tissue hypoxia associated with anemia resulting from:
decreased production of RBCs resulting from a decreased intake and absorption of vitamins and minerals and an inability of the liver to store vitamins and minerals
excessive RBC destruction resulting from hypersplenism (if venous congestion has resulted in splenomegaly, the spleen will destroy RBCs faster than usual)
blood loss if bleeding has occurred;
loss of muscle mass, tone, and strength associated with malnutrition and disuse if mobility has been limited for an extended period;
decrease in available energy associated with inability of the liver to metabolize glucose, fats, and proteins properly;
difficulty resting and sleeping associated with dyspnea, discomfort, frequent assessments and treatments, fear, anxiety, and unfamiliar environment.
The client will demonstrate an increased tolerance for activity as evidenced by:
verbalization of feeling less fatigued and weak
ability to perform activities of daily living without exertional dyspnea, chest pain, diaphoresis, dizziness, and a significant change in vital signs.
Nursing Actions and Selected Purposes/Rationales
Assess for signs and symptoms of activity intolerance:
statements of fatigue or weakness
exertional dyspnea, chest pain, diaphoresis, or dizziness
abnormal heart rate response to activity (e.g. increase in rate of 20 beats/minute above resting rate, rate not returning to preactivity level within 3 minutes after stopping activity, change from regular to irregular rate)
a significant change (15-20 mm Hg) in blood pressure with activity.
Implement measures to improve activity tolerance:
perform actions to promote rest and/or conserve energy:
maintain activity restrictions as ordered
minimize environmental activity and noise
organize nursing care to allow for periods of uninterrupted rest
limit the number of visitors and their length of stay
assist client with self-care activities as needed
keep supplies and personal articles within easy reach
instruct client in energy-saving techniques (e.g. using shower chair when showering, sitting to brush teeth or comb hair)
implement measures to reduce fear and anxiety (e.g. assure client that staff are nearby, explain all tests and procedures, encourage verbalization of fear and anxiety)
implement measures to promote sleep (e.g. elevate head of bed and support arms on pillows to facilitate breathing; maintain oxygen therapy during sleep; discourage intake of fluids high in caffeine, especially in the evening; encourage relaxing diversional activities in the evening)
implement measures to reduce discomfort (see Diagnoses 4, action b and 5, action c)
discourage smoking and excessive intake of beverages high in caffeine such as coffee, tea, and colas (nicotine and caffeine can increase cardiac workload and myocardial oxygen utilization, thereby decreasing oxygen availability)
perform actions to improve breathing pattern (see Diagnosis 1, action b) in order to decrease dyspnea and improve tissue oxygenation
maintain oxygen therapy as ordered
perform actions to improve nutritional status (see Diagnosis 3, action c)
perform actions to treat anemia (e.g. administer prescribed iron, folic acid, and/or vitamin B12; administer packed red blood cells if ordered)
increase client's activity gradually as allowed and tolerated.
Instruct client to:
report a decreased tolerance for activity
stop any activity that causes chest pain, a marked increase in shortness of breath, dizziness, or extreme fatigue or weakness.
Consult physician if signs and symptoms of activity intolerance persist or worsen.