Activity intolerance, clinically recognized as decreased activity tolerance, is a nursing diagnosis defined as 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 population, spanning from pediatric to geriatric patients. Individuals with a history of reduced physical activity or previous experiences of activity intolerance are at a heightened risk of recurrence. A multitude of underlying health conditions and factors can predispose a person to decreased activity tolerance.
Note: It’s important to acknowledge the recent shift in terminology. While the nursing diagnosis was traditionally known as “Activity Intolerance,” NANDA International has updated the label to “Decreased Activity Tolerance” to align with contemporary language standards. While this article will primarily use “decreased activity tolerance,” understanding both terms is beneficial as the older term may still be in use.
In this article, we will explore:
Common Causes of Decreased Activity Tolerance
Several factors can contribute to decreased activity tolerance. Identifying these underlying causes is crucial for effective nursing interventions and patient care. Common causes include:
- Respiratory Conditions: Conditions like Chronic Obstructive Pulmonary Disease (COPD) significantly impact respiratory function, leading to shortness of breath and reduced energy levels, directly affecting activity tolerance.
- Anemia: Anemia, characterized by a deficiency in red blood cells or hemoglobin, reduces the oxygen-carrying capacity of the blood, resulting in fatigue and decreased stamina for physical activities.
- Malnutrition: Inadequate nutrition or malnutrition deprives the body of essential nutrients needed for energy production and muscle function, leading to generalized weakness and reduced activity tolerance.
- Depression: Mental health conditions such as depression can profoundly affect energy levels and motivation, leading to fatigue and a decreased desire or capacity for physical activity.
- Pain (Acute or Chronic): Both acute pain and chronic pain can significantly limit mobility and willingness to engage in activities. Pain can be physically and psychologically draining, contributing to decreased activity tolerance.
- Decreased Mobility: Reduced mobility, often resulting from surgery, injury, or prolonged illness, directly restricts physical activity and can lead to muscle weakness and further activity intolerance.
- Sleep Deprivation: Insufficient or poor quality sleep impairs physical and cognitive function, leading to fatigue and reduced energy levels, directly 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 and tolerance.
- Generalized Weakness: Overall body weakness, stemming from various causes like illness, deconditioning, or age, reduces physical capacity and endurance for activities.
Alt text: Nurse attentively listening to a patient describing feelings of fatigue, illustrating a key subjective symptom of decreased activity tolerance.
Signs and Symptoms of Decreased Activity Tolerance
Recognizing the signs and symptoms of decreased activity tolerance is essential for accurate diagnosis and appropriate nursing care. These signs can be categorized into subjective (reported by the patient) and objective (observed by the nurse) data, aligning with the principles of subjective and objective data in nursing.
Subjective Symptoms (Patient Reports)
- Reported Decreased Activity/Weakness: Patients may verbally express a noticeable reduction in their usual activity levels or feelings of generalized weakness and lack of strength.
- Shortness of Breath with Exertion: Dyspnea or shortness of breath upon physical exertion, even with mild activities, is a common subjective complaint.
- Fatigue: Overwhelming and persistent fatigue, disproportionate to activity levels, is a hallmark subjective symptom.
- Exertional Discomfort: Patients might describe discomfort, pain, or heaviness in the chest, muscles, or joints during or after physical activity.
Objective Signs (Nurse Assessments)
- Abnormal Vital Sign Response to Activity: An exaggerated or blunted blood pressure or heart rate response to activity, such as a significant increase, decrease, or failure to increase appropriately, can indicate decreased activity tolerance.
- ECG Changes: Electrocardiogram (ECG) abnormalities occurring during or after activity may signal cardiac issues contributing to activity intolerance.
- Signs of Pain with Movement/Activity: Observable signs of pain, such as grimacing, guarding, or limping, during movement or activity are objective indicators.
- Difficulty Engaging in Activity: Observable struggle, hesitation, or inability to initiate or continue physical activities can be a clear objective sign.
- Increased Oxygen Demand: Clinical signs indicating increased oxygen demand during activity, such as increased respiratory rate, use of accessory muscles for breathing, or decreased oxygen saturation levels, are objective data points.
Alt text: A nurse diligently measuring a patient’s blood pressure, showcasing an essential objective assessment for decreased activity tolerance.
Expected Outcomes for Patients with Decreased Activity Tolerance
Establishing clear and measurable expected outcomes is crucial for guiding nursing care planning and evaluating patient progress. Common goals and expected outcomes for patients with decreased activity tolerance include:
- Normalization of Vital Signs with Activity: The patient will demonstrate a stable cardiovascular response to activity, with vital signs returning to within normal limits or baseline after activity.
