Causes (Related to)
Activity intolerance, a nursing diagnosis characterized by insufficient energy to perform daily activities, can stem from various underlying conditions. While the term itself is broad, understanding the specific contributing factors is crucial for effective nursing care. One significant factor, often intertwined with other causes, is generalized weakness.
Generalized weakness, in the context of nursing diagnosis, refers to a pervasive feeling of fatigue and lack of physical strength that is not localized to a specific body part but rather affects the entire body. This can significantly impact an individual’s ability to initiate or sustain physical activity, leading to activity intolerance.
Here’s how generalized weakness and other factors interrelate to cause activity intolerance:
- Generalized Weakness: This is a primary contributor, often arising from deconditioning, prolonged illness, or metabolic imbalances. It reduces the body’s overall capacity for exertion, directly leading to activity intolerance.
- Respiratory Conditions (e.g., COPD): Conditions like COPD compromise oxygen intake and delivery, causing shortness of breath and fatigue, both of which exacerbate generalized weakness and activity intolerance. The body struggles to maintain energy levels due to reduced oxygenation.
- Anemia: Reduced red blood cell count in anemia leads to decreased oxygen-carrying capacity, resulting in fatigue and generalized weakness. This directly limits physical endurance and contributes to activity intolerance.
- Malnutrition: Inadequate nutrient intake deprives the body of the fuel needed for energy production. This leads to muscle weakness, fatigue, and overall generalized weakness, significantly impacting activity levels.
- Depression: Mental health conditions like depression can manifest physically as fatigue and generalized weakness. Reduced motivation and energy levels inherent in depression directly translate to decreased physical activity and tolerance.
- Acute or Chronic Pain: Pain, whether acute or persistent, can significantly limit movement and activity. The body’s response to pain can also induce fatigue and generalized weakness, further contributing to activity intolerance as individuals avoid movement to minimize discomfort.
- Decreased Mobility due to Surgery: Post-surgical immobility leads to muscle deconditioning and generalized weakness. The body loses strength and endurance from lack of use, resulting in activity intolerance during recovery.
- Inadequate Sleep: Sleep deprivation impairs physical and cognitive function, leading to fatigue and generalized weakness. Lack of restorative sleep diminishes energy reserves, making physical activity more challenging.
- Cognitive Impairment: Cognitive deficits can affect a patient’s ability to understand and follow instructions for physical activity or self-care. This can indirectly lead to decreased activity and potentially contribute to generalized weakness through reduced physical engagement.
While “Activity Intolerance” has been updated to “Decreased Activity Tolerance” by NANDA International, the core nursing considerations remain the same. Understanding generalized weakness as a central or contributing factor is key to developing effective care plans.
Signs and Symptoms (As evidenced by)
Identifying activity intolerance, particularly when linked to generalized weakness, requires careful observation and patient communication. Signs and symptoms fall into subjective reports from the patient and objective data assessed by the nurse.
Subjective (Patient reports)
These are based on what the patient verbally communicates about their experience:
- Patient’s report of decreased activity/weakness: This is a direct indication of generalized weakness contributing to activity intolerance. Patients may describe feeling “weak all over” or “too tired to do things.”
- Shortness of breath with exertion: Exertion-induced dyspnea signals the body’s struggle to meet oxygen demands during activity, often linked to underlying generalized weakness or cardiopulmonary issues.
- Fatigue: Overwhelming and persistent tiredness is a hallmark symptom. Patients describe fatigue that is not relieved by rest, indicating a deeper issue than simple tiredness, potentially related to generalized weakness.
- Exertional discomfort: Pain, aches, or general discomfort experienced during or after activity. This can be a result of muscle weakness, deconditioning, or underlying conditions contributing to generalized weakness and activity intolerance.
Objective (Nurse assesses)
These are observable and measurable signs identified by the nurse:
- Abnormal blood pressure and heart rate response to activity: An exaggerated increase or decrease in blood pressure or heart rate during activity indicates the body’s inability to cope with exertion, often seen in patients with generalized weakness and deconditioning.
- Changes to ECG: Electrocardiogram abnormalities during activity can suggest cardiac issues impacting activity tolerance, especially if linked to underlying generalized weakness affecting cardiovascular function.
