NURSING CARE PLAN

FOR PRENATAL

FIRST TRIMESTER VISIT

Nursing Rationale to Goal/ objective
Cues diagnosis nursing Intervention Rationale Evaluation
diagnosis

SUBECTIVE CUES: Nausea related Nausea is a Short term goal: Independent:  To gain trust and Short term goal:
Nursing Care Plan 1 
“Madalas sumakit ang
ulo ko, at kapag
to pregnancy
associated by
subjective
unpleasant,
After 8 hours of
nursing intervention,
 Establish rapport. cooperation. After 8 hours of
nursing
 Note systemic  Helps determine
nagbibiyahi ako o nasa headache. wavelike the patient will be appropriate intervention, goal
conditions that may was met. The
labas, nahihilo ako, sensation in the able: results in nausea. interventions of
tapos parang back of the To know the patient was able
 Determine if underlying
naduduwal ako lagi” throat, epigastric, cause of nausea. to:
nausea is condition.
as verbalized by the or abdomen that To have  Indicates degree
potentially self- Know the
patient. may lead to the necessary of effect on fluid/
limiting and/or cause of
urge or need to information to electrolyte balance nausea.
mild or is severe
vomit and this is manage her own and nutritional Had
and prolonged.
OBJECTIVE CUES: common feeling care. status. necessary
- Increased especially in  Provide clean
peaceful  As they may information
swallowing early pregnancy. stimulate or to manage
environment and
- Increased worsen nausea. her own care.
fresh air w/ fan or
salivation  Provides
open window.
- Increased necessary
Avoid offending
perspiration information for
odors, such as Long term goal:
- Height: 167 cm Reference: Long term goal: client to manage
After 1 day of nursing cookins smells, After 1 day of
- Weight: 68 Kg (Maternal and own care.
interventions, the smoke, perfumes, nursing
- V/S as follows: Child Health
patient will be able to: mechanical intervention the
T: 37.1 Nursing 8th
Limit dwelling emissions. goal has met. The
P: 78 b/m Edition
Volume1.) on unpleasant  Review individual patient was able
R: 20 b/m to:
sensation. factors/ triggers
BP: 120/80 mmHg Limits
causing nausea and
 ways to avoid it. dwelling on
unpleasant
sensation.

Cues
 Nursing Care Plan 2 

Nursing Rationale to Goal/ objective

Cues diagnosis nursing Intervention Rationale Evaluation
diagnosis

SUBJECTIVE CUES: Fatigue related Fatigue is a self- Short term goal: Independent:
“Permi manla ako hini to physiologic recognized state After 2 days of nurse-  Establish rapport.  To gain trust Short term goal:
binubutlaw bisan changes of in which an patient interaction and cooperation. After 2 days of
waray ko pregnancy as individual and interventions, the  Monitor  Tolerance varies nurse-patient
gintratrabaho” As evidenced by experiences an client will be able to: physiological interaction and
greatly,
Verbalized by the lack of energy, overwhelming Report increased response to activity, interventions, the
depending on
patient. inability to sustained sense sense of well- including changes in client was able to:
the stage of the Report
maintain usual of exhaustion and being and energy blood pressure (BP)
decreased level. disease process, increased
OBJECTIVE CUES: routines and or heart and nutritional state,
capacity for respiratory rates. sense of
Height: 167 cm compromised and fluid well-being
physical and Long term goal:  Establish realistic
Weight: 68 Kg concentration. mental work that After 1 week of balance. and energy
Temperature: 36.5⁰C activity goals with
is not relieved by nurse-patient client. level.
Pulse: 78 Bpm rest. It is a term interaction and  Provides for a
Respiration: 20  Plan care to allow
used to describe interventions, the sense of control
Blood pressure: for rest periods. Long term goal:
an overall feeling client will be able to: Schedule activities and feelings of
120/70 mmHg of tiredness or After 1 week of
for periods accomplishment
lack of energy. Demonstrate nurse-patient
when client has most . interaction and
measurable  Frequent rest
energy. Involve interventions, the
increase in client and caregiver periods are
physical activity. goal was met. The
in needed to client was able to:
planning schedule. restore or Demonstrate
conserve
 energy. measurable
 Encourage client to Planning allows increase in
do self-care when client to be physical
Reference: appropriate, such as active during activity.
https://www. sitting up in chair times when
healthline.com/ and walking. energy level is
health/fatigue Increase activity higher, which
level, as may restore a
indicated. feeling of well-
 Provide passive and being and a
active range-of- sense of control.
motion (ROM)
 Increases
exercises to
strength and
bedridden clients.
stamina and
enables client to
 Keep bed in low become more
position and active without
walkways clear of undue fatigue.
furniture; assist
with ambulation.  The
 Assist with self-care development of
needs, as necessary. healthy lean
muscle mass
depends on the
provision of
Collaborative
both isotonic
 Provide
and isometric
supplemental O2, as
indicated. exercises.
Prevents
muscle wasting.
 Protects client
 Refer to physical or from injury
occupational therapy during activities.
 Generalized
 weakness may
make activities
of daily living
(ADLs) almost
impossible for
client to
complete.

