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Assessment

Subjective: Nanghihina ako, kadalasan hindi ko matapos ang mga ginagawa ko as verbalized by the patient. Objective:  + body weakness  greater need for sleep and rest  respiratory rate 24 bpm

Diagnosis
Activity intolerance related to imbalance oxygen supply and demand as manifested by decreased activities level

Planning
Short Term Goals: After 30 minutes of nursing intervention patient will be able to: -use identified techniques to enhance activity tolerance -participate willingly in necessary activities

Intervention
y Assess patient s ability to perform normal task for activities of daily living Evaluate client s actual and perceived limitations Monitor vital signs Recommend quiet atmosphere, bed rest if indicated

Rationale
o Influences choice of interventions or needed assistance o Provides comparative baseline data

Evaluation
After 30 minutes of nursing intervention patient was able to: -use identified techniques to enhance activity tolerance -participate willingly in necessary activities After 8 hours of nursing intervention patient was able to maintain the techniques and willingly in necessary activities Goal was met.

y y

Long Term Goal: y After 8 hours of nursing intervention patient will be able to maintain the techniques and willingly in y necessary activities

o For baseline data o Enhance rest to lower body s oxygen requirements o Although help Provide assistance may be with activities or necessary, selfambulation as esteem is necessary, allowing enhanced when patient to as much patient does as possible something for self. Involve relatives in o Promotes gradual return to normal planning activities, activity level and including activities improved muscle that the patient tone or stamina views essential. without undue Increase levels of fatigue

activities as tolerated Identify energy saving technique like sitting while doing a task.

Monitor laboratory studies including HB or HCT and RBC count, arterial blood gas (ABGs)

o Encourage patient to do as much as possible, while conserving limited energy and preventing fatigue o Identifies deficiencies in RBC components affecting oxygen transport and treatment needs or response to therapy