NURSING CARE PLAN

Date formulated: July 29, 2015

Nursing Diagnosis (NANDA Approved): Activity intolerance related to compromised
oxygen transport secondary to dysarrythmia
Level of Prioritization: Medium
Reason/Cause Analysis (Indicate your reference: As heart failure becomes more
severe, the heart is unable to pump the amount of blood required to meet all of the
bodys needs. To compensate, blood is diverted away from less-crucial areas, including
the arms and legs, to supply the heart and brain. As a result, people with heart failure
often feel weak (especially in their arms and legs), tired and have difficulty performing
ordinary activities such as walking, climbing stairs or carrying groceries
Goal: Patient will report measurable increase in activity intolerance
CUES
Subjective:
sige lang
siya ug
higda kung
naa sa
balay dili
kaayu ga
lihok-lihok
as
verbalized
by the
significant
others.
Objective:
>Weakness
noted.
> shortness
of breath
during
activity

DESIRED
OUTCOMES
Short Term:
After 8 hours
of nursing
intervention
patient will
verbalize
and show
willingness to
participate
plan of
activities to
help return
selfconfidence
and increase
activity
tolerance.
Long Term:
After 3 days
of nursing
intervention
Patient
maintains

NURSING
INTERVENTIONS
INDEPENDENT:
>assess persons
perceived
capability for
increased activity

>Increase the
activity gradually.

>reassure patient
that even small
increases in
activity can lift
spirits and restore
self confidence.

RATIONALE

EVALUATION

Short Term:
After 8 hours
of nursing
>to plan the
intervention
appropriate activities the goal was
that fits to patients
met as
capability.
evidenced by
patient being
able to
>to prevent a sudden partipate to
increase of cardiac
planned
workload.
activities.

>to promote patient

cooperation and
gain trust.

>activity tolerance

Long Term:
After 3 days of
nursing
intervention
the goal was
met as
evidenced by
patient being
able to
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activity level
within
capabilities,
as evidenced
by normal
heart rate
and blood
pressure
during
activity, as
well as
absence of
shortness of
breath,
weakness,
and fatigue.

>encourage the
patient to turn and
lift self actively
unless
contraindicated.

>promote optimal
sitting balance
and tolerance by
increasing muscle
strength through
active ROM
>gradually
increase
tolerance by
starting with 15
minutes the first
time out of bed.
>have the person
get out of bed
three times a day,
increasing thetime
out of bed by 15
minutes each day.
>plan rest periods
according to the
persons daily
schedule.
Encourage patient
to rest during the
first hour after
meals.

>promote a
sincere can do

develop cyclically
through adjusting
frequency, duration
and intensity of
activityuntil he
desired level is
achieved.

>people with
impaired cardiac
function oftn can
increase both activity
level and tolerance
through adaptations
in
lifestyle,modification
s in approach to
activities, and careful
monitoring of
responses.

manifest
normal heart
rate and blood
presuure
during activity,
as well as
absence of
shortness of
breath,
weakness and
fatigue.

>Rest relieves the

symptoms of activity
intolerance. The
daily schedule is
planned to allow for
alternating periods of
activity and rest and
coordinated to
reduce excess
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attitude. Identify
factors that
undermine
patients
confidence, such
as fear of falling,
perceived
weakness, and
visual impairment.

>initiate patient
and caregivers in
ROM and
therapeutic
exercises.

DEPENDENT:
>consult physical
therapist for an
exercise program
tailored to the
clients needs.

>consult dietitian
for dietary
evaluation and
nutritional
counselling

energy expenditure.
>knowledge, values,
beliefs and perceive
capability for action
influence a persons
decision to engage
in a particular
activity.

>to increase
endurance, the
exercise program
must be continued
after discharge.

Appropriate
therapy is
given
according to
the clients
level of
activity
tolerance

High fiber diet

is advised to
quickly gain
strength,
patient is also
advised for
low salt and
low fat diet to
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prevent
reoccurrence
of the
disease.

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