 Presence of
anemia or
hypoxemia
reduces O2
available for
cellular uptake
and contributes
to fatigue and
decreased
immune
response.
 Programmed
daily exercises
and activities
help client
maintain or
increase strength
and muscle tone
and enhance
sense of well-
being.
 Nursing Care Plan 3 
Nursing Rationale to Goal/ objective
Cues diagnosis nursing Intervention Rationale Evaluation
diagnosis

SUBJECTIVE CUES: Risk for Risk for Short-term goal: Independent:  To gain trust Short term goal:
“Kada aga kun nabuhat imbalanced imbalanced After 1 day of  Establish rapport. and cooperation After 1 day of nurse-
ako permi ako nutrition, less Nutrition: less Nurse-patient patient interaction
 Give frequent, small  This approach
nangangasuka” than body than body interaction and will help and interventions,
amounts of foods
As verbalized by the requirement requirements interventions, the maintain the goal was met.
that appeal to the
client. related to early might cause by client will be able to: nutritional The client was able
patient.
inability to Report status. For some to:
morning nausea
absorb nutrients decreased
 Provide an emesis
OBJECTIVE CUES: and vomiting. patients, an
needed by the basin within easy Report
severity or empty stomach
Height: 167 cm body, such as reach of the patient. decreased
elimination of exacerbates
Weight: 68 Kg nausea and nausea.  Educate and assist severity or
patient about oral nausea. elimination of
Temperature: 36.5⁰C vomiting.
hygiene.  Nausea and nausea past 3
Pulse: 78 Bpm Long term goal: vomiting are months of
Respiration: 20 Reference: After 1 week of  Eliminate strong
closely related. pregnancy.
Blood pressure: (Maternal and nurse-patient odors from the
Keep emesis
120/70 mmHg Child Health interaction and surrounding (e.g.,
basin out of Long term goal:
Nursing 8th interventions, the perfumes, dressings,
sight but within
Edition client will be able to: emesis. After 1 week of
the patient’s
Volume1)  Allow the patient to reach if nausea nursing
Take adequate use non- has a interventions, the
amount of food pharmacological psychogenic goal was met. The
with the nausea control component. patient was able to:
appropriate techniques such as  This is
calories and will relaxation, guided associated with Take adequate
report better imagery, music anorexia and amount of food
eating habits therapy, distraction, excessive with the
with no or deep breathing salivation. Oral appropriate
underlying exercises. hygiene helps calories and will
problem  Apply alleviate the report better
acustimulation condition and eating habits
bands as ordered, or with no
 apply acupressure. facilitates underlying
 Tell patient to avoid comfort. problem.
foods and smells  Strong and
that trigger nausea. noxious odors
 Review about the can contribute to
prenatal vitamins the nausea.
patient is taking, if  These methods
pregnant. have helped
 Keep rooms well- patients alleviate
ventilated. If the condition
possible, assist the but needs to be
patient to go outside used before it
to get some fresh air. occur
 Stimulation of
 Educate the patient
the Neiguan P6
to take prescribed
acupuncture
medications as
point on the
ordered.
ventral surface
 Inform the patient to of the wrist has
seek medical care if been found to
nausea and vomiting control nausea
develops or persists in some points.
longer than 3 This has been
months. found to be
helpful for
Dependent: patients who
experience
 Administer anti- motion-related
emetics as ordered. nausea.

 Strong and
noxious odors
can contribute to
nausea.
 Having too
much iron may
 cause nausea,
and switching to
a different
vitamin could
help.
 A well-
ventilated room
or having a fan
close by
promotes easier
breathing.
 Following the
prescribed
schedule for
medications
reduces episodes
of nausea.
 Persistent
vomiting can
result in
dehydration,
electrolyte
imbalance, and
nutritional
deficiencies. If
nausea and
vomiting
persists past 3
months of
pregnancy, it is
likely
hyperemesis
-gravidarum.

