Friday, November 26, 2010

Activity intolerance

 Activity Intolerance

NANDA Definition
Insufficient physiological or psychological energy to endure or complete required or desired daily activities


Discussion of the Problem
Activity tolerance is the type and amount of exercise or daily living activities an individual is able to perform without experiencing adverse effects. Functional strength is the ability of the body to perform work. When activity tolerance and functional strength had been affected by a certain condition, it leads to activity intolerance. Activity intolerance is usually associated to generalized weakness (body malaise) and debilitation secondary to acute or chronic illness and disease. Medical conditions that could lead to activity intolerance are as follows: hypertension, heart failure, myocardial infarction, anemia and end of life conditions.  This problem is especially apparent in geriatric patients who have the mentioned medical problems. In addition, the aging process causes reduction in muscle strength and function, which can impair the ability to maintain activity. Other factors that contribute to activity intolerance are as follows: obesity, malnourishment, side effects of medications, depression or lack of confidence to exert one's self. Nursing goals are as follows: to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Nursing Interventions Classification (NIC)
  • Energy Management
  • Teaching: Prescribed Activity/Exercise

Nursing Outcomes Classification (NOC)
  • Activity Tolerance
  • Energy Conservation
  • Knowledge: Treatment Regimen

Goals and Objectives
  • Patient will adjust lifestyle to energy level
  • Patient will demonstrate a reduction in physiological signs of tolerance
  • Patient will express understanding of potential loss of ability in relation to existing condition
  • Patient will Identify negative factors affecting performance and will remove or will minimize their effects when possible
  • Patient will maintain activity level within capabilities, as evidenced by the following: normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.
  • Patient will report a measurable augmentation in activity tolerance, manifested by reduced fatigue and weakness and by vital signs within acceptable limits during activity
  • Patient will report absence of chest pain with activity
  • Patient will take part in necessary or desired activities, and will meet own self-care needs
  • Patient will verbalize and utilize energy-conservation techniques.

Subjective and Objective Data
  • Abnormal heart rate or blood pressure (BP) response to activity
·         Changes in skin color/moisture
·         Changes in vital signs
·         Disinterested in surroundings/introspection
  • Electrocardiogram (ECG) changes reflecting ischemia; dysrhythmias
·         Exertional angina
  • Exertional discomfort or dyspnea
·         Generalized weakness
  • Inability to begin or perform activity
·         Lethargic; drowsy; decreased performance
·         Pallor, diaphoresis
·         Report of lack of energy, inability to maintain usual routines
  • Verbal report of fatigue or weakness
·         Verbalizes no desire and/or lack of interest in activity

Related Factors
·         Cognitive deficits/emotional status, secondary to underlying disease process/depression
  • Deconditioned state
  • Depression or lack of motivation
  • Generalized weakness
  • Imbalance between oxygen supply and demand
  • Imposed activity restriction
  • Insufficient sleep or rest periods
  • Pain, extreme stress
·         Presence of ischemia/necrotic myocardial tissues
  • Prolonged bed rest or immobility; progressive disease state/debilitating condition
  • Sedentary lifestyle
  • Side effects of medications; Cardiac depressant effects of certain drugs (beta-blockers, antidysrhythmics)

Assessment (Dx)
  • Determine patient's opinion of causes of fatigue or activity intolerance. The cause may be temporary or permanent, physical or psychological. Determination guides treatment.

  • Assess level of mobility of the patient. Defining what the patient is capable of is necessary before setting realistic goals.


GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL
ACTIVITY-EXERCISE PATTERN ASSESSMENT
SUBJECTIVE
1. Have patient rate each area of self-care on a scale of 0 to 4.

                        0 – Completely independent
                        1 – requires use of equipment or device
                        2 – requires help from another person for assistance, supervision or teaching
                        3 – requires help from another person and equipment device
                        4 – dependent; does not participate in activity

            Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__; Ambulation__; Care of             home__; Shopping__; Meal preparation__; Laundry__; Transportation__

2. Oxygen use at home? No__ Yes__ Describe: ______________________
3. How many pillows do you use to sleep on?_____
4. Do you frequently experience fatigue? No__ Yes__ Describe: _________
5. How many stairs can you climb without experiencing any difficulty (can be individual    number             or number of flights)? ___________________________
6. How far can you walk without experiencing any difficulty? _____________
7. Has assistance at home for self-care and maintenance of home:
            No__ Yes__ Who? __________ If no, would you like to have or believes needs             assistance: No__ Yes__ With what activities? _________________
8.Occupation (if retired, former occupation): _________________________
9.Describe you usual leisure time activities/hobbies: ___________________
10. Any complaints of weakness or lack of energy? No__ Yes__ Describe:
11. Any difficulties in maintaining activities of daily living? No__ Yes__ Describe:
12. Any problems with concentration? No__ Yes__ Describe: ______