- Participation in Therapy Sessions: The patient will be able to actively participate in Physical Therapy (PT) and Occupational Therapy (OT) sessions as prescribed, indicating improved activity tolerance.
- Return to Baseline Activity Level: The patient will gradually regain their pre-illness or baseline activity level, demonstrating improved endurance and functional capacity.
- Independent Completion of ADLs: The patient will achieve independence in performing Activities of Daily Living (ADLs) such as bathing, dressing, and eating, signifying improved functional independence.
- Stable Heart Rhythm During Activity: The patient’s heart rhythm will remain stable and within normal limits throughout physical activity, indicating cardiovascular stability.
- Verbalized Understanding of Gradual Activity Increase: The patient will articulate an understanding of the importance of gradually increasing activity levels and demonstrate knowledge of how to safely progress their activity at home.
Nursing Assessment for Decreased Activity Tolerance
A comprehensive nursing assessment is the foundation of effective care for patients with decreased activity tolerance. This assessment involves gathering both subjective and objective data across physical, psychosocial, emotional, and diagnostic domains. Key assessment areas include:
1. Current Activity Level and Tolerance: Assess the patient’s current level of physical activity, including the type, duration, and intensity of activities they can perform. Evaluate their tolerance to these activities, noting any symptoms of intolerance. This baseline assessment is crucial for developing a personalized activity plan and tracking progress.
2. Vital Signs Assessment: Establish baseline vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) at rest and monitor these during and after activity. This provides objective data on the patient’s physiological response to exertion and helps identify abnormal responses.
3. Underlying Causes Identification: Thoroughly investigate potential underlying causes of decreased activity tolerance. This involves reviewing medical history, current health conditions, and relevant diagnostic tests to identify contributing factors like respiratory conditions, anemia, malnutrition, pain, or depression.
4. Medication Review: Scrutinize the patient’s medication list, considering potential side effects of medications that could contribute to fatigue or decreased activity tolerance. Certain medications can induce tiredness or muscle weakness, impacting physical capacity. Collaborate with the healthcare team to explore alternative medications or adjusted dosages if appropriate. Timing of medication administration may also be adjusted to minimize side effects during activity periods.
5. Nutritional Status Evaluation: Assess the patient’s nutritional status, as adequate nutrition is vital for energy production and muscle strength. Identify any nutritional deficiencies that may be contributing to weakness and decreased activity tolerance.
6. Need for Assistive Devices: Evaluate the patient’s potential need for assistive devices such as walkers, canes, or wheelchairs to support mobility and increase activity levels. Assess if the lack of appropriate assistive devices is a barrier to activity. Providing necessary devices can significantly improve a patient’s ability to engage in physical activity.
7. Skin Integrity Assessment: Regularly assess skin integrity, particularly in patients with reduced mobility. Decreased activity increases the risk of pressure ulcers. Frequent skin assessments are crucial for early detection and prevention of skin breakdown.
Nursing Interventions for Decreased Activity Tolerance
Effective nursing interventions are essential to improve activity tolerance and promote patient recovery. These interventions are tailored to the individual patient’s needs and underlying causes of decreased activity tolerance. Key nursing interventions include:
1. Range of Motion (ROM) Exercises: For patients with limited mobility or bed rest restrictions, initiate Range of Motion (ROM) exercises. Begin with passive ROM if the patient cannot actively move, progressing to active ROM as tolerated. Adapt exercises to the patient’s current tolerance level and gradually increase intensity and duration.
2. Vital Signs Monitoring During Activity: Continuously monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) before, during, and after activity. This ensures patient safety and allows for immediate adjustments to the activity plan if vital signs become unstable.
3. Supplemental Oxygen Therapy: Provide supplemental oxygen therapy as needed, particularly for patients experiencing shortness of breath or decreased oxygen saturation during activity. Oxygen supplementation can help maintain adequate oxygen levels and improve activity tolerance.
4. Frequent Position Changes: For patients on bed rest or chair rest, implement frequent position changes to prevent complications of immobility, such as skin breakdown and respiratory issues. Regular repositioning promotes circulation and lung expansion.
5. Nutritional Support: Provide appropriate nutritional supplements or dietary modifications as indicated to address nutritional deficiencies and support energy production. Adequate nutrition is crucial for improving strength and activity tolerance.
6. Assistive Devices Provision and Training: Ensure patients have access to and are properly trained in the use of necessary assistive devices. Provide walkers, canes, wheelchairs, or other devices as needed to facilitate mobility and activity.
