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Jose Rizal University

NURSING CARE PLAN




CUES

NURSING
DIAGNOSIS

INFERENCE

GOALS


NURSING
INTERVENTION

RATIONALE

EVALUATION

Subjective :

"bago ako ma-
ospital hindi na
ako makatayo
hinang-hina
ang katawan
ko.

as verbalized
by the client

Objectives :

fatigue

RR: 22 cpm

DOB

On wheelchair
upon
admission



Activity
intolerance
realated to
impaired
respiratory
function.




























nfection


ncrease mucous
production


Lung
consolidation


Lungs filled with
pus and other
fluids


Occlusion


mpaired
pulmonary
function


Impaired
respiratory
function


DOB, fatigue

After 1 hour of
continuous
nursing
intervention the
patient will be
able to minimize
factors affecting
activity
intolerance.










1. Position the
client semi-
fowlers




2. Monitor vital
signs




3. Provide rest
periods
between
activity


4. Assist with
activities










1. To provide
maximum
lung
expansion;
promote
patent airway

2. ncrease in
RR and
temperature
may indicate
overexertion

3. To prevent
overexertion;
to reduce
fatigue


4. To protect
client from
injury

After 1 hour of
continuous
nursing
intervention the
patient was able
to minimize
factors affecting
activity
intolerance.

GOAL: met

As manifested
by:


Negative DOB,
fatigue and
gradual
increase in
activity.