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Nursing Diagnosis: Activity intolerance

Linda L. Straight
NANDA Definition: Insufficient physiological or
psychological energy to endure or complete required or
desired daily activities

Defining Characteristics: Verbal report of fatigue or


weakness, abnormal heart rate or blood pressure response to
activity, exertional discomfort or dyspnea,
electrocardiographic changes reflecting dysrhythmias or
ischemia

Related Factors: Bed rest or immobility; generalized


weakness; sedentary lifestyle; imbalance between oxygen
supply and demand

NOC Outcomes (Nursing Outcomes Classification)


Suggested NOC Labels

Endurance

Energy Conservation

Activity Tolerance

Self-Care: Activities of Daily Living (ADLs)

Client Outcomes

Participates in prescribed physical activity with


appropriate increases in heart rate, blood
pressure, and breathing rate; maintains monitor
patterns (rhythm and ST segment) within normal
limits

States symptoms of adverse effects of exercise


and reports onset of symptoms immediately

Maintains normal skin color and skin is warm


and dry with activity
Verbalizes an understanding of the need to
gradually increase activity based on testing,
tolerance, and symptoms

Expresses an understanding of the need to


balance rest and activity

Demonstrates increased activity tolerance

NIC Interventions (Nursing Interventions Classification)


Suggested NIC Labels

Energy Management

Activity Therapy

Nursing Interventions and Rationales

Determine cause of activity intolerance (see


Related Factors) and determine whether cause is
physical, psychological, or motivational.
Determining the cause of a disease can help direct
appropriate interventions.

Assess client daily for appropriateness of


activity and bed rest orders. Inappropriate
prolonged bed rest orders may contribute to
activity intolerance. A review of 39 studies on bed
rest resulting from 15 disorders demonstrated
that bed rest for treatment of medical conditions
is associated with worse outcomes than early
mobilization (Allen, Glasziou, Del Mar, 1999).

Minimize cardiovascular deconditioning by


positioning clients as close to the upright position
as possible several times daily. The hazards of bed
rest in the elderly are multiple, serious, quick to
develop, and slow to reverse. Deconditioning of
the cardiovascular system occurs within days and
involves fluid shifts, fluid loss, decreased cardiac
output, decreased peak oxygen uptake, and
increased resting heart rate (Resnick, 1998).
If appropriate, gradually increase activity,
allowing client to assist with positioning,
transferring, and self-care as possible. Progress
from sitting in bed to dangling, to chair sitting, to
standing, to ambulation. Increasing activity helps
to maintain muscle strength, tone, and
endurance. Allowing the client to participate
decreases the perception of the client as incapable
and frail (Eliopoulous, 1998).

Ensure that clients change position slowly.


Consider using a chair-bed (stretcher-chair) for
clients who cannot get out of bed. Monitor for
symptoms of activity intolerance. Bed rest in the
supine position results in loss of plasma volume,
which contributes to postural hypotension and
syncope (Creditor, 1993).

When getting clients up, observe for


symptoms of intolerance such as nausea, pallor,
dizziness, visual dimming, and impaired
consciousness, as well as changes in vital signs.
Heart rate and blood pressure responses to
orthostasis vary widely. Vital sign changes by
themselves should not define orthostatic
intolerance (Winslow, Lane, Woods, 1995).

Perform range-of-motion exercises if client is


unable to tolerate activity. Inactivity rapidly
contributes to muscle shortening and changes in
periarticular and cartilaginous joint structure.
These factors contribute to contracture and
limitation of motion (Creditor, 1994).

Refer client to physical therapy to help


increase activity levels and strength.