 Most anti-
emetics work by
 increasing the
threshold of the
chemoreceptor
trigger zone to
stimulation.

Nursing Care Plan 1  Drugs with

antiemetic
actions include
antihistamines,
anticholinergics,
dopamine
antagonists,
serotonin (5-
HT3) receptor
antagonists, and
benzodiazepine.

SECOND TRIMESTER VISIT

 Nursing diagnosis Rationale to Goal/ objective
Cues nursing Intervention Rationale Evaluation
diagnosis

SUBJECTIVE CUES: Disturbed sleeping Frequency of Short-term goals: Independent:  To gain trust Short term goals:
“Dire ak nangangaturog pattern related to urination may After 2 days of  Establish rapport. and cooperation. After 2 days of
hin tuhay kada gab-e kay nurse-patient nurse-patient
physiologic return at the  Encourage  To reduce the
sige tak buhat buhat interaction and interaction and
interruptions such end of interventions, the patient to void amount of intervention, the
pakadtu CR kay perme ak
as nocturia. pregnancy as client will be able before going to urine in the goal was met. The
nahinganga-ihi” As
verbalized by the patient. lightening to: sleep. bladder client was able to:
 Identify at  Advised patient therefore Verbalize the
occurs and the
least one normal
OBJECTIVE CUES: fetal head to limit fluid decreasing the
individual physiologic
Height: 167 cm exerts intake specially number of body changes
appropriate
Weight: 68 Kg renewed intervention during night. voiding at of a woman`s
Temperature: 36.5⁰C pressure on  Advised patient night body during
to promote
Pulse: 78 Bpm pregnancy.
the bladder. sleep. to take  Drinking fluids
Respiration: 20 Understand that
 Verbalize afternoon naps. at night urinary
Blood pressure: Reference: the normal
120/70 mmHg  Assess for pain increases frequency is
(Maternal and physiologic and burning one of the
chance to void
child health body sensation during normal
changes of a since the
nursing urination or changes.
woman`s whether she has bladder will be
volume 1. Page body during full
noticed blood in
236) pregnancy. her urine.  Afternoon
 Understand  Educate pregnant
that urinary naps will help
woman not to wait Long term goal:
frequency is reduce fatigue
but to void as
one of the often as necessary, due to lack of After 1 week of
normal as urine stasis can sleep nursing intervention,
changes. the goal was met.
lead to infection.  Pain and
 Encourage not to The client was able
burning
restrict fluid intake to:
Long-term goal: sensation during
After 3 days of to diminish urination as well Verbalize ways
nurse-patient frequency of as presence of on how to
interaction and urination. blood in the achieve
interventions, the  Educate the urine, role out optimum level
client will be able patient to reduce presence of of rest and
to: daily caffeine infection. sleep.
 Verbalize intake.  Avoiding to
ways on void when
how to
urinating
achieve
sensation is felt
optimum
level of rest can lead to
and sleep. urinary stasis
and
consequently to
UTI.
 Fluids in
adequate
amount is
necessary for
the maternal
blood volume to
double.
 Caffeine is a
form of
stimulant that is
very likely to
disrupt normal
sleep pattern. It
also poses risk
for low birth
weight.
Reducing intake
has subsequent
benefit added on
 reducing urinary
frequency.

Nursing Rationale to Goal/ objective

Cues diagnosis nursing Intervention Rationale Evaluation
Nursing Care Plan 2  diagnosis

