Activity intolerance as a nursing diagnosis is defined as insufficient physiological or psychological energy to perform or complete desired or necessary daily activities. This condition spans across all age groups, affecting individuals from pediatric to geriatric populations. Patients with a history of decreased activity levels or previous episodes of intolerance are at a heightened risk of experiencing it again. Numerous underlying conditions and factors can predispose an individual to activity intolerance.
Important Note: It’s crucial to be aware that this nursing diagnosis has been officially renamed. The NANDA International Diagnosis Development Committee (DDC), responsible for revising and updating nursing diagnoses to reflect current language standards, has changed “Activity Intolerance” to “Decreased Activity Tolerance.” While this article will continue using “Activity Intolerance” for broader understanding and until the updated term gains widespread recognition among both students and experienced nurses, it is important to acknowledge this change in terminology.
Causes (Related Factors)
Activity intolerance can stem from a variety of underlying health issues and conditions. Identifying the root cause is crucial for effective nursing interventions. Common causes include:
- Respiratory Conditions: Conditions like COPD significantly impact respiratory function, leading to reduced oxygen intake and increased breathlessness during activity, thereby causing activity intolerance.
- Anemia: Anemia, characterized by a deficiency in red blood cells or hemoglobin, reduces the oxygen-carrying capacity of the blood. This results in fatigue and insufficient energy for physical activities, leading to activity intolerance.
- Malnutrition: Malnutrition deprives the body of essential nutrients required for energy production and muscle function. This lack of fuel and building blocks weakens the body and causes activity intolerance.
- Depression: Depression is a mental health condition that often manifests with profound fatigue, loss of interest in activities, and decreased energy levels. These psychological factors directly contribute to activity intolerance.
- Pain (Acute or Chronic): Both acute pain and chronic pain can significantly limit a person’s ability to move and engage in activities. Pain can be physically debilitating and psychologically discouraging, resulting in activity intolerance.
- Decreased Mobility due to Surgery: Post-surgical recovery often involves a period of decreased mobility. Surgical procedures can lead to pain, weakness, and restrictions that directly contribute to activity intolerance during the recovery phase.
- Inadequate Sleep: Insufficient or poor quality sleep disrupts the body’s restorative processes. Lack of sleep leads to fatigue, reduced energy levels, and impaired physical and cognitive function, all of which contribute to activity intolerance.
- Cognitive Impairment: Cognitive impairments, such as dementia or delirium, can affect a person’s ability to understand and follow instructions for physical activity, or to initiate and maintain activity independently. This can indirectly lead to activity intolerance.
- Generalized Weakness: Generalized weakness, which can arise from various medical conditions or prolonged inactivity, reduces overall muscle strength and endurance. This physical limitation makes it difficult to perform activities and leads to activity intolerance.
Signs and Symptoms (As Evidenced By)
Recognizing the signs and symptoms of activity intolerance is crucial for nurses to accurately diagnose and develop appropriate care plans. These signs and symptoms are categorized as subjective (patient-reported) and objective (nurse-assessed) data, providing a comprehensive picture of the patient’s condition. Understanding the difference between subjective and objective data in nursing is fundamental in nursing assessment.
Subjective Data (Patient Reports)
Subjective data relies on what the patient verbally communicates about their experience. Key subjective symptoms of activity intolerance include:
- Patient’s report of decreased activity/weakness: Patients may express feeling less active than usual or describe a general sense of weakness that hinders their ability to perform activities.
- Shortness of breath with exertion: Dyspnea or shortness of breath that occurs or worsens with physical activity is a common subjective complaint.
- Fatigue: Fatigue, an overwhelming feeling of tiredness and lack of energy, is a significant subjective symptom reported by patients with activity intolerance.
- Exertional discomfort: Patients may describe discomfort, pain, or other unpleasant sensations experienced during or after physical exertion.
Objective Data (Nurse Assesses)
Objective data is gathered through direct observation and measurement by the nurse. Objective signs of activity intolerance include:
- Abnormal blood pressure and heart rate response to activity: An exaggerated increase or decrease in blood pressure or heart rate that is disproportionate to the level of activity is an objective indicator.
- Changes to ECG: Electrocardiogram (ECG) changes, such as arrhythmias or signs of cardiac ischemia during or after activity, can be objectively measured and indicate activity intolerance.
- Signs of pain with movement/activity: Observable signs of pain, such as grimacing, guarding, or reluctance to move during activity, are objective data points.
- Difficulty engaging in activity: Observable struggles or inability to initiate or sustain physical activity at an expected level is an objective sign.
- Increased oxygen demands: Objective measurements, such as decreased oxygen saturation levels (SpO2) during activity, indicate increased oxygen demand and potential activity intolerance.
