Clinical Practice Guideline for Nursing Care Plan

Of Patient With Activity Intolerance Issue Date: 01/01/2007

Revision Date: 04/08/2013 Code #: ND/CPG/ACTI/001 Page 13 of 13

TITLE: NURSING CARE PLAN OF PATIENT WITH ACTIVITY INTOLERANCE EFFECTIVE DATE: 30 May 2015SCOPE: These are specific Goals and objectives to be achieved by the nurse:1. Patient will actively progress to specific level of activity.2. Patient will maintain activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.

RECOMMENDATION I: A statement of patients problem (actual or risk) obtained from the nursing assessment to direct the nurses in the selection of nursing intervention.

PATIENTS PROBLEM: Activity Intolerance DEFINITION: A state in which an individual has insufficient physiological or psychological energy to endure or complete required or desired daily activity.CAUSES:

1. Decreased strength, endurance2. Limited range of motion (ROM) of involved areas3. Impaired muscle mass

4. Altered toneRELATED FACTORS:

1. Generalized weakness

2. Deconditioned state3. Sedentary lifestyle

4. Insufficient sleep or rest periods5. Lack of motivation or depression

6. Prolonged bed rest

7. Imposed activity restriction8. Cardiopulmonary disorders

9. Imbalance between oxygen supply and demand

10. Pain

11. Side effects of medications

RECOMMENDATION II: A collection of nursing data or information that acts to support the statement of identified patient problem.SUPPORTING DATA:

a. Pain on exerciseb. Fatiguec. Weaknessd. Dyspneae. Depressionf. Hyperventilationg. No desire or lack of interest in activityh. Respiratory rate increased > 20 breaths/min normal= 12-20 breaths/min

i. Pulse rate increased > 80 beats/min normal= 80 beats/minj. Blood pressure increased > 120/80 normal= 120/80k. Limited joint movement, see Appendix A for Types of Joint Movementsl. Bed rest or immobility RECOMMENDATION III: A selection of nursing interventions needed by nurses to carry out the specific nursing care applicable to the identified patients problem and to achieve the desired scope and nursing goal. NURSING INTERVENTIONS:

1. Assess patients level of mobility. Aids in defining what patient is capable of, which is necessary before setting realistic goals. See Appendix B for Mobility Assessment Tools for Nurses.2. Assess patients cardiopulmonary status before activity.i. Heart rate. Heart rate should not increase greater than 20 to 30 beats above resting with routine activities. This number will change depending on the intensity of exercise the patient is attempting (climbing four flights of stairs versus shoveling snow).ii. Orthostatic BP changes. Elderly patients are more prone to drops in blood pressure with position changes.

iii. Need for oxygen with increased activity. Portable pulse oximetry can be used to assess for oxygen desaturation. Supplemental oxygen may help compensate for the increased oxygen demands.3. Assess patients nutritional status. Adequate energy is needed to perform activities. 4. Monitor patients sleep pattern and amount of sleep achieved over past few days. Difficulties sleeping need to be addressed before activity progression can be achieved.5. Observe and document response to activity.

i. Rapid pulse (20 beats over resting state or 120 beats per minute)ii. Palpitations

iii. Significant increase in systolic BP (20 mmHg)

iv. Significant decrease in systolic BP (drop of 20 mmHg)

v. Dyspnea, labored breathing, wheezing

vi. Weakness, fatigue

vii. Lightheadedness, dizziness, pallor, diaphoresis6. Anticipate patients need by keeping needed things and call bell within reach.7. Teach energy conservation techniques to reduce oxygen consumption, allowing more prolonged activity.i. Carefully plan activities. Organizing a work-rest-work schedule

ii. Sitting to do tasks because standing requires more workiii. Changing positions often distributes work to different muscles to avoid fatigueiv. Pushing rather than pullingv. Sliding rather than liftingvi. Working at an even pace allows enough time so not all work is completed in a short period of timevii. Storing frequently used items within easy reach to avoid bending and reachingviii. Resting for at least 1 hour after meals before starting a new activity because energy is needed to digest foodix. Using wheeled carts for laundry, shopping, and cleaning needsx. Provide bedside commode or bedpan.