SUBJECTIVE CUES: Fatigue related Fatigue is a self- Short term goal: Independent: After 2-3 hours of
“Maluya la po tak lawas to sleep recognized state After 2-3 days of  Establish rapport. nurse-patient
 To gain trust
kay piraw ako” as deprivation in which an nurse-patient  Assess the following and cooperation. interaction and
verbalized by the patient. and individual interaction and characteristic of  This allows the intervention, goal
experiences an fatigue: nurse to
pregnancy. intervention, the has met. The
OBJECTIVE CUES: overwhelming - Severity compare
sustained sense
patient will be able patient was able
- Changes in changes in the
Height: 167 cm of exhaustion and to: severity over to:
patient’s fatigue
Weight: 68 Kg time
decreased level over time.
Temperature: 36.5⁰C  Manifest - Aggravating  Manifest
capacity for It is important to
Pulse: 78 Bpm comfort, ease comfort, ease
physical and factors determine if the
Respiration: 20
mental work that and alertness - Alleviating patient’s level of and alertness
Blood pressure:
is not relieved by  Actively factors fatigue is  Actively
120/70 mmHg
rest. It is a term participate in  Assist the patient to constant or if it participate in
used to describe develop a schedule varies over time.
nursing nursing
an overall feeling for daily activity and  A plan that
activities to be rest. activities to be
of tiredness or balances periods
lack of energy. done.  Help patient set of activity with done.
 Verbalize priorities for desired periods or rest  Verbalized
adequate activities and role can help the adequate
responsibilities.
number of patient complete number of
 Encourage the desired activities
hours of sleep patient to identify hours of sleep
from previous without adding
Reference: task that can be from previous
to levels of
https://www. rest and delegated to others. rest and
fatigue.
healthline.com/ express relief.  Help the patient
 Setting priorities express relief.
health/fatigue engage in increasing
is one example
levels of physical
activity and of an energy Long term goal:
Long term goal: exercise. conservation After 1 week of
After 1 week of technique that
 Help the patient nurse-patient
nurse-patient develop habits to allows the interaction and
interaction and promote effective patient to use interventions, the
interventions, the rest/sleep patterns. available energy goal was met. The
client will be able to: to accomplish client was able to:
 Display important Display
effectiveness in activities. effectiveness
 doing usual Achieving in doing usual
physical desired goals physical
can improve the activity.
activity.
patient’s mood
and sense of
emotional well-
being.

Nursing Rationale to Goal/ objective

Nursing
Cues Care Plan 3  diagnosis nursing
diagnosis
Intervention Rationale Evaluation

SUBJECTIVE CUES: Impaired physical Varicose veins Short term goal: Independent: Short term goal:
“Maul-ul it ak tiil kun mobility related are a common After 8 hours of
naglalakat o natukdaw  Establish rapport.  To gain trust After 8 hours of
to activity usually nurse-patient
ako” As verbalized by the  Assess degree and and nursing
patient.
limitations due to harmless part interaction and
characteristics of cooperation. intervention, goal
pain felt from of pregnancy intervention, the
discomfort and  Changes in was met. As
varicose veins for some patient will be
pain. degree &
OBJECTIVE CUES: women. They able:  Monitor vital signs characteristics evidence by:
Facial grimace happen when  Elevate the foot of of pain may
To decrease Decrease in
Varicose veins seen on the uterus the bed indicate the
in pain scale pain scale
the calf or posterior applies  Encourage patient development
from 8/10
leg
from 8/10 to
pressure to the to change of to 4/10.
Difficulty walking 4/10.
large vein (the positions complication. Active
Pain scale: 8/10 To follow
inferior vena frequently  Elevation in participatio
Height: 167 cm prescribed or
Weight: 68 Kg cava) that  Apply a warm the heart rate n of the
offered
Temperature: 36.5⁰C carries blood compress to the may indicate patient in
medication
Pulse: 78 Bpm back to the affected leg using increased taking the
Respiration: 20 to manage
heart from a 2 hour-on, 2- discomfort or medication
Blood pressure: pain
your feet and hour-off schedule may occur in on time
120/70 mmHg (analgesics)
legs. Varicose around the clock. response for and
To continue understand
veins can  Teach patient fever and
to use ing what it
become itchy, breathing inflammatory
proper is for.
uncomfortable exercises process. Fever
breathing Patients
, or even can also
and other pain scale
painful. increase
relaxation Dependent: rating
client’s
techniques (4/10) and
Reference:
to divert  Administer discomfort.
continuing
Reference: analgesic as  Encourages
attention breathing
(Maternal and prescribed venous return exercises
and minimize
child health to facilitate though
pain.
nursing circulation, squinting
volume 1. Page reducing stasis and
236) Long term goal: and edema guarding
formation. still persist.
After 4-5 days of
 Reduces
nurse-patient
muscle fatigue,
interaction and
helps minimize
intervention the muscle spasm Long term goal:
patient will be and maximizes After 4-5 days of
able to: circulation to nurse-patient
tissues. interaction and
Verbalize
 Moist heat intervention, goal
that pain is
may be not met. As
no longer felt
applied to the evidence by:
in posterior
affected region
leg Patient
to relive pain
verbalized
Mobilize and improve
that pain is
without any circulation
still felt in
difficulties through
the posterior
vasodilation. leg but from
 Helps in 8/10 now it’s
minimizing 4/10.
pain. Too early for
 Analgesics ambulation.
help in
relieving pain
and decreases
muscle
tension.
 Nursing Care Plan 2 

