1. Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. R/: Determining the cause of a disease can help direct appropriate interventions.
2. Assess client daily for appropriateness of activity and bed rest orders. R/ : 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).
3. Minimize cardiovascular deconditioning by positioning clients as close to the upright position as possible several times daily.
R/ : 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).
4. 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. R/ : 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).
5. 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.
R/ : Bed rest in the supine position results in loss of plasma volume, which contributes to postural hypotension and syncope (Creditor, 1993).
6. 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.
R/ : Heart rate and blood pressure responses to orthostasis vary widely. Vital sign changes by themselves should not define orthostatic intolerance (Winslow, Lane, Woods, 1995).
7. Perform range-of-motion exercises if client is unable to tolerate activity.
R/ : 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).
8. Refer client to physical therapy to help increase activity levels and strength.
9. 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 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
10. 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.
R/ : 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).
11. Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity.
R/ : Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).
12. Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers.
R/ : Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998).
13. Assess urinary incontinence related to functional ability. Assess independent ability to get to the toilet and remove and adjust clothing. R/ : 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).
14. Assess for constipation.
R/ : 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).
15. Consider dietitian referral to assess nutritional needs related to activity intolerance.
R/ : Severe malnutrition can lead to activity intolerance. Dietitians can recommend dietary changes that can improve the client's health status (Peckenpaugh, Poleman, 1999).
16. Refer the cardiac client to cardiac rehabilitation for assistance in developing safe exercise guidelines based on testing and medications. R/ : 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).
17. 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.
R/ : Supplemental oxygen increases circulatory oxygen levels and improves activity tolerance (Petty, Finigan, 1968; Casaburi, Petty, 1993).
18. 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.
19. Instruct and assist COPD clients in using conscious controlled breathing techniques such as pursing their lips and diaphragmatic breathing.
R/ : 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).
20. Provide emotional support and encouragement to client to gradually increase activity.
R/ : Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
21. Refer the COPD client to a pulmonary rehabilitation program.
R/ : Pulmonary rehabilitation has been shown to improve exercise capacity, walking ability, and sense of well-being (Fishman, 1994).
22. Observe for pain before activity. If possible, treat pain before activity, and ensure that client is not heavily sedated.
R/ : Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
23. Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen). R/ : Assistive devices can increase mobility by helping the client overcome limitations.
24. Use a walking belt when ambulating a client who is unsteady.
R/ : With a walking belt the client can walk independently, but the nurse can provide support if the client's knees buckle.
25. Work with client to set mutual goals that increase activity levels.
26. Slow the pace of care. Allow client extra time to carry out activities.
27. 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.
R/ : 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).
28. When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting.
R/ : Orthostatic hypotension is common in the elderly as a result of cardiovascular changes, chronic diseases, and medication effects (Mobily, Kelley, 1991).
NANDA Activity Intolerance
Activity Intolerance - Home Care Interventions and Client / Family Teaching
Nursing Interventions and Rationales for Activity Intolerance