Nursing Dx

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities
RELATED FACTORS
Generalized weakness
Sedentary lifestyle
Bedrest/immobility
Imbalance between oxygen supply and demand, [anemia]
[Cognitive deficits/emotional status; secondary to underlying disease process/depression]
[Pain, vertigo, dysrhythmias, extreme stress]
DEFINING CHARACTERISTICS
Subjective
Verbal report of fatigue/weakness
Exertional discomfort/dyspnea
[Verbalizes no desire and/or lack of interest in activity]
Objective
Abnormal heart rate/blood pressure response to activity
Electrocardiographic changes reflecting arrhythmias/or ischemia
[Pallor, cyanosis]
FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987):
Level I: Walk, regular pace, on level indefinitely; one flight or more but more short of breath
than normally
Level II: Walk one city block [or] 500 ft on level; climb one flight slowly without stopping
Level III: Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
Level IV: Dyspnea and fatigue at rest

Sample Clinical Applications: Anemias, angina, aortic stenosis, bronchitis, emphysema, diabetes mellitus, dysmenorrhea, heart failure, human immunodeficiency virus/acquired immunodeficiency disease (HIV/AIDS), labor/preterm labor, leukemias, mitral stenosis, obesity, pain, pericarditis, peripheral vascular disease, rheumatic fever, thrombocytopenia, tuberculosis, uterine bleeding

Client Will (Include Specific Time Frame)
• Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.
• Use identified techniques to enhance activity tolerance.
• Participate in necessary/desired activities.
• Report measurable increase in activity tolerance.
• Demonstrate a decrease in physiological signs of intolerance (e.g., pulse, respirations, and
blood pressure remain within client’s usual range).

NURSING PRIORITY NO.1 To identify causative/precipitating factors:

• Note presence of acute or chronic illness, such as heart failure, hypothyroidism, diabetes mellitus, AIDS, cancers, acute and chronic pain, etc. Many factors cause or contribute tofatigue, but acitivity intolerance implies that the client cannot endure or adapt to increasedenergy or oxygen demands caused by an actvity.

• Assess cardiopulmonary response to physical activity by measuring vital signs, noting heart rate/regularity, respiratory rate/work of breathing, and blood pressure before, during, andafter activity. Note progression/accelerating degree of fatigue. Dramatic changes in heartrate and rhythm, changes in usual blood pressure, and progressively worsening fatigue resultfrom imbalance of oxygen supply and demand. These changes are potentially greater in thefrail, elderly population.

• Note treatment-related factors such as side effects/interactions of medications. Caninfluence presence and degree of fatigue.

• Determine if client is receiving medications such as vasodilators, diuretics, or beta-blockers.Orthostatic hypotension can occur with activity because of medication effects(vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.

• Note client reports of difficulty accomplishing tasks or desired activities. Evaluate current limitations/degree of deficit in light of usual status and what the client perceives causes, exacerbates, and helps the problem. Provides comparative baseline and influences choice of interventions and may reveal causes that the client is unaware of affecting energy, such as sleep deprivation, smoking, poor diet, depression, or lack of support. 1
• Ascertain ability to sit, stand, and move about as desired. Note degree of assistance necessary, and/or use of assistive equipment. Helps to differentiate between problems relating to movement and problems with oxygen supply and demand characterized by fatigue and weakness.
• Identify activity needs versus desires (e.g., client barely able to walk upstairs but states would like to play racquetball). Assists caregiver in dealing with reality of situation, as well as the feasibility of goals client wants to achieve when developing activity plan. 

• Assess emotional/psychological factors affecting the current situation. Stress and/or depression may be exacerbating the effects of an illness, or depression may be the result of therapy/limitations.