THIRD TRIMESTER VISIT

Nursing Rationale to Goal/ objective

Nursing
Cues Care Plan 1  diagnosis nursing Intervention Rationale Evaluation
diagnosis

SUBJECTIVE CUES: Constipation Reasons of Short-term goals: Independent:  To gain trust After 8 hours of
“Han yana po nga related to constipation After 8 hours of  Establish rapport. and nurse-patient
nakalabay nga mga simana reduced gastric nursing intervention,
maybe changes  Inform the patient cooperation. interaction and
constipated ak, maul tak motility as the client will be able
produced in the to: that constipation  The intervention, goal
pag uro.” As verbalized by evidenced by
digestive tract is a usual causative has met. The patient
the patient. infrequent
passage of stool.
due to Verbalize discomfort in factors have was able to:
OBJECTIVE CUES: hormones understanding of pregnancy.
constipation as a
been shown
Height: 167 cm slowing down  Determine fluid Verbalize
physiologic to contribute
Weight: 68 Kg the movement understanding
change of intake of the to
Temperature: 36.5⁰C of food. Added of the
pregnancy. patient. constipation.
Pulse: 78 Bpm to this, during discomfort.
 Note energy,  This will
the last Had a change in
Respiration: 20 trimester there Maintain activity levels and evaluate bowel pattern
Blood pressure: is more passage of soft, exercise pattern of client’s and character
120/70 mmHg pressure on formed stool at a of stool.
frequency perceived the client. hydration
your rectum as “normal” by the  Instruct and status.
from your patient. encourage a diet  Sedentary
uterus. of balanced fiber lifestyle may
and fiber affect
Reference: supplements. elimination
Long term goals:
(Maternal and  Promote adequate patterns. After 1 week of
Long term goals:
Child Health fluid intake,  To improve nursing intervention,
After 1 week of
Nursing 8th including high consistency the goal was met. The
nursing interventions,
Edition the client will be able fiber fruit juices, of stool and client was able to:
Volume1.) to: Verbalize
suggest drinking facilitate measures on
Verbalize passage
warm, stimulating how to lessen
measures on
how to lessen fluids. through constipation
constipation  Encourage activity colon. from
from pregnancy.
and exercise  This
pregnancy. within limits of promotes
State relief individual activity. passage of State relief
from from
 Encourage the soft stool.
discomfort of
discomfort of  This will
patient to take in constipation
constipation.
fluid 2000 to 3000 stimulate
mL/day. contractions
 Urge patient for of the
some physical intestines
activity and  Sufficient
exercise such as fluid is needed
to keep the
walking
fecal mass
soft.
  Movement
Dependent: promotes
 Administer peristalsis.
laxative Simple
walking for
per MD order
pregnant
woman
decreases the
risks of severe
constipation
 Laxatives
contain
chemicals that
help increase
stool motility,
bulk, and
frequency -
relieving
discomforts of
constipation.
 Nursing Care Plan 2 
Nursing Rationale to Goal/ objective
Cues diagnosis nursing Intervention Rationale Evaluation
diagnosis