Expected Outcomes (Goals)
Establishing clear goals and expected outcomes is essential for effective nursing care planning for activity intolerance. These outcomes guide interventions and provide measurable targets for patient improvement. Common expected outcomes include:
- Patient’s vital signs will normalize with activity: The patient’s blood pressure, heart rate, and respiratory rate will remain within acceptable limits and return to baseline levels promptly after activity.
- Patient will be able to participate in PT and OT sessions: The patient will achieve sufficient activity tolerance to actively engage in physical therapy (PT) and occupational therapy (OT) sessions aimed at improving their functional abilities.
- Patient’s activity will return to baseline activity level: The patient will gradually regain their pre-diagnosis or pre-illness activity level and functional capacity.
- Patient will be able to independently complete activities of daily living (ADLs): The patient will achieve the ability to perform essential self-care tasks, such as bathing, dressing, and eating, without undue fatigue or distress.
- Patient’s heart rhythm will remain stable throughout activity: For patients at risk of cardiac issues, maintaining a stable heart rhythm during activity is a critical outcome.
- Patient will verbalize understanding of the need to gradually increase activity level and how to accomplish this: Patient education is key. The patient will understand the importance of a gradual approach to increasing activity and demonstrate knowledge of safe methods to achieve this at home.
Nursing Assessment
A thorough nursing assessment is the cornerstone of addressing activity intolerance. It involves gathering comprehensive data across physical, psychosocial, emotional, and diagnostic domains. Key components of the nursing assessment for activity intolerance include:
1. Assess the patient’s present level of activity and tolerance to activity: This initial assessment establishes a baseline. Understanding the patient’s current activity level helps tailor an individualized activity plan and track progress effectively.
2. Assess the patient’s vital signs: Monitoring vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) provides a baseline and allows nurses to detect any abnormal responses to activity. Changes in vital signs during activity are crucial indicators of tolerance.
3. Assess the underlying cause of activity intolerance: Identifying the root cause is essential for targeted interventions. Determining if activity intolerance is due to respiratory issues, anemia, pain, or other factors guides appropriate treatment strategies.
4. Review medication list: Certain medications and their side effects can contribute to fatigue and activity intolerance. Reviewing the patient’s medication list helps identify potential medication-related causes. When possible, exploring alternative medications or adjusting administration times may be beneficial.
5. Assess nutritional status: Adequate nutrition is fundamental for energy production and physical function. Assessing nutritional status helps identify any deficiencies that may be contributing to activity intolerance. Ensuring the patient’s nutritional needs are met is vital for improving activity tolerance.
6. Assess potential need for assistive devices with activity: Lack of appropriate assistive devices can significantly limit activity levels. Assessing the need for devices like walkers, canes, or wheelchairs and ensuring their availability can greatly enhance a patient’s ability to engage in activity.
7. Assess skin integrity frequently: Patients with decreased activity levels or activity intolerance are at increased risk of developing pressure ulcers. Regular skin integrity assessments, particularly in pressure-prone areas, are crucial for prevention.
Nursing Interventions
Nursing interventions are essential for managing activity intolerance and promoting patient recovery. These interventions are tailored to address the identified causes and symptoms, and aim to gradually improve the patient’s activity tolerance. Effective nursing interventions include:
1. If the patient is limited to bed-rest, begin with range of motion (ROM) exercises: For patients on bed rest, initiating ROM exercises is crucial to prevent muscle atrophy and joint stiffness. Adapt exercises to the patient’s current tolerance and progressively increase intensity and range.
2. Monitor vital signs throughout activity: Continuously monitoring vital signs before, during, and after activity ensures patient safety and helps gauge their response to activity. This allows for timely adjustments to the activity plan if needed.
3. Provide supplemental oxygen therapy as needed: Patients with activity intolerance, particularly those with respiratory conditions, may experience shortness of breath during activity. Administering supplemental oxygen as prescribed helps maintain adequate oxygen saturation levels.
4. Provide frequent position changes: For patients with limited mobility, frequent repositioning is essential to prevent pressure ulcers and promote circulation. Regular position changes should be incorporated into the care plan.
5. Provide appropriate nutritional supplements when indicated: Addressing nutritional deficiencies is crucial. If malnutrition is identified, providing appropriate nutritional supplements supports energy levels and muscle strength, facilitating improved activity tolerance.
6. Utilize appropriate assistive devices if needed: Ensure patients have access to and are properly using necessary assistive devices. Walkers, canes, wheelchairs, or other devices can significantly improve mobility and activity levels.
7. Treat pain as needed: Pain is a major barrier to activity. Effective pain management, including administering pain medication prior to activity, is essential to enable patients to participate in therapeutic activities.
