NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION /

DIAGNOSIS INTERVENTION OUTCOME
Subjective Cues: Independent:

>Patient states, “I get Activity Intolerance Within 8 hours, Obtained resting vital Goal Met. Patient
tired easily.” signs. >Baseline data is
related to imbalance patient will: important to help participated willingly
between oxygen determine patient’s in ADLs and
supply and demand >participate willingly degree of activity demonstrated
in necessary activities intolerance tolerance to activities
of daily living as evidenced by
Assessed patient’s >Determines nursing normal BP, HR, and
(A state in which an >demonstrate a ability to perform interventions needed RR.
Objective Cues: individual has decrease in physiologic ADLs, providing to assist patient;
insufficient physiologic signs of activity assistance as ensures patient safety
>Increased heart rate or psychologic energy intolerance as necessary especially
(HR=112 ) to endure or complete evidenced by BP, HR, during tasks requiring
required or desired and RR within N range ambulation.
>Increased blood daily activities.)
pressure (BP=140/100) Noted changes in >Patients with Vitamin
balance/gait B12 deficiency often
>Increased respiratory disturbance, muscle manifest neurologic
rate (RR=24) weakness. changes.
>pallor Monitored BP, pulse, > Increase in BP, HR,
respirations, and skin RR, and changes in
>unsteady gait color during and after skin color result from
activity. the attempts of the
heart and lungs to
supply adequate
amounts of oxygen to
the tissues.

Instructed patient to >Postural hypotension

change position slowly may cause dizziness
and increased risk of
injury.
Provided adequate >Rest lowers the
rest and sleep periods body’s oxygen
especially between
requirements
activities.
 Elevated head of bed >Promotes lung
as tolerated. expansion for
maximum oxygenation

Provided health
teachings on the
importance of:

>prioritization of
>Promotes adequate
activities
rest and maintains
energy level

>energy-saving >Encourages patient to

techniques such sitting perform activities
when performing while avoiding fatigue
tasks/use of shower
chair

> activity progression >Encourages gradual

as tolerated return to normal
activity level;
increases self-esteem
and sense of control
> adequate rest >Prevents fatigue
periods between
activities

>cessation of activities > Excessive

when dizziness, chest cardiopulmonary stress
pain, palpitations, and may lead to
shortness of breath complications such as
occur. ischemia, myocardial
infarction, .and
eventual heart failure.
.

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 Dependent:

Administered > Supplemental oxygen may

supplemental oxygen be ordered to improve
as indicated patient’s ability to function

Administered Vitamin > Vitamin B12

B12 injections as injections are given to
ordered prevent permanent
neurological
complications

Administered iron >Iron supplementation

preparations as may be given if Hgb
ordered level is inadequate

Collaborative:

Monitor laboratory > Identifies

studies, e.g., Hb/Hct deficiencies in RBC
and RBC count, components affecting
arterial blood gases oxygen transport and
treatment
needs/response to
therapy.
Consulted dietitian on >Patients with
therapeutic diet for Pernicious Anemia
patients with have special
Pernicious Anemia nutritional needs. A
diet rich is Vitamin B-
12 should be
considered.

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