SUBJECTIVE CUES: Stomach pain The pressure of Short-term Goal: Independent: Short term goal:
“Maul-ul tak tiyan ngan and back pain the fetal After 2-3 hours of  Establish rapport. After 2-3 hours of
talikuran bangin nag related to presenting parts nursing intervention,  To gain trust and nursing
 Establish a rapport
lalabor nak hine” As Braxton hick’s to the tissues also the client will be able cooperation intervention, the
that enables client/
verbalized by the patient. contraction. contributes to the to:  Answers to goal was met. The
partner to feel
discomfort that Report pain questions can client was able to:
comfortable asking
the woman is is alleviate fear and
feeling. Pain reduced/man questions. Report pain
OBJECTIVE CUES:  Instruct simple promote
sensations start in ageable. is
Height: 167 cm breathing understanding.
nociceptors Appear reduced/man
Weight: 68 Kg
which are relaxed techniques.  Encourages ageable.
Temperature: 36.5⁰C stimulated by between  Encourage client to relaxation and
Pulse: 78 Bpm mechanical, contractions use relaxation gives client a Appear
Respiration: 20 chemical, or techniques. Provide means of coping relaxed
Blood pressure: thermal stimuli. instruction as with, and between
120/70 mmHg As they are Long term Goal: controlling the contractions.
necessary.
stimulated, After 2-3 days of level of,
nursing intervention,  Provide comfort
chemical discomfort. Long term goal:
the client will be able measures (e.g.,
mediators help  Relaxation can aid After 2-3 days of
transmit the pain to: effleurage, back in reducing nursing
impulse along Participate in rub, propping with tension and fear, interventions, the
myelinated and behaviors to pillows, applying which magnify goal was met. The
unmyelinated diminish pain cool washcloths, pain and hamper patient was able to:
fibers to the sensations and offering ice labor progress.
spinal cord. enhance chips/lip balm)  Promotes Participate
Neurotransmitter comfort relaxation, reduces in
s assist the pain behaviors
 Discuss anticipated tension and
impulse across to diminish
changes /difference anxiety and
the synapse pain
in labor pattern and enhances client’s
between the sensations
contractions coping and sense
peripheral and and
the spinal nerve. of control. enhance
The pain impulse  Helps prepare comfort.
Dependent: client because
ascends the
spinal cord to the  Administer induction
brain cortex analgesic procedures and
where it would medications once use of oxytocin
be interpreted as dilation and can result in rapid
pain. contractions are onset of strong,
established frequent
Source: contractions,
(Maternal and which often
Child Health interfere
Nursing 8th
negatively with
Edition
the client’s ability
Volume1. Page
376) to use learned
coping techniques,
which a slower
buildup in the
contractile pattern
would allow.
 Relieves pain;
promotes
relaxation and
 coping with
contractions,
allowing client to
Nursing Care Plan 3  remain focused on
work of labor.

Nursing Rationale to Goal/ objective

Cues diagnosis nursing Intervention Rationale Evaluation
diagnosis

SUBJECTIVE CUES: Activity Activity Short term goal: Independent: Short term goal:
“ Maluya la perme tak Intolerance intolerance After 8 hours of  Establish rapport After8 hours of
pag- abat haak lawas, related to occurs when our nursing interventions,  To gain trust nursing
 Help the patient
asya d ak nakakag pregnancy, as body does not the client will be able and intervention, goal
evidenced by have enough to: engage in has met. the client
trabaho hin bisan la d cooperation
magkuri nga trabaho ha report of fatigue energy that is increasing levels of was able to:
 Exercise can
balay” As verbalized by and weakness. required to do Participate in physical activity reduce fatigue
daily tasks.” desired Participate
the patient. and exercise and help the
Activity activities; meet in desired
own self-care  Assess level of patient build
activities;
intolerance endurance for
mainly occurs needs fatigue, and meet own
OBJECTIVE CUES: physical
due to weakness evaluate for other self-care
Height: 167 cm activity.
and tiredness. precipitators and needs
Weight: 68 Kg Long term goal:
Temperature: 36.5⁰C After 3 days of causes of fatigue,  Fatigue because
Reference: nursing intervention, of advanced HF Long term goal:
Pulse: 78 Bpm https://healthap
for example, HF
Respiration: 20 the client will be able treatments, pain, can be profound After 3 days of
es.com/ to: nursing intervention,
Blood pressure: and is related to
activity- Achieve cachexia, anemia, the goal has met.
120/70 mmHg intolerance/ hemodynamic,
measurable and depression. respiratory, and The client was able
#:~:text= increase in  Evaluate peripheral to:
%E2%80%9C activity Achieve
accelerating muscle
tolerance, activity abnormalities. measurable
evidenced and intolerance. Fatigue is also a increase in
vital signs side effect of activity
within some tolerance,
acceptable limits  Provide assistance medications evidenced
during activity. with self-care (e.g., beta and vital
activities, as blockers). Other signs within
key causes of acceptable
indicated.
limits during
Intersperse fatigue should
activity.
activity with rest be evaluated and
treated as
periods.
appropriate and
desired.
Collaborative:
 Implement graded  May denote
cardiac increasing
rehabilitation and cardiac
decompensation
activity program.
rather than over
Activity.
 Meets client’s
personal care
needs without
undue
myocardial
stress or
excessive
oxygen demand.

 Strengthens and
improves
cardiac function
under stress if
cardiac
dysfunction is
not irreversible.
Gradual increase
in activity
avoids excessive
myocardial
workload and
oxygen
consumption.