Medical Diagnoses: Activity Intolerance, Weakness and fatigueAssessment Nursing

DX/Clinical Problem

Client Goals/Desired Outcomes/Objective

s

Nursing Interventions/Actions/Orders

and Rationale

*I EvaluationGoals Interventions

Subjective  Pt states that he cannot walk any farther than the bathroom or the chair without experiencing shortness of breath.  Pt states that he was admitted because he was experiencing unusual shortness of breath        Objective      Chart states

Problem      Activity Intolerance

 

Long Term:  Pt will demonstrate increased tolerance to activity by discharge.

*Evaluate medications the client is taking to see if they could be causing activity intolerance.      Rationale: “Medications such as beta-blockers, lipid- lowering agents, which can damage muscle, and some antihypertensives such as Clonedine and lowering the blood pressure to normal in the elderly can result in decreased functioning.” (Ackley & Ladwig, 2008, p 121)      *Assess nutritional needs associated with activity intolerance.   Rationale: “The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers.” (Ackley & Ladwig,

Goal met. Pt demonstrated increased tolerance to activity. Pt was able to ambulate to the room door and back to the bed without any abnormal changes in vitals. Pt stated that he felt stable after ambulating.  

Continue interventions as listed. Continue to evaluate the pt’s medications to see if they could be causing the activity intolerance. Continue to assess pt’s nutritional needs. Continue to provide emotional support and encouragement so that the pt may feel more confident about resuming activity.

chief complaint as “shortness of air”       Diagnosis of congestive heart failure      Pt demonstrates dyspnea upon exertion and acitivty.

2008, p 120)      *Provide emotional support and encouragement to the client to gradually increase activity.      Rationale: “Fear of breathlessness, pain, or falling may decrease willingness to increase activity.” (Ackley & Ladwig, 2008, p 120)                 

R/T  Weakness and fatigue          

Short Term:  Pt will participate in physical activity with appropriate changes in heart rate, blood pressure, and respirations within three days, by [date].

* Monitor vitals before and after any activity, noting any abnormal changes.   Rationale: “This can be caused by a temporary insufficiency of blood supply” (Ackley & Ladwig, 2008, p 119)  *Assess for pain before activity.   Rationale:“Pain restricts the client from achieving a maximal activity level and if often

  Goal met. Pt was able to participate in physical activity with appropriate vitals changes. His vitals were checked before and after activity and there were no indications of unstable vitals.

Continue interventions as listed. Continue to monitor vitals before and after activity. Continue to assess for pain before activity. Continue to obtain any assistive devices before activity.

AEB  Pt states that he cannot ambulate far without experiencing shortness of

breath.  Diagnosis of congestive heart failure   Chief complaint of shortness of breath       

exacerbated by movement. (Ackley & Ladwig, 2008, p 120)  *Obtain any necessary assistive devices or equipment needed before assisting in ambulation

Goals:

After 5 hours of nursing interventions, the patient will be able to report/demonstrate an increase in activity tolerance AEB increased movement and increased participation to activities

Patient Outcomes:

After 5 hours of nursing interventions, the patient shall have reported/demonstrated an increase in activity tolerance AEB increased movement and increased participation to activities

nursing Interventions:

Assess muscle strength , gross, fine motor coordination and ability of the patient to do activities Note presence of factors contributing to fatigue of the patient Evaluate current limitations or degree of deficit to activity and compare to future references this will serve as a baseline data Note clients demonstration of weakness, pain if there is any, or any probable cause of activity intolerance

Eliminate possible causes of fatigue or stressors that adds up to the inability of the patient to do activities Provide patient adequate rest periods to conserve energy Plan for maximal activity within the clients ability Promoter comfort measures to alleviate pain if any and alleviation of pain leads to increase activity tolerance Provide positive atmosphere while acknowledging difficulty of the situation Provide an environment conducive for rest Plan care with rest periods between activities to reduce fatigue

Evaluation:

Goal met: AEB patients report/demonstration of increased activity tolerance and increased participation to activities

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

Defining Characteristics: Verbal report of fatigue or weakness, abnormal heart rate or blood pressure response to activity, exertional discomfort or dyspnea, electrocardiographic changes reflecting dysrhythmias or ischemia

Related Factors: Bed rest or immobility; generalized weakness; sedentary lifestyle; imbalance between oxygen supply and demand

NOC Outcomes (Nursing Outcomes Classification)Suggested NOC Labels • Endurance • Energy Conservation • Activity Tolerance • Self-Care: Activities of Daily Living (ADLs)

Client Outcomes• Participates in prescribed physical activity with appropriate increases in heart rate, blood pressure, and breathing rate; maintains monitor

patterns (rhythm and ST segment) within normal limits • States symptoms of adverse effects of exercise and reports onset of symptoms immediately • Maintains normal skin color and skin is warm and dry with activity • Verbalizes an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms • Expresses an understanding of the need to balance rest and activity • Demonstrates increased activity tolerance

NIC Interventions (Nursing Interventions Classification)Suggested NIC Labels • Energy Management • Activity Therapy

Nursing Interventions and Rationales• Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Determining the cause of a disease can help direct appropriate interventions. • Assess client daily for appropriateness of activity and bed rest orders. Inappropriate prolonged bed rest orders may contribute to activity intolerance. A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999). • Minimize cardiovascular deconditioning by positioning clients as close to the upright position as possible several times daily. The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998). • If appropriate, gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to chair sitting, to standing, to ambulation. Increasing activity helps to maintain muscle strength, tone, and endurance. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous, 1998). • Ensure that clients change position slowly. Consider using a chair-bed (stretcher-chair) for clients who cannot get out of bed. Monitor for symptoms of activity intolerance. Bed rest in the supine position results in loss of plasma volume, which contributes to postural hypotension and syncope (Creditor, 1993). • When getting clients up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs. Heart rate and blood pressure responses to orthostasis vary widely. Vital sign changes by themselves should not

define orthostatic intolerance (Winslow, Lane, Woods, 1995). • Perform range-of-motion exercises if client is unable to tolerate activity. Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Creditor, 1994). • Refer client to physical therapy to help increase activity levels and strength. • Monitor and record client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (ACSM, 1995): o Excessive fatigue o Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency o Onset of angina with exercise o Palpitations o Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced left bundle block, second- or third-degree atrioventricular block, frequent premature ventricular contractions) o Exercise hypotension (drop in systolic blood pressure of more than 10 mm Hg from baseline blood pressure despite an increase in workload, when accompanied by other evidence of ischemia) o Excessive rise in blood pressure (systolic greater than 220 mm Hg or diastolic greater than 110 mm Hg); NOTE: these are upper limits; activity may be stopped before reaching these values o Inappropriate bradycardia (drop in heart rate greater than 10 beats/min) with no change or increase in workload o Increased heart rate above the prescribed limit• Instruct client to stop activity immediately and report to physician if experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort, tightness, or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician (McGoon, 1993). The client should be evaluated before resuming activity (Thompson, 1988). • Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992). • Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998). • Assess urinary incontinence related to functional ability. Assess independent ability to get to the toilet and remove and adjust clothing. The loss of functional ability that accompanies disease often leads to continence problems. The cause may not be the person's bladder instability but