7. Pain Management: Proactively manage pain to optimize patient comfort and ability to participate in activity. Administer pain medication as prescribed, especially prior to planned activities, to minimize pain-related limitations.
8. Physical Therapy (PT) and Occupational Therapy (OT) Consultation: Discuss referrals to Physical Therapy (PT) and Occupational Therapy (OT) with the physician. PT and OT professionals are specialized in developing and implementing individualized exercise programs and strategies to improve strength, endurance, and functional abilities. They can also guide patients on safe and effective activity progression.
9. Emotional Support and Encouragement: Provide emotional support and encouragement to patients who may feel discouraged by their decreased activity level. Acknowledge their challenges, celebrate small achievements, and motivate them to gradually increase activity as tolerated. Positive reinforcement and emotional support are crucial for maintaining patient motivation and adherence to activity plans.
10. Patient Education on Safe Activity Increase at Home: Educate patients and their families on strategies for safely increasing activity levels at home after discharge. Provide clear instructions on gradual progression, recognizing signs of intolerance, and energy conservation techniques. Empowering patients with knowledge promotes independence and self-management of their activity levels.
Alt text: A nurse attentively assisting a patient in using a walker, demonstrating a key intervention to improve mobility and activity tolerance.
Nursing Care Plans for Decreased Activity Tolerance
Nursing care plans are structured frameworks that guide nursing care, prioritizing assessments and interventions to achieve both short-term and long-term patient goals. Here are examples of nursing care plans for decreased activity intolerance, illustrating different scenarios and focuses of care.
Care Plan #1: Activity Intolerance related to Generalized Weakness
Diagnostic Statement:
Decreased activity intolerance related to generalized weakness as evidenced by verbal reports of fatigue and exertional discomfort.
Expected Outcomes:
- Patient will demonstrate stable cardiopulmonary status, indicated by:
- Heart rate within patient’s normal range.
- Systolic blood pressure increase within 20mmHg over resting systolic BP during activity.
- Respiratory rate less than 20 breaths per minute.
- Patient will report a Rate of Perceived Exertion (RPE) of 0 or a decreased rating on a scale of 0-10 after physical activity.
- Patient will report absence or reduction of fatigue.
- Patient will perform Activities of Daily Living (ADLs) with minimal assistance.
Assessment:
1. Identify Precipitating Factors: Assess for underlying medical conditions that may contribute to generalized weakness, fatigue, and exertional discomfort. Consider chronic diseases such as pulmonary disease, anemia, malignancy, or hypothyroidism.
2. Monitor Cardiopulmonary Status: Regularly monitor:
- Heart rate and rhythm.
- Orthostatic blood pressure changes (lying, sitting, standing).
- Respiratory rate and pattern.
- Level of consciousness.
- Skin color (pallor, cyanosis).
- Reports of chest discomfort.
Interventions:
1. Assist with ADLs: Provide assistance with ADLs as needed, 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. Rest allows for energy conservation and recovery.
3. Activity Planning: Assist the patient in planning activities for times when they have the most energy. Schedule activities according to the patient’s peak energy levels to maximize participation and tolerance.
4. Promote Physical Activity: Encourage appropriate physical activity, focusing on exercises that enhance endurance and strength. Strength training and endurance exercises are valuable in improving activity tolerance.
5. Gradual Activity Progression: Implement a gradual activity progression plan:
- Begin with active ROM exercises in bed, progressing to sitting and standing exercises.
- Encourage dangling legs at the bedside for 10-15 minutes daily to improve orthostatic tolerance.
- Implement deep breathing exercises at least three times daily to improve respiratory function.
- Initiate short walks in the room (1-2 minutes, three times daily), gradually increasing duration and distance.
- Progress to walking outside the house as tolerated.
6. Assistive Devices: Encourage and assist the patient in using assistive devices (e.g., transfer chairs, wheelchairs, bath benches) as needed to conserve energy and reduce discomfort during activities.
Care Plan #2: Activity Intolerance related to Compromised Oxygen Transport (Atelectasis)
Diagnostic Statement:
Decreased Activity Intolerance related to compromised oxygen transport system secondary to atelectasis as evidenced by increased respiratory rate and cyanosis.
Expected Outcomes:
- Patient will demonstrate improved respiratory function and oxygenation, indicated by:
- Respiratory rate less than 20 breaths per minute.
- Absence of dyspnea (shortness of breath).
- Pinkish skin and nail beds (absence of cyanosis).
