Activity intolerance - Assessment Nursing DX/Clinical...

Assessment Nursing DX/Clinical Problem Client Goals/Desired
Outcomes/Objectives
Nursing Interventions/Actions/Orders and Rationale
Subjective:
Client expressed she
didn’t want to move
“anymore than she has
to.”
Hx of DM II, CAD
Objective:
Temp: 101.0
Basilar rales bilaterally
Elevated BP (145/86)
Elevated HR (110)
Client is in atrial
fibrillation w/ rapid
ventricular response
EKG findings of
inferior infarction and
left axis deviation
Decreased
grips/weakness on left
side
Decreased urine output
(0 ml/10 hours)
Elevated potassium
level of 5.3
Elevated BUN (41)
Elevated Creatinine
(1.73)
2x3, 1 inch depth stage
II ulceration on coccyx
Unstageable ulceration
on right heal
Presence of multiple
tears on upper
extremities
Client is NPO
Problem
Activity intolerance
Long Term:
Client will meet
mutually defined goals
of ambulation by
[date], 12:00.
-Refer client to PT to help increase activity
levels and strength.
-Provide emotional support and
encouragement to the client to gradually
increase mobility.