- Signs of pain with movement/activity: Observable signs of pain like grimacing, guarding, or limping during activity indicate physical limitations and discomfort contributing to activity intolerance.
- Difficulty engaging in activity: Observable struggle or inability to initiate or continue physical tasks, reflecting the functional impact of generalized weakness and activity intolerance.
- Increased oxygen demands: Signs like increased respiratory rate, use of accessory muscles, or decreased oxygen saturation during activity indicate the body’s increased effort and demand for oxygen, often exacerbated by generalized weakness and underlying conditions.
Expected Outcomes
Nursing care for activity intolerance, especially when related to generalized weakness, aims to achieve specific, measurable outcomes:
- Patient’s vital signs will normalize with activity: This indicates improved cardiovascular response and tolerance to exertion as generalized weakness is addressed.
- Patient will be able to participate in PT and OT sessions: This signifies improved physical capacity and reduced generalized weakness, allowing for active participation in rehabilitation.
- Patient’s activity will return to baseline activity level: The goal is to restore the patient’s pre-illness or pre-deconditioning activity level, addressing the impact of generalized weakness.
- Patient will be able to independently complete activities of daily living (ADLs): This reflects functional improvement and reduced generalized weakness, enabling self-care and independence.
- Patient’s heart rhythm will remain stable throughout activity: Ensuring cardiac stability during activity is crucial, particularly when generalized weakness might be linked to cardiovascular issues.
- Patient will verbalize understanding of the need to gradually increase activity level and how to accomplish this: Patient education empowers self-management and promotes safe, progressive activity increases as generalized weakness improves.
Nursing Assessment
A thorough nursing assessment is the foundation for addressing activity intolerance and underlying generalized weakness. Key assessment areas include:
1. Assess the patient’s present level of activity and tolerance to activity. Understanding the patient’s baseline and current limitations is crucial. This includes asking about daily routines, types of activities they can perform, and what triggers fatigue or weakness. This establishes a starting point for care planning and tracking progress as generalized weakness is addressed.
2. Assess the patient’s vital signs. Baseline vital signs and monitoring responses to activity are essential. Abnormal responses (exaggerated heart rate or blood pressure changes) can indicate the severity of activity intolerance and potential cardiovascular limitations related to generalized weakness.
3. Assess the underlying cause of activity intolerance. Identifying contributing factors is vital for targeted interventions. Specifically assess for conditions that cause generalized weakness, such as malnutrition, anemia, chronic illnesses, and medication side effects.
4. Review medication list. Medications can contribute to fatigue and generalized weakness. Certain drugs have side effects that directly impact energy levels and muscle strength, exacerbating activity intolerance. Identifying these allows for potential adjustments in medication regimens in consultation with the physician.
5. Assess nutritional status. Nutrition plays a critical role in energy production and muscle function. Malnutrition can directly cause generalized weakness and worsen activity intolerance. Assess dietary intake, weight changes, and signs of nutritional deficiencies.
6. Assess potential need for assistive devices with activity. Assistive devices can compensate for generalized weakness and improve activity tolerance. Evaluate the need for walkers, canes, or other aids to support safe and increased mobility.
7. Assess skin integrity frequently. Patients with activity intolerance and generalized weakness are at higher risk for pressure ulcers due to reduced mobility. Regular skin assessments are crucial for prevention, especially in areas prone to pressure.
Nursing Interventions
Nursing interventions for activity intolerance, particularly when considering generalized weakness, are focused on gradually improving activity levels, managing symptoms, and addressing underlying causes.
1. If the patient is limited to bed-rest, begin with range of motion (ROM) exercises. Even in bed, maintaining joint mobility and preventing muscle atrophy is essential. ROM exercises counteract deconditioning and generalized weakness associated with immobility.
2. Monitor vital signs throughout activity. Continuous monitoring ensures patient safety and allows for adjustments in activity levels based on physiological responses. Abnormal vital sign changes indicate the need to reduce activity intensity or address underlying generalized weakness.
3. Provide supplemental oxygen therapy as needed. For patients experiencing shortness of breath or desaturation during activity, supplemental oxygen can improve oxygenation and reduce exertional dyspnea, making activity more tolerable. This is especially important when respiratory conditions contribute to generalized weakness and activity intolerance.
4. Provide frequent position changes. Regular repositioning prevents complications of immobility, such as pressure ulcers and respiratory issues. This is crucial for patients with activity intolerance and generalized weakness who may spend prolonged periods in one position.
