting. Patients
who are elderly > it helps to
likewise 10. promote determine
experience pleasant, nutritional needs
problems in relaxing
nutrition related environment
to lack of
financial >to reduce
resources, 11. >promote possibility of
cognitive adequate/ early satiety
impairments timely food
causing them to intake
forget to eat, >to monitor
physical 12. >weigh at effectiveness of
limitations that regular dietary plan
interfere with intervals and
preparing food, document
deterioration of results
their sense of
taste and smell,
reduction of
gastric secretion
that
accompanies
aging and
interferes with
digestion, and
social isolation
and boredom
that cause a lack
of interest in
eating. This care
plan addresses
general concerns
related to
nutritional
deficits for the
hospital or home
setting.