NCP- Activity Intolerance (Click Here)

ASSESSMENT	NURSING DIAGNOSIS	NURSING GOAL	NURSING INTERVENTION	RATIONALE	EVALUATION
SUBJECTIVE: “Agkakapsuttak ken, marigatanak aggunay”as verbalized by the pt. OBJECTIVE: Ø  Weak in appearance Ø  With Pale skin and conjunctiva Ø  With fatigability Ø  Looks thin in appearance Ø  Dec. Hgb. Level; 12.9 g/dl	Activity intolerance r/t Muscle weakness 2o to Decreased hemoglobin level.	Short Term: After 8 hours of nursing intervention, the patient will: a.        Be free from decubitus ulcer/bedsores or hematomas on the most prominent parts of the body such as the back and the buttocks. Long Term: Within 2 days of nursing interventions, the patient will: a.  Be completely independent on all ADLs and without asking assisitance with his S/O b. Have good skin turgor c.  Have normal hemoglobin level from 104 g/L to 120g/L Hct. from 31% to 40%. d.  Reports increased sense of well being	Independent Mgt: §  Assess patients ability to perform ADLs   noting reports of weakness, fatigue and difficulty in accomplishing task §  Promote independence in self-care activities as tolerated §  Encourage alternating activity with rest §  Explain importance of be rest in treatment. §  Monitor laboratory results like Hgb. & Hct. §  Encourage increase intake of iron-rich foods.	§  Influences choice of interventions or needed assistance §  Mild/moderate activities & improved self-esteem are promoted. §  Minimized exhaustion & helps balance O2 supply and demand. §  Bedrest is maintained to decrease metabolic demands thus conserving energy. §  To identify the extent of deficiency & for better treatment plan. §  To increase iron supplement of the body.	Short Term: After 8 hours of nursing intervention, GOAL was met, as evidence by: a.        Patient’s back and buttocks are free from bedsores/hematomas respectively and free from swelling/redness as well. Long Term: Within 2 days of nursing interventions, GOAL was partially met, as evidence by: a.        The patient Verbalized partial dependence on ADLs with his S/O such as able to feed himself, assistance in toileting & bathing. b. Demonstrates Improved skin turgor & well being c. Able to participate in self care activities (grooming dressing) d.   Hgb and Hct level still needs to be evaluated.