Activity Tolerance Nursing Diagnosis: A Comprehensive Guide for Healthcare Professionals

Activity intolerance is a prevalent nursing diagnosis defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities. This condition affects individuals across all age groups, from pediatric to geriatric populations. Patients with a history of reduced activity levels or prior episodes of activity intolerance are at a heightened risk of recurrence. Numerous underlying health conditions and factors can predispose individuals to activity intolerance.

Note: It is important to acknowledge that the nursing diagnosis “Activity Intolerance” has been officially renamed to “Decreased Activity Tolerance” by NANDA International. This change reflects ongoing efforts to standardize nursing language. While the updated term is gaining acceptance, this article will continue to use “Activity Intolerance” for broader recognition and accessibility, aligning with common usage in clinical practice and educational resources.

Unpacking the Causes of Activity Intolerance

Identifying the root causes of activity intolerance is crucial for effective nursing interventions. Several factors can contribute to this diagnosis, broadly categorized as physiological and psychological. Common causes include:

• Respiratory Conditions: Conditions like Chronic Obstructive Pulmonary Disease (COPD) significantly impact respiratory function, leading to reduced oxygen intake and subsequent activity intolerance. The impaired gas exchange and increased work of breathing associated with COPD contribute to fatigue and shortness of breath during exertion.
• Anemia: A deficiency in red blood cells or hemoglobin, anemia reduces the oxygen-carrying capacity of the blood. This results in decreased oxygen delivery to tissues and muscles, causing fatigue and limiting activity tolerance. Different types of anemia, such as iron-deficiency anemia or vitamin B12 deficiency, can all manifest as activity intolerance.
• Malnutrition: Inadequate nutrition deprives the body of essential energy sources and nutrients required for optimal physiological function. Malnutrition can lead to muscle weakness, fatigue, and reduced overall energy levels, directly impacting activity tolerance. Both macro- and micronutrient deficiencies can play a role.
• Depression: Mental health conditions like depression can profoundly affect energy levels and motivation. Depression often manifests as persistent fatigue, loss of interest in activities, and a general feeling of weakness, all contributing to activity intolerance. The neurochemical imbalances in depression can directly impact energy regulation.
• Pain (Acute or Chronic): Both acute and chronic pain can significantly limit a person’s ability to engage in physical activity. Pain can restrict movement, cause discomfort with exertion, and lead to fatigue due to the body’s stress response. Conditions like arthritis, post-surgical pain, or neuropathic pain are common pain-related causes of activity intolerance.
• Decreased Mobility (Post-Surgical or Injury-Related): Surgical procedures, injuries, or conditions causing physical impairments can lead to prolonged periods of decreased mobility. This immobility can result in muscle deconditioning, weakness, and reduced cardiovascular fitness, all contributing to activity intolerance.
• Inadequate Sleep: Sufficient and restorative sleep is vital for physical and mental restoration. Chronic sleep deprivation or poor sleep quality leads to fatigue, reduced energy levels, and impaired cognitive function, directly impacting activity tolerance. Sleep disorders like insomnia or sleep apnea can be significant contributors.
• Cognitive Impairment: Cognitive deficits, such as those seen in dementia or delirium, can affect a person’s ability to plan, initiate, and safely execute activities. Cognitive impairment can lead to decreased awareness of physical limitations, poor judgment regarding activity levels, and reduced motivation to engage in activity.
• Generalized Weakness: Generalized weakness, often stemming from prolonged illness, aging, or muscle atrophy, can directly limit physical capacity and endurance. Conditions causing muscle wasting (e.g., prolonged bed rest, certain neuromuscular diseases) can significantly reduce activity tolerance.

Image alt text: Nurse guides patient in deep breathing exercises, supporting respiratory health and improved activity tolerance.

Recognizing the Signs and Symptoms of Activity Intolerance

Identifying the signs and symptoms of activity intolerance is crucial for accurate diagnosis and timely intervention. These indicators can be categorized into subjective reports from the patient and objective observations made by the nurse during assessment.