8. Discuss order for PT/OT with MD: Collaborate with physicians to obtain orders for physical therapy (PT) and occupational therapy (OT) consultations. PT and OT specialists can develop structured exercise programs and strategies to gradually build endurance and improve functional abilities.
9. Provide emotional support to the patient: Activity intolerance can be discouraging and frustrating for patients. Providing emotional support, encouragement, and positive reinforcement is crucial to maintain motivation and promote gradual increases in activity levels.
10. Educate the patient on how to safely increase activity level at home: Patient education empowers individuals to take control of their recovery. Educating patients on safe methods for gradually increasing activity at home, including pacing strategies and recognizing signs of overexertion, promotes independence and long-term improvement.
Nursing Care Plans
Nursing care plans are vital tools for organizing and prioritizing nursing care. They provide a structured framework for assessments and interventions, guiding both short-term and long-term goals for patients with activity intolerance. Below are examples of nursing care plans addressing different aspects of activity intolerance.
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 within normal limits for activity level.
- 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 physical activity.
- Patient will report the absence of fatigue hindering daily activities.
- Patient will perform activities of daily living (ADLs) with minimal assistance.
Assessment:
1. Assess precipitating factors: Generalized weakness, fatigue, and exertional discomfort are often non-specific and can be linked to various chronic conditions such as pulmonary diseases, anemias, malignancy, hypothyroidism, and more. Identifying potential underlying causes guides targeted interventions.
2. Monitor the patient’s cardiopulmonary status:
- Heart rate and rhythm: Regular monitoring helps detect abnormal heart rate responses to activity.
- Orthostatic BP changes: Assessing for orthostatic hypotension (drop in blood pressure upon standing) is important as it can exacerbate activity intolerance.
- Rate of breathing: Monitoring respiratory rate helps assess for signs of respiratory distress during activity.
- Level of consciousness: Changes in alertness can indicate decreased oxygenation or cardiac output during activity.
- Skin color: Pale or cyanotic skin can suggest poor oxygenation.
- Chest discomfort: Monitoring for chest pain is crucial to rule out cardiac issues.
Changes in cardiopulmonary status provide essential feedback on the patient’s tolerance to planned activity and guide activity progression.
Interventions:
1. Assist with ADLs as indicated, but avoid promoting dependency: Providing assistance with ADLs conserves the patient’s energy. However, the goal is to enhance activity tolerance and self-esteem, not to increase dependency. A balance between support and encouragement of independence is key.
2. Encourage adequate rest periods: Schedule rest periods, especially before meals, ADLs, and planned exercise. Rest allows for energy conservation and recovery between activities.
3. Assist the patient with planning activities for peak energy levels: Schedule activities for times when the patient typically experiences the most energy. This optimizes participation and success.
4. Encourage physical activity, focusing on endurance-enhancing exercises: Regular exercise, including endurance training, helps maintain muscle strength, joint range of motion (ROM), and overall exercise tolerance. Strength training is particularly valuable for building endurance.
5. Progress activities gradually:
- Begin with active ROM exercises in bed, progressing to sitting and standing.
- Encourage dangling legs for 10 to 15 minutes daily to improve orthostatic tolerance.
- Implement deep breathing exercises at least 3 times daily to enhance respiratory function.
- Start with short walks in the room (1 to 2 minutes, 3 times daily) and gradually increase duration and distance.
- Progress to walking outside the house as tolerance improves.
Gradual progression of activities prevents cardiac overexertion and promotes cardiovascular reconditioning.
6. Encourage or assist with assistive devices when necessary: (e.g., transfer chairs/wheelchairs, bath benches). Assistive devices reduce fatigue and discomfort, enabling greater participation in activities.
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 nursing interventions, the patient will not exhibit signs of respiratory distress due to atelectasis as evidenced by:
- Respiratory rate less than 20 breaths/min.
- Absence of dyspnea (shortness of breath).
- Pinkish skin and nails, indicating adequate oxygenation.
- Absence of use of accessory muscles for breathing.
- Absence of finger clubbing.
- O2 saturation (SpO2) >95%.
- The patient will effectively utilize energy-conservation techniques to manage activity levels.
Assessment:
1. Assess for signs and symptoms of atelectasis:
- Decreased or absent breath sounds: Atelectasis often reduces or eliminates breath sounds in affected lung areas.
- Crackles: Abnormal lung sounds (crackles) may be present due to alveolar collapse.
- Cough: Coughing may be present, but may be ineffective.
- Sputum production: Sputum may be present, but may be difficult to expectorate.
- Dyspnea: Shortness of breath is a common symptom.
- Tachypnea: Increased respiratory rate is often observed as the body attempts to compensate for reduced oxygenation.
