Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

RATIONALE

Subjective Cues: Activity intolerance related Activity Intolerance After 30 minutes of Independent: After 30 minutes of
“Dire na gad to presence of ischemia is the insufficient nursing 1. Assess heart rate 1. Determines nursing
nasakit tak and imbalance myocardial physiologic or interventions, the and rhythm and BP client’s response interventions, the
dughan, pero oxygen supply and demand psychological client will be able to: changes before, to activity and client was able to:
usahay nala kun as evidenced by alterations energy to endure during and after may indicate
naglilinanguya in heart rate and BP, or complete a. Demonstrate activity as myocardial O2 a. Demonstrate
ako.” as verbalized fatigue and ECG changes required and daily progressive indicated. deprivation that progressive
by the patient. reflecting ischemia. activiti. increase in Correlates report may require increase in
tolerance for with chest pain or short-term tolerance for
“Inkadto ako ICU, The most common activity. SOB. reduction of activity.
mga upat ka adlaw etiology of Activity activities.
kay grabe an Intolerance is b. Verbalize
paginul-olon nak related to b. Verbalize absence of
dughan,” as generalized absence of 2. Encourage bed 2. Reduces angina with
verbalized by the weakness and angina with rest. Encourage to myocardial activity
patient. debilitation from activity. limit activity on workload and O2
acute or chronic basis of pain or consumption
Objective Cues: illnesses adverse cardiac reducing risk of
 Dyspnea response. repeated MI or
upon Source: Berman, A. cardiac heart
exertion Snyder, S. Frandsen, failure.
G. 2015, Kozier and
Erb’s Fundamentals 3. Instruct client to Activities that
 Abnormal 3.
of Nursing 10th
heart avoid actions that require holding
Edition, Philippines
sound: raise abdominal breath and
presence pressure such as bearing down
of S3 straining during such as Valsalva
defecation. maneuver can
result in reduced
cardiac output.
 Nursing Care Plan
 ECG result
reflecting
ischemia 4. Review signs and 4. Palpitations,
(Elevated symptoms development of
ST reflecting chest pain,
segment) intolerance of dyspnea may
present activity indicate need for
 Increased level or requiring exercise regimen
BP : notification of or medication.
160/100 nurse or physician.
mmHg
5. Re-evaluate client’s 5. Determines the
vital sign before progression of
and after activity. tolerance for
activity and
effectiveness of
intervention.