ASSESSMENT DIAGNOSIS PLANNING RATIONALE EVALUATION

IMPLEMENTATION

Subjective Cues: Activity Short term: Independent: Short term:

Intolerance At the end of 1 1. Determine the 1. Fatigue can limit At the end of 1 hour
Ginatabangan ko related to hour of nursing clients routine and the clients ability to of nursing
mag lakaw as generalized body intervention the over the counter perform needed intervention the
verbalized. weakness client will be able medication. activity. It can also client was able to:
secondary to to: be a medication
Objective Cues: progressive effect. a. Verbalize
disease state a. Verbalize how to how to use
-Dependent use energy 2. Placed client in a 2. a comfortable energy
mobility conservation comfortable position positon will help conservation
-Needs assistance techniques. and adjust the provide techniques
from time to time b. Identify methods position comfortable opportunities for b. Identify
-LOM: limited to reduce activity as preferred. relaxation the methods to
mobility intolerance. muscles optimally reduce
-Body weakness is c. Participate by activity
observed cooperating in the 3. Minimize 3. Quiet intolerance.
nursing environmental environment lessen c. Participate
management to activity and noise; stimuli that may by
alleviate providing clean, aggravate pain; cooperating
intolerance. quiet and calm calm environment in the
environment. help the client rest nursing
well management
Long term: to alleviate
At the end of 4 4. Instruct the client 4. Energy-saving intolerance.
hours of nursing in energy-saving techniques helps
intervention the techniques such as the client exert less Long Term:
client will be able sitting when effort in activities At the end of 4
to: bathing, sitting to that cannot be hours of nursing
brush or comb hair. tolerated
a. Demonstrate 5. instruct the client 5. Strenuous intervention the
non- to avoid strenuous activities may client was able to:
pharmacological activities consume a lot of
ways to reduce energy that may a. Demonstrate
activity trigger the inability
non-
b. Rest/Sleep and to perform activities
pharmacological
participate in ways to reduce
activities 6. Monitor hours of 6. Enough sleep for activity
appropriately. sleep at least 6-8 hours, b. Rest/Sleep and
c. Participate in the helps to conserve participate in
treatment regimen and provide activities
or activities to energy. appropriately.
correct the crisis.
d. Report the ability 7.Observe and 7. Close monitoring
to perform required document response will serve as a
activities. to activity guide for optimal
progression of
activity.
Collaborative:
1. Administer 1. Analgesic
pain mediation
medications can help
as ordered: reduce the
paracetamol clients pain.
600 mg IV
Q6 and
tramadol
5mg IV Q6
 ASSESSMENT DIAGNOSIS PLANNING RATIONALE EVALUATION
IMPLEMENTATION

Subjective Cues: Short term: Independent: Short term:

mura kog Risk for injury At the end of 1 1.Assess general 1. This is to At the end of 1
madagma kung related to hour of nursing status of patient determine the hour of nursing
ako ra isa generalized intervention the patients condition intervention the
maglakaw as weakness client will be able that may cause client was able to:
verbalized to: injury.
a. Explain methods a. Explain methods
Objective Cues: to prevent injury 2. Thoroughly 2. The patient must to prevent injury
-Needs assistance b. Identifies factors conform patient to get used to the b. Identifies factors
in ambulation that increase risk surroundings. Put layout of the that increase risk
-Limited motion for injury call light within environment to for injury
reach and teach avoid accidents.
how to call for Items that are too
Long term: assistance; respond far from the patient Long Term:
At the end of 4 to call light may cause hazard. At the end of 4
hours of nursing immediately. hours of nursing
intervention the intervention the
client will be able 3. Avoid use of 3. If patients are client was able to:
to: restraints. restrained, they
can sustain a. Remains free of
a. Remains free of injuries, including injuries
injuries strangulation, b. Relates intent to
b. Relates intent to asphyxiation, or practice selected
practice selected head injury leading prevention
prevention with their heads to measures.
measures. get out of the bed. c. Increase
c. Increase activities if feasible
activities if feasible 4. Ask family or 4. This is to prevent
significant others to the patient from
be with the patient accidentally falling.
to prevent him or
her from
accidentally falling.

5. Place in an 5. Such
injury-prone room placements allows
that is near the regular observation
nurses station. of the patient.

Collaborative:
1. Coordinate with 1.Gait training in
physical therapist physical therapy
for strengthening has been proven to
exercises and gait effectively prevent
training to increase falls.
mobility. Contact
occupational
therapist for
assistance with
helping patients
perform with ADLs.