Nursing Care Plans For Activity Intolerance rest for treatment of medical conditions is associated with

worse outcomes than early mobilization (Allen, Glasziou, Del

Posted by d.nurisna at Thursday, February 12, 2009 . Mar, 1999).
Thursday, February 12, 2009 • Minimize cardiovascular deconditioning by positioning
Labels: NURSING CARE PLANS clients as close to the upright position as possible several
times daily. The hazards of bed rest in the elderly are
Nursing Diagnosis: Activity intolerance multiple, serious, quick to develop, and slow to reverse.
Deconditioning of the cardiovascular system occurs within
NANDA Definition: days and involves fluid shifts, fluid loss, decreased cardiac
Insufficient physiological or psychological energy to endure or output, decreased peak oxygen uptake, and increased resting
complete required or desired daily activities heart rate (Resnick, 1998).
• If appropriate, gradually increase activity, allowing client to
Defining Characteristics: assist with positioning, transferring, and self-care as possible.
Verbal report of fatigue or weakness, abnormal heart rate or Progress from sitting in bed to dangling, to chair sitting, to
blood pressure response to activity, exertional discomfort or standing, to ambulation. Increasing activity helps to maintain
dyspnea, electrocardiographic changes reflecting muscle strength, tone, and endurance. Allowing the client to
dysrhythmias or ischemia participate decreases the perception of the client as
incapable and frail (Eliopoulous, 1998).
Related Factors: • Ensure that clients change position slowly. Consider using a
Bed rest or immobility; generalized weakness; sedentary chair-bed (stretcher-chair) for clients who cannot get out of
lifestyle; imbalance between oxygen supply and demand bed. Monitor for symptoms ofactivity intolerance . Bed rest in
the supine position results in loss of plasma volume, which
NOC Outcomes (Nursing Outcomes Classification) contributes to postural hypotension and syncope (Creditor,
Suggested NOC Labels 1993).
• Endurance • When getting clients up, observe for symptoms of
• Energy Conservation intolerance such as nausea, pallor, dizziness, visual dimming,
• Activity Tolerance and impaired consciousness, as well as changes in vital signs.
• Self-Care: Activities of Daily Living (ADLs) Heart rate and blood pressure responses to orthostasis vary
widely. Vital sign changes by themselves should not define
Client Outcomes orthostatic intolerance (Winslow, Lane, Woods, 1995).
• Participates in prescribed physical activity with appropriate • Perform range-of-motion exercises if client is unable to
increases in heart rate, blood pressure, and breathing rate; tolerate activity. Inactivity rapidly contributes to muscle
maintains monitor patterns (rhythm and ST segment) within shortening and changes in periarticular and cartilaginous joint
normal limits structure. These factors contribute to contracture and
• States symptoms of adverse effects of exercise and reports limitation of motion (Creditor, 1994).
onset of symptoms immediately • Refer client to physical therapy to help increase activity
• Maintains normal skin color and skin is warm and dry with levels and strength.
activity • Monitor and record client's ability to tolerate activity: note
• Verbalizes an understanding of the need to gradually pulse rate, blood pressure, monitor pattern, dyspnea, use of
increase activity based on testing, tolerance, and symptoms accessory muscles, and skin color before and after activity. If
• Expresses an understanding of the need to balance rest and the following signs and symptoms of cardiac decompensation
activity develop, activity should be stopped immediately (ACSM,
• Demonstrates increased activity tolerance 1995):
o Excessive fatigue
NIC Interventions (Nursing Interventions Classification) o Lightheadedness, confusion, ataxia, pallor, cyanosis,
Suggested NIC Labels dyspnea, nausea, or any peripheral circulatory insufficiency
• Energy Management o Onset of angina with exercise
• Activity Therapy o Palpitations
o Dysrhythmia (symptomatic supraventricular tachycardia,
Nursing Interventions and Rationales ventricular tachycardia, exercise-induced left bundle block,
• Determine cause of activity intolerance (see Related second- or third-degree atrioventricular block, frequent
Factors) and determine whether cause is physical, premature ventricular contractions)
psychological, or motivational. Determining the cause of a o Exercise hypotension (drop in systolic blood pressure of
disease can help direct appropriate interventions. more than 10 mm Hg from baseline blood pressure despite
• Assess client daily for appropriateness of activity and bed an increase in workload, when accompanied by other
rest orders. Inappropriate prolonged bed rest orders may evidence of ischemia)
contribute toactivity intolerance . A review of 39 studies on o Excessive rise in blood pressure (systolic greater than 220
bed rest resulting from 15 disorders demonstrated that bed mm Hg or diastolic greater than 110 mm Hg); NOTE: these are
upper limits; activity may be stopped before reaching these
values muscles, and skin tone changes such as pallor and cyanosis.
