NURSING SCIENTIFIC

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE

SUBJECTIVE CUES: Activity Activity intolerance is After 8 hours of nursing 1. Establish rapport to the 1. Good rapport creates a close After 8 hours of nursing
“dre na ako nakaka intolerance related a state in which an interventions, the client and harmonious relationship interventions, the patient
trabaho hin 3 ka oras, to easy fatigability individual’s ability to patient will be able to: with patients was able to:
yana, bisan 30 ka
minute pala nga
and shortness of perform his activities  Demonstrate  Demonstrate improved
trabaho ha farm gin breath as of daily living are improved well-being 2. Assess the client’s response 2. Changes in baseline are helpful well-being and energy
kakapoy naak dre ko evidenced by decreased. As heart and energy as to activity, noting pulse rate in assessing physiological as evidenced by:
nakakaya mag difficulty in failure becomes more evidenced by: more than 20 beats per responses to the stress of - minimal assistance
padayon” performing severe, the heart is - minimal minute faster than resting activity and, if present, are in activities of daily
activities of daily unable to pump the assistance in rate; marked increase in BP indicators of overexertion. living.
living secondary to amount of blood activities of daily during and after activity. - Report a
OBJECTIVE CUES: right-sided heart required to meet all of living. measurable
 Easy Fatigability failure the body’s needs. To - Report a 3. Compromised myocardium
3. Document cardiopulmonary increase in activity
 Shortness of compensate, blood is and/or inability to
measurable response to activity. Note tolerance.
breath
diverted away from increase in tachycardia, dysrhythmias, increase stroke volume during
 Tachypnea
 Vital signs as
less-crucial areas, activity tolerance. dyspnea, diaphoresis, pallor. activity may cause an  Able to participate in
follows: including the arms and immediate increase in heart desired self-care
BP: 70/50 mmHg legs, to supply the  Able to participate rate and oxygen demands, needs
HR: 120 bpm heart and brain. As a in desired self-care thereby aggravating weakness - Grooming
(irregular) result, people with needs and fatigue. - Drinking
RR: 35 cpm right-sided heart - Grooming - Eating
O2 SAT: 60 % failure often feel weak - Drinking 4. Instruct client in energy-
(room air) especially in the arms - Eating conserving techniques, such 4. Energy-saving techniques  Demonstrate a
TEMP: 35.4 C and legs. Performing reduce the energy
as using chair when decrease in
daily activities such as  Demonstrate a showering, sitting to brush expenditure, thereby assisting physiological signs of
walking, carrying decrease in teeth or comb hair, and in equalization of oxygen intolerance as
things or climbing the physiological signs carrying out activities at a supply and demand. evidenced by
stairs become very of intolerance as slower pace such as: absence of
difficult to do if not evidenced by fatigability and
 Rest before, between
with assistance. absence of shortness of breath
and after activities
fatigability and  Divide tasks among
shortness of breath
family members to avoid
unnecessary tasks
 plan activities ahead of
time
 avoiding strenuous
physical activities (no
 pushing, pulling,
climbing up and down
the stairs of lifting heavy
objects)
 keeping necessities close
to the patient’s bed
5. Encourage progressive
activity and self-care when
tolerated. Provide assistance
as needed.
6. Assess patient’s general
condition
Therapeutic:
1. Evaluate accelerating activity
intolerance.
2. Provide assistance with self-
care activities as indicated.
Intersperse activity periods
with rest periods.
3. Assist patient with
ROM exercises. Check
regularly for calf pain and
tenderness.
4. Adjust client’s daily activities
and reduce intensity of level.
Discontinue activities that
cause undesired
5. Gradual activity progression
prevents a sudden increase in
cardiac workload. Provide
assistance only as needed,
which encourages
independence in performing
activities.
6. To note for any abnormalities
and deformities present within
the body.
1. May denote increasing cardiac
decompensation rather than
overactivity.
2. Meets patient’s personal care
needs without undue
myocardial stress and
excessive oxygen demand.
3. To prevent deep vein
thrombosis due to vascular
congestion.
4. Prevents straining and
overexertion which may
aggravate symptoms.
 psychological changes.

5. Instruct client in unfamiliar

activities and in alternate
ways of conserve energy. 5. Conserves energy and promote
safety.

