Activity intolerance is a significant nursing diagnosis that describes a state where an individual has insufficient physiological or psychological energy to perform or complete their desired or necessary daily activities. This condition affects a diverse patient population, ranging from children to older adults. Patients with a history of reduced activity levels or previous experiences of activity intolerance are at a higher risk of recurrence. Numerous underlying health conditions and factors can contribute to an increased susceptibility to activity intolerance.
Note: It is important to acknowledge that the nursing diagnosis “Activity Intolerance” has been updated to “Decreased Activity Tolerance” by the NANDA International Diagnosis Development Committee (DDC). While the official terminology is evolving, this article will continue to use “Activity Intolerance” for broader understanding and accessibility, recognizing that widespread adoption of the revised term is still in progress.
Common Causes of Activity Intolerance
Several factors can contribute to activity intolerance. Identifying these underlying causes is crucial for effective diagnosis and management. Common causes include:
- Respiratory Conditions: Conditions like Chronic Obstructive Pulmonary Disease (COPD) significantly impact respiratory function, leading to decreased oxygenation and subsequent activity intolerance.
- Anemia: Anemia reduces the oxygen-carrying capacity of the blood, resulting in fatigue and decreased tolerance for physical activity.
- Malnutrition: Malnutrition leads to a deficiency in essential nutrients required for energy production and muscle function, directly impacting activity tolerance.
- Depression: Depression can cause profound fatigue and loss of motivation, significantly reducing an individual’s desire and capacity for activity.
- Pain: Both acute pain and chronic pain can severely limit movement and activity due to discomfort and functional impairment.
- Decreased Mobility: Reduced mobility, often resulting from surgery or prolonged illness, leads to muscle weakness and deconditioning, contributing to activity intolerance.
- Inadequate Sleep: Insufficient or poor quality sleep disrupts the body’s restorative processes, leading to fatigue and reduced energy levels, impacting activity tolerance.
- Cognitive Impairment: Cognitive deficits can affect a patient’s ability to plan, initiate, and safely perform activities, contributing to decreased activity levels.
- Generalized Weakness: Overall physical weakness, which can stem from various medical conditions or prolonged inactivity, directly limits the ability to engage in physical activities.
Recognizing Signs and Symptoms of Activity Intolerance
Identifying the signs and symptoms of activity intolerance is essential for accurate diagnosis and intervention. These indicators can be categorized as subjective (reported by the patient) and objective (observed by the nurse or healthcare provider). Understanding both types of data provides a comprehensive picture of the patient’s condition.
Subjective Symptoms (Patient Reported)
- Patient Report of Weakness or Decreased Activity: Patients often verbalize a general feeling of weakness or a noticeable reduction in their usual activity levels. This subjective feeling is a primary indicator of activity intolerance.
- Shortness of Breath with Exertion: Dyspnea, or shortness of breath, that occurs or worsens with physical activity is a significant subjective symptom.
- Fatigue: Fatigue, an overwhelming feeling of tiredness and lack of energy, is a common complaint from patients experiencing activity intolerance. This fatigue is often disproportionate to the activity performed.
- Exertional Discomfort: Patients may describe discomfort, pain, or heaviness in the chest or limbs during or after physical exertion. This discomfort can be a limiting factor in their ability to perform activities.
Objective Signs (Nurse Assessed)
- Abnormal Blood Pressure and Heart Rate Response to Activity: An exaggerated increase or decrease in blood pressure or heart rate that is outside the normal physiological response to activity is an objective sign. This may manifest as tachycardia, bradycardia, hypertension, or hypotension during or after activity.
- Changes in ECG (Electrocardiogram): ECG abnormalities, such as arrhythmias or ischemic changes, that appear or worsen with activity can indicate cardiac intolerance to increased exertion.
- Signs of Pain with Movement/Activity: Observable signs of pain, such as grimacing, guarding, or verbalizations of pain, during attempted movement or activity are objective indicators of intolerance.
- Difficulty Engaging in Activity: Observable struggle or inability to initiate or sustain physical activity, despite encouragement or assistance, is a clear objective sign. This can include needing frequent breaks or stopping activity prematurely.
- Increased Oxygen Demand: Objective evidence of increased oxygen demand, such as increased respiratory rate, use of accessory muscles for breathing, or decreased oxygen saturation during activity, indicates physiological stress and intolerance.
Expected Outcomes for Patients with Activity Intolerance
Establishing clear and measurable expected outcomes is crucial for guiding nursing care and evaluating the effectiveness of interventions for activity intolerance. These outcomes should be patient-centered and focused on improving their ability to engage in daily activities.
- Normalization of Vital Signs with Activity: The patient’s vital signs, including heart rate, blood pressure, and respiratory rate, will return to within normal limits or their baseline range during and after activity.