his or her ability to get to the toilet quickly (Nazarko, 1997). • Assess for constipation. Impaired mobility is associated with increased risk of bowel dysfunction, including constipation. Constipation increases the risk of urinary tract infection and urge incontinence (Nazarko, 1997). • Consider dietitian referral to assess nutritional needs related to activity intolerance. Severe malnutrition can lead to activity intolerance. Dietitians can recommend dietary changes that can improve the client's health status (Peckenpaugh, Poleman, 1999). • Refer the cardiac client to cardiac rehabilitation for assistance in developing safe exercise guidelines based on testing and medications. Cardiac rehabilitation exercise training improves objective measures of exercise tolerance in both men and women, including elderly patients with coronary heart disease and heart failure. This functional improvement occurs without significant cardiovascular complications or other adverse outcomes (Wenger et al, 1995). • Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity. Supplemental oxygen increases circulatory oxygen levels and improves activity tolerance (Petty, Finigan, 1968; Casaburi, Petty, 1993). • Monitor a chronic obstructive pulmonary disease (COPD) client's response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, and skin tone changes such as pallor and cyanosis. • Instruct and assist COPD clients in using conscious controlled breathing techniques such as pursing their lips and diaphragmatic breathing. Training clients with COPD to slow their respiratory rate with a prolonged exhalation (with or without pursed lips) helps control dyspnea and results in improved ventilation, increased tidal volume, decreased respiratory rate, and a reduced alveolar-arterial oxygen difference. This breathing pattern not only helps relieve dyspnea but can improve the ability to exercise and carry out ADLs (Mueller, Petty, Filley, 1970; Casaburi, Petty, 1993). • Provide emotional support and encouragement to client to gradually increase activity. Fear of breathlessness, pain, or falling may decrease willingness to increase activity. • Refer the COPD client to a pulmonary rehabilitation program. Pulmonary rehabilitation has been shown to improve exercise capacity, walking ability, and sense of well-being (Fishman, 1994). • Observe for pain before activity. If possible, treat pain before activity, and ensure that client is not heavily sedated. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement. • Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen). Assistive devices can increase mobility by helping the client overcome limitations. • Use a walking belt when ambulating a client who is unsteady. With a walking belt the client can walk independently, but the nurse can provide support if the client's knees buckle.

• Work with client to set mutual goals that increase activity levels.

Geriatric • Slow the pace of care. Allow client extra time to carry out activities. • Encourage families to help/allow elder to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary. Encouraging activity not only enhances good functioning of the body's systems but also promotes a sense of worth by providing an opportunity for productivity (Eliopoulous, 1997). • When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting. Orthostatic hypotension is common in the elderly as a result of cardiovascular changes, chronic diseases, and medication effects (Mobily, Kelley, 1991).

Home Care Interventions• Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services. • Assess the home environment for factors that precipitate decreased activity tolerance: presence of allergens such as dust, smoke, and those associated with pets; temperature; energy-intensive activity patterns; and furniture placement. Refer to occupational therapy if needed to assist the client in restructuring the home and activity of daily living patterns. Clients and families often estimate energy requirements inaccurately during hospitalization because of the availability of support. • Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events). • Provide client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity. Social isolation can contribute to activity intolerance. • Discuss the importance of sexual activity as part of daily living. Instruct the client in adaptive techniques to conserve energy during sexual interactions. Families may make unsafe choices for sexual activity or place added stress on themselves trying to cope with this issue without proper support or teaching. • Instruct the client and family in the importance of maintaining proper nutrition and rest for energy conservation and rehabilitation. • Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living. • 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. • Describe to client the symptoms of activity intolerance, including which symptoms to report to the physician. • Explain to client how to use assistive devices or medications before or during activity. • Help client set up an activity log to record exercise and exercise tolerance.

Activity Intolerance(_)Actual (_) PotentialRelated To:[Check those that apply](_) Alterations in O2 transport(_) Chronic disease:________________________________________(_) Depression(_) Diabetes Mellitus

(_) Fatigue(_) Lack of motivation(_) Malnourishment(_) Pain(_) Prolonged immobility(_) Stressors(_) Other:_____________________________________________________________________________________________________As evidenced by:[Check those that apply]Major:(Must be present)(_) _____________________________________________________________________________________________________________________________________________________________________Date &Sign.Plan and Outcome[Check those that apply]TargetDate:Nursing Interventions[Check those that apply]DateAchieved:The patient will:(_) Identify factors that reduceactivity tolerance.(_) Progress to highest level ofmobility possible. Describe:

(_) Exhibit a decrease in anoxic(_) Reduce or eliminatecontributing factors by:l Assess patient'sschedule. Allow restperiods between allactivities.l Encourage person to notedaily progress.l Evaluate patient's painand the present treatmentregimen.l Check pulse rates restingand after activity to avoidhttp://www.rncentral.com/careplans/plans/ai.html (1 of 2)09/27/2005 10:36:31 AMActivity Intolerance

signs of increased activity. (eg:BP, pulse, resp.)(_) Other:danger of too great anincrease.l Assess skin color (hands,nails, circumoral) beforeand after activity.l Relaxation training (workwith pulmonary rehab.)l Cough/deep breathe.l Encourage fluid intake,roughage.l Teach inhaler use.l Sit when conversing with

patient.l Progress the activitygradually.(_) Other:________________________________________________________________

Imbalanced Nutrition: Less than Body Requirements

Nursing diagnosis: Imbalanced Nutrition: Less than Body Requirement

related to Insufficient intake to meet metabolic demands—anorexia,

nausea, vomiting, Altered absorption and metabolism of ingested

foods—reduced peristalsis (visceral reflexes), bile stasis, Increased

caloric needs, hypermetabolic state

Possibly evidenced by

Aversion to eating, lack of interest in food; altered taste sensation

Abdominal pain, cramping

Loss of weight, poor muscle tone

Desired Outcomes/Evaluation Criteria—Client Will

Treatment Behavior: Illness or Injury

Initiate behaviors and lifestyle changes to regain or maintain

appropriate weight.

Nutritional Status

Demonstrate progressive weight gain toward goal with normalization of

laboratory values and no signs of malnutrition.

Nursing intervention with rationale:

1. Monitor dietary intake and calorie count. Provide meals in several

small feedings and offer largest meal at breakfast.

Rationale: Large meals are difficult to manage when client is anorexic.

Anorexia may also worsen during the day, making intake of food difficult

later in the day.

2. Encourage mouth care before meals.

Rationale: Eliminating unpleasant taste may enhance appetite.

3. Recommend eating in upright position.

Rationale: Reduces sensation of abdominal fullness and may enhance intake.

4. Encourage intake of fruit juices, carbonated beverages, and hard

candy throughout the day.

Rationale: These supply extra calories and may be more easily digested

and tolerated than other fluids and foods.

5. Consult with dietitian or nutritional support team to provide diet

according to client’s needs, with fat and protein intake as tolerated.

Rationale: Useful in formulating dietary program to meet individual

needs. Fat metabolism varies according to bile production and excretion

and may necessitate restriction of fat intake if diarrhea develops. If

tolerated, a normal or increased protein intake helps with liver

regeneration. Protein restriction may be indicated in severe disease,

such as fulminating hepatitis, because the accumulation of the end

products of protein metabolism can potentiate hepatic encephalopathy.

6. Monitor serum glucose, as indicated.

Rationale: Hyperglycemia or hypoglycemia may develop, necessitating

dietary changes or insulin administration. Fingerstick monitoring may be

done by client on a regular schedule to determine therapy needs.

7. Administer medications, as indicated, for example: Antiemetics, such

as metoclopramide (Reglan) and trimethobenzamide (Tigan)

Rationale: Given before meals these drugs may reduce nausea and increase

food tolerance. Note: Prochlorperazine (Compazine) is contraindicated in

hepatic disease.

8. Antiulcer agents and antacids, such as lansoprazole (Prevacid),

esomeprazole (Nexium), and magnesium hydroxide/aluminum hydroxide

(Maalox, Mylanta)

Rationale: Counteracts gastric acidity, reducing irritation and risk of

bleeding.

9. Vitamins, such as B complex, C, and other dietary supplements, as

indicated

Rationale: Corrects deficiencies and aids in the healing process.

10. Provide supplemental feedings, enteral or parenteral nutrition if

needed.

Rationale: May be necessary to meet nutrient requirements if marked

deficits are present and intestinal symptoms are prolonged.