6. Encourage patient to have

adequate bed rest and sleep
and  with a calm and quiet 6. Relaxes the body and
environment. promotes comfort, relaxation
and decreases stress.

7. Provide client with a positive

atmosphere.
8. Instruct the SO to monitor
response of patient to an
activity and recognize the
signs and symptoms.
7. Helps minimize frustration and
rechannel energy.
8. Indicates need to alter activity
level

Collaborative:
1. Refer to cardiac
rehabilitation program.
1. Provides continued support
and additional supervision and
promotes participation in
2. Refer to Physical therapist recovery and wellness process.
for rehabilitation as ordered
2. Provides continued support
and additional supervision and
promotes participation in
activities of daily living.

NURSING SCIENTIFIC
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS RATIONALE
SUBJECTIVE: Imbalanced Anorexia is a disorder SHORT TERM: Establish rapport to the client Good rapport creates a close and SHORT TERM:
Nutrition: Less characterized by an After 8 hours of nursing harmonious relationship with After 8 hours of nursing
Than Body intense fear of obesity intervention the client patients intervention the client was
Requirements or weight gain and the will be able to: be able to:
OBJECTIVE: related to inability or refusal to  Verbalize Measure height, weight, and If these measurements fall  Verbalize understanding
Diminished appetite shortness of breath maintain body weight understanding of tricep skinfold thickness (or below the minimum standards, of nutritional needs.
Anorexic and easy within the normal rage nutritional needs. other anthropometric the patient's chief source of  Establish a dietary
Height: 5 ft 2 inches fatigability as (62-year-old Filipino  Establish a dietary measurements as stored energy (fat tissue) is pattern with caloric intake
Weight: 43kg evidenced by male: 48-59kg) pattern with caloric adequate to
intake adequate to
appropriate). Ascertain depleted. regain/maintain an
BMI: 17.3 weight loss expected for their
regain/maintain an amount of recent weight loss. appropriate weight.
height. This is marked Weigh daily or as indicated.
appropriate weight.  Demonstrate weight gain
by severely restricted
 Demonstrate weight toward the individually
calorie intake, despite
gain toward the expected range.
hunger, which leads to individually expected Metabolic tissue needs are
Encourage patient to eat a  Demonstrate weight gain
malnourishment and range. increased as well as fluids (to
high-calorie, nutrient-rich toward the individually
serious weight loss.  Demonstrate weight eliminate waste products). expected range.
Imbalanced Nutrition: diet, with adequate fluid
gain toward the intake. Encourage use of Supplements can play an
Less Than Body individually expected
Requirements is supplements and frequent or important role in maintaining
range.
evidenced by below smaller meals spaced adequate caloric and protein LONG TERM:
intake. By hospital discharge, the
normal BMI of the throughout the day.
patient has achieved
patient, LONG TERM: adequate nutrition as
By hospital discharge, evidenced by stable
(dre pa ako maaram the patient has These supplements replace
weight, normalization of
how na connect ini ha adequate nutrition as Provide supplemental deficiencies
cor pulmonal pero laboratory values and be
evidenced by stable vitamins and minerals as Oral hygiene minimizes
mayda hadi na basa free of signs of
weight, normalization of prescribed and provide oral anorexia and helps treat malnutrition.
ko: “In advanced laboratory values and hygiene before and after stomatitis, which can occur as a
stages, passive hepatic
be free of signs of meals. side effect of chemotherapy
congestion secondary
malnutrition.
to severe right
ventricular failure may
To ensure compliance with the
lead to anorexia”)
dietary treatment program.
Supervise the patient during For a hospitalized patient with
mealtimes and for a anorexia, food is considered
specified period after meals a medication.
(usually one hour).

Liquids are more acceptable
than solid.
Target weight gain of about
1 kg per week.
If edema or bloating occurs
after the patient has
returned to normal eating
behavior, reassure her that
this phenomenon is
temporary.
Provide small, frequent, and
nutritionally dense meals and
supplemental snacks, as appropriate.
Fluids eliminate the need to
choose between foods –
something the patient with
anorexia may find difficult.
To see the effectiveness of the
treatment regimen.
She may fear that she’s
becoming fat and stop
complying with the plan of
treatment.
Gastric dilation may occur if refeeding
is too rapid following a
period of starvation dieting. Client may
feel bloated for
weeks while body adjusts to increased
food intake.