NURSING CARE PLAN
Nursing diagnosis #3: Activity Intolerance related to imbalance in oxygen supply
and demand as evidenced by generalized body weakness and low blood pressure
Goal: To restore tolerance to activity
Expected Outcomes: At the end of 8 hours shift, the client will be able to:
a)Report increase in activity tolerance
b) Eliminate the factors that lead to activity intolerance
c)Participate willingly in necessary and desired activities
Nursing Interventions Nursing Evaluations
Promotive/ Preventive
1. Monitor vital signs hourly Latest vital signs as of January 28,2010
Rationale:. To serve as a baseline in are as follows:
the possible activities that the patient Temperature of 35.8 ºC, Respiratory rate of
can tolerate 17 cpm , Pulse rate of 85 bpm and Blood
pressure of 80/60 mmHg.
2. Adjust and space nursing activities Patient was able to rest between activites
according to patient’s tolerance such as bed bath and internal jugular vein
Rationale: To prevent overexertion insertion
3. Elevate the head part of the bed to Patient was able to tolerate the position and
semi-Fowlers to High-Fowlers verbalized preference for such position
position.
Rationale: To promote physiological
and psychological ease of maximal
inspiration.
4. Increase levels of activity gradually Patient was able to tolerate passive range
such as passive range of motion of motion exercises and verbalized increase
exercises but take note to also conserve in energy after doing the exercises
energy
Rationale: To promote circulation and
oxygenation
5. Encourage to have enough rest for 2-3 Maintained in complete bed rest. Well-
hours and limit activities to level of rested
respiratory tolerance.
Rationale: To prevent fatigue.
NURSING CARE PLAN
Curative
6. Assisted in administering Patient was able to verbalize more
bronchodilators as ordered tolerance to activities after the
Rationale: To promote oxygenation administration of medications