Nursing Care Plan for Activity IntoleranceSample of nursing care plan for activity intolerance

Nursing diagnosis: activity intolerance

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Definition of activity intolerance| Nursing Care Plan for Activity Intolerance

Insufficient physiological or psychological energy to endure or complete required or desired daily activities

 

Related Factors of activity intolerance| Nursing Care Plan for Activity Intolerance

  • Generalized weakness
  • Sedentary lifestyle
  • Bedrest or immobility
  • Imbalance between oxygen supply and demand
  • [Cognitive deficits/emotional status; secondary to underlying disease process/depression]
  • [Pain, vertigo, extreme stress]

 

Defining Characteristics of activity intolerance| Nursing Care Plan for Activity Intolerance

SUBJECTIVE

  • Report of fatigue or weakness
  • Exertional discomfort or dyspnea
  • [Verbalizes no desire and/or lack of interest in activity]

OBJECTIVE

  • Abnormal heart rate or blood pressure response to activity
  • Electrocardiographic changes reflecting dysrhythmias or ischemia
  • [Pallor, cyanosis]

 

Functional Level Classification (Gordon, 1987) | Nursing Care Plan for Activity Intolerance

  • Level I:Walk, regular pace, on level indefinitely; one flight or more but more short of breath than normally
  • Level II:Walk one city block [or] 500 ft on level; climb one flight slowly without stopping
  • Level III:Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
  • Level IV: Dyspnea and fatigue at rest

 

Desired Outcomes/Evaluation of activity intolerance| Nursing Care Plan for Activity Intolerance

Criteria—Client Will:

  • Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.
  • Use identified techniques to enhance activity tolerance.
  • Participate willingly in necessary/desired activities.
  • Report measurable increase in activity tolerance.
  • Demonstrate a decrease in physiologic signs of intolerance (e.g., pulse, respirations, and blood pressure remain within client’s normal range).

 

Nursing interventions for activity intolerance| Nursing Care Plan for Activity Intolerance

NURSING PRIORITY NO. 1. To identify causative/precipitating factors:

  • Note presence of factors contributing to fatigue (e.g., acute or chronic illness, heart failure, hypothyroidism, cancer, and cancer therapies, etc.).
  • Evaluate current limitations/degree of deficit in light of usual status. (Provides comparative baseline.)
  • Note client reports of weakness, fatigue, pain, difficulty accomplishing tasks, and/or insomnia.
  • Assess cardiopulmonary response to physical activity, including vital signs before, during, and after activity. Note progression/accelerating degree of fatigue.
  • Ascertain ability to stand and move about and degree of assistance necessary/use of equipment.
  • Identify activity needs versus desires (e.g., is barely able to walk upstairs but would like to play racquetball).
  • Assess emotional/psychologic factors affecting the current situation (e.g., stress and/or depression may be increasing the effects of an illness, or depression might be the result of being forced into inactivity).
  • Note treatment-related factors, such as side effects/interactions of medications.

NURSING PRIORITY NO. 2. To assist client to deal with contributing factors and manage activities within individual limits:

  • Monitor vital/cognitive signs, watching for changes in blood pressure, heart and respiratory rate; note skin pallor and/or cyanosis, and presence of confusion.
  • Adjust activities to prevent overexertion. Reduce intensity
  • Provide/monitor response to supplemental oxygen and medications and changes in treatment regimen.
  • Increase exercise/activity levels gradually; teach methods to conserve energy, such as stopping to rest for 3 minutes during a 10-minute walk, sitting down instead of standing to brush hair.
  • Plan care with rest periods between activities to reduce fatigue.
  • Provide positive atmosphere, while acknowledging difficulty of the situation for the client. (Helps to minimize frustration, rechannel energy.)
  • Encourage expression of feelings contributing to/resulting from condition.
  • Involve client/SO(s) in planning of activities as much as possible.
  • Assist with activities and provide/monitor client’s use of assistive devices (crutches, walker, wheelchair, oxygen tank, etc.) to protect client from injury.
  • Promote comfort measures and provide for relief of pain to enhance ability to participate in activities. (Refer to ND Pain, acute or Pain, chronic.)
  • Provide referral to other disciplines as indicated (e.g., exercise physiologist, psychologic counseling/therapy, occupational/physical therapists, and recreation/leisure specialists) to develop individually appropriate therapeutic regimens.

NURSING PRIORITY NO. 3. To promote wellness (Teaching/Discharge Considerations):

  • Plan for maximal activity within the client’s ability.
  • Review expectations of client/SO(s)/providers to establish individual goals. Explore conflicts/differences to reach agreement for the most effective plan.
  • Instruct client/SO(s) in monitoring response to activity and in recognizing signs/symptoms that indicate need to alter activity level.
  • Plan for progressive increase of activity level as client tolerates.
  • Give client information that provides evidence of daily/ weekly progress to sustain motivation.
  • Assist client to learn and demonstrate appropriate safety measures to prevent injuries.
  • Provide information about the effect of lifestyle and overall health factors on activity tolerance (e.g., nutrition, adequate fluid intake, mental health status).
  • Encourage client to maintain positive attitude; suggest use of
  • Encourage participation in recreation/social activities and hobbies appropriate for situation. (Refer to ND Diversional Activity, deficient.)

 

Documentation Focus | Nursing Care Plan for Activity Intolerance

ASSESSMENT/REASSESSMENT

• Level of activity as noted in Functional Level Classification.

• Causative/precipitating factors.

• Client reports of difficulty/change.

 

PLANNING| Nursing Care Plan for Activity Intolerance

• Plan of care and who is involved in planning.

 

IMPLEMENTATION/EVALUATION| Nursing Care Plan for Activity Intolerance

  • Response to interventions/teaching and actions performed.
  • Implemented changes to plan of care based on Assessment/Reassessment findings.
  • Teaching plan and response/understanding of teaching plan.
  • Attainment/progress toward desired outcome(s).

 

DISCHARGE PLANNING| Nursing Care Plan for Activity Intolerance

  • Referrals to other resources.
  • Long-term needs and who is responsible for actions.

This is a sample of Nursing Care Plan for Activity Intolerance.