NURSING DIAGNOSIS: Activity intolerance

related to:
  1. tissue hypoxia associated with decreased cardiac output, impaired alveolar gas exchange, and anemia (results from hemodilution, blood loss, and red cell hemolysis [red cells are traumatized by the cardiopulmonary bypass machine]);
  2. difficulty resting and sleeping associated with frequent assessments and treatments, discomfort, fear, and anxiety.
Desired Outcome
The client will demonstrate an increased tolerance for activity (see Standardized Postoperative Care Plan, Diagnosis 11, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 11, for measures related to assessment and improvement of activity tolerance.
  2. Implement additional measures to improve activity tolerance:
    1. perform actions to maintain an adequate cardiac output (see Postoperative Diagnosis 1, action b)
    2. perform actions to maintain adequate respiratory function (see Postoperative Diagnosis 2, action b)
    3. perform actions to treat anemia:
      1. encourage client to increase intake of foods high in iron (e.g. organ meats, dried fruit, dark green leafy vegetables, whole-grain or iron-enriched breads and cereals) and vitamin C (enhances the absorption of iron from plant products)
      2. autotransfuse blood from the mediastinal drainage collection device or administer packed red blood cells if ordered
      3. administer iron supplements if ordered
    4. increase client's activity gradually as allowed and tolerated; explain to client that a progressive and gradual increase in activity is necessary in order to strengthen the myocardium without causing a sudden increase in cardiac workload.