Nurse's Pocket Guide

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
Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify negative factors affecting activity tolerance and
eliminate or reduce their effects when possible.
• Use identified techniques to enhance activity tolerance.
• Participate willingly 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 normal range).
Actions/Interventions
NURSING PRIORITY NO.1.To identify causative/precipitating factors:
• Note presence of factors contributing to fatigue (e.g., age,
frail, acute or chronic illness, heart failure, hypothyroidism,
cancer, and cancer therapies). Fatigue affects both the client’s
actual and perceived ability to participate in activities.
(Refer to ND Fatigue.)
• Evaluate client’s actual and perceived limitations/degree of
deficit in light of usual status. Provides comparative baseline
and provides information about needed education/
interventions regarding quality of life.
• Note client reports of weakness, fatigue, pain, difficulty
accomplishing tasks, and/or insomnia. Symptoms may be
result of/or contribute to intolerance of activity.
• Assess cardiopulmonary response to physical activity, including
vital signs before, during, and after activity. Note progression/accelerating
degree of fatigue.
• Ascertain ability to stand and move about and degree of assistance
necessary/use of equipment to determine current status
and needs associated with participation in needed/
desired activities.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 71
ACTIVITY INTOLERANCE