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Activity Intolerance

Assessing for activity intolerance is a dynamic process that starts before the onset of activity,
proceeds continuously throughout the activity, and terminates in a post-activity evaluation.
During pre-activity assessment, the nurse establishes baseline “at rest” measurements of blood
pressure, pulse, and respiration. The nurse also assesses incentives for activity and the person’s
perceived capabilities for activity, as well as factors that may decrease tolerance for activity. If a
known pathology exists in a particular organ system, then assessment during activity focuses on
signs and symptoms indicating intolerance in that system (e.g., exertional dyspnea or cyanosis in
pulmonary disease, angina in cardiac disease, increased spasticity or decreased coordination in
neuromuscular disease). During post-activity assessment, the nurse assesses recovery time,
which evaluates physiologic tolerance for activity.

Subjective Data
ASSESS FOR DEFINING CHARACTERISTICS
Weakness Dyspnea
Fatigue Lack of sleep or rest

ASSESS FOR RELATED FACTORS


Lack of incentive
Disinclination to participate in activities
Lack of confidence in ability to perform activity
Fear of injury or aggravating disease as a result of participating in activity
Difficulty performing activities of daily living because of decreased energy or a lack of
strength
Pain that interferes with performance of activities

Objective Data
ASSESS FOR DEFINING CHARACTERISTICS
Assess strength and balance; evaluate person’s ability to:
Reposition self in bed
Maintain body alignment
Assume and maintain sitting position
Rise to standing position
Maintain erect posture
Perform Romberg test
Ambulate
Perform activities of daily living
Assess response to activity:
Take resting vital signs
Have person perform the activity
Take vital signs immediately after the activity
Have person rest for 3 minutes; take vital signs again
Assess for presence of:
Pallor Cyanosis
Confusion Vertigo

ASSESS FOR RELATED FACTORS


Situational
Personal
Coping strategies focusing on avoidance
Inadequate social support
Environmental
Social isolation Climatic extremes
Sensory deprivation Insufficient rest and sleep periods
Sensory overload

Disease-Related
Cardiopulmonary disorders Fluid/electrolyte imbalance
Neurologic disorders Musculoskeletal disorders
Nutritional deficiencies Chronic diseases

Treatment-Related
Bed rest/imposed immobility
Diet
Diagnostic studies
Surgery
Medications
Caregivers’ expectations
Treatment schedule
Assistive equipment that requires strength
Pertinent literature for people with lung disorders