OBJECTIVE
1.Cardiovascular
            a.         Cyanosis: No__ Yes__ Where? _______________________________
            b.         Pulses: Easily palpable?
                        Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__
                        Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__;
                        Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__
            c.         Extremities:
                        i.          Temperature: Cold__ Cool__ Warm__ Hot__
                        ii.          Capillary refill: Normal__ Delayed__
                        iii.         Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________
                        iv.         Homan’s sign: No__ Yes__
                        v.         Nails: Normal__ Abnormal__ Describe: _____________________
                        vi.         Hair distribution: Normal__ Abnormal__ Describe: ____________
                        vii.        Claudication: No__ Yes__ Describe: _______________________
            d.         Heart: PMI location: ________
                        i.          Abnormal rhythm: No__ Yes__ Describe: ___________________
                        ii.          Abnormal sounds: No__ Yes__ Describe: ___________________

2.Respiratory
            a.         Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__
            b.         Have patient cough. Any sputum? No__ Yes__ Describe: ___________
            c.         Fremitus: No__ Yes__
            d.         Any chest excursion? No__ Yes__ Equal__ Unequal__
            e.         Auscultate chest:
                        i.          Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __
            f.          Have patient walk in place for 3 minutes (if permissible):
            i.          Any shortness of breath after activity? No__ Yes__
                        ii.          Any dypnea? No__ Yes__
                        iii.         BP after activity: ___/___  in (right/left) arm
                        iv.         Respiratory rate after activity: _______
                        v.         Pulse rate after activity: _______

3.Musculoskeletal
            a.         Range of motion: Normal__ Limited__ Describe: __________________
            b.         Gait: Normal__ Abnormal__ Describe: __________________________
            c.         Balance: Normal__ Abnormal__ Describe: ______________________
            d.         Muscle mass/strength: Normal__ Increased__ Decreased__
                        Describe: ________________________________________________
            e.         Hand grasp: Right:: Normal__ Decreased__
                        Left: Normal__ Decreased__
            f.          Toe wiggle: Right: Normal__ Decreased__
                         Left: Normal__ Decreased__
            g.         Postural: Normal__ Kyphosis__ Lordosis__
            h.         Deformities: No__ Yes__ Describe: ____________________________
            i.          Missing limbs: No__ Yes__ Where? ____________________________
            j.          Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____
            k.         Tremors: No__ Yes__ Describe: ______________________________
4.Spinal cord injury: No__ Yes__ Level: ____________________________
5. Paralysis present: No__ Yes__ Where? ___________________________
6.Developmental Assessment: Normal__ Abnormal__ Describe: _________


FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987)
Level 1
Walk, regular pace, on level indefinitely; one flight or more but more short of breath than normally
Level 2
Walk one city block or 500 ft on level; climb one flight slowly without stopping
Level 3
Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
Level 4
Dyspnea and fatigue at rest

  • Assess for possible physical injury with activity. Injury may be results of falls or overexertion.

  • Review nutritional status or the use of food supplements. Adequate reserves of energy are necessary for activity.

  • Assess need for ambulation aids, such as bracing, cane, walker, equipment modification, for activities of daily living (ADLs). Some aids may necessitate more energy expenditure for patients who have diminished upper arm strength. Sufficient estimation of energy requirements is indicated.

           AMBULATORY (GAIT) AIDS
Purposes
            1. To increase area of support
            2. To decrease loading & demand on the lower extremities. & skeletal structures
            3. To reduce lower limb pain
            4. To assist with acceleration & deceleration during ambulation
            5. To provide additional sensory information
            
Indications
            1. For need of increase in balance
            2. For pain reduction of the lower extremities
            3. For decreased weight bearing on the injure/inflamed lower extremity
            4. For compensation of weak muscles.

                ENERGY USING IN GAIT TRAINING AMBULATION
GAIT TRAINING
% ENERGY INCREASE
(FROM NORMAL AMBULATION)
Three point (NWB)
61
Three point (PWB)
36
Two point
18
Swing through
41
Wheelchair
9
          

  • Assess patient's cardiopulmonary status before activity using the following measures:
1)     Chest pain or dyspnea; too much weakness and fatigue
2)     Dizziness or fainting; excessive perspiration
3)     Effect of Valsalva maneuver on heart rate. When patient moves in bed, the patient holds breath and bears down. This then causes bradycardia and decreased cardiac output.
4)     Heart rate should not rise to more than 20 to 30 beats per min over resting with routine activities. Depending on the intensity of exercise the patient is attempting, this range will change.
5)     Oxygen demand with increased activity. Evaluation for oxygen desaturation can be done with the aid of portable pulse oximetry. Compensation for the increased oxygen demands can be aided by supplemental oxygen.
6)     Postural hypotension. Geriatric patients are more prone to drops in blood pressure with changes is position.

