Ongoing assessment is essential in order to identify potential problems that may have lead to Activity Intolerance as well as identify any issues that may arise during nursing care. Monitoring the individual’s responses to activity are cue points in performing an assessment related to activity intolerance:
|Assess the physical activity level and mobility of the patient.
|Provides baseline information for formulating nursing goals during goal setting.
Discontinue the activity if the patient responds with:
Reduce the duration and intensity of the activity if:
|Investigate the patient’s perception of causes of activity intolerance.||Causative factors may be temporary or permanent as well as physical or psychological. Determining the cause can help guide the nurse during the nursing intervention.|
|Assess the patient’s nutritional status.||Adequate energy reserves are needed during activity.|
|Observe and monitor the patient’s sleep pattern and the amount of sleep achieved over the past few days.||Sleep deprivation and difficulties during sleep can affect the activity level of the patient – these needs to be addressed before successful activity progression can be achieved.|
|Determine the patient’s daily routine and over-the-counter medication.||Fatigue can limit the patient’s ability to perform needed activity. It can also be a medication side effect. Pay attention to the patient’s use of beta-blockers, calcium channel blockers, tranquilizers, antihistamines, relaxants, alcohol, and sedatives.|
|Assess the need for ambulation aids (e.g., cane, walker) for ADLs.||Assistive devices enhance the mobility of the patient by helping him overcome limitations.|
|Use portable pulse oximetry to assess for oxygen desaturation during activity.||May determine the use of supplemental oxygen to help compensate for the increased oxygen demands during physical activity.|
|Assess the patient’s baseline cardiopulmonary status (e.g., heart rate, orthostatic BP) before initiating activity.||In normal adults, HR should not increase more than 20 to 30 beats/min above resting with routine activities. Older patients are more susceptible to orthostatic drops in BP with position changes.|
|Observe and document response to activity.||Close monitoring will serve as a guide for optimal progression of activity.|
|Assess emotional response to limitations in physical activity.||Depression over the inability to perform activities can be a source of stress and frustration.|
The following are the therapeutic nursing interventions for patients with activity intolerance:
|Establish guidelines and goals of activity with the patient and/or SO.||Motivation and cooperation are enhanced if the patient participates in goal setting.|
|Evaluate the need for additional help at home.||Coordinated efforts are more meaningful and effective in assisting the patient in conserving energy.|
|Have the patient perform the activity more slowly, in a longer time with more rest or pauses, or with assistance if necessary.||Helps in increasing the tolerance for the activity.|
|Gradually increase activity with active range-of-motion exercises in bed, increasing to sitting and then standing.||Gradual progression of the activity prevents overexertion.|
|Dangle the legs from the bed side for 10 to 15 minutes.||Prevents orthostatic hypotension.|
|Refrain from performing nonessential activities or procedures.||Patient with limited activity tolerance need to prioritize important taks first.|
|Assist with ADLs while avoiding patient dependency.||Assisting the patient with ADLs allows conservation of energy. Carefully balance provision of assistance; facilitating progressive endurance will ultimately enhance the patient’s activity tolerance and self-esteem.|
|Provide bedside commode as indicated.||Use of commode requires less energy expenditure than using a bedpan or ambulating to the bathroom.|
|Encourage physical activity consistent with the patient’s energy levels.||Helps promote a sense of autonomy while being realistic about capabilities.|
|Instruct patient to plan activities for times when they have the most energy.||Activities should be planned ahead to coincide with the patient’s peak energy level. If the goal is too low, negotiate.|
|Encourage verbalization of feelings regarding limitations.||This helps the patient to cope. Acknowledgment that living with activity intolerance is both physically and emotionally difficult.|
|Gradually progress patient activity with the following:
|Duration and frequency should be increased before intensity.|
|Encourage active ROM exercises. Encourage the patient to participate in planning activities that gradually build endurance.||Exercise maintains muscle strength, joint ROM, and exercise tolerance. Physical inactive patients need to improve functional capacity through repetitive exercises over a long period of time. Strength training is valuable in enhancing endurance of many ADLs.|
|Provide emotional support and positive attitude regarding abilities.||Patient may be fearful of overexertion and potential damage to the heart. Appropriate supervision during early efforts can enhance confidence.|
|Provide the patient with the adaptive equipment needed for completing ADLs.||Appropriate aids will enable the patient to achieve optimal independence for self-care and reduce energy consumption during activity.|
|Teach the patient and/or SO to recognize signs of physical overactivity or overexertion.||Knowledge promotes awareness to prevent the complication of overexertion.|
|Teach energy conservation techniques, such as:
|These techniques reduce oxygen consumption, allowing a more prolonged activity.|
|For patients with pulmonary insufficiency:|
|Encourage conscious-controlled breathing techniques (e.g., pursed-lip breathing and diaphragmatic breathing) during increased activity and times of emotional or physical stress.
Diaphragmatic-breathing or abdominal breathing:
|Helps in performing efficient breathing by maximizing the expansion of the lungs.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.