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Monday, June 19, 2017

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

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