5. Provide appropriate nutritional supplements when indicated. Addressing nutritional deficiencies is vital for improving energy levels and muscle strength. Nutritional supplements can help combat generalized weakness caused by malnutrition and support increased activity tolerance.
6. Utilize appropriate assistive devices if needed. Providing and training patients on the use of assistive devices enhances mobility and safety. These devices compensate for generalized weakness, allowing patients to engage in more activity and improve their functional capacity.
7. Treat pain as needed. Pain management is essential as pain can significantly limit activity and contribute to generalized weakness due to reduced movement. Effective pain control enables patients to participate more actively in rehabilitation and daily activities.
8. Discuss order for PT/OT with MD. Physical and Occupational Therapy are crucial for structured rehabilitation. PT/OT professionals can develop individualized exercise programs to gradually improve strength, endurance, and activity tolerance, directly addressing generalized weakness and its impact.
9. Provide emotional support to the patient. Activity intolerance and generalized weakness can be discouraging. Emotional support and encouragement are vital to maintain motivation and promote adherence to activity plans. Addressing psychological barriers is as important as physical interventions.
10. Educate the patient on how to safely increase activity level at home. Patient education empowers self-management and promotes long-term improvement. Teaching safe progression of activity at home is crucial for sustained gains in activity tolerance and overcoming generalized weakness in the long run.
Nursing Care Plans
Nursing care plans provide structured approaches to address activity intolerance. Here are examples highlighting different aspects, including generalized weakness:
Care Plan #1
Diagnostic statement:
Activity intolerance related to generalized weakness as evidenced by verbal reports of fatigue and exertional discomfort.
Expected outcomes:
- Patient will exhibit a stable cardiopulmonary status as evidenced by:
- Heart rate
- Systolic BP within 20mmHg increase over resting systolic BP
- Respiratory rate less than 20 breaths/min
- Using the Rate of Perceived Exertion (RPE) Scale from 0 to 10, the patient will report 0 or a decreased rating of perceived exertion after a physical activity.
- Patient will report the absence of fatigue.
- Patient will perform activities of daily living.
Assessment:
1. Assess precipitating factors. Generalized weakness, fatigue, and exertional discomfort are nonspecific subjective complaints that may be traced from several chronic diseases such as pulmonary diseases, anemias, malignancy, hypothyroidism, etc.
2. Monitor the patient’s cardiopulmonary status such as:
- Heart rate and rhythm
- Orthostatic BP changes
- Rate of breathing
- Level of consciousness
- Skin color
- Chest discomfort
Changes in cardiopulmonary status provide a guide on the progression of planned activity.
Interventions:
1. Assist with ADLs as indicated, but not to the extent of promoting dependency. Assisting the patient with ADLs allows for the conservation of energy. However, the nurse must remember that this intervention must enhance the patient’s activity tolerance and self-esteem and not increase patient dependency. There should be a balance between providing assistance and facilitating endurance.
2. Encourage adequate rest periods, especially before meals, other ADLs, and exercise. Rest between activities provides adequate time for energy conservation.
3. Assist the patient with planning activities when they have the most energy. Activities should be planned according to the patient’s peak energy level.
4. Encourage physical activity, especially exercises that enhance endurance. Exercise maintains muscle strength, joint ROM, and exercise tolerance. Strength training is valuable in enhancing endurance.
5. Progress activities gradually as follows:
- Active ROM exercises in bed, progressing to sitting and standing
- Dangling legs 10 to 15 minutes daily
- Deep breathing exercises at least 3x daily
- Walking in room 1 to 2 minutes 3x daily
- Walking outside the house
These activities help in deconditioning the heart. Appropriate progression prevents over-exerting the heart.
6. Encourage or assist the patient in using assistive devices if necessary (i.e., transfer chairs/wheelchairs, bath benches, etc.). Assistive devices help in easing fatigue and discomfort.
Care Plan #2
Diagnostic statement:
Activity Intolerance related to compromised oxygen transport system secondary to atelectasis as evidenced by increased respiratory rate and cyanosis.