o Inappropriate bradycardia (drop in heart rate greater than • Instruct and assist COPD clients in using conscious
10 beats/min) with no change or increase in workload controlled breathing techniques such as pursing their lips and
o Increased heart rate above the prescribed limit diaphragmatic breathing. Training clients with COPD to slow
• Instruct client to stop activity immediately and report to their respiratory rate with a prolonged exhalation (with or
physician if experiencing the following symptoms: new or without pursed lips) helps control dyspnea and results in
worsened intensity or increased frequency of discomfort, improved ventilation, increased tidal volume, decreased
tightness, or pressure in chest, back, neck, jaw, shoulders, respiratory rate, and a reduced alveolar-arterial oxygen
and/or arms; palpitations; dizziness; weakness; unusual and difference. This breathing pattern not only helps relieve
extreme fatigue; excessive air hunger. These are common dyspnea but can improve the ability to exercise and carry out
symptoms of angina and are caused by a temporary ADLs (Mueller, Petty, Filley, 1970; Casaburi, Petty, 1993).
insufficiency of coronary blood supply. Symptoms typically • Provide emotional support and encouragement to client to
last for minutes as opposed to momentary twinges. If gradually increase activity. Fear of breathlessness, pain, or
symptoms last longer than 5 to 10 minutes, the client should falling may decrease willingness to increase activity.
be evaluated by a physician (McGoon, 1993). The client • Refer the COPD client to a pulmonary rehabilitation
should be evaluated before resuming activity (Thompson, program. Pulmonary rehabilitation has been shown to
1988). improve exercise capacity, walking ability, and sense of well-
• Allow for periods of rest before and after planned exertion being (Fishman, 1994).
periods such as meals, baths, treatments, and physical • Observe for pain before activity. If possible, treat pain
activity. Rest periods decrease oxygen consumption (Prizant- before activity, and ensure that client is not heavily sedated.
Weston, Castiglia, 1992). Pain restricts the client from achieving a maximal activity
• Observe and document skin integrity several times a day. level and is often exacerbated by movement.
Activity intolerance may lead to pressure ulcers. Mechanical • Obtain any necessary assistive devices or equipment
pressure, moisture, friction, and shearing forces all needed before ambulating client (e.g., walkers, canes,
predispose to their development (Resnick, 1998). crutches, portable oxygen). Assistive devices can increase
• Assess urinary incontinence related to functional ability. mobility by helping the client overcome limitations.
Assess independent ability to get to the toilet and remove • Use a walking belt when ambulating a client who is
and adjust clothing. The loss of functional ability that unsteady. With a walking belt the client can walk
accompanies disease often leads to continence problems. The independently, but the nurse can provide support if the
cause may not be the person's bladder instability but his or client's knees buckle.
her ability to get to the toilet quickly (Nazarko, 1997). • Work with client to set mutual goals that increase activity
• Assess for constipation. Impaired mobility is associated with levels.
increased risk of bowel dysfunction, including constipation.
