Name of Patient: Z.

D Age: 42 years old Sex: Female Chief complaint: Irregular contractions coupled with lower back pain
Physician: Dr. Ran Date of Admission: January 15, 2023 Civil Status: Married

DATE AND NURSING GOALS & NURSING RATIONALE EVALUATION

TIME/CUES DIAGNOSIS OBJECTIVES INTERVENTIONS

January 15, 2023 Decreased Activity After the 8 hours span INDEPENDENT INDEPENDENT
(8:00 am) Tolerance related to of care: 1. Assess the 1. To know what January 15, 2023
oxygen supply patient’s ability to activity to avoid and “GOAL MET”
Subjective: imbalance as SHORT TERM GOAL: perform a task and allow with
● Patient report evidenced by ● Patient will note for activities assistance After the 8 hours span
of dizziness fatigue learn the that she can’t 2. To encourage the of care:
before the basic tolerate patient for a better
admission Scientific Basis: methods of 2. Discuss and lifestyle as her daily SHORT TERM
● The patient Activity Intolerance effective recommend exercise activity ● Patient reported of
reports is the inability of an breathing activities that would 3. As it promotes improved breathing
difficulty individual to perform technique be beneficial for her good circulation, through effective
breathing or complete ● Patient will health such as thus promotes breathing methods
when lying flat necessary activities report exercises. oxygen transport such as: Inhale deeply
on bed and due to insufficient decrease of 3. Encourage the and good through your nose and
doing physical or fatigue and patient to ambulate respiratory function out through your mouth
household psychological increase of as soon as possible 4. To allow an ● Patient reported to
activity, once energy. This activity 4. Provide a good adequate comfort have lessened the
in a while. insufficient energy tolerance environment for the and effective feeling of fatigue with
● Patient to endure or ● Patient will patient to rest and relaxation improvement of activity
expresses complete required follow a make her time 5. To have a baseline tolerance such as
fatigue or desired activities modified diet alone data and to patient can now
which may be is plan ordered 5. Monitor hemoglobin determine the ambulate and walk
Objective: caused by by the doctor level of the patient response to the through long distances
● Pallor increased blood and the 6. Monitor input and treatment ● Patient followed a
● Tachycardia pressure and blood physician output of the patient 6. To know any modified diet plan from
 ● Low viscosity and that 7. Advise the patient patterns and the dietician such as:
hemoglobin may lead to LONG TERM to increase fluid determine any eating healthy green
level decreased oxygen GOALS: intake possible leafy vegetables and
● Respiratory supply in the blood ● Achieve a complications fruits and increasing
disorder vessels, and then normal DEPENDENT 7. To rehydrate and fluid intake
(tachypnea) manifests as body hemoglobin 8. Give medication for improve blood
● Sedentary weakness. level iron deficiency and circulation LONG TERM
lifestyle ● Improve vitamins as ordered ● Patient’s hemoglobin is
● Vital Signs respiratory by the physician DEPENDENT in a normal range (from
- BP 130/80 condition 9. Administer fluid and 8. To improve 11.1 to 13.5)
mmHg ● Patient will electrolytes hemoglobin level ● Patient reported of
- HR 99 bpm carry on daily COLLABORATIVE thus improving improved respiratory
- RR 23 cpm activities 10. Discuss and respiratory condition “I can breathe
without collaborate with a conditions and well na kahit nakahiga”
discomfort dietician about the cardiac output ● Patient verbalized
● Patient will appropriate diet for 9. To help ensure and “nagagawa ko na mga
practice the patient adequate fluid normal na gawain ko
active lifestyle 11. Discuss and volume restoration without fatigue or
encourage the panghihina”
patient to partake in COLLABORATIVE ● The patient reported to
healthy lifestyle 10. For more effective engage in aerobic
organizations for and appropriate exercises once a day.
long term health. diet nutrition
11. To enhance Student Nurse:
socialization as well
as improving health
in long term

Mary Alliza De Polonia

REFERENCES:
Doenges, M.E., Moorhouse, M.F., Murr, A.C., Nursing Care Plans:guidelines for individualizing client care across the life span (10th
edition), Nursing Care Plans - D.M.M (wps.com)

Herdman, T.H., Kamitsuru, S., Lopes, C.T., Nursing Diagnoses 2021–2023 PDF,
NANDA Nursing Diagnoses 2021 - 2023 (wps.com)