Nursing diagnosis – risk for activity intolerance

Risk for Activity Intolerance
At risk for experiencing insufficient physiological or psychological
energy to endure or complete required or desired activity
• Circulatory or respiratory
• History of previous intolerance
• Inexperience with a particular
• Deconditioned status
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
The patient will
• Maintain muscle strength and joint ROM.
• Carry out isometric exercise regimen.
• Communicate understanding of rationale for maintaining activity
• 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).
Activity Tolerance; Endurance; Energy Conservation; Self-Care:
ADLs; Self-Care: IADLs
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.
Activity Therapy; Ambulation; Body Mechanics Promotion; Energy
Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance, Joint Mobility, Muscle Control
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.