Date/Time Cues/Assessment Need Diagnosis Planning Implementation Evaluation
November Subjective: A Activity intolerance related to Within 2- 3 hours of 1. Encouraged adequate rest Within 2-3 hours of
15, 2010 “Luya akong paminaw. C deconditioned state and nursing intervention, the periods. nursing intervention,
7:00 PM Manlisod kog lihok-lihok T physical limitations as patient will: R: To provide time for patient:
sa akong hiwa.” I evidenced by verbalization of energy conservation and
V weakness. Patient maintains recovery. Maintained activity
Objective: I activity level within level within
Noted body malaise T Rationale: capabilities, as 2. Assisted patient in early capabilities by not
Presence of Y Immobility, stress, and evidenced by normal ambulation and doing range moving too much
generalized – weakness are some factors heart rate and blood of motion exercises while in and by asking for
weakness E which affects client’s pressure during bed. assistance in
Deconditioned X tolerance to activity. activity, as well as R: To promote circulation moving with vital
status E Insufficient physiological and absence of shortness within the body. signs within normal
Shows some R psychological energy may of breath, weakness, range.
reluctant in C hinder client’s ability to and fatigue. 3. Monitored vital signs. Verbalized and
performing some I engage in necessary Patient verbalizes R: Excessive activity or used energy
activities S activities. The client has just and uses energy- inactivity may cause any conservation
Temperature: 36.1C E undergone C-section a few conservation alterations in the vital signs. techniques by
Respiratory Rate: 24 days ago which altered her techniques. resting and placing
breaths/min P physical state and restricts 4. Provided a urinal when frequently used
A the patient from achieving full patient wants to urinate. items within reach.
Pulse rate: 69
T level of activity. R: To reduce energy (Water bottle and
beats/min
T consumption cell phone.)
Blood pressure:
E
100/80mmhg
R 5. Encouraged to increase oral
N fluid intake.
R: Increased fluid intake will
promote hydration.
6. Encouraged to eat foods
rich in vitamins and
minerals like fruits and
vegetables.
R: To aid in increasing the
body’s immune system.
7. Assisted client with self-
care activities as needed.
R: To promote rest and
conserve energy.
8. Encouraged deep breathing
exercises three times daily
R: To relieve stress and
tension and to increase
lung volume.
9. Instructed to place
frequently used items within
easy reach.
R: To avoid bending and
reaching and overexertion
of the body
10. Taught importance of
continued activity at home.
R: This maintains strength
and endurance gain.
