Assessment

Subjective: “nahilo ug luya sya permi maam” as verbalized by SO.

Objective

Restlessness noted

Ambulatory with assistance

Temperature – 38.1OC

Pulse rate – 92 bpm

Respiratory rate – 32 cpm

Blood Pressure – 90/60 mmHg

Diagnosis

Activity intolerance related to imbalance between oxygen supply (delivery) and

demand

Planning

Within 8 hrs of rendering nursing intervention, patient will Report an increase in activity
tolerance including activities of daily living

Intervention

DEPENDENT RATIONALE

Monitor hemoglobin, hematocrit, RBC Decreased RBC indexes are associated with

counts, and reticulocyte counts.
decreased oxygen-carrying capacity of the
blood. It is critical to compare serial laboratory
values to evaluate progression or deterioration
in the client and to identify changes before they
become potentially life-threatening.

INDEPENDENT RATIONALE

Assess patient’s Influences choice of interventions or

ability to perform normal task or activities needed assistance.
of daily living.
 Recommend quiet atmosphere, bed rest Enhances rest to lower body’s oxygen
if indicated. requirements, and reduces strain on the heart and
lungs.

Assist with activity/progressive ambulation. Until activity is limited and advanced slowly
according to individual tolerance

Elevate the head of the bed as tolerated. Enhances lung expansion to maximize oxygenation
for cellular uptake.

COLLABORATIVE RATIONALE

Monitor the laboratory result To decrease swelling related to the build-up of

fluid with the help of the therapist.

Evaluation

Goal met. After 8 hrs of rendering nursing intervention, patient was able to participate in
ADLs (activities of daily living) and desired activities.