Nursing diagnosis – risk for activity intolerance

Risk for Activity Intolerance
DEFINITION
At risk for experiencing insufficient physiological or psychological
energy to endure or complete required or desired activity
RISK FACTORS
• Circulatory or respiratory
problems
• History of previous intolerance
• Inexperience with a particular
activity
• Deconditioned status
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
EXPECTED OUTCOMES
The patient will
• Maintain muscle strength and joint ROM.
• Carry out isometric exercise regimen.
• Communicate understanding of rationale for maintaining activity
level.
• Avoid risk factors that may lead to activity intolerance.
• Perform self-care activities to tolerance level.
• Maintain blood pressure, pulse, and respiratory rate within
prescribed range during periods of activity (specify).
SUGGESTED NOC OUTCOMES
Activity Tolerance; Endurance; Energy Conservation; Self-Care:
ADLs; Self-Care: IADLs
INTERVENTIONS AND RATIONALES
Determine: Assess patient’s level of functioning using the functional
mobility scale to determine patient’s capabilities.
Assess patient’s physiologic response to increased activity (blood
pressure, respirations, heart rate, and rhythm). Monitoring vital
signs helps assess tolerance for increased exertion and activity.
Perform: Position patient to maintain proper body alignment. Use
assistive devices as needed to maintain joint function and prevent
musculoskeletal deformities.
Turn and position patient at least every 2 hr. Establish turning
schedule for the dependent patient. Post at bedside and monitor frequency.
Turning helps prevent skin breakdown by relieving pressure.
Unless contraindicated, perform ROM exercises every 2–4 hr.
Progress from passive to active, according to patient tolerance.
ROM exercises prevent joint contractures and muscular atrophy.
Encourage active movement by helping patient use trapeze or
other assistive devices to improve muscle tone and enhance selfesteem.
Inform: Teach patient how to perform isometric exercises to
maintain and improve muscle tone and joint mobility.
Teach patient, family member, or other caregiver skills such as
placing joints in proper body alignment or correct positioning to
maximize patient’s participation in self-care. Informed caregivers can
encourage patient to become more independent.
Teach patient symptoms of overexertion, such as dizziness, chest
pain, and dyspnea, to help him or her take responsibility for monitoring
his or her own activity level.
Assist patient in carrying out self-care activities. Increase patient’s
participation in self-care, as tolerated, to foster independence and
improve mobility.
Attend: Encourage patient to become involved in planning care and
making decisions related to treatment. Participation in planning
enhances patient compliance.
Explain rationale for maintaining or improving activity level. Discuss
factors that increase the risk of activity intolerance. Education
helps patient avoid activity intolerance.
Encourage patient to carry out ADLs. Provide emotional support,
and offer positive feedback when the patient displays initiative.
Offering emotional support enhances patient’s self-esteem and motivation.
Manage: Communicate patient’s level of functioning to all staff.
Communication among staff members ensures continuity of care and
enables patient to preserve the identified level of independence.
SUGGESTED NIC INTERVENTIONS
Activity Therapy; Ambulation; Body Mechanics Promotion; Energy
Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance, Joint Mobility, Muscle Control
Reference
Killey, B., & Watt, E. (2006, July). The effect of extra walking on the mobility,
independence, and exercise self-efficacy of elderly patients: A pilot study.
Contemporary Nurse, 22(1), 120–133.

Nursing diagnosis – activity intolerance

Activity Intolerance
DEFINITION
Insufficient physiological or psychological energy to endure or complete
required or desired daily activities
DEFINING CHARACTERISTICS
• Abnormal blood pressure and heart rate response to activity
• Electrocardiographic changes reflecting arrhythmias and/or ischemia
• Exertional discomfort and/or dyspnea
• Verbal report of fatigue and/or weakness
RELATED FACTORS
• Bed rest • Immobility
• Generalized weakness • Sedentary lifestyle
• Imbalance between oxygen
supply and demand
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
EXPECTED OUTCOMES
The patient will
• Regain and maintain muscle mass and strength.
• Maintain maximum joint range of motion (ROM).
• Perform isometric exercises.
• Help perform self-care activities.
• Maintain heart rate, rhythm, and blood pressure within expected
range during periods of activity.
• State understanding of and willingness to cooperate in maximizing
the activity level.
• Perform self-care activities to tolerance level.
SUGGESTED NOC OUTCOMES
Activity Tolerance; Endurance; Energy Conservation; Self-Care:
Activities of Daily Living (ADLs); Self-Care: Instrumental Activities
of Daily Living (IADLs)
INTERVENTIONS AND RATIONALES
Determine: Monitor physiologic responses to increased activity level,
including respirations, heart rate and rhythm, and blood pressure, to
ensure that these return to normal within 2–5 min after stopping
exercise.
Perform: Perform active or passive ROM exercises to all extremities
every 2–4 hr. These exercises foster muscle strength and tone, maintain
joint mobility, and prevent contractures.
Turn and reposition patient at least every 2 hr. Establish a turning
schedule for the dependent patient. Post schedule at bedside and
• ACTIVITY INTOLERANCE
monitor frequency. Turning and repositioning prevent skin
breakdown and improve lung expansion and prevent atelectasis.
Maintain proper body alignment at all times to avoid
contractures and maintain optimal musculoskeletal balance and
physiologic function.
Encourage active exercise: Provide a trapeze or other assistive
device whenever possible. Such devices simplify moving and turning
for many patients and allow them to strengthen some upper-body
muscles.
Inform: Teach about isometric exercises to allow patients to maintain
or increase muscle tone and joint mobility.
Teach caregivers to assist patients with ADLs in a way that maximizes
patients’ potential. This enables caregivers to participate in
patients’ care and encourages them to support patients’
independence.
Attend: Provide emotional support and encouragement to help
improve patient’s self-concept and motivate patient to perform
ADLs.
Involve patient in planning and decision making. Having the ability
to participate will encourage greater compliance with the plan
for activity.
Have patient perform ADLs. Begin slowly and increase daily, as
tolerated. Performing ADLs will assist patient to regain independence
and enhance self-esteem.
Manage: Refer to case manager/social worker to ensure that a home
assessment has been done and that whatever modifications were
needed to accommodate the patient’s level of mobility have been
made. Making adjustments in the home will allow the patient a
greater degree of independence in performing ADLs, allowing better
conservation of energy.
SUGGESTED NIC INTERVENTIONS
Activity Therapy; Ambulation; Body Mechanics Promotion; Energy
Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance, Joint Mobility, Muscle Control
Reference
Shin, Y., Yun, S., Jang, H., & Lim, J. (2006). A tailored program for the promotion
of physical exercise among Korean adults. Applied Nursing
Research, 19(2), 88–94.