Subjective Data (Patient-Reported Symptoms)

Subjective symptoms are based on the patient’s personal experiences and descriptions. These may include:

• Patient Report of Decreased Activity/Weakness: Patients may verbally express a noticeable decline in their usual activity levels or a general feeling of weakness or lack of strength. This is a primary indicator, reflecting the patient’s perception of their reduced physical capacity.
• Shortness of Breath with Exertion (Dyspnea): Experiencing shortness of breath or difficulty breathing during or after physical activity is a significant subjective symptom. Patients may describe feeling winded or struggling to catch their breath even with minimal exertion.
• Fatigue: Persistent and overwhelming fatigue, disproportionate to the level of activity, is a hallmark subjective symptom. This fatigue is often described as not relieved by rest and significantly impacting daily functioning.
• Exertional Discomfort: Patients may report discomfort, pain, or heaviness in the chest, muscles, or joints during physical activity. This discomfort can range from mild to severe and often limits their ability to continue the activity.

Objective Data (Nurse-Observed Signs)

Objective signs are measurable or observable by the nurse during physical assessment. These include:

• Abnormal Blood Pressure and Heart Rate Response to Activity: An exaggerated increase or decrease in blood pressure or heart rate in response to activity is an objective sign. This may manifest as tachycardia (rapid heart rate), bradycardia (slow heart rate), hypertension (high blood pressure), or hypotension (low blood pressure) that is disproportionate to the activity level.
• Changes to ECG (Electrocardiogram): Abnormalities on an ECG during or after activity can indicate cardiac stress or ischemia (reduced blood flow to the heart muscle). These changes may include arrhythmias, ST-segment depression, or T-wave inversions, suggesting underlying cardiac issues contributing to activity intolerance.
• Signs of Pain with Movement/Activity: Observable signs of pain, such as grimacing, guarding, or reluctance to move, during activity are objective indicators. These signs suggest that pain is a limiting factor in the patient’s activity tolerance.
• Difficulty Engaging in Activity: Observable struggle or difficulty in initiating, maintaining, or completing physical activities is a key objective sign. This can manifest as slow movements, frequent pauses, or inability to complete tasks that were previously manageable.
• Increased Oxygen Demands: Objective signs of increased oxygen demand during activity may include increased respiratory rate (tachypnea), use of accessory muscles for breathing, nasal flaring, or decreased oxygen saturation levels measured by pulse oximetry. These signs indicate the body is working harder to maintain oxygenation during activity.

Image alt text: Nurse monitors patient’s blood pressure response to activity, assessing for signs of activity intolerance.

Defining Expected Outcomes for Activity Tolerance

Establishing realistic and measurable expected outcomes is essential for guiding nursing care and evaluating the effectiveness of interventions. These outcomes should be patient-centered and focused on improving activity tolerance and overall functional status. Common expected outcomes include:

• Normalization of Vital Signs with Activity: The patient will demonstrate stable vital signs (heart rate, blood pressure, respiratory rate) within acceptable limits during and after activity, indicating improved physiological response to exertion.
• Participation in Physical and Occupational Therapy Sessions: The patient will be able to actively engage in prescribed physical therapy (PT) and occupational therapy (OT) sessions, demonstrating progress in regaining strength, endurance, and functional abilities.
• Return to Baseline Activity Level: The patient will gradually return to their pre-illness or pre-injury activity level, or achieve the highest possible activity level considering their current health status, indicating improved activity tolerance and functional recovery.
• Independent Completion of Activities of Daily Living (ADLs): The patient will be able to perform ADLs (e.g., bathing, dressing, eating, toileting) independently or with minimal assistance, reflecting improved functional independence and activity tolerance in daily life.
• Stable Heart Rhythm Throughout Activity: For patients with cardiac conditions, maintaining a stable heart rhythm (absence of significant arrhythmias) during activity is a crucial outcome, demonstrating improved cardiac tolerance to exertion.
• Verbalized Understanding of Gradual Activity Increase: The patient will demonstrate understanding of the importance of gradually increasing activity levels and the strategies to safely progress their activity at home, promoting self-management and long-term improvement in activity tolerance.

Comprehensive Nursing Assessment for Activity Intolerance

A thorough nursing assessment is the foundation of effective care planning for activity intolerance. This assessment involves gathering both subjective and objective data to understand the patient’s current activity level, limitations, and underlying contributing factors. Key assessment components include:

1. Assess Current Activity Level and Tolerance: Evaluate the patient’s baseline activity level and their current capacity to perform activities. This includes inquiring about their daily routines, usual physical activities, and any recent changes in their activity patterns. Determine the level of activity that triggers symptoms of intolerance, such as fatigue, shortness of breath, or pain. This baseline assessment is crucial for developing an individualized activity plan and tracking progress.

