Activity Intolerance
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Independent:
Subjective Wholly Allow for rest -Promotes rest and
compensatory periods between conserves energy.
“J. takes thirty to Short term
care; disturb only
forty minutes to take Short term
when necessary
two to three ounces Goal met
After 8 hours of for care and
of formula” as
nursing intervention procedures. Patient condition improved
verbalized by the
mother the patient should as evidenced by normal
demonstrate a Monitor heart rate, - To monitor and
pulse rate, respiratory rate,
decrease in respiratory rate, obtain basic
and blood pressure.
physiological signs and blood indicators of a
Objective of activity pressure. patient's health
intolerance. status and to
● HR: 195 at rest compare baseline. Long term
us Long term
● RR: 70 (rapid -to conserve patients Goal met
Avoid allowing
breathing) After 1 week of energy
the infant to cry
● BP: 120/80 nursing intervention
for long periods The patient’s condition
● Appears weak the patient will show
of time, improved as evidenced by
● gets damp and physical
sweaty when manifestations of
Position patient to
she feeds measurable increase - Upright position is
semi-fowlers
in activity tolerance. recommended to
position.
reduce preload and
ventricular filling
when fluid overload
is the cause;
Nursing Diagnosis
Facilitates lung
Activity Intolerance expansion.
related to imbalance
between oxygen -This provides a
supply and demand. Watch out for baseline for
client’s current comparison and an
activity level and opportunity to track
physical condition changes.
with observation.
-To help reduce
Plan care to weakness and
carefully balance fatigue.
rest periods with
activities.
- This helps to
Provide pleasant minimize frustration
environment. and rechannel
energy.
Instruct the parents -to avoid fatigue
the need of the
client to conserve
energy and
encourage rest.
- It is needed because
Dependent the failing heart may
Provide and not be able to
monitor response respond to increased
to supplemental oxygen demands.
oxygen,
medications, and
changes in
treatment regimen
as prescribed.
-to evaluate more about
Collaborative:
J.T’s condition
·Collaborate with
regarding her activity
J.T’s cardiologist
intolerance and to
about her
develop individually
condition
appropriate therapeutic
regimens.
Decreased Cardiac Output
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Independent:
Subjective Wholly compensatory Short term
Position patient to - This decreases oxygen
“J. gets damp and Short term goal Goal met:
semi-fowlers consumption and the
sweaty when she feeds“
After 8 hours of nursing position. risk of After 3 days of nursing
as verbalized by the
intervention J.T. will decompensation. interventions, J.T.
mother.
display hemodynamic achieved hemodynamic
stability. Keep patient on - Rest is necessary for stability, as evidenced
bed rest and energy conservation. by normal heart rate,
Objective Data Long term goal monitor sleep decreases metabolic increase in activity
patterns. rate, decreasing tolerance and normal
● HR: 195 at rest After 1 week of nursing myocardial and urinary output.
us intervention patient will oxygen demand.
● RR: 70 per/min demonstrate Long term
● BP: 120/80 will demonstrate - to promote adequate
Provide a quiet
● decreased urine adequate cardiac output. rest Goal partially met:
environment.
output (fewer
wet diapers) The patient’s condition
-vital signs indicate
● appears weak has improved as
Monitor vital signs how well circulation
evidenced by blood
frequently and perfusion are
pressure and pulse rate
working. Consistent
and rhythm within
or abrupt changes in
normal parameters for
the patient's VS may
patient; strong
indicate an
peripheral pulses; and
unresolved or
Nursing Diagnosis an ability to tolerate
worsening disease.
Decreased Note skin color, - A compensatory activity without
Cardiac Output temperature, and increase in symptoms of dyspnea,
related to moisture. sympathetic nervous and chest pain.
structural factors system activation,
of congenital reduced cardiac
heart defect output, and oxygen
desaturation which
causes cold, clammy,
and pallid skin
Assess urine output - In order to monitor if
hourly or there’s an adequate
periodically; weigh output, avoid fluid
daily, noting total overload and allow for
fluid. timely alterations in
therapeutic regimen
Check for peripheral - Weak pulses are
pulses, including present in reduced
capillary refill. stroke volume and
cardiac output.
- Fatigue and exertional
Check out for any dyspnea are common
reports of fatigue problems with low
and reduced activity cardiac output states.
tolerance Close monitoring of
the patient’s response
serves as a guide for
optimal progression of
activity.
Dependent
-The failing heart may
Administer oxygen
not be able to respond
therapy as
to increased oxygen
prescribed.
demands.
Administer medications
as prescribed:
- Increases
Digoxin (Lanoxin) contractility of the
60 mcg PO now, heart and force of
then 20 mcg PO contraction.
every 12 hours
- Decreases edema
Furosemide (Lasix) formation and
PO 4 mg now, then diminishes afterload.
every 12 hours
- Cardiac dysrhythmias
Monitor may occur from low
electrocardiogram perfusion, acidosis, or
(ECG) for rate, hypoxia. Tachycardia,
rhythm, and ectopy bradycardia, and
ectopic beats can
as ordered by the
physician. further compromise
cardiac output.
Collaborative: -to help evaluate more
Refer to J.T.’s about the patient's
cardiologist about condition.
her condition.
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Short term goal Independent Short term
After 8 hours of nursing Wash hands or -Hand washing is an Goal met
interventions the patient perform hand hygiene effective technique to The patient has prevented
will be free of purulent before having contact prevent the spread of infection as evidenced by
with the patient.
Objective Data drainage and erythema and infection. Dry surfaces are absence of purulent
Post cardiac will remain afebrile. better in preventing the drainage absence of
catheterization. achieve timely wound transfer of erythema and remains
healing. microorganisms. afebrile.
Nursing Diagnosis Change surgical or - To avoid introducing Long term
Risk for infection related Long term goal other wound dressings infections into a wound. Goal partially met
using aseptic
to Invasive procedure After 5 weeks of nursing the patients improved as
techniques
intervention, the patient evidenced by
will Cleanse incisions and - To reduce the potential
insertion sites per for catheter-related
facility protocol with bloodstream infections,
appropriate and to prevent the growth
antimicrobial topical of bacteria.
or solution
Monitor patient for - It could be signs of
changes in skin color, developing localized
temperature and infection.
warmth at insertion
sites or wounds.
Monitor for changes in - indicates onset of
color and/or odor of infection.
secretions, from the
wound drains or
invasive tubes
Monitor the patient for - These are the classic
any signs of swelling, signs of infection.
purulent discharge or
presence of pain from
wounds or drains.
Teach the parent how - Patient or caregivers need
to perform procedures to master these skills to
at home, like dressing make sure that they can
changes and assessing continue preventing the
wound site for signs of
risk of infection even if
infection.
they are already
discharged.
Use proper technique -to prevent spreading of
for changing/disposing microorganisms.
of contaminated
materials.
- It can reduce stress and
Encourage adequate
rest. boost the immune system.
Check the patient’s - People with insufficient
immunization history. immunization may not
have adequate acquired
immunity.
Dependent
Administer/monitor
medication regimen
(e.g., - To determine
antimicrobials/topical effectiveness of therapy or
antibiotics) and note presence of side effects.
the client’s response
Emphasize the
necessity of taking - Premature
antivirals or discontinuation of
antibiotics, as directed
treatment may result in
(e.g., dosage and
length of therapy). return of infection and
potentiation of drug-
resistant strains.
