Central Philippine Adventist College

SCHOOL OF NURSING
CLINICAL DIVISION
Bacolod Adventist Medical Center Compound C.V. Ramos Avenue Taculing, Bacolod City
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
Website: www.cpacsn.info ♦ Email: inquiry@cpacsn.info

NURSING CARE PLAN

Cues Actual/Potential Expected Outcome Nursing Orders Rationale Evaluation

Nursing Diagnosis (SMART) (OME)
Activity Intolerance Short-term goal Observation
S - Patient verbalized related to muscular - Observe and document - Close monitoring will After 4 hours of nursing
tiredness weakness After 4 hours of nursing response to activity serve as a guide for interventions, the client
secondary to interventions, the client optimal progression of demonstrated active
O– hyperaldosteronism will be able to activity participation in
Fatigue demonstrate active Management necessary and desired
participation in Independent activities
Overwhelming lack of energy necessary and desired - Assess the patient’s - To create a baseline of
activities activities of daily living, as activity levels and mental
Generalized weakness well as actual and status related to fatigue
perceived limitations. Ask and activity tolerance
Shortness of breath upon Long-term goal for any form of exercise
exertion that she used to do or After 8 hours of nursing
After 8 hours of nursing wants to try interventions, the client
interventions, the client - Provide adequate - To allow enough reported an increased
will be able to report an ventilation in the room oxygenation in the room tolerance to perform
increased tolerance to activities
perform activities - Have the patient perform - Helps in increasing the
the activity more slowly, in tolerance for activity
a longer time with more
rest or pauses, or with
assistance if necessary
- Gradually increase - Gradual progression of
activity with active range- the activity prevents
of-motion exercises in bed, overexertion
increasing to sitting and
 then standing
- Provide bedside
commode as indicated
Collaborative
- Refer the patient to
physiotherapy/
occupational therapy team
as required
Education
- Encourage progressive
activity through self-care
and exercise as tolerated.
Explain the need to reduce
sedentary activities such
as watching television and
using social media on long
periods. Alternate periods
of physical activity with 60-
90 minutes of undisturbed
rest
- Teach deep breathing
exercises and relaxation
techniques.
- Teach the patient and/or
SO to recognize signs of
physical overactivity or
overexertion.
Reference:
https://nurseslabs.com/activity-
intolerance/
- Use of commode
requires less energy
expenditure than using a
bedpan or ambulating to
the bathroom
- To provide a more
specialized care for the
patient in terms of
helping her build
confidence in increasing
daily physical activity
- To gradually increase
the patient’s tolerance to
physical activity
- To allow the patient to
relax while at rest and to
facilitate effective stress
management
- Knowledge promotes
awareness to prevent the
complication of
overexertion