2. Monitor Vital Signs: Establish baseline vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) at rest and monitor them before, during, and after activity. This provides objective data on the patient’s physiological response to exertion and helps identify abnormal responses indicative of activity intolerance. Pay close attention to heart rate recovery time after activity.

3. Identify Underlying Causes: Investigate potential underlying medical conditions or factors that may be contributing to activity intolerance. This includes reviewing the patient’s medical history, current diagnoses, and recent health events. Consider conditions such as respiratory disorders, cardiovascular disease, anemia, metabolic imbalances, pain conditions, and mental health issues. Addressing the underlying cause is essential for long-term improvement in activity tolerance.

4. Review Medication List: Assess the patient’s current medications, including dosages and potential side effects. Certain medications can contribute to fatigue, weakness, or dizziness, thereby impacting activity tolerance. Identify medications that may be contributing to the problem and collaborate with the healthcare team to explore potential adjustments or alternative medications if appropriate. Consider the timing of medication administration in relation to planned activities.

5. Evaluate Nutritional Status: Assess the patient’s nutritional intake and overall nutritional status. Malnutrition or specific nutrient deficiencies can lead to fatigue and muscle weakness, directly affecting activity tolerance. Evaluate dietary habits, appetite, weight changes, and any signs of nutritional deficiencies. Consider consulting with a registered dietitian for comprehensive nutritional assessment and intervention.

6. Determine Need for Assistive Devices: Assess whether the patient requires assistive devices (e.g., walkers, canes, wheelchairs, orthotics) to support mobility and activity. Evaluate their current use of assistive devices, if any, and identify any unmet needs. Ensure that patients have access to and are properly instructed on the use of appropriate assistive devices to maximize their activity level and safety.

7. Frequent Skin Integrity Assessment: Patients with decreased activity levels or activity intolerance are at increased risk of pressure ulcers due to prolonged immobility or reduced movement. Conduct frequent and thorough skin assessments, particularly over bony prominences, to identify early signs of skin breakdown and implement preventive measures. Implement pressure relief strategies and repositioning schedules as needed.

Image alt text: Nurse meticulously examines patient’s heel for skin integrity, preventing pressure ulcers in individuals with limited mobility.

Implementing Effective Nursing Interventions for Activity Intolerance

Nursing interventions for activity intolerance are aimed at gradually improving the patient’s physical capacity, managing symptoms, and promoting safe and progressive increases in activity levels. Key interventions include:

1. Initiate Range of Motion (ROM) Exercises: For patients on bed rest or with severely limited mobility, begin with passive or active-assisted ROM exercises. These exercises help maintain joint flexibility, prevent muscle stiffness, and improve circulation. Gradually progress to active ROM exercises as tolerated. Tailor the exercises to the patient’s current tolerance level and progressively increase the intensity and duration.

2. Monitor Vital Signs During Activity: Continuously monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) throughout activity sessions. This ensures patient safety and allows for prompt identification of adverse responses. Stop or modify the activity if significant changes in vital signs occur, such as excessive tachycardia, hypotension, or desaturation. Document vital sign responses to guide activity progression.

3. Administer Supplemental Oxygen as Needed: Patients with activity intolerance, particularly those with respiratory or cardiac conditions, may require supplemental oxygen during activity to maintain adequate oxygen saturation levels. Administer oxygen as prescribed and monitor oxygen saturation levels closely. Titrate oxygen flow rate as needed to maintain SpO2 within the target range.

4. Frequent Position Changes: For patients with limited mobility, implement a regular schedule of position changes to prevent complications of immobility, such as pressure ulcers and respiratory compromise. Reposition patients at least every two hours, or more frequently as needed, to promote circulation and lung expansion. Utilize pressure-relieving devices as indicated.

5. Provide Nutritional Support: Ensure adequate nutritional intake to support energy production and muscle strength. Provide appropriate nutritional supplements, as indicated, to address any identified nutritional deficiencies. Collaborate with a registered dietitian to optimize the patient’s nutritional plan. Address any barriers to adequate nutrition, such as nausea, decreased appetite, or swallowing difficulties.