- Diminished chest expansion: The affected side of the chest may exhibit reduced expansion during breathing.
- Cyanosis: Bluish discoloration of the skin and mucous membranes indicates severe oxygen deprivation.
Atelectasis can sometimes be asymptomatic initially. However, these signs and symptoms suggest a pulmonary complication requiring prompt attention.
2. Monitor laboratory findings:
- Chest x-ray results: May reveal tracheal shift towards the affected side, pulmonary opacities, and displacement of interlobar fissures, indicating lung collapse.
- Arterial Blood Gases (ABGs): May show arterial hypoxemia (low blood oxygen) and respiratory alkalosis (initially).
- Chest CT scan: May reveal lung densities at the peripheries and reduced lung volume on the affected side, providing a more detailed view of atelectasis.
Interventions:
1. Administer medications as indicated: Mucolytics like acetylcysteine may be prescribed to help liquefy and clear mucous plugs in the airways, which are common in atelectasis. Other medications may target the underlying cause of atelectasis or include inhaled bronchodilators to open airways.
2. Encourage deep breathing exercises or use incentive spirometry: These techniques promote lung re-expansion by encouraging deep inhalation and sustained inflation, helping to open collapsed alveoli.
3. Teach energy conservation techniques:
- Changing positions often to improve lung expansion and reduce fatigue.
- Pushing rather than pulling objects to reduce exertion.
- Sitting down to perform tasks to conserve energy.
- Resting for at least 1 hour after meals before starting new activities to allow for digestion and reduce fatigue.
- Organizing a work-rest-work schedule to prevent overexertion and manage energy levels.
Energy conservation strategies reduce oxygen consumption, allowing for more sustained activity without exacerbating respiratory distress.
4. Refer the patient to a respiratory therapist for pulmonary rehabilitation: Pulmonary rehabilitation programs provide comprehensive support to alleviate respiratory symptoms, prevent further disability, encourage participation in physical and social activities, and enhance the quality of life for individuals with pulmonary diseases like those predisposing to atelectasis.
5. Provide supplemental oxygenation: Oxygen therapy assists in lung re-expansion and increases arterial oxygen saturation levels to above 90%, improving oxygen delivery to tissues.
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, progressing towards their prior functional level.
- Patient will participate in prescribed physical activity with appropriate physiological responses, including heart rate, blood pressure, and breathing rate within acceptable ranges.
Assessment:
1. Assess the level of physical activity and mobility: This assessment determines the patient’s baseline functional capacity and the level of assistance required to improve activity tolerance. It helps tailor interventions to the individual’s starting point.
2. Determine the cause of activity intolerance: Identify whether the primary cause is physical deconditioning, psychological factors (like fear of falling), or motivational issues. Understanding the root cause allows for targeted nursing strategies to address deconditioning effectively.
3. Monitor and record the patient’s ability to tolerate activity: Document vital signs (pulse rate, blood pressure, respiratory pattern) and subjective reports of breathing effort before, during, and after activity. Signs and symptoms of cardiac decompensation (dyspnea, palpitations, chest discomfort, hypotension/hypertension, tachycardia, decreased oxygen saturation, lightheadedness) are critical indicators to immediately stop the activity and reassess.
Interventions:
1. If the patient is on bed rest, position the patient upright: Elevating the head of the bed or using a chair position minimizes cardiovascular deconditioning associated with prolonged bed rest. An upright position helps maintain optimal fluid distribution and orthostatic tolerance.
2. Assist the patient with self-care activities, positioning, and transferring: Provide assistance as needed, gradually increasing the patient’s participation as tolerated. Progress activity levels from sitting in bed to dangling legs at the bedside, standing, and ambulating. Always have the patient dangle at the bedside before standing to assess for postural hypotension. Reduced plasma volume from bed rest affects autonomic circulatory control.
3. Perform range-of-motion (ROM) exercises: For immobile patients, implement passive or active-assisted ROM exercises to maintain joint mobility, improve joint integrity, reduce pain, and promote a degree of independence within limitations.
4. Refer to physical therapy: Consult physical therapy for expert assessment and development of a personalized physical activity plan. Physical therapists are specialized in designing programs to increase activity levels and build strength safely and effectively.
5. Provide emotional support and encouragement: Address potential fear of breathlessness, pain, or falling, which can hinder willingness to increase activity. Offer consistent emotional support and positive reinforcement to encourage gradual progress, improve patient confidence, and promote the understanding that exercise is beneficial.
6. Obtain necessary assistive devices or equipment before ambulating: (e.g., walkers, canes, crutches, portable oxygen). Ensure appropriate assistive devices are available and properly fitted before initiating ambulation or increased activity levels to provide support and enhance safety.
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
