NURSING CARE PLAN

CUES/NEEDS NURSING SCIENTIFIC OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS BASIS
Subjective: Activity intolerance Activity General:
“NONE” related to imbalance intolerance is a After nursing intervention,
between oxygen classic sign of the patient will be able to
Objective: supply and demand patients with increase their activity level to
- Abnormal as evidenced by cardiomyopathy perform desired activities.
blood reports of fatigue and along with other
pressure weakness symptoms like Specifically the patient will Independent: Independent:
response dyspnea at rest be able to:
to activity or on exertion, 1. Understanding of 1. Establish rapport to the 1. To promote effective
fatigue, and potential loss of patient. communication and
- Abnormal orthopnea. This ability in relation to effective patient
heart rate is a direct result existing condition outcomes.
response of decreased
to activity cardiac function. 2. Identify alternative 2. Assess cardiopulmonary 2. Dramatic changes in
ways to maintain response to physical heart rate and rhythm,
- exertion desired activity level activity, including vital changes in blood
discomfort signs (Blood Pressure, pressure, and
3. Indicates decrease pulse, and respirations) progressively
- Exertion in physiological during and after activity. worsening fatigue
dyspnea signs of intolerance, result from an
such as pulse, imbalance of oxygen
- Expresses respiration, and supply and demand
fatigue blood pressure is
still within the
normal range. 3. Determine current 3. To provide baseline for
activity level and comparison and an
physical condition with opportunity to track
observation, exercise- changes
capacity testing, or use
of functional level of
classification system, as
appropriate

4. Provide or recommend 4. Although help may be

assistance with activities necessary, self-
 and ambulation as
necessary, allowing
client to be an active
participant as much as
possible.
esteem is enhanced
when client does some
things for self.

5. Identify and implement 5. To encourage client to

energy-saving do as much as
techniques possible, while
conserving limited
energy and preventing
fatigue.

6. Instruct client in proper 6. To conserve energy

performance of and promote safety.
unfamiliar activities and
in alternate ways of
doing familiar activities.

7. Identify and discuss 7. To provide timely

symptoms for which intervention.
clients need to seek
medical
assistance/evaluation.

Collaborative:
1. To sustain activity
1. Refer to appropriate level
resources for assistance
and/or equipment, as
ordered.