- Participation in Physical and Occupational Therapy Sessions: The patient will be able to actively participate in prescribed physical therapy (PT) and occupational therapy (OT) sessions, demonstrating improved tolerance for structured exercise and rehabilitation.
- Return to Baseline Activity Level: The patient will gradually return to their pre-illness or pre-event activity level, or achieve their optimal functional capacity within their current health limitations.
- Independent Completion of Activities of Daily Living (ADLs): The patient will be able to independently perform essential ADLs, such as bathing, dressing, eating, and toileting, without experiencing undue fatigue or distress.
- Stable Heart Rhythm Throughout Activity: For patients with cardiac concerns, their heart rhythm will remain stable and within normal limits throughout periods of activity, as monitored by ECG if necessary.
- Verbalized Understanding of Gradual Activity Progression: The patient will demonstrate understanding of the importance of gradually increasing activity levels and will be able to describe strategies for safely progressing their activity at home.
Comprehensive Nursing Assessment for Activity Intolerance Diagnosis
A thorough nursing assessment is the cornerstone of managing activity intolerance. This process involves gathering both subjective and objective data to understand the patient’s current functional status, identify contributing factors, and develop an individualized care plan.
1. Evaluate Current Activity Level and Tolerance: Assess the patient’s baseline activity level and their current ability to perform activities. This includes inquiring about the types of activities they can perform, the duration and intensity of activity, and any symptoms they experience during or after activity. Tools like activity logs or questionnaires can be helpful. This assessment establishes a starting point for tracking progress.
2. Monitor Vital Signs Regularly: Obtain baseline vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) at rest and during activity, if appropriate and safe. This provides a baseline for comparison and allows for the detection of abnormal physiological responses to activity. Monitor for changes like excessive tachycardia, hypertension, hypotension, or desaturation.
3. Identify Underlying Causes of Activity Intolerance: Investigate potential medical conditions, medications, or lifestyle factors that may be contributing to the patient’s activity intolerance. This involves reviewing the patient’s medical history, current medications, and recent health events. Consider conditions such as respiratory diseases, cardiac conditions, anemia, thyroid disorders, and mental health issues.
4. Review Medication Profile: Analyze the patient’s medication list for drugs that may cause side effects like fatigue, weakness, or dizziness, which can contribute to activity intolerance. Certain medications can directly impact energy levels or cardiovascular response to exertion. Identify potential medications that may need adjustment or timing modifications.
5. Assess Nutritional Status: Evaluate the patient’s nutritional intake and status. Malnutrition or specific nutrient deficiencies can significantly impact energy levels and muscle strength, leading to activity intolerance. Assess for signs of malnutrition, such as weight loss, muscle wasting, and dietary inadequacies.
6. Determine Need for Assistive Devices: Assess whether the patient requires assistive devices, such as walkers, canes, or wheelchairs, to safely and effectively engage in activities. Lack of appropriate assistive devices can be a significant barrier to activity. Ensure devices are properly fitted and patients are instructed on their safe use.
7. Frequent Skin Integrity Assessment: For patients with limited mobility or activity intolerance, regularly assess skin integrity, particularly pressure points. Reduced activity increases the risk of pressure ulcers. Implement preventive measures and monitor for early signs of skin breakdown.
Effective Nursing Interventions for Activity Intolerance
Nursing interventions are crucial for managing activity intolerance and helping patients gradually increase their activity levels safely and effectively. These interventions are tailored to the individual patient’s needs, limitations, and underlying causes of activity intolerance.
1. Initiate Range of Motion (ROM) Exercises for Bed-Rest Patients: For patients confined to bed rest, begin with passive or active ROM exercises. This helps maintain joint mobility, prevent muscle atrophy, and improve circulation, even with limited activity. Gradually progress to more active exercises as tolerated.
2. Continuous Vital Sign Monitoring During Activity: Closely monitor vital signs before, during, and after activity. This is essential to ensure the patient remains physiologically stable and to identify any adverse responses to activity. Stop or modify activity if significant changes in vital signs occur.
3. Administer Supplemental Oxygen as Needed: Provide supplemental oxygen therapy if the patient experiences shortness of breath or oxygen desaturation during activity. This helps maintain adequate oxygenation and allows for greater participation in activities. Monitor oxygen saturation levels closely and adjust oxygen delivery as needed.
4. Implement Frequent Position Changes: For patients with limited mobility, implement a schedule for frequent position changes. This helps prevent complications of immobility, such as pressure ulcers and respiratory issues, and promotes comfort.
5. Provide Nutritional Support and Supplements: Address any nutritional deficiencies by providing appropriate nutritional supplements as indicated. Adequate nutrition is vital for energy production and muscle strength, supporting increased activity levels. Consult with a dietitian for personalized nutritional plans.
