Activity Intolerance

Assessment

Diagnosis

Planning

Subjective
cues:
Verbal report
of fatigue or
weakness

Activity
Intolerance

Short Term
Goal: After
2-3h of
nursing
interventio
ns, the
patient will
gradually
resume
usual
physical
activities.

Objective
cues:
SOB
Bp :
170/10
0

Long Term
Goal:
Pt will
demonstrat
e increased
tolerance
to activity
by
discharge.

Nursing
Interventio
n

Rationale

Evaluation

Goal is met:
1. Assess
potential
for
physical
injury with
activity

1. Injury may
be related to
falls or
overexertion..

2. Observe
and
document
response
to activity.

2. Close
monitoring
serves as a
guide for
optimal
progression of
activity.

3. Refrain
from
performing
nonessenti
al
procedures
.

3. To promote
rest. Patients
with limited
activity
tolerance need
to prioritize
tasks.

4.
Encourage
verbalizati
on of
feelings
regarding
limitations.

4.
Acknowledgme
nt that living
with activity
intolerance is
both physically
and emotionally
difficult aids

coping.

Decrease cardiac output

Assessment

Diagnosis

Subjective cues:
Verbal report of
fatigue or
weakness

Decrease
Short Term
cardiac output Goal: After 23h patient will
maintain BP
will decrease
gearing
towards
normal range.

Objective cues:
Bp :
170/100
Wt gain
Urine
ouput
<30ml/d
ay
K+ 6.5
mEq/L
(normal
3.5 to 5
mEq/L)

Planning

Long Term
Goal:
After 2-4 days
intervention,
patient BP
will be at
patients
normal range.
Signs of
fatique and
weakness will
be gone and
urine output
will be
normal.

Nursing
Intervention

Rationale

Evaluation
Goal is met:

1. Assess
heart rate and
blood
pressure.

1. sinus
tachycardia and
increased
arterial blood
pressure are
seen in the early
stages

2. Assess skin
color and
temperature.

2. Cold,
clammy skin is
secondary to
compensatory
increase in
sympathetic
nervous system
stimulation and
low cardiac
output.

3. Assess
fluid balance
and weight
gain.

3. Body weight
is a more
sensitive

indicator of
fluid or sodium
retention than
intake and
output.
4. place
client in a
semi- to high
Fowler's
position
5. instruct
client to
avoid
activities that
create a
Valsalva
response
6.Administer
medications
as ordered
( diuretics)

4. reduce
cardiac
workload
5. reduce
caridiac
workload

6. remove
excess fluid.
Reduces cardiac
workload.

Excess fluid volume

Assessment

Diagnosis

Subjective
cues:

Excess
fluid
volume

Objective
cues:
SOB
Bp :
170/10
0
Wt
gain
Urine
ouput
<30ml/d
ay
K+
6.5

Planning

Short Term
Goal: After
2-3 hours
of nursing
interventio
n, patient
will be to
demonstrat
e
preventive
measures
to reduce
recurrence
of fluid
excess.
Long Term

Nursing
Interventio
n

Rationale

Evaluation

Goal is met:
1. Accurate
i&o will help
determine renal
function and
fluid
2. weight
replacement
daily at
same time, needs.
same scale
and same
clothing.
2. Daily body
weight is best to
monitor excess
fluid.
1. Monitor
and record
I & O.

3. Asses
for edema.

mEq/L
(norma
l 3.5 to
5
mEq/L)

Goal:
After 2-3
days
nursing
interventio
n the
patient will
be at
stable fluid
volume.
Balance I &
o, stable
weight.

3. Edema is a
sign of fluid
retention.
4. Instruct
client to
change
position
often.
Collaborati
ve:
1.
Administer
medication
as ordered.
(diuretics,
furusemide
,
mannitol )
Antihypert
ensives

4. prevent
pressure
ulcers.

1. Reduce
hyperkalemi
a and
promote
output.

May be
given to
treat HTN by
counteractin
g effects of
decreases
renal blood
flow and
circulating
volume
overload