Cues/Needs Nursing Diagnosis Rationale Goals and

Objectives

Intervention Rationale Evaluation

Objective Data:

Easily

fatigue

Exertional

Dyspnea

when

walking

Body

weakness

Vital Signs:

Respiratory Rate = 25 breaths per

minute

Pulse Rate = 104

beats per minute

Activity intolerance

related to imbalances

to oxygen supply and

demand secondary to

obstruction in the

airway primary to

hypersecretions of the

mucous secreting

organs as manifested

by exertional

dyspnea, body

weakness and easily

fatigue.

Insufficient

physiological

energy to

complete required

or desired daily

activities limiting

the client with

obstruction in the

airway due to

increase secretions

by mucus secreting

organs.

Short term goal:

Psychomotor:

Within 30

minutes of

nursing care,

client’s care

giver will follow

necessary

management in

the activity of the

client.

Affective:

Within 10-30

minutes of

nursing care,

health care giver

will exhibit

compliance of

the right

activities based

on the client’s

condition.

Independent:

Assist with the

client’s activities

and provide the

use of assistive

devices.

Instruct the health

care giver to

monitor client’s

activities.

Adjust the

activities of the

client.

Advise client’s

caregiver to avoid

conditions that

increase oxygen

demand such as

stress, and

extreme

temperatures.

To protect the

client from

injury.

To evaluate the

client’s

progress in

participating to

activities.

To prevent

overexertion

and onset of

fatigue.

Prevent

increase in

peripheral

vascular

resistance

which

increases

cardiac

workload and

oxygen

requirements.

Goal: Met

After 1

hour and

30 minutes

of nursing

interventio

n, the

caregiver

has

demonstrat

ed the

necessary

manageme

nt of the

activities

based on

the

condition

of the

client and

complied

to monitor

any signs

of

intolerance

with the

activities.

Cognitive:

Within 10-30

minutes of health

teaching client’s

caregiver will

understand the

contributing

factors of limited

activity in

relation to his

condition.

Monitor signs of

intolerance of

activities (e.g.

weakness,

fatigue).

Demonstrate

appropriate safety

measures in

activities of the

client to the

caregiver.

Interdependent:

Collaborate with

his physical

therapist for the

proper exercise to

his left sided

weakness.

Evaluate the

client for signs

of intolerance

to activities.

Prevent injury

and promote

safety to the

client.

Provide a

proper exercise

for weakness.