Monitor and record client's ability to tolerate


activity: note pulse rate, blood pressure, monitor
pattern, dyspnea, use of accessory muscles, and
skin color before and after activity. If the following
signs and symptoms of cardiac decompensation
develop, activity should be stopped immediately
(ACSM, 1995):

o Excessive fatigue

o Lightheadedness, confusion, ataxia, pallor,


cyanosis, dyspnea, nausea, or any
peripheral circulatory insufficiency

o Onset of angina with exercise

o Palpitations

o Dysrhythmia (symptomatic
supraventricular tachycardia, ventricular
tachycardia, exercise-induced left bundle
block, second- or third-degree
atrioventricular block, frequent premature
ventricular contractions)

o Exercise hypotension (drop in systolic


blood pressure of more than 10 mm Hg
from baseline blood pressure despite an
increase in workload, when accompanied
by other evidence of ischemia)

o Excessive rise in blood pressure (systolic


greater than 220 mm Hg or diastolic
greater than 110 mm Hg); NOTE: these
are upper limits; activity may be stopped
before reaching these values

o Inappropriate bradycardia (drop in heart


rate greater than 10 beats/min) with no
change or increase in workload

o Increased heart rate above the prescribed


limit

Instruct client to stop activity immediately


and report to physician if experiencing the
following symptoms: new or worsened intensity or
increased frequency of discomfort, tightness, or
pressure in chest, back, neck, jaw, shoulders,
and/or arms; palpitations; dizziness; weakness;
unusual and extreme fatigue; excessive air
hunger. These are common symptoms of angina
and are caused by a temporary insufficiency of
coronary blood supply. Symptoms typically last for
minutes as opposed to momentary twinges. If
symptoms last longer than 5 to 10 minutes, the
client should be evaluated by a physician
(McGoon, 1993). The client should be evaluated
before resuming activity (Thompson, 1988).

Allow for periods of rest before and after


planned exertion periods such as meals, baths,
treatments, and physical activity. Rest periods
decrease oxygen consumption (Prizant-Weston,
Castiglia, 1992).

Observe and document skin integrity several


times a day. Activity intolerance may lead to
pressure ulcers. Mechanical pressure, moisture,
friction, and shearing forces all predispose to their
development (Resnick, 1998).

Assess urinary incontinence related to


functional ability. Assess independent ability to get
to the toilet and remove and adjust clothing. The
loss of functional ability that accompanies disease
often leads to continence problems. The cause
may not be the person's bladder instability but his
or her ability to get to the toilet quickly (Nazarko,
1997).

Assess for constipation. Impaired mobility is


associated with increased risk of bowel
dysfunction, including constipation. Constipation
increases the risk of urinary tract infection and
urge incontinence (Nazarko, 1997).
Consider dietitian referral to assess nutritional
needs related to activity intolerance. Severe
malnutrition can lead to activity intolerance.
Dietitians can recommend dietary changes that
can improve the client's health status
(Peckenpaugh, Poleman, 1999).

Refer the cardiac client to cardiac


rehabilitation for assistance in developing safe
exercise guidelines based on testing and
medications. Cardiac rehabilitation exercise
training improves objective measures of exercise
tolerance in both men and women, including
elderly patients with coronary heart disease and
heart failure. This functional improvement occurs
without significant cardiovascular complications or
other adverse outcomes (Wenger et al, 1995).

Ensure that the chronic pulmonary client has


oxygen saturation testing with exercise. Use
supplemental oxygen to keep oxygen saturation
90% or above or as prescribed with activity.
Supplemental oxygen increases circulatory oxygen
levels and improves activity tolerance (Petty,
Finigan, 1968; Casaburi, Petty, 1993).

Monitor a chronic obstructive pulmonary


disease (COPD) client's response to activity by
observing for symptoms of respiratory intolerance
such as increased dyspnea, loss of ability to
control breathing rhythmically, use of accessory
muscles, and skin tone changes such as pallor and
cyanosis.

Instruct and assist COPD clients in using


conscious controlled breathing techniques such as
pursing their lips and diaphragmatic breathing.
Training clients with COPD to slow their
respiratory rate with a prolonged exhalation (with
or without pursed lips) helps control dyspnea and
results in improved ventilation, increased tidal
volume, decreased respiratory rate, and a reduced
alveolar-arterial oxygen difference. This breathing
pattern not only helps relieve dyspnea but can
improve the ability to exercise and carry out ADLs
(Mueller, Petty, Filley, 1970; Casaburi, Petty,
1993).

Provide emotional support and


encouragement to client to gradually increase
activity. Fear of breathlessness, pain, or falling
may decrease willingness to increase activity.

Refer the COPD client to a pulmonary


rehabilitation program. Pulmonary rehabilitation
has been shown to improve exercise capacity,
walking ability, and sense of well-being (Fishman,
1994).

