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NURSING CARE PLAN

PROBLEM: Activity intolerance


NURSING DIAGNOSIS: Activity Intolerance related to pain secondary to postpartum delivery
TAXONOMY: Activity-Exercise Pattern
CAUSE ANALYSIS: Pain limits patient’s activity. Individual has insufficient physiological or psychological energy to endure or complete required or desired daily
activities thereby affecting the physical activity.

CUES OBJECTIVE NURSING RATIONALE EVALUATION


INTERVENTIONS

SUBJECTIVE: STO: INDEPENDENT: Demonstrate activity tolerance.


Patient report discomfort and Within 8 hours of nursing Determine cause of activity Determining the cause of a Absence of signs and
pain. intervention and management, intolerance disease can help direct symptoms.
Patient verbalized that he had the patient will able to: appropriate interventions
difficulty in performing his --identify activities and factors
daily activities due to the pain. that contribute to activity
Monitor and record client’s
Pain scale 5/10. intolerance ability to tolerate activity; note
“Dili ayo ko ganahan pulse rate, blood pressure,
maglihok-lihok kay sakit ako LTO: monitor pattern, dyspnea, use
gioperahan”..as verbalized byAfter 3 days of nursing of accessory muscles, and skin
patient intervention and management, color before and after activity.
the patient will be able to
Objective: demonstrate activity tolerance Teach client the need to pace Rest periods decrease oxygen
as evidenced by wlking and activity and rest after meals consumption
• presence of dressing doing ADL’s without
• decreased mobility as assistance Observe for pain before Pain restricts the client from
observed activity and, if possible treat achieving a maximum activity
• pt. always lying on bed pain before activity. level and is often exacerbated
• needs assistance in by movement.
ADL
Immobilization and enforced
Encourage client to change bedrest in the supine position
position from supine to sitting have considerable adverse
several times daily and to effects on nearly every system
avoid prolonged bedrest. in the body.

Inactivity rapidly contributes


Perform passive range-of- to muscle shortening and
motion exercise if client is changes in periarticular and
unable to tolerate activity cartilaginous joint structure.
These factors contribute to
contracture and limitation of
motion
Implement measures to
conserve the client’s energy Measures to conserve the
during activity client’s energy enable the
client to increase activity
tolerance
Suggest that the client perform
activities more slowly and for Shorter activity periods
shorter time periods, resting performed more slowly and
more often, and using more more frequent rest periods
assistance as required. promote optimal performance
and achievement levels.
Appropriate assistance ensure
safety and prevents falling.
Instruct client in energy-
conserving techniques, e.g., Energy-saving techniques
sitting to brush teeth or comb reduce the energy expenditure,
hair, carrying out activities at a thereby assisting in
slower pace. equalization of oxygen supply
and demand.
Encourage progressive
activity/ self-care when
tolerated. Provide assistance as Gradual activity progression
needed. prevents a sudden increase in
cardiac workload. Providing
assistance only as needed
encourages independence in
performing activites.

Referrence: Kozier, et. al .Fundamentals of Nursing, 5th edition.


Doenges, et. al. Nursing Care Plans, 6th edition.