NURSING PRIORITY NO.2 To assist client to deal with contributing factors and manage activities within individual limits:
• Monitor vital signs, before and during activity, watching for changes in blood pressure, heart and respiratory rate, as well as postactivity vital sign response. Vital signs increase during activity and should return to baseline within 5 to 7 minutes after activity if response to activity is normal.
• Observe respiratory rate, noting breathing pattern, breath sounds, skin color, and mental status. Pallor and/or cyanosis, presence of respiratory distresss, or confusion may be indicative of need for oxygen during activities, especially if respiratory infection or compromise is present.
• Plan care with rest periods between activities to reduce fatigue.
• Assist with self-care activities. Adjust activities/reduce intensity level, or discontinue activities that cause undesired physiological changes. Prevents overexertion.
• Increase exercise/activity levels gradually; encourage stopping to rest for 3 minutes during a 10-minute walk, sitting down instead of standing to brush hair, etc. Methods of conserving energy.
• Encourage expression of feelings contributing to/resulting from condition. Provide positive atmosphere while acknowledging difficulty of the situation for the client. Helps to minimize frustration, rechannel energy.
• Involve client/significant others (SOs) in planning of activities as much as possible. May give client opportunity to perform desired/essential activities during periods of peak energy.
• Assist with activities and provide/monitor client’s use of assistive devices. Enables client to maintain mobility while protecting from injury.
• Promote comfort measures and provide for relief of pain to enhance client’s ability and desire to participate in activities. (Refer to NDs acute Pain, chronic Pain.)
• Provide referral to collaborative disciplines such as exercise physiologist, psychological counseling/therapy, occupational/physical therapy, and recreation/leisure specialists. May be needed to develop individually appropriate therapeutic regimens.
• Prepare for/assist with and monitor effects of exercise testing. May be performed to determine degree of oxygen desaturation and/or hypoxemia that occurs with exertion, or to optimize titration of supplemental oxygen when used.
• Implement graded exercise/rehabilitation program under direct medical supervision. Gradual increase in activity avoids excessive myocardial workload/excessive oxygen demand.

• Administer supplemental oxygen, medications, prepare for surgery, as indicated. Type of therapy or medication is dependent on the underlying condition and might include medications (such as antiarryhthmics) or surgery (e.g., stents or CABG) to improve myocardial perfusion and systemic circulation. Other treatments might include iron preparations or blood transfusion to treat severe anemia, or use of oxygen and bronchodilators to improve respiratory function.

NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Review expectations of client/SO(s)/providers and explore conflicts/differences. Helps to establish goals and to reach agreement for the most effective plan.
• Assist/direct client/SO to plan for progressive increase of activity level aiming for maximal activity within the client’s ability. Promotes improved or more normal activity level, stamina, and conditioning.
• Instruct client/SOs in monitoring response to activity and in recognizing signs/symptoms that indicate need to alter activity level. Assists in self-management of condition and in understanding of reportable problems.
• Give client information that provides evidence of daily/weekly progress to sustain motivation.
• Assist client to learn and demonstrate appropriate safety measures to prevent injuries.
• Provide information about proper nutrition to meet metabolic and energy needs, obtaining or maintaining normal body weight. Energy is improved when nutrients are sufficient to meet metabolic demands.
• Encourage client to use relaxation techniques such as visualization/guided imagery as appropriate. Useful in maintaining positive attitude and enhancing sense of well-being.
• Encourage participation in recreation/social activities and hobbies appropriate for situation. (Refer to ND deficient Diversional Activity.)
• Monitor laboratory values (such as for anemia) and pulse oximetry.

DOCUMENTATION FOCUS
Assessment/Reassessment
• Level of activity as noted in Functional Level Classification.
• Causative/precipitating factors.
• Client reports of difficulty/change.
Planning
• Plan of care and who is involved in planning.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Implemented changes to plan of care based on assessment/reassessment findings.
• Teaching plan and response/understanding of teaching plan.
• Attainment/progress toward desired outcome(s).
Discharge Planning
• Referrals to other resources.
• Long-term needs and who is responsible for actions.