NURSING DIAGNOSIS: Risk for activity intolerance

related to:
  1. decrease in available energy associated with an inadequate nutritional status and a slowed metabolic rate when inactive;
  2. loss of muscle mass, tone, and strength associated with disuse and inadequate nutritional status;
  3. eventual decrease in cardiac reserve associated with:
    1. increased cardiac workload resulting from the increased venous return in a recumbent position
    2. decreased coronary blood flow resulting from a shortened diastolic filling time (a result of the progressive increase in heart rate that occurs when a person is immobile)
    3. weakening of the myocardium (not usually a factor until client has been immobilized for 3 weeks or longer);
  4. difficulty resting and sleeping associated with inability to assume usual sleep position, frequent assessments and treatments, fear, anxiety, unfamiliar environment, and discomfort resulting from current illness/injury.
Desired Outcome
The client will not experience activity intolerance as evidenced by:
  1. no reports of fatigue and weakness
  2. ability to perform activities of daily living within physical limitations/restrictions without exertional dyspnea, chest pain, diaphoresis, dizziness, and a significant change in vital signs.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of activity intolerance:
    1. statements of fatigue or weakness
    2. exertional dyspnea, chest pain, diaphoresis, or dizziness
    3. 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)
    4. a significant change (15-20 mm Hg) in blood pressure with activity.
  2. Implement measures to prevent activity intolerance:
    1. perform actions to promote rest and/or conserve energy:
      1. minimize environmental activity and noise
      2. organize nursing care to allow for periods of uninterrupted rest
      3. limit the number of visitors and their length of stay
      4. assist client with self-care activities as needed
      5. keep supplies and personal articles within easy reach
      6. implement measures to reduce fear and anxiety (see Diagnosis 13, action b)
      7. implement measures to promote sleep (see Diagnosis 10, action c)
    2. perform additional actions to reduce cardiac workload and help maintain adequate cardiac reserve:
      1. place client in a semi- to high Fowler's position periodically if allowed
      2. instruct client to avoid activities that create a Valsalva response (e.g. straining to have a bowel movement, holding breath while moving up in bed)
      3. implement measures to improve breathing pattern and airway clearance (see Diagnoses 1, action b and 2, action b) in order to promote adequate tissue oxygenation
      4. discourage smoking and excessive intake of beverages high in caffeine such as coffee, tea, and colas
    3. perform actions to help maintain muscle strength (see Diagnosis 6, actions a.1 - 4)
    4. perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c)
    5. when activity can be increased:
      1. increase activity gradually
      2. instruct client in energy-saving techniques (e.g. using shower chair when showering, sitting to brush teeth or comb hair).
  3. Instruct client to:
    1. report a decreased tolerance for activity
    2. stop any activity that causes chest pain, shortness of breath, dizziness, or extreme fatigue or weakness.
  4. Consult physician if signs and symptoms of activity intolerance develop and persist or worsen.