xi. Encourage adequate rest period to reduce cardiac overload.8. Provide a diet high in essential nutrients and dietary supplements, e.g. administer vitamins and minerals as ordered to increase energy production. Increase in physical activity level and regular intake of food rich in calcium, magnesium, phosphorus, vitamin D were associated with optimal functional status.9. Assist in range of motion exercises TID to maintain muscle strength and joint range of motion. Progress activity gradually to prevent overexerting the heart and to promote attainment of short range of goals, e.g.i. Active range of motion exercises in bed progressing to sitting or standingii. Dangling feet 10-15 minutes TID iii. Deep breathing exercises TID

iv. Sitting up in chair TID

v. Walking in room 1-2 minutes TID

vi. Walking in hall 25 feet, then slowly progressing, saving energy for return trip.10. Provide comfort measures:i. Administer analgesic as ordered by the Doctor 30 minutes prior to exercise therapy, e.ga. Injection Tramal IV / IM or Voltaren PO / PR STATii. Assist in diversional activities according to patient interest and hospital availability, e.g. watching TV and listening to musiciii. Provide quiet environment to induce rest and sleepiv. Change clothing to keep patient dry when sweating11. Provide and teach patient and family with the ideas for conserving energy to allow patient sufficient time to recuperate between activities. See Appendix C for Joint Protection and Energy Conservation

i. Sit whenever possible when performing activity of daily living, e.g. on a stool when showering

ii. Pace activities throughout the day

iii. Schedule adequate rest periods

iv. Alternate easy and hard task throughout the day12. Encourage independence in activities that afford mobilization of affected limb joints.

i. Obtain Physiotherapy Consultation as required if limb joints are affected. ii. Maintain splints in proper position as prescribed by the Doctor.

13. Provide emotional support while increasing activity. i. Promote positive feedbacks for every progress in abilitiesii. Avoid doing for patient what they can do for themselves to increase patient self-esteem.iii. Encourage verbalization of feelings regarding limitations.14. Provide spiritual support for emotional well being, e.g.

i. Reading Quran

ii. Provide turab for prayer

iii. Allow patient to share thoughts with their Sheik

15. Encourage family (murafiq) involvement in providing comfort and reassurance.RECOMMENDATION IV: A statement of evaluation to determine whether the scope or nursing goal is met or not met.

a. Goal Met: i. Patient assumes increase in usual daily activities.ii. Patient appears comfortable and rested.

b. Goal Not Met:i. Patient was unable to tolerate activities as characterized by presence of shortness of breath, fatigue, and weakness during activities.RATIONALE:

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary-related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g. beta-blockers), or emotional states such as depression or lack of confidence to exert ones self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

A gradual increase in activity helps prevent a sudden increase in cardiac workload and myocardial oxygen consumption and the subsequent imbalance between oxygen supply and demand. Progressive activity also helps strengthen the myocardium, which enhances cardiac output and subsequently improves activity tolerance. Cells utilize oxygen and fat, protein and carbohydrate to produce the energy needed for all body activities. Rest and activities that conserve energy result in a lower metabolic rate, which preserves nutrients and oxygen for necessary activities. Metabolism is the process by which nutrients are transformed into energy. If nutrition is inadequate, energy production is decreased, which subsequently reduces ones ability to tolerate activity. Early recognition of signs and symptoms of activity intolerance allows for prompt intervention and notifying the physician for modification of treatment plan.APPENDICES:APPENDIX A: Types of Joint MovementsAPPENDIX B: Mobility Assessment tools for NursesAPPENDIX C: Joint Protection and Energy Conservation REFERENCES:1. Boynton, T., Kelly, L. & Perez, A. (2014). Implementing a mobility assessment tool for nurses. American Nurse today 9 (9). Retrieved from http://www.americannursetoday.com/implementing-mobility-assessment-tool-nurses/ 2. Tasoulis, A. Dimopoulos, S. Repasos, E. Manetos, C. Tzanis, G., Nanas, S. (2014). Respiratory drive and breathing pattern abnormalities are related to exercise intolerance in chronic heart failure patients. Respiratory, Physiology and Neurobiology, 192, 90-94.3. Lewis, Heitkemper, Dirksen, OBrien & Bucher (2013). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Mosby, Inc., an affiliate of Elsevier Inc.