Constipation increases the risk of urinary tract infection and Geriatric
urge incontinence (Nazarko, 1997). • Slow the pace of care. Allow client extra time to carry out
• Consider dietitian referral to assess nutritional needs activities.
related to activity intolerance. Severe malnutrition can lead • Encourage families to help/allow elder to be independent in
to activity intolerance. Dietitians can recommend dietary whatever activities possible. Sometimes families believe they
changes that can improve the client's health status are assisting by allowing clients to be sedentary. Encouraging
(Peckenpaugh, Poleman, 1999). activity not only enhances good functioning of the body's
• Refer the cardiac client to cardiac rehabilitation for systems but also promotes a sense of worth by providing an
assistance in developing safe exercise guidelines based on opportunity for productivity (Eliopoulous, 1997).
testing and medications. Cardiac rehabilitation exercise • When mobilizing the elderly client, watch for orthostatic
training improves objective measures of exercise tolerance in hypotension accompanied by dizziness and fainting.
both men and women, including elderly patients with Orthostatic hypotension is common in the elderly as a result
coronary heart disease and heart failure. This functional of cardiovascular changes, chronic diseases, and medication
improvement occurs without significant cardiovascular effects (Mobily, Kelley, 1991).
complications or other adverse outcomes (Wenger et al,
1995). Home Care Interventions
• Ensure that the chronic pulmonary client has oxygen • Begin discharge planning as soon as possible with case
saturation testing with exercise. Use supplemental oxygen to manager or social worker to assess need for home support
keep oxygen saturation 90% or above or as prescribed with systems and the need for community or home health
activity. Supplemental oxygen increases circulatory oxygen services.
levels and improves activity tolerance (Petty, Finigan, 1968; • Assess the home environment for factors that precipitate
Casaburi, Petty, 1993). decreased activity tolerance: presence of allergens such as
• Monitor a chronic obstructive pulmonary disease (COPD) dust, smoke, and those associated with pets; temperature;
client's response to activity by observing for symptoms of energy-intensive activity patterns; and furniture placement.
respiratory intolerance such as increased dyspnea, loss of Refer to occupational therapy if needed to assist the client in
ability to control breathing rhythmically, use of accessory restructuring the home and activity of daily living patterns.
Clients and families often estimate energy requirements • Describe to client the symptoms of activity intolerance,
inaccurately during hospitalization because of the availability including which symptoms to report to the physician.
of support. • Explain to client how to use assistive devices or medications
• Teach the client/family the importance of and methods for before or during activity.
setting priorities for activities, especially those having a high • Help client set up an activity log to record exercise and
energy demand (e.g., home/family events). exercise tolerance.
• Provide client/family with resources such as senior centers,
exercise classes, educational and recreational programs, and Most activity intolerance is related to generalized weakness
volunteer opportunities that can aid in promoting and debilitation secondary to acute or chronic illness and
socialization and appropriate activity. Social isolation can
disease. This is especially apparent in elderly patients with a
contribute to activity intolerance.
history of orthopedic, cardiopulmonary, diabetic, or
• Discuss the importance of sexual activity as part of daily
living. Instruct the client in adaptive techniques to conserve pulmonary- related problems. The aging process itself causes
energy during sexual interactions. Families may make unsafe reduction in muscle strength and function, which can impair
choices for sexual activity or place added stress on the ability to maintain activity. Activity intolerance may also
themselves trying to cope with this issue without proper be related to factors such as obesity, malnourishment, side
support or teaching. effects of medications (e.g., -blockers), or emotional states
• Instruct the client and family in the importance of
such as depression or lack of confidence to exert one's self.
maintaining proper nutrition and rest for energy conservation
and rehabilitation. Nursing goals are to reduce the effects of inactivity, promote
• Refer to medical social services as necessary to assist the optimal physical activity, and assist the patient to maintain a
family in adjusting to major changes in patterns of living. satisfactory lifestyle.
• 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.