ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: (I’m Activity Short term: After Independent : Influences the choice Patient reveals an
feeling weak, I intolerance 8 hours of nursing - Assess patient’s ability of interventions or increase in activity
can’t even related to interventions the to perform normal task or needed tolerance,
complete my imbalance patient will: activities of daily living. Assistance. demonstrating a
chores )” as between reduction in
verbalized by the oxygen - Report an - Note changes in balance/ This may indicate physiological signs
patient. supply increase in gait disturbance, muscle neurological changes of intolerance and
(delivery) activity tolerance weakness. associated with laboratory values
Objective: and demand. including vitamin B12 within normal
*Fatigue activities of daily - Recommend quiet deficiency, affecting range.
*Greater need for living. atmosphere, bed rest if patient safety or risk
sleep and rest. indicated. of injury.
V/S taken as - Demonstrate a
follows: T: 36.9 decrease in - Elevate the head of the Improves sleep,
P:75 R: 18 BP: physiological bed as tolerated. lowers oxygen
100/80 signs of requirements, and
intolerance. - Provide recommend relieves strain on the
assistance with activities heart and lungs.
- Display or ambulation as
laboratory values necessary, allowing Enhances lung
within acceptable patient to do as much as expansion to
range. possible. maximize oxygenation
for cellular uptake.
Long term: After - Plan activity progression
months of with patient, including Although help may be
nursing activities that the patient necessary, self-
interventions , views essential. Increase esteem is enhanced
the patient: levels of activities as when a patient does
tolerated. things for themselves.
- Is free from
weakness and risk - Identify or implement Promotes gradual
for complications energy saving technique return to normal
has been like sitting while doing a activity level and
prevented. task. improved muscle tone
or stamina without
undue fatigue.

Encourages patients
to do as much as
possible, while
conserving energy
and preventing
fatigue.
 Collaborative :
- Monitor laboratory Identifies deficiencies
studies. Hb or Hct and RBC in RBC components
count, arterial blood gases affecting oxygen
(ABGs). transport, treatment
needs, or response to
therapy.

Nursing Care Plan: Anemia