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Showing posts with label Activity Intolerance. Show all posts
Showing posts with label Activity Intolerance. Show all posts

Activity Intolerance - Nursing Diagnosis and Interventions

Risk for Activity Intolerance related to physical weakness

Activity Intolerance is a decrease in physiological capacity to maintain activity to the level desired or required.


Defining Characteristics:

Major :
  • Change the client's physiological response to the activity undertaken.
  • Respiratory: dyspnea (breathing frequency increased exaggeration).
  • Shortness of breath (decrease frequency).
  • Pulse: weak, declining, excessive increase, the increase in the rhythm, failed to return to the level before the activity after 3 minutes.
  • Blood pressure: failed to increase the activity, an increase in diastolic over 15 mmHg.

Minor:
  • fatigue
  • weakness, 
  • cyanosis or pale, 
  • mental chaotic, 
  • vertigo


Subjective Data:

  • weakness
  • fatigue
  • dyspnea
  • lack of sleep

Objective Data :

Assess the strength and balance, the evaluation of an individual's ability to:
  • Changing positions himself on the bed.
  • Ambulation.
  • Doing ADL (activity daily living) or daily activities.

Assess for the presence of:
  • pale
  • cyanosis
  • mental chaotic
  • vertigo

Nursing Interventions:

Activity intolerance related to physical weakness

Goal: after the act of nursing for 5 x 24 hours the patient does not experience injury.

Expected outcomes:
  • The patient is able to identify risk factors and individual strengths that affect tolerance to activity.
  • Participate in rehabilitation programs to improve the ability to move.
  • Being able to choose several alternatives to maintain the level of activity.

Intervention:

1. Assess the level of the client's ability to exercise.
R /: As a base to provide an alternative and appropriate motion exercises with ability.

2. Plan on giving training program according to the ability of the patient.
R /: Exercise may increase the movement of muscles and stimulate blood circulation.

3. Provide a diet high in calcium.
R /: Helps replace calcium lost.

4. Teach the client on how to perform daily activities.
R /: To improve the movement and perform safe movement.

5. Involve the family to train the patient's mobility.
R /: To support the patient.

6. Consult with a physical therapist.
R /: Helpful in developing individualized exercise program and identify the need for a tool to eliminate muscle spasm, improving motor function, prevent / decrease atrophy and contractures in the muscular system.

(doengoes, 2000)

Nursing Diagnosis for Activity Intolerance

Nursing Care Plan for Activity Intolerance

Nursing Care Plan for Activity Intolerance

A nursing care plan for Activity Intolerance is used when a patient has insufficient physiological or psychological energy to endure or complete required or desired daily activities

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications, or emotional states such as depression or lack of confidence to exert one’s self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Related to:
  • Generalized weakness / Fatigue
  • Malnourishment
  • Chronic disease
  • Stressors
  • Insufficient sleep or rest periods
  • Prolonged immobility/bed rest
  • Depression
  • Lack of motivation
  • Imbalance of oxygen supply and demand
  • Pain

As evidenced by:
  • Verbal report of fatigue or weakness
  • Inability to begin or perform activity
  • Abnormal heart rate or blood pressure (BP) response to activity
  • Exertional discomfort or dyspnea

Outcome:
  • The patient maintains activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.
  • Patient verbalizes and uses energy-conservation techniques.