Activity Intolerance
(_)Actual (_) Potential
| (_)
Alterations in O2 transport (_) Chronic disease:____________ ____________________________ (_) Depression (_) Diabetes Mellitus (_) Fatigue (_) Lack of motivation (_) Malnourishment |
(_) Pain (_) Prolonged immobility (_) Stressors (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major:
(Must be present) |
(_)
_____________________________________________________ ________________________________________________________ ________________________________________________________ |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Identify factors that reduce activity tolerance. (_) Progress to highest level of mobility possible. Describe:
(_) Exhibit a decrease in anoxic signs of increased activity. (eg: BP, pulse, resp.) (_) Other: |
(_)
Reduce or eliminate contributing factors by:
(_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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