NURSING CARE PLAN

Cues Nursing Rationale to Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Nursing Diagnosis Interventions
SUBJECTIVE Activity GOALS/ DESIRED OUTCOME -Assess the extent of -Provides information
CUES: intolerance r/t at the end of nursing care weakness, fatigue, ability to about the impact of
deconditionin the patient will : participate in active and activities on fatigue and
g secondary  Exhibit tolerance during passive activities. energy reserves.
to prolong physical activity as -Schedule care and provide -Promote autonomy and
immobilazatio evidenced by a normal rest period following an control of situation as
n and pain fluctuation of vital signs activity; allow the patient to presence of chronic
during physical activity. set own limits in the amount disease may encourage
 Identify factors that of exertion tolerated. independence.
aggravate activity -Explain to the patient
intolerance. purpose for restriction. -Promote understanding
 Patient verbalize and Explain when to rest and of the need to conserve
uses energy-conservation when to stop an activity to energy and rest.
technique the patient.
OBJECTIVE - Educate patient’s - Promotes an active and
CUES: significant others that normal life for the patient
complete participation in with a chronic illnes
activities is essential and
should be sustained for as
long as possible (within
capabilities and disease
restriction). This helps the patient to
cope. Acknowledgement
Encourage verbalization of that living with activities
feelings regarding intolerance is both
limitation. physically and
emotionally difficult.
Patient may be fearful of
over exertion and
Provide emotional support potential damage to the
and positive attitude heart. Appropriate
regarding abilities. supervision during early
efforts can enhance
confidence.
 NURSING CARE PLAN

Nursing Diagnosis Goals and Objectives Nursing Interventions Rationale to Nursing Interventions Evaluation
Ineffective coping After 1 week of nursing  Assess for the  Behavioral and After 1 week of
related to inadequate intervention the patient presence of physiological nursing intervention
preparation for stressors will be able to: defining responses to stress can the patient will be
characteristics. be varied and provide able to:
 Describes and clues to the level of
initiates effective coping difficulty.  Describes and
coping strategies.  Assess for the  The patient’s coping initiates
 Describe positive influence of behavior may be based effective
results from new cultural beliefs, on cultural perception coping
behaviors. norms and values of normal and strategies.
 Focuses on the on the patient’s abnormal coping  Describe
present perception of behavior. positive
 Identifies personal effective coping. results from
strengths and  Observe for causes  Situational factor must new
accepts support of ineffective be identified to gain an behaviors.
through the coping such as poor understanding of the  Focuses on the
nursing self concept, grief, patient’s current present
relationship. lack of problem- situation and to avoid  Identifies
 Verbalizes feelings solving skills or patient with coping personal
related to recent change in effectively. strengths and
emotional state. life situation. accepts
support
 Identify specific through the
stressor  Accurate appraisal can nursing .
facilitate development
of appropriate coping
strategies because a
patient has an altered
health status does not
mean the coping
difficulties she exhibits
are only related to that.
Persistent stressors
may exhaust the
patients ability to
maintain effective
coping.
 Observe for
strengths  Family members who
such as the ability are coping with critical
to relate the facts injuries often feel
to acknowledge the defeated, hopeless and
source of stressors. like a failure.
Therefore, it is
necessary to verbally
praise and use those
strengths to aid
 Determine the functioning.
patient’s  The patient may
understanding of believe that the threat
the stressful is great than their
situation. resources to handle it
and feel a loss of
control over solving
the threat problem.
The patient’s cultural
heritage and previous
experiences may affect
the patients
understanding of an
response to present
situation. This
information provides a
recommendation for
planning care and
choosing relevant
intervention.
 Monitor risk of  A patient with
harming self or hopeless and an
others and inability to problem
intervene solve often runs the
appropriately. risk of suicide.
 Patient may have
 Evaluate resources support in a single
 and support setting such as during
systems available hospitalization yet lack
to the patient. sufficient support in
the home setting.
 Identify an emergency
 Assess for suicidal plan should the patient
tendencies. Refer become suicidal. A
for mental health suicidal patient is not
care immediately if safe in the home
indicated. environment unless
supported by
professional help.