4. Doenges, M. E., Moorhouse, M. F. & Geisslur-Murr, A. C. (2013). Nurses Pocket Guide: Diagnoses, Interventions and Rationales (13th ed.). F.A. Davis Company

5. Gulanick, M. (2012). Activity Intolerance-Weakness; Deconditioned; Sedentary. Mosby Elsevier, Inc. Retrieved from: http://www.1.us.elsevierhealth.com/MERLIN/Gulanick/ archive/Constructor/gulanick01.html

6. Berman, A. & Snyder, S. (2012). Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice (9th ed.). Pearson Education, Inc.7. Osho, O.A., Abidoye, R.O., Owoeye, O.B., Akinfeleye, A.M. & Akinbo, S.R. (2011) Physical activity level, nutritional intake, functional status and quality of life of geriatric individuals in Lagos, South-West, Nigeria: a cross sectional survey. Nigerian quarterly journal of hospital medicine, 21(1), 9-15.

REVISION DATE: 30 March 2018DISCLAIMER:

Because nursing derives principles from many disciplines, this guideline made use of several books regarding progressive care. It is not meant to be a complete reference rather it is intended to focus mainly on common questions on nursing care and to stimulate further discussion and research. This is produced for easy accessibility of guidelines in nursing care planning and has placed emphasis practical clinical information for evidence-based management. This guideline is not intended to replace professional nursing care or attention by a qualified nurse practitioner. The EBM committee is not responsible or liable for directly or indirectly any form of damage whatsoever resulting from use/misuse of any information contained or implied by this guideline.

REVIEWERS:

1. Prepared by: __________________________ ______________ Ms. Febie Calis Romarate

Date

Staff Nurse, Female Surgical Ward II2. Prepared by: __________________________

______________

Ms. Charlotte Marcelino

Date

Staff Nurse, Emergency Department3. Reviewed by: __________________________ _______________ Ms. Fawziah Bakheet Al Mowalad Date Director of Nursing Services4. Reviewed by: __________________________ _______________ Dr. Danyah Al Safadi

Date

Chairperson of EBM Committee5. Approved by: _________________________ _______________

Dr. Reda M. Matbuli

Date

Asst. Supervisor General for Medical Affairs

6. Approved by: _________________________ _______________ Dr. Faisal Mahmoud Tallab

Date

Supervisor GeneralAppendix A: TYPES OF JOINT MOVEMENTS

MOVEMENTACTION

FlexionDecreasing the angle of the joint (e.g. bending the elbow)

ExtensionIncreasing the angle of the joint (e.g. straightening the arm at the elbow)

HyperextensionFurther extension or straightening of a joint (e.g. bending the head backward)

AbductionMovement of the bone away from the midline of the body

AdductionMovement of the bone toward the midline of the body

RotationMovement of the bone around its central axis

CircumductionMovement of the distal part of the bone in a circle while the proximal end remains fixed

EversionTurning the sole of the foot outward by moving the ankle joint

InversionTurning the sole of the foot inward by moving the ankle joint

PronationMoving the bones of the forearm so that the palm of the hand faces downward when held infront of the body

SupinationMoving the bones of the forearm so that the palm of the hand faces upward when held infront of the body

Adapted from: Berman, A. & Snyder, S. (2012). Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice (9th ed.). Pearson Education, Inc..Appendix B: MOBILITY ASSESSEMENT TOOLS FOR NURSESTESTTASKRESPONSEFAIL =

Choose Most Appropriate

Equipment/Device(s)PASS

Assessment

Level 1

Assessment of:-Cognition-Trunk strength

-Seated balanceSit and Shake: From a semi-reclined position, ask

patient to sit upright and rotate* to a seated position at

the side of the bed; may use the bedrail.Note patients ability to maintain bedside position.

Ask patient to reach out and grab your hand and shake

making sure patient reaches across his/her midline.

Note: Consider your patients cognitive ability, including

orientation and CAM assessment if applicable.Sit: Patient is able to follow commands,

has some trunk strength; caregivers may be able to try weight-bearing if patient is able to maintain seated balance greater

than two minutes (without caregiver

assistance).Shake: Patient has significant upper body

strength, awareness of body in space, and

grasp strengthMOBILITY LEVEL 1

- Use total lift with sling and/or repositioning

sheet and/or straps.

