Nursing Care Plan Activity Intolerance
Nursing Care Plan Activity Intolerance Definition:Insufficient physiological or psychological energy to endure or complete required or desired daily activities Defining Characteristics Abnormal blood pressure and heart rate response to activity, Electrocardiographic changes reflecting arrhythmias and/or ischemia,Exertional discomfort and/or dyspnea,Verbal report of fatigue and/or weakness, Nursing Care Plan Activity Intolerance
- Bed rest • Immobility
- Generalized weakness
- Sedentary lifestyle
- Imbalance between oxygen supply and demand
- Cardiac function
- Respiratory function
Expected Outcomes The Patient Will
- Regain and maintain muscle mass and strength.
- Maintain maximum joint range of motion (ROM).
- Perform isometric exercises.
- Help perform self-care activities.
- Maintain heart rate, rhythm, and blood pressure within expected range during periods of activity.
- State understanding of and willingness to cooperate in maximizing the activity level.
- Perform self-care activities to tolerance level.
Suggested Noc Outcomes
Activity Tolerance; Endurance; Energy Conservation; Self-Care: Activities of Daily Living (ADLs); Self-Care: Instrumental Activitie of Daily Living (IADLs)
Interventions And Rationales
Determine: Monitor physiologic responses to increased activity level,including respirations, heart rate and rhythm, and blood pressure, to ensure that these return to normal within 2–5 min after stopping exercise.Perform: Perform active or passive ROM exercises to all extremities every 2–4 hr. These exercises foster muscle strength and tone, maintain joint mobility, and prevent contractures. Turn and reposition patient at least every 2 hr. Establish a turning schedule for the dependent patient. Post schedule at bedside and
monitor frequency. Turning and repositioning prevent skin breakdown and improve lung expansion and prevent atelectasis.Maintain proper body alignment at all times to avoid contractures and maintain optimal musculoskeletal balance and physiologic function.Encourage active exercise: Provide a trapeze or other assistive device whenever possible. Such devices simplify moving and turning for many patients and allow them to strengthen some upper-body muscles.Inform: Teach about isometric exercises to allow patients to maintain or increase muscle tone and joint mobility.Teach caregivers to assist patients with ADLs in a way that maximizes patients’ potential. This enables caregivers to participate in patients’ care and encourages them to support patients’independence. Attend: Provide emotional support and encouragement to help improve patient’s self-concept and motivate patient to perform ADLs. Involve patient in planning and decision making. Having the ability to participate will encourage greater compliance with the plan for activity.Have patient perform ADLs. Begin slowly and increase daily, as tolerated. Performing ADLs will assist patient to regain independence and enhance self-esteem. Manage: Refer to case manager/social worker to ensure that a home assessment has been done and that whatever modifications were needed to accommodate the patient’s level of mobility have been made. Making adjustments in the home will allow the patient a greater degree of independence in performing ADLs, allowing better conservation of energy.
Suggested Nic Interventions
Activity Therapy; Ambulation; Body Mechanics Promotion; Energ Management; Exercise Promotion: Strength Training; Exercise Therapy: Balance, Joint Mobility, Muscle Control
Shin, Y., Yun, S., Jang, H., & Lim, J. (2006). A tailored program for the promotion of physical exercise among Korean adults. Applied Nursing Research, 19(2), 88–94.