Patient’s Name: X

Nursing Diagnosis: Activity intolerance r/t imbalance between oxygen supply/demand as evidenced by weakness.
Submitted by: Estoya, Gen Paulo C.
Reference: https://nurseslabs.com/
ASSESSMENT PLANNING/GOAL IMPLEMENTATION RATIONALE EVALUATION GOAL
Desired Outcome Independent/Dependent Reason for the Intervention Expected Outcome MET
Nursing Intervention
Pertinent Data: Patient will: Nurse will: Why: Positive result: Yes/No
Subjective:  Participate in desired  Monitor and evaluate  Vital signs and oxygen  Patient now can participate 
 Fatigue activities; meet own the patient’s saturation levels should be in desired activities; met
 Weakness self-care needs. response to monitored before, during, and own self-care needs.
 Discomfort activities. immediately after activity to
 Achieve measurable determine whether they are  Patient achieved
Objective: increase in activity within the desired range. measurable increase in
 Abnormal heart tolerance, evidenced activity tolerance,
by reduced fatigue  Consider the use of  6MWT is an exercise test that evidenced by reduced
rate/bp in response
and weakness and by the 6-minute walk entails measuring the distance fatigue and weakness and
to activity.
vital signs within test (6MWT) to walked over a span of 6 minutes by vital signs within
 ECG change acceptable limits determine the (Enright, 2003). It helps gauge acceptable limits during
 Dyspnea during activity. patient’s physical the patient’s cardiopulmonary activity.
ability. response.

 Evaluate accelerating  May denote increasing cardiac

activity intolerance. decompensation rather than
overactivity.

 Assist with self-care  Assisting with ADLs ensure that

activities as the patient’s need is met while
necessary. reducing cardiac workload. As
Encourage much as possible and as
independence within tolerated by the patient, involve
prescribed limits. them in promoting a sense of
control and reducing
helplessness.

 Slow the pace of  Allow the patient extra time to

 care and provide carry out physical tasks,
adequate rest before especially on geriatric clients.
and after periods of Older patients are more
exertion (e.g., vulnerable to falls and injuries
bathing, eating, due to decreased muscle
exercise). strength, reduced balance, etc.

 Organize nursing  Intersperse activity periods with

care activities to rest periods by developing a
allow rest periods. schedule that promotes pacing
and prioritizes activities to meet
the patient’s personal care needs
without undue myocardial stress
and excessive oxygen demand.

 Implement a graded  Strengthens and improves

cardiac rehabilitation cardiac function under stress if
program. cardiac dysfunction is not
irreversible. Gradual increase in
activity avoids excessive
myocardial workload and
oxygen consumption. Cardiac
rehabilitation offers an effective
model of care for older patients
with heart failure.

 Adjust the client’s  It prevents straining and

daily activities and overexertion, which may
reduce the intensity aggravate symptoms. Stop all
of the level. activity if severe shortness of
Discontinue breath, pain, or dizziness
activities that cause develops.
undesired
physiological and
psychological
changes.
 Encourage patient to
have adequate bed  It relaxes the body and promotes
rest and sleep comfort. Temporary bed rest
should also be implemented
during an acute exacerbation of
heart failure symptoms.
 Initiate interventions
and safeguards to  Interventions include:
promote safety and  Assist the patient during
prevent risk for ambulation, if necessary.
injury during activity  Ascertain the patient’s
ability to stand and move
about and degree of
assistance needed or use of
movement aids or
equipment.
 Instruct or demonstrate
physical activities that may
be unfamiliar with the
patient.
 Start with warm-up activity
and end with cool-down
activities.
 Avoid performing physical
activities outside extreme
temperatures or during
humid weather.
 Wait 2 hours after eating a
meal before performing a
physical activity.

 Encourage the client

to maintain a  It helps enhance the patient’s
positive attitude; sense of well-being and raises
provide evidence of the patient’s motivation and
daily or weekly morale. Motivation is necessary
progress. for patients with HF who are
attempting to become more
physically active but may not be
sufficient to initiate physical
activity. In addition to a high
level of motivation to be
physically active, patients with
HF must have a high degree of
self-efficacy