6. Utilize Assistive Devices: Ensure that patients have access to and are properly using appropriate assistive devices to support their mobility and activity. Provide instruction and training on the safe and effective use of walkers, canes, wheelchairs, or other devices. Regularly assess the patient’s need for assistive devices and adjust as their activity tolerance improves or declines.

7. Pain Management: Address pain effectively to minimize its impact on activity tolerance. Administer pain medication as prescribed and assess its effectiveness in relieving pain associated with activity. Utilize non-pharmacological pain management strategies, such as positioning, heat or cold therapy, and relaxation techniques. Optimize pain control to facilitate participation in activity and rehabilitation.

8. Consult Physical and Occupational Therapy: Collaborate with physical therapists (PT) and occupational therapists (OT) to develop individualized activity and rehabilitation plans. PTs and OTs are experts in assessing and improving physical function and activity tolerance. Refer patients to PT/OT for comprehensive evaluation, exercise prescription, and gait training. Participate in interdisciplinary care planning meetings to coordinate care and maximize patient outcomes.

9. Emotional Support and Encouragement: Provide emotional support and encouragement to patients who may feel discouraged or frustrated by their activity limitations. Acknowledge their challenges and celebrate their progress, no matter how small. Help patients set realistic activity goals and provide positive reinforcement to motivate them to gradually increase their activity levels. Address any anxiety or fear related to activity.

10. Patient Education on Safe Activity Progression at Home: Educate patients and their caregivers on strategies for safely increasing activity levels at home after discharge. Provide clear and concise instructions on gradual activity progression, symptom monitoring, and when to seek medical advice. Develop a written home exercise program tailored to the patient’s individual needs and abilities. Emphasize the importance of pacing activities and incorporating rest periods.

Nursing Care Plans for Activity Intolerance: Examples and Applications

Nursing care plans provide a structured framework for organizing and delivering patient care. They outline specific nursing diagnoses, expected outcomes, and nursing interventions tailored to the individual patient’s needs. Here are examples of nursing care plans for 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 exhibit stable cardiopulmonary status during activity, evidenced by:
  • Heart rate within normal limits or within patient’s baseline.
  • Systolic blood pressure increase within 20mmHg over resting systolic BP.
  • Respiratory rate less than 20 breaths per minute.
• Patient will report a rating of perceived exertion (RPE) of 0-3 (on a 0-10 scale) after physical activity.
• Patient will report reduced fatigue levels.
• Patient will perform activities of daily living (ADLs) with minimal assistance.

Assessment:

1. Assess Precipitating Factors: Identify potential underlying causes of generalized weakness, such as chronic diseases (pulmonary disease, anemia, malignancy, hypothyroidism), prolonged illness, or deconditioning.
2. Monitor Cardiopulmonary Status: Assess heart rate and rhythm, orthostatic blood pressure changes, respiratory rate, level of consciousness, skin color, and chest discomfort before, during, and after activity to guide activity progression and detect adverse responses.

Interventions:

1. Assist with ADLs: Provide assistance with ADLs as needed to conserve energy, but encourage independence and avoid promoting dependency. Balance assistance with promoting patient endurance and self-esteem.
2. Encourage Rest Periods: Promote adequate rest periods, especially before meals, ADLs, and planned exercise, to allow for energy conservation and recovery.
3. Plan Activities for Peak Energy Levels: Assist the patient in scheduling activities for times when they report having the most energy to maximize participation and tolerance.
4. Promote Endurance-Enhancing Exercise: Encourage physical activity, focusing on exercises that improve endurance, such as walking, chair exercises, or water aerobics (if appropriate).
5. Gradual Activity Progression: Implement a gradual activity progression plan:
   • Begin 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 3 times daily to improve respiratory function.
   • Encourage walking in the room for 1-2 minutes, 3 times daily, progressing to longer durations and distances.
   • Gradually progress to walking outside the home as tolerated.
6. Assistive Devices: Encourage and assist the patient in using assistive devices (transfer chairs, wheelchairs, bath benches) as needed 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 exhibit improved respiratory status and oxygenation, evidenced by:
  • Respiratory rate less than 20 breaths per minute.
  • Absence of dyspnea (shortness of breath).
  • Pinkish skin and mucous membranes.
  • Absence of accessory muscle use.
  • Absence of clubbing of fingers.
  • Oxygen saturation (SpO2) greater than 95%.
• Patient will utilize energy-conservation techniques during activities.