- Absence of accessory muscle use for breathing.
- Absence of finger clubbing.
- 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 in affected lung areas.
- Crackles (abnormal lung sounds).
- Cough (may be present or absent).
- Sputum production (note color and quantity).
- Dyspnea (shortness of breath).
- Tachypnea (increased respiratory rate).
- Diminished chest expansion on the affected side.
- Cyanosis (bluish discoloration of skin and mucous membranes).
2. Monitor Laboratory and Diagnostic Findings: Review results of:
- Chest X-ray: Assess for tracheal shift, pulmonary opacities, and displacement of interlobar fissures, indicative of atelectasis.
- Arterial Blood Gases (ABGs): Evaluate for arterial hypoxemia (low blood oxygen) and respiratory alkalosis.
- Chest CT Scan: Assess for lung densities and volume reduction on the affected side, confirming atelectasis.
Interventions:
1. Administer Medications: Administer medications as prescribed, which may include:
- Mucolytics (e.g., acetylcysteine) to help clear mucus plugs in airways.
- Medications to treat underlying causes of atelectasis (e.g., antibiotics for infection).
- Inhaled medications (bronchodilators) to open airways and improve breathing.
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 such as:
- Changing positions frequently to improve lung expansion and reduce fatigue.
- Pushing rather than pulling objects to reduce strain.
- Sitting down to perform tasks whenever possible to conserve energy.
- Resting for at least one hour after meals before engaging in new activities.
- Organizing a work-rest-work schedule to balance activity and rest.
4. Respiratory Therapy Referral: Refer the patient to a respiratory therapist for pulmonary rehabilitation. Pulmonary rehabilitation programs provide comprehensive support to alleviate respiratory symptoms, improve exercise tolerance, and enhance quality of life for patients with pulmonary conditions.
5. Supplemental Oxygenation: Provide supplemental oxygen as prescribed to improve oxygen saturation levels and support lung re-expansion. Aim to maintain oxygen saturation above 90%.
Care Plan #3: Activity Intolerance related to Physical Deconditioning
Diagnostic Statement:
Decreased 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, evidenced by improved endurance and reduced symptoms of intolerance.
- Patient will participate in prescribed physical activity with appropriate physiological responses, including heart rate, blood pressure, and breathing rate within acceptable limits.
Assessment:
1. Assess Activity and Mobility Level: Determine the patient’s current level of physical activity and mobility. Assess their baseline functional capacity and the level of assistance required to improve activity tolerance.
2. Determine Cause of Activity Intolerance: Identify the contributing factors to activity intolerance, differentiating between physical deconditioning, psychological factors (e.g., fear of falling), or motivational issues. Understanding the cause guides tailored interventions.
3. Monitor Activity Tolerance: Closely monitor and record the patient’s ability to tolerate activity. Assess vital signs (pulse rate, blood pressure, respiratory rate and pattern) and work of breathing before, during, and after activity. Be alert for signs and symptoms of cardiac decompensation (dyspnea, palpitations, chest discomfort, hypotension/hypertension, tachycardia, decreased oxygen saturation, lightheadedness), which indicate the need to stop activity immediately.
Interventions:
1. Upright Positioning During Bed Rest: If the patient is on bed rest, position them upright in bed when possible to minimize cardiovascular deconditioning. Upright positioning helps maintain fluid distribution and orthostatic tolerance.
2. Assist with Self-Care and Gradual Activity Increase: Assist the patient with self-care activities, positioning, and transferring, gradually increasing activity levels as tolerated. Progress from sitting in bed to dangling legs, standing, and ambulating. Always ensure the patient dangles legs at the bedside before standing to assess for postural hypotension.
3. Range of Motion (ROM) Exercises: Implement ROM exercises if the patient is immobile or cannot tolerate active activity. ROM exercises maintain joint mobility, improve circulation, and prevent muscle stiffness.
4. Physical Therapy Referral: Refer the patient to physical therapy for a comprehensive physical activity plan. Physical therapists are experts in designing exercise programs to increase 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 fears of breathlessness, pain, or falling, and build confidence in their ability to exercise safely.
6. Assistive Devices and Equipment: Obtain and ensure availability of necessary assistive devices or equipment (e.g., walkers, canes, crutches, portable oxygen) before ambulating the patient. Assistive devices provide support and safety as patients increase their physical activity levels.
These care plans provide a framework for addressing decreased activity tolerance in various clinical scenarios. Nursing care should always be individualized and adapted to the specific needs and circumstances of each patient.
References
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- 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/
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