ASSESSMENT S : Nang hihina ako, madali ako mapagod at para kong lagi inaantok as verbalized by the patient >Weak

in appearance >Always asleep but easily awakens >Shallow respiration RR of 30cpm >With blood pressure of 130/100 mmhg >Slow movements noted >Needs assistance upon changing positions >Dyspnea noted >Pallor noted

Explanation of the Problem Activity intolerance is a state in which an individual has insufficient physiologic or psychological energy to endure or complete required or desired daily activities which may be is caused by Increased blood pressure and blood viscosity and that may lead to decreases oxygen supply in the blood vessels, and then manifests as body weakness.

Objectives STO: After 8 hours of Nursing intervention the patient will demonstrate an increase in activity level as manifested by gradual tolerance to active range of motion.

Intervention Dx >monitor heart rate, rhythm, respirations and blood pressure for abnormalities. Notify physician of significant changes in VS. >Assess usual daily activities of patient vs. Tolerated activities during complain of patient

Rationale >changes in VS assist with monitoring physiologic responses to increase in activity. >This may suggest extent of immobility/ mobility as affected by the weakness will also serve as data where interventions will be based. >Muscle strength may suggest the extent of weakness of patient, will also serve as basis for planning of progress. >Data may serve as baseline data for progress of interventions, as well as it will help determine extent of severity of condition. > Activity intolerance may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development. >Since patient feels weak, it may be best if he will be given support when changing position so that occurrence of injury may be prevented, also, so that patient will not be exhausted. >To avoid occurrence of conditions that is caused by prolong stay in bed like bed sores and also, Pneumonia.

Evaluation Sto : Goal was met After 8 hours of Nursing intervention the patient l demonstrated an increase in activity level as manifested by gradual tolerance to active range of motion.

LTO: After 72 hours of Nursing intervention the patient was able to increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise

LTO: >Assess muscle strength After 72 hours of Nursing intervention the patient will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise

>Assess laboratory results

A: Activity intolerance related to imbalance between myocardial oxygen supply and demand as manifested by body weakness.

> Observe and document skin integrity several times a day.

Tx: > Give assistance to patient when moving

>Reposition the patient every 2 hours

>Performed active range of motion intermittently >Regulated IVF at ordered rate

>Interact with patient

>Make a schedule for nursing time to provide for uninterrupted rest periods Edx >Discuss with patient the need for gradual activity increase and resumption >Encourage/ Explain to patient to adhere to advised treatment

>To promote minimal exercise for the patient especially that he is not yet able to tolerate heavy activities >IVF may help in the regain of strength since it contains electrolytes also it is where IV meds will be given, hence/ also, it must be regulated accordingly, to prevent occurrence of cardiac overload, hence, aggravating condition. >To elicit other more concerns from patient, hence, having the ability to plan appropriate nursing care to be performed. >To promote restful sleep, reduces fatigue, and may improve cognition.

>Advice to avoid abrupt standing and moving

>Education may provide motivation to increase activity level even though patient may feel too weak initially. >So that patient may easily recover from condition.

>Encourage the use of Bed pan for urinating until tolerance to walking resumes

>To prevent orthostatic hypotension that may cause falls, injury, or any trauma to the patient. >Since the patient feels weak, use of bed pan helps

the patient to avoid going in the bathroom frequently and also to avoid valsalva maneuver.