ASSESSMENT EXPLANATION OF THE
PROBLEM/ pathophysiology
S: “my breasts are Risk for activity intolerance as
sore and tender but defined by NANDA is vulnerable
there is no milk to experiencing insufficient
coming out and Im physiological or psychological
also in pain due to energy to endure or complete
uterine cramping ” required or desired daily
as verbalized by the activities, which may
patient. compromise health.
As for the condition of the
patient, one of her main concern participate in self-care
is pain because there is a qi and activities
blood deficiency that causes
weak body, blood loss, blood and
O: T=36.5 , qi weakening and blood that
BP=110/80,
cannot move causing poor blood
RR=14, flow and lack of nourishment
O2 Sat= 94% that brings up pain and the qi
PR=78 deficiency opens the blood
chamber and receives cold –
>edematous
blood clotting, obstructed
perineum , as
placental membranes in the
examined
uterus, emotional disorders- liver vital signs during
qi stagnation leading to blood
>Cannot perform
stasis and blocking that causes
ADL’s alone
general activation of immune
> facial grimacing system leading to signs and
symptoms such as pain , uterine
OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
GOAL: DX:
>Note presence of acute or chronic >. Many factors can
illness, , pregnancy-induced cause or contribute to
STO: STO:
hypertension, and acute and chronic fatigue, having
After 6 hours pain potential to interfere
of effective nursing with client’s ability to
perform at a desired Goal met if patient,
interventions, the
patient will be able to level of activity.
will be able to do ADL’s
do ADL’s alone and to However, the term
alone and to participate
“activity intolerance”
in self-care activities
implies that the client
cannot endure or adapt
to increased energy or
oxygen demands Goal partially met if
LTO: patient,
caused by an activity
After 2 days of effective >Ask client/significant other (SO) >to identify potential Will be able to do some
nursing interventions, about usual level of energy problems and/or ADL with the help of
the patient will be able
client’s/SO’s significant others.
to maintain activity
perception of client’s
level within capabilities Goal not met if patient,
energy and ability to
as evidenced by normal
perform needed or Will not be able to do
desired activities. ADL’s alone and to
activity, as well as
participate in self-care
absence of weakness,
activities
pain, and difficulty
>Note client reports of weakness, >Symptoms may be a
accomplishing tasks
fatigue, pain, difficulty accomplishing result of or contribute
>irritability cramping ,fever, chills, chest
pain , fatigue, and muscle
constrain and if this
manifestation wouldn’t be given
appropriate nursing intervention
Nursing Diagnosis: it will lead to risk for activity
intolerance. A risk diagnosis is
 Risk for Activity
not evidenced by signs and
Intolerance related
symptoms as the problem has
to decreased energy
not yet occurred; rather, nursing
requirements as
interventions are directed at
evidenced by
prevention.
decrease muscle
strength
tasks, and/or insomnia. to intolerance of
activity
>to determine current
>Ascertain the client’s ability to stand LTO:
status and needs
and move about and the degree of associated with
assistance necessary or use of
participation in
equipment needed/desired GOAL met if patient,
activities.
will be able to maintain
activity level within
capabilities as evidenced
> Determine the client’s current >This provides a by normal vital signs
baseline for
activity level and physical condition during activity, as well
with observation, exercise-capacity comparison and an as absence of weakness,
testing, or use of a functional-level opportunity to track pain, and difficulty
classification system (e.g., Gordon’s), changes accomplishing tasks.
as appropriate
GOAL partially met if
TX: >to prevent patient,
>Reduce intensity level or discontinue overexertion Will be able to maintain
activities that cause undesired activity level within
physiological changes capabilities as evidenced
>This helps to minimize by normal vital signs
> Provide positive atmosphere while
frustration and during activity, but still
acknowledging the difficulty of the
situation for the client. rechannel energy. have presence of
weakness, mild pain,
and difficulty
 >to enhance ability to accomplishing tasks.
>Promote comfort measures and participate in activities
provide for relief of pain . GOAL not met if patient,

Will not be able to

>to conserve energy maintain activity level
>Instruct client in proper performance and promote safety within capabilities as
of unfamiliar activities and in alternate evidenced by normal
ways of doing familiar activities vital signs during
activity, as well as
Edx: presence of weakness,
>Understanding this pain, and difficulty
> Discuss with client/SO(s) the relationship can help accomplishing tasks.
relationship between illness or with acceptance of
debilitating condition and the ability limitations or reveal
to perform desired activities opportunity for
changes of practical
value

>This promotes the

>Plan for maximal activity within the idea of normalcy of
client’s ability progressive abilities in
this area.

>To promote wellness

> Instruct client/SO(s) in monitoring

response to activity and in recognizing
signs/symptoms that indicate need to
alter activity level.

>Both activity tolerance

 and health status may
> Plan for progressive increase of improve with
activity level/participation in exercise progressive training.
training, as tolerated by client.
> to sustain motivation

>Give client information that provides

evidence of daily/ weekly progress