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NURSING INTERVENTIONS FOR CLIENT WITH A NURSING DIAGNOSIS OF ACTIVITY INTOLERANCE:
(I KNOW IT'S LONG BUT IT INCLUDES RATIONALES FOR THE INTERVENTIONS)

Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Determining the cause of a disease can help direct appropriate interventions.
Assess the client daily for appropriateness of activity and bed rest orders. Inappropriate prolonged bed rest orders may contribute to activity intolerance (Kasper, Braunwald, & Fauci, 2005). EB: A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen et al, 1999).
If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an upright position several times daily. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998; Fletcher, 2005; Kasper, Braunwald, & Fauci, 2005).
If client is mostly immobile, consider use of a transfer chair, a chair that becomes a stretcher. Using a transfer chair where the client is pulled onto a flat surface and then seated upright in the chair can help previously immobile clients get out of bed (Nelson et al, 2003).
When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation. Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension. Watch the client closely for dizziness during increased activity (Fried & Fried, 2001). Postural hypotension can be detected in up to 30% of elderly clients. These methods can help prevent falls (Tinetti, 2003).
When getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs. When an adult rises to the standing position, 300 to 800 mL of blood pools in the lower extremities. Maintenance of blood pressure during position change is quite complex; many sensitive cardiac, vascular, neurologic, muscular, and neurohumoral responses must occur quickly. If any of these responses are abnormal, blood pressure and organ perfusion can be reduced. As a result, symptoms of central nervous system hypoperfusion may occur, including feelings of weakness, nausea, headache, neck ache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations, and impaired cognition (Bradley & Davis, 2003).
If a client experiences syncope with activity, refer for evaluation by a physician. Syncope has many causes, including benign vasovagal, but can also be due to serious cardiac disease, resulting in death (Hauer, 2003).
Perform range-of-motion (ROM) exercises if the client is unable to tolerate activity or is mostly immobile. Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Fried & Fried, 2001).
Monitor and record the client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (Wenger, 2001):
Onset of chest discomfort
Dyspnea
Palpitations
Excessive fatigue
Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency
Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced intraventricular conduction defect, second- or third-degree atrioventricular block, frequent premature ventricular contractions)
Exercise hypotension (drop in systolic blood pressure of 10 mm Hg from baseline blood pressure despite an increase in workload)
Excessive rise in blood pressure (systolic >180 mm Hg or diastolic >110 mm Hg) Note: These are upper limits; activity may be stopped before reaching these values
Inappropriate bradycardia (drop in heart rate >10 beats/min or < 50 beats/min)
Increased heart rate above 100 beats/min
Inappropriate bradycardia (drop in heart rate >10 beats/min or < 50 beats/min)
Increased heart rate above 100 beats/min
Instruct the client to stop the activity immediately and report to the physician if the client is experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort; tightness or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician. The client should be evaluated before resuming activity.
Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998; Kasper, Braunwald, & Fauci, 2005).
Assess for constipation. If present, refer to care plan for Constipation. Impaired mobility is associated with increased risk of constipation.
Refer the client to physical therapy to help increase activity levels and strength.
Consider dietitian referral to assess nutritional needs related to activity intolerance. Recognize that undernutrition causes significant morbidity due to the loss of lean body mass. The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis and pressure sores. Respiratory muscle weakness causes difficulty in expectorating, increasing susceptibility to chest infection. Immunocompetence declines, increasing the risk of infection, which in turn reduces nutritional status (Holmes, 2003).
Identify the factors that contribute to undernutrition in hospital patients. There are two main ways in which undernutrition develops. The first, protein-energy malnutrition arises during acute injury or illness when increased nutrient requirements and loss of body protein are common. The second is inadequate nutrient intake during a time of increased nutritional demand or over a prolonged period of reduced dietary consumption. This is particularly common in older people and those with disabilities and chronic or mental illness (Holmes, 2003).
Provide emotional support and encouragement to the client to gradually increase activity. Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
Observe for pain before activity. If possible, treat pain before activity and ensure that the client is not heavily sedated. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
Obtain any necessary assistive devices or equipment needed before ambulating the client (e.g., walkers, canes, crutches, portable oxygen). Assistive devices can increase mobility by helping the client overcome limitations.
Use a gait walking belt when ambulating the client. Gait belts help improve the caregiver's grasp, reducing the incidence of injuries (Nelson, 2003).
Work with the client to set mutual goals that increase activity levels.
If the client is scheduled for a surgical intervention that will result in bed rest in intensive care, consider referring to physical therapy for a prehabilitation program including warm-up, aerobic conditioning, strength building, and flexibility enhancement. EBN: Increasing a client's functional capacity before hospitalization can be a helpful means of modifying the predictable deconditioning that happens with intensive care unit (ICU) admission (Topp et al, 2002).I GOT THE INFO FROM EVOLVE