Observe for pain before activity. If possible,


treat pain before activity, and ensure that client is
not heavily sedated. Pain restricts the client from
achieving a maximal activity level and is often
exacerbated by movement.

Obtain any necessary assistive devices or


equipment needed before ambulating client (e.g.,
walkers, canes, crutches, portable oxygen).
Assistive devices can increase mobility by helping
the client overcome limitations.

Use a walking belt when ambulating a client


who is unsteady. With a walking belt the client can
walk independently, but the nurse can provide
support if the client's knees buckle.

Work with client to set mutual goals that


increase activity levels.
Geriatric
Slow the pace of care. Allow client extra time
to carry out activities.

Encourage families to help/allow elder to be


independent in whatever activities possible.
Sometimes families believe they are assisting by
allowing clients to be sedentary. Encouraging
activity not only enhances good functioning of the
body's systems but also promotes a sense of
worth by providing an opportunity for productivity
(Eliopoulous, 1997).

When mobilizing the elderly client, watch for


orthostatic hypotension accompanied by dizziness
and fainting. Orthostatic hypotension is common
in the elderly as a result of cardiovascular
changes, chronic diseases, and medication effects
(Mobily, Kelley, 1991).

Home Care Interventions

Begin discharge planning as soon as possible


with case manager or social worker to assess need
for home support systems and the need for
community or home health services.

Assess the home environment for factors that


precipitate decreased activity tolerance: presence
of allergens such as dust, smoke, and those
associated with pets; temperature; energy-
intensive activity patterns; and furniture
placement. Refer to occupational therapy if
needed to assist the client in restructuring the
home and activity of daily living patterns. Clients
and families often estimate energy requirements
inaccurately during hospitalization because of the
availability of support.

Teach the client/family the importance of and


methods for setting priorities for activities,
especially those having a high energy demand
(e.g., home/family events).

Provide client/family with resources such as


senior centers, exercise classes, educational and
recreational programs, and volunteer opportunities
that can aid in promoting socialization and
appropriate activity. Social isolation can contribute
to activity intolerance.

Discuss the importance of sexual activity as


part of daily living. Instruct the client in adaptive
techniques to conserve energy during sexual
interactions. Families may make unsafe choices
for sexual activity or place added stress on
themselves trying to cope with this issue without
proper support or teaching.

Instruct the client and family in the


importance of maintaining proper nutrition and
rest for energy conservation and rehabilitation.

Refer to medical social services as necessary


to assist the family in adjusting to major changes
in patterns of living.

Assess the need for long-term supports for


optimal activity tolerance of priority activities
(e.g., assistive devices, oxygen, medication,
catheters, massage), especially for hospice
patients. Evaluate intermittently. Assessments
ensure the safety and appropriate use of these
supports.

Refer to home health aide services to support


the client and family through changing levels of
activity tolerance. Introduce aide support early.
Instruct the aide to promote independence in
activity as tolerated. Providing unnecessary
assistance with transfers and bathing activities
may promote dependence and a loss of mobility
(Mobily, Kelley, 1991).

Be aware of increased risk of bone fracture


even after muscle strength is normalized,
especially in osteopenic-prone individuals such as
estrogen-deficient women and the elderly.
Reduction in weight bearing muscle activity during
bed rest invariably produces significant changes in
calcium balance and, in weeks, changes in bone
mass (Bloomfield, 1997)

Allow terminally ill clients and their families to


guide care. Control by the client or family
promotes effective coping.

Provide increased attention to comfort and


dignity of the terminally ill client in care planning.
For example, oxygen may be more valuable as a
support to the client's psychological comfort than
as a booster of oxygen saturation.

Client/Family Teaching

Instruct client on rationale and techniques for


avoiding activity intolerance.

Teach client to use controlled breathing


techniques with activity.

Teach client the importance and method of


coughing, clearing secretions.

Instruct client in the use of relaxation


techniques during activity.
Help client with energy conservation and work
simplification techniques in ADLs.

Teach client the importance of proper


nutrition.

Describe to client the symptoms of activity


intolerance, including which symptoms to report to
the physician.

Explain to client how to use assistive devices


or medications before or during activity.

Help client set up an activity log to record


exercise and exercise tolerance.