ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE Activity At the end of 8  INDEPENDENT:  INDEPENDENT: At the end of
DATA: intolerance hours Nursing 8 hours
“Nanghihina at related to interventions  Checked vital signs  Orthostatic hypotension Nursing
nahihilo pa rin decrease the patient before and can occur with activity interventions
ako”, as cardiac should be able immediately after because of medication the patient
verbalized by output. to: activity, especially if effect (vasodilation), was able to:
the patient. Participate in the patient receives fluid shifts (diuresis), or Participated in
desired vasodilators, diuretics, compromised cardiac desired
OBJECTIVE activities; meet or beta-blockers. pumping function. activities;
DATA: own self-care meet own
 + Mitral needs.  Documented  Compromised self-care
valve Achieve cardiopulmonary myocardium and needs but still
replacement measurable response to activity. inability to increase with a little bit
 Dyspnea increase in Note tachycardia, stroke volume during of fatigue and
during activity dysrhythmias, activity may cause an body
activity tolerance, dyspnea, diaphoresis, immediate increase in weakness
 Abnormal evidenced by pallor. heart rate and oxygen during
Vital Signs: reduced fatigue demands, thereby activities.
BP: 80/60 and weakness aggravating weakness Achieved
HR: 105bpm and by vital and fatigue. measurable
RR:13cpm signs within increase in
 Assessed for other  It can cause fatigue as a
acceptable activity
causes of fatigue side effect. Pain and
limits during tolerance,
(treatments, pain, stressful procedures can
activity. evidenced
medications). also diminish the
Verbalize normal vital
Medications such as patient’s energy can
understanding signs within
beta-blockers, cause fatigue.
of potential acceptable
tranquilizers, and
loss of ability limits during
sedatives  Age, pain, breathing
in relation to activity but
 Identified factors that problems, impaired
existing still with a
could affect the visual
condition. little bit of
desired level of acuity, hearing problems, fatigue and
activity and functional decline, etc.,
 motivation. are all factors that could weakness
hinder interventions during
from improving activity activity.
tolerance.
BP: 90/60
 Vital signs and oxygen HR: 100bpm
saturation levels should RR:16cpm
 Monitored and be monitored before,
evaluated the patient’s during, and immediately
response to activities. after activity to Verbalized
determine whether they understanding
are within the desired of potential
range.  loss of ability
in relation to
 6MWT is an exercise existing
 Considered the use of test that entails condition.
the 6-minute walk test measuring the distance
(6MWT) to determine walked over a span of 6
the patient’s physical minutes (Enright, 2003).
ability within his/her It helps gauge the
limitations and as patient’s
tolerated. cardiopulmonary
response.

 Evaluated accelerating  May denote increasing

activity intolerance. cardiac decompensation
rather than overactivity.

 Assisted with self-care  Assisting with ADLs

activities as necessary. ensure that the patient’s
Encourage need is met while
independence within reducing cardiac
prescribed limits. workload. As much as
possible and as tolerated
 by the patient, involve
them in promoting a
sense of control and
reducing helplessness.
 Slowed the pace of  Allow the patient extra
care and provide time to carry out
adequate rest before physical tasks, especially
and after periods of on geriatric clients. 
exertion (e.g., bathing,
eating, exercise).

 Organized nursing  Grouping nursing care

care activities to allow allows adequate time for
rest periods. the patient to recharge.

 Adjusted the client’s  It prevents straining and

daily activities and overexertion, which may
reduce the intensity of aggravate symptoms.
the level. Discontinue
activities that cause
undesired
physiological and
psychological
changes.
 It relaxes the body and
 Encouraged patient to promotes comfort.
have adequate bed rest
and sleep; provide
a calm and quiet
environment.  To promote safety and
prevent risk for
 Initiated interventions
injury during activity.
and safeguards to
promote safety and
prevent risk for
injury during
activity. Interventions
include:

 Assisted the
patient during
ambulation, if
necessary.

 Ascertained the
patient’s ability to
stand and move
about and degree
of assistance
needed or use of
movement aids or
equipment.

 Instructed or
demonstrate
physical activities
that may be
unfamiliar with the
patient.

 Started with warm-

up activity and end
with cool-down
activities.

 Avoid performing
 physical activities
outside extreme
temperatures or
during humid
weather.

 Waited 2 hours
after eating a meal
before performing
a physical activity.  It helps enhance the
patient’s sense of well-
 Encouraged the client being and raises the
to maintain a positive patient’s motivation and
attitude; provide morale.
evidence of daily or
weekly progress.  COLLABORATIVE:

 COLLABORATIVE:  Strengthens and

improves cardiac
 Implemented a graded function under stress if
cardiac rehabilitation cardiac dysfunction is
program. not irreversible. 
MA. ANGELICA CLYNNE S. URBI- BSN5 OR ACTIVITY GROUP-C
NURSING CARE PLAN