6. Utilize Appropriate Assistive Devices: Ensure patients have access to and are properly using necessary assistive devices. Provide education and training on the safe and effective use of devices such as walkers, canes, or wheelchairs to maximize mobility and independence.
7. Manage Pain Effectively: Address pain management needs proactively. Administer pain medication as prescribed and consider non-pharmacological pain relief measures before activity. Effective pain management is crucial for enabling patients to participate in activity and rehabilitation.
8. Consult with Physical and Occupational Therapy: Discuss referrals to physical therapy (PT) and occupational therapy (OT) with the physician. PT and OT professionals can develop individualized exercise programs and strategies to gradually build endurance and improve functional abilities. They can also provide guidance on safe and effective activity progression.
9. Provide Emotional Support and Encouragement: Offer consistent emotional support and encouragement to patients who may feel discouraged by their activity limitations. Acknowledge their efforts and progress, and help them set realistic goals. Positive reinforcement can enhance motivation and adherence to activity plans.
10. Patient Education on Safe Activity Increase at Home: Educate patients and their caregivers on how to safely and gradually increase activity levels at home after discharge. Provide clear instructions, written materials, and resources to support their continued progress and independence. Emphasize the importance of listening to their body and avoiding overexertion.
Nursing Care Plans for Activity Intolerance
Nursing care plans are essential tools for organizing and prioritizing care for patients with activity intolerance. They provide a structured framework for addressing the patient’s specific needs and achieving desired outcomes. Here are examples of nursing care plans addressing different aspects of activity intolerance:
Care Plan #1: Activity Intolerance related to Generalized Weakness
Diagnostic Statement:
Activity intolerance related to generalized weakness as evidenced by verbal reports of fatigue and exertional discomfort.
Expected Outcomes:
- Patient will demonstrate stable cardiopulmonary status as evidenced by:
- Heart rate and systolic BP within acceptable limits during activity.
- Respiratory rate less than 20 breaths per minute.
- Patient will report a perceived exertion level of 0-2 (very light to light) on the Rate of Perceived Exertion (RPE) scale after physical activity.
- Patient will report a decrease in fatigue levels.
- Patient will participate in activities of daily living (ADLs) with minimal assistance.
Assessment:
1. Identify Precipitating Factors: Assess for underlying conditions contributing to generalized weakness, such as chronic diseases (pulmonary disease, anemia, malignancy, hypothyroidism). Understanding the root cause guides appropriate interventions.
2. Monitor Cardiopulmonary Status: Regularly monitor heart rate, heart rhythm, orthostatic blood pressure changes, respiratory rate, level of consciousness, skin color, and reports of chest discomfort. These parameters provide objective data on the patient’s physiological response to activity and guide activity progression.
Interventions:
1. Assist with ADLs, Promoting Independence: Provide assistance with ADLs as needed, but encourage patient independence to the extent possible. Balance assistance with promoting self-care and preventing dependency.
2. Encourage Rest Periods: Promote adequate rest periods, especially before meals, ADLs, and planned exercise. Rest allows for energy conservation and recovery.
3. Plan Activities During Peak Energy Levels: Help the patient schedule activities for times of the day when they typically experience the most energy. This optimizes participation and success with activities.
4. Promote Endurance-Enhancing Physical Activity: Encourage appropriate physical activity, focusing on exercises that build endurance. Strength training and aerobic exercises are beneficial for improving activity tolerance over time.
5. Gradual Activity Progression: Implement a gradual activity progression plan:
- Start with active ROM exercises in bed, progressing to sitting and standing.
- Encourage dangling legs for 10-15 minutes daily to improve orthostatic tolerance.
- Implement deep breathing exercises at least three times daily to improve respiratory function.
- Progress to short walks in the room (1-2 minutes, three times daily), then gradually increase distance and duration.
- Eventually progress to walking outside the house as tolerated.
Gradual progression prevents overexertion and cardiovascular strain while promoting deconditioning.
6. Utilize Assistive Devices: Provide and encourage the use of assistive devices (transfer chairs, wheelchairs, bath benches) to reduce fatigue and discomfort during activities.
Care Plan #2: Activity Intolerance related to Compromised Oxygen Transport (Atelectasis)
Diagnostic Statement:
Activity Intolerance related to compromised oxygen transport system secondary to atelectasis as evidenced by increased respiratory rate and cyanosis.
Expected Outcomes:
- Patient will demonstrate resolution of respiratory distress related to atelectasis as evidenced by:
- Respiratory rate less than 20 breaths per minute.
- Absence of dyspnea, cyanosis, and use of accessory muscles.
- Pinkish skin and nail beds.
- Oxygen saturation >95%.
- Patient will utilize energy-conservation techniques effectively.