  • Monitor sleep pattern of the patient and amount of sleep for the recent days. Sleeping difficulties should be prioritized before activity progression can be achieved.

  • Monitor and document response to activity. Report any of the following:
1)     Body malaise, fatigue
2)     Dizziness, excessive perspiration, lightheadedness, pallor
3)     Increase or decrease of about 20 mm Hg in systolic BP
4)     Labored breathing
5)     Palpitations
6)     Rapid pulse (120 beats per min during resting rate )
A guide for optimal progression of activity is provided during close monitoring of these responses to activity.

  • Assess response of the patient’s emotions with regards to change in physical status. Inability to perform required activities can result to depression that could further worsen the activity intolerance.

Therapeutic Interventions (Tx)
  • Anticipate patient's needs.

  • Assist with ADLs as indicated. Supporting the patient with ADLs allows for conservation of energy.

  • Avoid performing unnecessary procedures. Patients with limited tolerance to activity need to prioritize tasks.

  • Combine activity periods with ample rest periods, especially for the following: during ambulation, before meals, other ADLs, and exercise sessions. Time for energy conservation and recovery is provided during rest between activities.

  • Help out patient to plan activities during the times when the patient has the most energy. Not all self-care and hygiene activities need to be completed at once. Likewise, not all house chores need to be done in a day.

  • Offer bedside commode as indicated. This reduces expenditure of energy. It must be noted that a bedpan would require more energy than a commode.

  • Set up guidelines and goals of activity with the patient and caregiver. Goal setting involving participation of the patient enhances motivation. Depending on the cause of the activity intolerance, some patients may be able to live independently and work outside the home, while others remain homebound.

  • Progress activity slowly, as with the following:
1)     Active range-of-motion (ROM) exercises in bed, progressing lying to sitting and standing
2)     Dangling of feet 10 to 15 minutes three times a day.
3)     Deep breathing exercises three times a day
4)     Sitting up in chair 30 minutes three times a day
5)     Walking in room 1 to 2 minutes three times a day
This promotes achievement of short-range goals and avoids overexerting the heart.

  • Offer emotional support while the patient increases his/her activity. Upholds a positive attitude regarding abilities.

Educative (EDx)
  • Encourage expression of feelings with regard to limitations. Coping is enhanced, when it is acknowledged that living with activity intolerance is both physically and emotionally difficult.

  • Persuade performing of active ROM exercises three times a day. Exercises sustain muscle strength and joint ROM.

CLIENT TEACHING: ACTIVE ROM
Exercises
  1. Execute each ROM exercise as trained to the point of slight resistance, but not beyond, and by no means to the point of discomfort.
  2. Execute the actions systematically, using the similar sequence during each session.
  3. Execute each exercise thrice.
  4. Execute each series of exercises twice a day.
  5.  
Geriatric considerations
Ø   For geriatric patients, it is not necessary to attain full ROM in all joints. Emphasize instead on achieving a adequate ROM to carry out activities of daily living, such as the following: walking, dressing, combing hair, showering, and preparing a meal.


  • Educate patient and caregivers to be familiar with signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician. This promotes awareness of when to decrease present activity. Also, development of signs and symptoms such as syncope, angina, and dyspnea, point outs the need for changes in exercise procedure or medication.

  • Educate the importance of continued activity at home. This sustains strength, ROM, and endurance gain.

  • Involve patient together with the caregivers in the setting of goal and planning of care. Setting little, achievable goals can augment self-confidence and self-esteem.

  • Persuade progressive activity and self-care as tolerated. Offer support as needed. Continuing activity progression avoids a sudden increase in workload of the heart. Offering support as needed encourages independence in performing activities.

  • Help out in assigning priority to activities in able to accommodate energy levels.

  • Teach energy conservation techniques. Some examples include the following:
1)     Changing positions frequently. This distributes work to different muscles to prevent fatigue.
2)     Making a work-rest-work schedule
3)     Pushing instead of  pulling
4)     Resting for at least an hour after meals before initiating a new activity. Energy is required to digest food.
5)     Sitting to do everyday activities. Standing requires more work.
6)     Sliding instead of  lifting
7)     Storing often used items within easy reach. This avoids bending and reaching.
8)     Utilizing wheeled carts for laundry, shopping, and cleaning requirements
9)     Working at an even pace. This allows sufficient time so not all work is done in a short period.
These allow more prolonged activity due to reduced oxygen consumption.

  • Teach appropriate use of environmental aids such as bed rails. These preserve energy and avoid injury from fall.

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