Goal :
Able to maintain / improve ambulation / activity.
Expected Outcomes :
Reported an increase in activity tolerance (including daily activities).
Indicates decrease in physiological signs of intolerance, such as pulse, respiration, and blood pressure is still within the normal range.
Nursing Intervention :
Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity.
Rational : Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues.
Assess patient ability to perform ADLs
Rational : Influences choice of interventions and needed assistance.
Provide or recommend assistance with activities and ambulation as necessary, allowing client to be an active participant as much as possible.
Rational : Although help may be necessary, self-esteem is enhanced when client does some things for self.
Suggest client change position slowly; monitor for dizziness.
Rational : Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
Identify and implement energy-saving techniques
Rational : Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.
Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.
Rational : Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary strain and stress may lead to decompensation and failure.
Source : http://nanda-list.blogspot.com/2011/11/nursing-intervention-for-anemia.html
