Cues/Needs Nursing Diagnosis Rationale Goals and

Objectives
Intervention Rationale Evaluation

Objective Data:
Easily
fatigue
Exertional
Dyspnea
when
walking
Body
weakness

Vital Signs:

Respiratory Rate
= 25 breaths per
minute
Pulse Rate = 104
beats per minute


Activity intolerance
related to imbalances
to oxygen supply and
demand secondary to
obstruction in the
airway primary to
hypersecretions of the
mucous secreting
organs as manifested
by exertional
dyspnea, body
weakness and easily
fatigue.


Insufficient
physiological
energy to
complete required
or desired daily
activities limiting
the client with
obstruction in the
airway due to
increase secretions
by mucus secreting
organs.
Short term goal:

Psychomotor:
Within 30
minutes of
nursing care,
clients care
giver will follow
necessary
management in
the activity of the
client.

Affective:

Within 10-30
minutes of
nursing care,
health care giver
will exhibit
compliance of
the right
activities based
on the clients
condition.






Independent:


Assist with the
clients activities
and provide the
use of assistive
devices.

Instruct the health
care giver to
monitor clients
activities.


Adjust the
activities of the
client.


Advise clients
caregiver to avoid
conditions that
increase oxygen
demand such as
stress, and
extreme
temperatures.






To protect the
client from
injury.



To evaluate the
clients
progress in
participating to
activities.

To prevent
overexertion
and onset of
fatigue.

Prevent
increase in
peripheral
vascular
resistance
which
increases
cardiac
workload and
oxygen
requirements.
Goal: Met

After 1
hour and
30 minutes
of nursing
interventio
n, the
caregiver
has
demonstrat
ed the
necessary
manageme
nt of the
activities
based on
the
condition
of the
client and
complied
to monitor
any signs
of
intolerance
with the
activities.







Cognitive:
Within 10-30
minutes of health
teaching clients
caregiver will
understand the
contributing
factors of limited
activity in
relation to his
condition.
Monitor signs of
intolerance of
activities (e.g.
weakness,
fatigue).


Demonstrate
appropriate safety
measures in
activities of the
client to the
caregiver.

Interdependent:
Collaborate with
his physical
therapist for the
proper exercise to
his left sided
weakness.
Evaluate the
client for signs
of intolerance
to activities.



Prevent injury
and promote
safety to the
client.




Provide a
proper exercise
for weakness.