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Nursing Care Plan: Cues and Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

The nursing care plan summarizes the care provided to a client over 2 days for an issue of activity intolerance due to discomfort and pain. The client expressed not wanting to move and fatigue. The objectives were for the client to tolerate activity by being positioned slowly from side to side and from lying down to upright. Interventions included monitoring vitals, encouraging activity, and allowing the client to do as much as possible. By the end of the 2 days, the client was able to tolerate more activity by being positioned slowly and could get out of bed and stay upright for a few minutes before lying down again.

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Amzie Ong
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468 views3 pages

Nursing Care Plan: Cues and Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

The nursing care plan summarizes the care provided to a client over 2 days for an issue of activity intolerance due to discomfort and pain. The client expressed not wanting to move and fatigue. The objectives were for the client to tolerate activity by being positioned slowly from side to side and from lying down to upright. Interventions included monitoring vitals, encouraging activity, and allowing the client to do as much as possible. By the end of the 2 days, the client was able to tolerate more activity by being positioned slowly and could get out of bed and stay upright for a few minutes before lying down again.

Uploaded by

Amzie Ong
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Silliman University College of Nursing Dumaguete City

Nursing Care Plan


Cues and Evidences
Subjective: Verbalized, Maglisod ko ug lihok ug dili ko ganahan molihok Bantay verbalized, Ganahan ra siya mag-sige ug higda

Nursing Diagnosis
Activity Intolerance r/t discomfort and pain

Objectives
Within our 2 day care, the client will be able to have activity tolerance by positioning slowly from side to side and from supine to upright position as evidenced by: Able to move out from his bed

Interventions
Independent: Monitor vital signs of the patient Provide assurance with activities or ambulation as necessary, allowing client to do as much as possible

Rationale

Evaluation

Objective: Upon getting the BP, clients arm was not properly positioned Does not move from side to side and refuse

Needs little assistance for his needs

Regain his strength to perform normal activity

Provide positive atmosphere while acknowledging of the situation for the client

At the end of our 2 day care, the client was able to tolerate To little activity by provide positioning slowly baseline data from side to side and Self from supine to upright esteem of position as evidenced client is by: enhanced when Client was able he does to get up from something for bed slowly and himself. stayed in an According to upright position Dorothea for a few minutes Orems Theory and lied down of self care again deficit, human has ability to perform self Client asked us care activities and the significant other to position him to the left Help to side of the bed minimize frustration and re-channel energy Client was no

to be positioned every 2 hours When asked by the nurse on duty to move a little to the right side, client refused Demonstrate physical mobility by moving from side to side

Plan activity progression with client, including activities that client views as essential

Note presence of factors contributing to discomfort or pain

Promote s gradual return to normal activity level and improved muscle tone/stamina without undue fatigue increases self esteem and sense of control. According to Joyce Travelbees Human to Human Relationship Model, nursing is an interpersonal process whereby the nurse assists an individual. Discomf ort and pain affects both the clients actual and perceived

longer lethargic and weak. He became more responsive and cooperative in every procedure that we perform Client frequently asks assistance from the significant other to support him as he is about to sit up straight

ability participate activities

to in

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