- Use lateral transfer devices such as roll

board, friction reducing (slide sheets/tube),

or air assisted device.NOTE: If patient has strict bed rest or

bilateral non-weight bearing restrictions,

do not proceed with the assessment;

patient is MOBILITY LEVEL 1.

Passed Assessment

Level 1 = Proceed with

Assessment Level 2.

Assessment

Level 2

Assessment of :-Lower extremity

strength

-StabilityStretch and Point: With patient in seated position

at the side of the bed, have patient place both feet on

the floor (or stool) with knees no higher than hips.

Ask patient to stretch one leg and straighten the knee,

then bend the ankle/flex and point the toes. If

appropriate, repeat with the other leg.Patient exhibits lower extremity stability,

strength and control.

May test only one leg and proceed

accordingly (e.g., stroke patient, patient

with ankle in castMOBILITY LEVEL 2

- Use total lift for patient unable to weight bear

on at least one leg.

- Use sit-to-stand lift for patient who can

weight-bear on at least one leg.Passed Assessment

Level 2 = Proceed with

Assessment Level 3

Adapted from: Boynton, T., Kelly, L. & Perez, A. (2014). Implementing a mobility assessment tool for nurses. American Nurse today 9 (9). Retrieved from http://www.americannursetoday.com/implementing-mobility-assessment-tool-nurses/ Appendix B: MOBILITY ASSESSEMENT TOOLS FOR NURSES continuedTESTTASKRESPONSEFAIL =

Choose Most Appropriate

Equipment/Device(s)PASS

Assessment

Level 3

Assessment of:

-Lower extremity

strength for standingStand: Ask patient to elevate off the bed or chair

(seated to standing) using an assistive device (cane,

bedrail).

Patient should be able to raise buttocks off bed and

hold for a count of five. May repeat once.

Note: Consider your patients cognitive ability, including

orientation and CAM assessment if applicablePatient exhibits upper and lower extremity

stability and strength.

May test with weight-bearing on only

one leg and proceed accordingly (e.g.,

stroke patient, patient with ankle in

cast).

If any assistive device (cane, walker,

crutches) is needed, patient is Mobility

LevelMOBILITY LEVEL 3

- Use non-powered raising/stand aid; default

to powered sit-to-stand lift if no stand aid

available.

- Use total lift with ambulation accessories.

- Use assistive device (cane, walker,

crutches).

NOTE: Patient passes Assessment Level 3

but requires assistive device to ambulate

or cognitive assessment indicates poor

safety awareness; patient is MOBILITY

LEVEL 3.Passed Assessment Level

3 AND no assistive

device needed = Proceed

with Assessment Level 4.

Consult with

Physical Therapist when

needed and appropriate

Assessment

Level 4

Assessment of:

-Standing balance

-GaitWalk: Ask patient to march in place at bedside.

Then ask patient to advance step and return each foot.

Patient should display stability while performing tasks.

Assess for stability and safety awareness.Patient exhibits steady gait and good

balance while marching, and when

stepping forwards and backwards.

Patient can maneuver necessary turns for

in-room mobility.

Patient exhibits safety awarenessMOBILITY LEVEL 3

If patient shows signs of unsteady gait or

fails Assessment Level 4, refer back to

MOBILITY LEVEL 3; patient is MOBILITY

LEVEL 3MOBILITY LEVEL 4

MODIFIED

INDEPENDENCE

Passed = No assistance

needed to ambulate; use

your best clinical judgment

to determine need for

supervision during

ambulation.

Adapted from: Boynton, T., Kelly, L. & Perez, A. (2014). Implementing a mobility assessment tool for nurses. American Nurse today 9 (9). Retrieved from http://www.americannursetoday.com/implementing-mobility-assessment-tool-nurses/

Appendix C: JOINT PROTECTION AND ENERGY CONSERVATION

Lose or maintain weight. Use assistive devices, if indicated. Avoid forceful repetitive movements Provide sufficient rest period in every task. Avoid positions of joint deviation and stress. Use good posture and proper body mechanics to reduce risk of injury. Seek assistance with necessary tasks that may cause pain. Develop organizing and pacing techniques for routine tasks. Eat a well balanced diet. Modify home and work environment to create less stressful ways to perform tasks.Adapted from: Lewis, Heitkemper, Dirksen, OBrien & Bucher (2013). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Mosby, Inc.KAAH ND-CPG-ACTI-001