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Cues/needs Subjective Data: Hindi ako masyado nagkikilos dito, lagi ako nasa kama as verbalized by the patient

Objective Data: -immobility(stays in bed most of the time) -Presence of fresh surgical incision -sleeps most of the time -weakness -pain scale of 4/10

Nursing diagnosis Activity intolerance related to impaired skin integrity or fresh surgical incision.

Rationale Insufficient physiological energy to endure or complete required or desired activity due to pain and distress with chest tube movement or removal

Goals and objectives After 8 hours of nursing intervention, patient will be able to use appropriate techniques to enhance activity intolerance

Nursing Intervention -Encourage ambulation.


evaluation After 8 hours of nursing intervention: Goal was met as evidence by patients ability to use appropriate techniques to enhance activity intolerance

-to restore movement and prevent painful -Begin patients arm stiffening and shoulder exercise -to prevent overexertion -Adjust activities. Reduce intensity level of the activities that cause undesired physiological changes -assist with activities and provide/monitor clients use of assistive device -Promote comfort measures to provide for relief of pain

-to protect client from injury

-to enhance ability to participate in activities