Name: Franzi Alyanna A.

Mugar
Clinical Instructor: Ms. Anne Jillian RN NURSING CARE PLAN Section & Group: BSN4F Group 3 ICU3 - TDHI(Batch 2)
 Assessment Cues Nursing Diagnosis (Rationale) Desired Outcome Nursing Intervention Justification Evaluation
Pathophysiologic / Schematic Diagram
Subjective: Activity intolerance After 8 hours of After 8 hours of
 Fatigue related to cardiac Predisposing Precipitating nursing nursing intervention,
 Generalized depressant drugs as Factors: Factors: intervention, the the patient was able
weakness evidenced by -Female -Immobility patient will be to:
 Exertional generalized weakness -71 yrs old -Hypertension able to: Dependent:
Discomfort -Genetics -Diabetes
Definition: -Family history: Mellitus Type 2 1. Gain an Determine vital signs To provide a baseline for 1. Gain an adequate
Objective: Insufficient siblings: diabetes -Sedentary adequate energy including cognitive status comparison to monitor and energy level and
 Patient nauseous physiological or and hypertensive lifestyle level and evaluate response to perform desired
 Cold clammy psychological energy to -Single -Bedridden perform desired interventions activities with
skin endure or complete -Physical activities with minimal help and
 Limited range required or desired deconditioning minimal help Document heart rate, rhythm Patient’s response to activity supervision.
of motion daily activities. -Diagnosis: ACS- and changes in BP before, may require decrease in GOAL
and supervision
NSTEMI; CAP- during, and after activity. activity level and/or return to PARTIALLY MET
Abnormal Findings: MR, DMT2-NIR; Correlate with reports of bedrest, changes in
 Latest Vital Source/Reference: Complicated UTI chest pain or shortness of medication regimen, or use
Signs: Doenges, M.E., breath. of supplemental oxygen.
BP - 140/80 Moorhouse, M.F., and
mmHg; Murr, A.C. (2019). 2. Ability to Note for progressing Prolonged bed rest or
Nurse’s pocket guide tolerate activity thrombophlebitis (e.g., calf immobility allows clot 2. Ability to tolerate
Bacterial or viral respiratory pathogens activity without
 RBS: 71mg/dL 15th Edition. without pain, redness, localized formation
Philadelphia, symptoms of swelling, a rise in symptoms of
Pennsylvania: F.A. generalized temperature). generalized
Strengths: Davis Infection of the lung (coughing) weakness, fatigue
weakness,
1. Strong faith in Company.NANDA Check for skin integrity for Routine inspection of the and discomfort.
fatigue and
God (church signs of redness and tissue skin (especially over bony
discomfort GOAL
staff) Community-Acquired Pneumonia- ischemia (especially over prominences) will allow for
Moderate Risk ears, shoulders, elbows, prevention or early PARTIALLY MET
2. Supportive sacrum, hips, heels, ankles, recognition and treatment of
niece/nephew and toes). pressure ulcers.
and neighbor Plaque rupture and formation of
thrombus 3. Participate in Provide safe environment: These measures promote a
3. Optimistic the therapeutic bed rails up, safe, secure environment and
may reduce risk for falls. 3. Participate in the
(Strong regimen therapeutic
independent Decreased blood flow to part of heart (tolerable ROM
Execute tolerable or limited Exercise enhances increased regimen (tolerable
woman) musculature (chest pain/angina) exercises)
ROM exercises to all venous return, prevents ROM exercises)
extremities. stiffness, and maintains
Weaknesses: GOAL
muscle strength and stamina.
1. Lack of Acute Coronary Syndrome - Non ST- It also avoids contracture PARTIALLY MET.
knowledge segment elevation myocardial infarction deformation, which can build
2. No children up quickly and could hinder
prosthesis usage.
3. Time Hospitalized: Generalized weakness,
management bedridden, physical deconditioning Turn and position the patient Position changes optimize
every 2 hours or as needed. circulation to all tissues and