Kapiolani Community College

Associate Degree Nursing Program

Nurs320 Nursing Care Plan
Student Name Bradley Keown
Nursing Diagnosis: Risk for activity intolerance.

Date of Care: 12/03/15

Date Submitted: 12/07/15

Related to: Anemia induced by chemotherapy.

As manifested by: Post chemotherapy CBC w/ HgB: 7.8 and Hct: 22.4%; periods of rest after minor exertion.
Scientific Rationale: AML causes there to be less room for RBCs to be produced. After being treated with chemotherapy, total production of blood cells are
severely lowered as well as decreasing appetite which leads to decreased nutrient intake to make cells. Due to the lack of circulating red blood cells in her
system, there is an increased risk of oxygen and nutrients not being properly transported, leading to a decrease in function and stability.
Reference: http://www.cancer.gov/about-cancer/treatment/side-effects/fatigue/fatigue-pdq

Outcomes (measurable)
Short Term
No reports of any fatigue and/or
weakness.

Interventions
1. Assess for the signs and symptoms
of activity intolerance (reports of
fatigue/weakness, exertional
dyspnea, chest pain, diaphoresis or
dizziness).
2. Assess patients level of mobility.
3. Assess vital signs.
4. Perform actions to promote rest
and/or conserve energy (minimize
environment activity and noise,
cluster care, keep personal articles
within reach, reduce fear and
anxiety, promote rest).
5. Perform actions to reduce cardiac
workload and maintain adequate
cardiac reserve (place client in
semi- to high Fowlers, instruct
client to avoid Valsalva response,
promote deep breathing,
discourage caffeine).
6. Assess/Promote adequate
nutritional intake.
7. Instruct client to report decreased
activity or s/s of activity intolerance.

Rationale
1. These signs and symptoms can be
indications of a worsening in
condition.
2. Obtaining a baseline for patients
capability is essential for noting
alterations.
3. Abnormal heartrate, respiratory rate
or blood pressure can indicate
change in condition.
4. Increased rest and conservation of
energy can help prevent
development of fatigue.
5. Increased cardiac workload can
further lead to fatigue and
weakness.
6. Adequate nutrition is required to
create energy and for proper
function of all body parts.
7. Changes in activity tolerance can
indicate a worsening in condition.

Evaluation
1. Patient reported no
fatigue/weakness. No overt s/s
other than pt laying down after
ambulation to and from play room
(sat in playroom to make doll
dresses).
2. Pt is reported by previous nurses to
be very energetic with no limitations
in mobility.
3. Patients vital signs remained within
normal limits. 1220 HR: 92, RR: 20,
BP: 100/62.
4. Clustered care around 0815 and
1220, kept lights low and kept
patients frequently used items near
bedside. Patient displayed ability to
provide self-care and ambulation
w/o issue.
5. Kept patient in semi- Fowlers or
upright, informed patient not to
strain herself and promoted fluids
that were non-caffeinated
(Grandmother verbalized
understanding).
6. Patient was informed, but was a

pecky eater. 25% of breakfast was

eaten and 50% of lunch after
obtaining ranch. Informed nurse,
she reported that low percentages is
normal for pt and that she makes up
for it by snacking throughout the
day.
7. Informed patient and patients care
provider (grandmother) to monitor
for s/s of activity intolerance. Both
reported understanding
Long Term

Pt will continue to be able to

perform activities of daily living
without exertional dyspnea, chest
pain, diaphoresis, dizziness,
and/or change in vital signs.

Reference: http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=35 (8th ed.). Philadelphia, PA: Elsevier.