Assessment Nursing

Name of student: Eyanah Diagnosis

S. Delos Reyes (Rationale) Desired Nursing Section Justification
and group number: BSN 4EEvaluation
Group 1
Cues
Name
NURSING CARE
of CI: Ma. Teresa Severino, RN, MN
PLAN
Pathophysiologic / Schematic Outcome Intervention Area of exposure: Surgical ward
Diagram
Subjective: Decreased activity Short term goal:
intolerance related to After 8hours of Independent
“Medyo
surgical incision site as intervention: To gain patient`s
nahihirapan po
evidenced by limited Diet Establish rapport cooperation and
akong gumalaw
mobility. Female The patient will be motivation.
dahil sa operasyon Lifestyle able to execute
or tahi ko”
39 years Low HDL early ambulation. Monitor vital Vital signs may be
old cholesterol signs/cognitive signs altered in response
Patient will be able to activity
level
to demonstrate
methods of Assess the physical To provide baseline
controlled breathing activity level and information for
Objective: technique to mobility of the patient. formulating nursing
 Facial Cholelithiasis conserve energy. goals and to help
grimace guide nursing
when
Definition:
interventions.
moved The patient will be
Decreased Activity
 Pain scale Gallstones in the bile duct able to participate Encouraged and assist Assistive ambulation
Tolerance related to
8/10 willingly in to ambulate the patient enhances the
decreased cardiovascular
 Limited necessary activities. a few hours after the mobility of the
function, imbalanced,
mobility surgery or the patient by helping
oxygen supply and
 Guarded Increased bile cholesterol following day. him overcome
demand, as evidenced by
movement Long term goals: limitations.
fatigue, shortness of
 Vs: After 4 days of
breath, and generalized
T- 36.2 intervention: Promote comfort Help minimize
weakness during physical
PR - 66 Surface changes measures and provide frustration and
activity secondary to
RR – 20 The patient will be relief of pain by rechannel energy
heart failure.
O2 sat – able to maintain encouraging deep
95% activity level with in breathing exercises.
BP – 110/75 Increase mucus secretion capabilities.

Patient will be able Assess the patient’s Adequate energy

to describe adaptive nutritional status. reserves are needed
techniques to during activity.
perform activities of
Impaired gallbladder implying daily living. Observe and monitor
 the Sleep deprivation
Source/Reference patient’s sleep pattern and difficulties during
and the amount of sleep can affect the
NANDA sleep achieved over the activity level of the
Precipitate out of the bile past few days. patient.
Strength:
The aim is not to tire
Family and God
Evaluate their gait, and out the patient but to
Form small crystals into gallbladder’s always remain by the improve circulation
Weakness: mucosa surface patient’s side until and rehabilitate
Pain and limited they’re fully stable. them to their
movement everyday mobility.
Independent
Enlarges to groslly visible stone
Administer medication For faster recovery.
as ordered.

Several stones develop Collaborative

To develop
Provide referral to individually
Sudden and rapidly intensifying pain other disciplines as appropriate
in the right upper quadrant, nausea indicate (e.g., Physical therapeutic
and vomiting, backpain between therapist and regimens.
shoulder blades. occupational therapist).

Decrease activity intolerance

Reference:
2023.Nurses labs. Activity intolerance
pathophysiology.
https://nurseslabs.com/activity-
intolerance/