Assessment:
1. Assess for Signs and Symptoms of Atelectasis: Monitor for decreased or absent breath sounds, crackles, cough, sputum production, dyspnea, tachypnea, diminished chest expansion, and cyanosis. These signs indicate potential lung collapse and respiratory compromise.
2. Monitor Laboratory and Diagnostic Findings: Review chest x-ray results for tracheal shift, pulmonary opacities, and fissure displacement. Monitor arterial blood gases (ABGs) for hypoxemia and respiratory alkalosis. Review chest CT scans for lung densities and volume reduction.
Interventions:
1. Administer Medications as Prescribed: Administer mucolytics (e.g., acetylcysteine) to help clear airway mucus plugging. Administer other medications as ordered to treat underlying causes or to promote bronchodilation.
2. Encourage Deep Breathing and Incentive Spirometry: Instruct and encourage the patient to perform deep breathing exercises and use incentive spirometry to promote lung re-expansion and improve ventilation.
3. Teach Energy Conservation Techniques: Educate the patient on energy conservation strategies:
- Frequent position changes to optimize respiratory function.
- Pushing rather than pulling objects to reduce exertion.
- Sitting to perform tasks to minimize energy expenditure.
- Resting for at least one hour after meals before activity.
- Organizing a work-rest-work schedule to balance activity and rest.
Energy conservation reduces oxygen consumption and improves activity tolerance.
4. Refer to Respiratory Therapy for Pulmonary Rehabilitation: Refer the patient to a respiratory therapist for pulmonary rehabilitation. Pulmonary rehab programs provide comprehensive strategies to improve respiratory function, exercise tolerance, and quality of life.
5. Provide Supplemental Oxygenation: Administer supplemental oxygen as prescribed to improve oxygen saturation and support lung re-expansion. Maintain oxygen saturation above 90% as directed.
Care Plan #3: Activity Intolerance related to Physical Deconditioning/Immobility
Diagnostic Statement:
Activity intolerance related to physical deconditioning or immobility as evidenced by dyspnea on exertion and abnormal heart rate or blood pressure response to activity.
Expected Outcomes:
- Patient will demonstrate increased tolerance to activity, progressing towards pre-immobility functional level.
- Patient will participate in prescribed physical activity with appropriate physiological responses (heart rate, blood pressure, breathing rate within acceptable limits).
Assessment:
1. Assess Level of Physical Activity and Mobility: Evaluate the patient’s current level of physical activity, mobility limitations, and functional capacity. Determine the degree of assistance needed for mobility and ADLs.
2. Determine Cause of Activity Intolerance: Identify whether the activity intolerance is primarily due to physical deconditioning, psychological factors (e.g., fear of falling), or motivational issues. Understanding the cause informs targeted interventions.
3. Monitor Activity Tolerance: Closely monitor and document the patient’s ability to tolerate activity. Record vital signs (pulse rate, blood pressure, respiratory pattern) and work of breathing before, during, and after activity. Be alert for signs of cardiac decompensation (dyspnea, palpitations, chest discomfort, hypotension/hypertension, tachycardia, decreased oxygen saturation, lightheadedness), which necessitate immediate cessation of activity.
Interventions:
1. Upright Positioning During Bed Rest: If the patient is on bed rest, position them upright periodically to minimize cardiovascular deconditioning. Upright positioning helps maintain fluid distribution and orthostatic tolerance.
2. Assist with Activity Progression: Assist with self-care activities, positioning, and transfers, gradually increasing activity as tolerated. Progress from sitting in bed to dangling, standing, and ambulating. Always assess for postural hypotension by dangling legs before standing.
3. Implement Range of Motion (ROM) Exercises: Perform ROM exercises if the patient is immobile or has limited activity tolerance. ROM exercises maintain joint mobility, improve circulation, and reduce muscle stiffness.
4. Refer to Physical Therapy: Refer the patient to physical therapy for a comprehensive physical activity plan to improve activity levels and strength. PT professionals can provide expert guidance and tailored exercise regimens.
5. Provide Emotional Support and Goal Setting: Offer emotional support and encouragement to gradually increase activity. Collaborate with the patient to set mutual, achievable goals that incrementally increase activity levels. Address fears of breathlessness, pain, or falling with reassurance and strategies.
6. Obtain Assistive Devices: Ensure necessary assistive devices (walkers, canes, crutches, portable oxygen) are available and used correctly before ambulating the patient. Assistive devices enhance safety and support increased physical activity.
References
- Ackley, B.J., Ladwig, G.B., Flynn Makic M.B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook: An evidence-based guide to planning care (12th edition). Mosby.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Grott, K., Chauhan, S.& Dunlap, J.D. (2022). Atelectasis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK545316/
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Sharma, S. (2023). Pulmonary rehabilitation. MedScape. https://emedicine.medscape.com/article/319885-overview