Expected outcomes:
- After the nursing interventions, the patient will not exhibit signs of respiratory distress brought by atelectasis as evidenced by:
- Respiratory rate less than 20 breaths/min
- Absence of dyspnea
- Pinkish skin and nails
- Absence of use of accessory muscles
- Absence of clubbing
- O2 saturation >95%
- The patient will use energy-conservation techniques.
Assessment:
1. Assess for signs and symptoms of atelectasis:
- Decreased or absent breath sounds
- Crackles
- Cough
- Sputum production
- Dyspnea
- Tachypnea
- Diminished chest expansion
- Cyanosis
Atelectasis is typically asymptomatic. But these signs and symptoms indicating lung collapse may already suggest a pulmonary complication that must be promptly addressed.
2. Monitor laboratory findings including:
- Chest x-ray results will reveal a tracheal shift toward the affected side, pulmonary opacities, and displacement of interlobar fissures.
- Arterial Blood Gasses will reveal arterial hypoxemia and respiratory alkalosis.
- Chest CT will reveal lung densities at the peripheries and a lung volume reduction on the affected side.
Interventions:
1. Administer medications as indicated. Mucolytics such as acetylcysteine benefit patients with atelectasis experiencing mucous plugging in the airways. Other medications may be used to treat the underlying cause of atelectasis or inhaled medications may be used to open airways.
2. Encourage the patient to take deep breaths or use incentive spirometry. These activities allow the reexpansion of a collapsed lung.
3. Teach energy conservation techniques such as:
- Changing positions often
- Pushing rather than pulling
- Sitting to do tasks
- Resting at least 1 hour after meals before starting a new activity
- Organizing a work-rest-work schedule
Energy conservation techniques decrease oxygen consumption allowing more prolonged activity.
4. Refer the patient to a respiratory therapist for pulmonary rehabilitation. Pulmonary rehabilitation will help alleviate pulmonary symptoms, prevent further disability, encourage participation in physical and social activities, and enhance the quality of life for patients with pulmonary diseases.
5. Provide supplemental oxygenation. Oxygenation helps in lung reexpansion and increases arterial oxygen saturation to more than 90%.
Care Plan #3
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.
- Patient will participate in prescribed physical activity with appropriate changes in heart rate, blood pressure, and breathing rate.
Assessment:
1. Assess the level of physical activity and mobility. This will provide information on the baseline functional capacity of the patient and the level of assistance necessary to improve activity tolerance.
2. Determine the cause of activity intolerance, whether physical, psychological, or motivational. Identifying the cause will help the nurse plan and implement evidence-based nursing care strategies to reduce deconditioning.
3. Monitor and record the patient’s ability to tolerate activity. Noting the vital signs (i.e., pulse rate, blood pressure, respiratory pattern) and work of breathing before, during, and after the activity will provide information on the patient’s tolerance to the activity. Signs and symptoms of cardiac decompensation (i.e., dyspnea, palpitations, chest discomfort, hypotension/hypertension, tachycardia, decreased oxygen saturation, lightheadedness) are indications to stop the activity immediately.
Interventions:
1. If the patient is on bed rest, position the patient upright to minimize cardiovascular deconditioning. During bed rest, gravitational stress is lost, causing fluids to shift from the extremities to the thoracic cavity. An upright position helps maintain optimal fluid distribution and orthostatic tolerance.
2. Assist the patient with self-care activities, positioning, and transferring. When appropriate, gradually increase activity as able. Progress the patient from sitting in bed to dangling, standing, and ambulating. Always have the client dangle at the bedside before standing to evaluate for postural hypotension. A reduction in plasma volume associated with bed rest impacts the physiological responses of autonomic control of circulation.
3. Perform range-of-motion (ROM) exercises if the patient is immobile and cannot tolerate activity. ROM exercises increase joint movement, improve joint integrity, decrease pain, and promote independence.
4. Refer to physical therapy. Physical therapists are experts who can provide a physical activity plan to help increase activity levels and strength.
5. Provide emotional support and encouragement to gradually increase activity by setting mutual goals that increase activity levels. Fear of breathlessness, pain, or falling may decrease willingness to increase activity. Emotional support prevents a decline in function, improves the patient’s feeling with exercise, and promotes the belief that exercise is beneficial.
6. Obtain any necessary assistive devices or equipment (e.g., walkers, canes, crutches, portable oxygen) before ambulating the patient. Assistive devices may be used to support patients in increasing 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