Assessment:

1. Assess for Atelectasis Signs and Symptoms: Monitor for indicators of atelectasis, including decreased or absent breath sounds, crackles, cough, sputum production, dyspnea, tachypnea, diminished chest expansion, and cyanosis.
2. Monitor Laboratory and Diagnostic Findings: Review chest x-ray results for tracheal shift, pulmonary opacities, and interlobar fissure displacement. Monitor arterial blood gases (ABGs) for arterial hypoxemia and respiratory alkalosis. Review chest CT scans for lung densities and volume reduction.

Interventions:

1. Administer Medications: Administer mucolytics (e.g., acetylcysteine) as prescribed to help clear airway mucus plugs. Administer other medications to treat the underlying cause of atelectasis or inhaled bronchodilators to open airways.
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 oxygenation.
3. Teach Energy Conservation Techniques: Educate the patient on energy conservation strategies:
   • Change positions frequently to improve ventilation and circulation.
   • Push rather than pull objects to reduce exertion.
   • Sit down to perform tasks whenever possible.
   • Rest for at least one hour after meals before resuming activity.
   • Organize a work-rest-work schedule to balance activity and rest.
4. Refer to Respiratory Therapy: Refer the patient to a respiratory therapist for pulmonary rehabilitation to improve respiratory function, endurance, and quality of life.
5. Supplemental Oxygenation: Provide supplemental oxygen as prescribed to improve oxygen saturation and support lung re-expansion. Titrate oxygen to maintain SpO2 above 90%.

Care Plan #3: Activity Intolerance related to Physical Deconditioning

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 physical activity.
• Patient will participate in prescribed physical activity with appropriate physiological responses:
  • Heart rate within target range.
  • Stable blood pressure response.
  • Normal breathing rate and pattern.

Assessment:

1. Assess Physical Activity and Mobility Level: Evaluate the patient’s current level of physical activity, mobility status, and functional capacity to establish a baseline and determine the level of assistance needed.
2. Determine Cause of Activity Intolerance: Identify contributing factors, including physical deconditioning, psychological factors (fear of falling, anxiety), or motivational issues, to tailor interventions effectively.
3. Monitor Activity Tolerance: Assess and record the patient’s physiological response to activity, including vital signs (pulse rate, blood pressure, respiratory pattern), work of breathing, and subjective symptoms (dyspnea, palpitations, chest discomfort, lightheadedness) before, during, and after activity.

Interventions:

1. Upright Positioning (Bed Rest): If the patient is on bed rest, position them upright in bed as tolerated to minimize cardiovascular deconditioning and promote optimal fluid distribution.
2. Assist with Self-Care and Gradual Activity Increase: Assist with self-care activities, positioning, and transfers. Gradually increase activity level as tolerated, progressing from sitting in bed to dangling, standing, and ambulating. Monitor for postural hypotension when transitioning to upright positions.
3. Range of Motion (ROM) Exercises: Implement ROM exercises if the patient is immobile to maintain joint mobility, improve circulation, and prevent muscle atrophy.
4. Refer to Physical Therapy: Refer the patient to physical therapy for a comprehensive physical activity plan to improve activity levels, strength, and endurance.
5. Emotional Support and Goal Setting: Provide emotional support and encouragement to gradually increase activity. Set mutual, realistic goals with the patient to progressively increase activity levels. Address fear of breathlessness, pain, or falling.
6. Assistive Devices and Equipment: Obtain and ensure availability of necessary assistive devices (walkers, canes, crutches, portable oxygen) before ambulating the patient to support safe and effective activity. Provide instruction on proper use.

References

1. Ackley, B.J., Ladwig, G.B., Flynn Makic M.B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Mosby.
2. Carpenito, L.J. (2017). Nursing diagnosis: Application to clinical practice (14th ed.). Wolters Kluwer Health.
3. 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.
4. Grott, K., Chauhan, S., & Dunlap, J.D. (2023). Atelectasis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545316/
5. Gulanick, M. & Myers, J.L. (2018). Nursing care plans: Diagnoses, interventions, and outcomes (9th ed.). Elsevier.
6. Sharma, S. (2024). Pulmonary rehabilitation. MedScape. Available from: https://emedicine.medscape.com/article/319885-overview