Nurse's Pocket Guide

ACTIVITY INTOLERANCE
• Identify activity needs versus desires (e.g., is barely able to
walk upstairs but would like to play racquetball).
• Assess emotional/psychological factors affecting the current
situation (e.g., stress and/or depression may be increasing
the effects of an illness, or depression might be the result of
being forced into inactivity).
• Note treatment-related factors, such as side effects/interactions
of medications.
NURSING PRIORITY NO.2.To assist client to deal with contributing
factors and manage activities within individual limits:
• Monitor vital/cognitive signs, watching for changes in blood
pressure, heart and respiratory rate; note skin pallor and/or
cyanosis and presence of confusion.
• Adjust activities to prevent overexertion. Reduce intensity
level or discontinue activities that cause undesired physiological
changes.
• Provide/monitor response to supplemental oxygen and medications
and changes in treatment regimen.
• Increase exercise/activity levels gradually; teach methods to conserve
energy, such as stopping to rest for 3 minutes during a
10-minute walk or sitting down to brush hair instead of standing.
• Plan care to carefully balance rest periods with activities to
reduce fatigue.
• Provide positive atmosphere, while acknowledging difficulty
of the situation for the client. Helps to minimize frustration
and rechannel energy.
• Encourage expression of feelings contributing to/resulting
from condition.
• Involve client/SO(s) in planning of activities as much as
possible.
• Assist with activities and provide/monitor client’s use of assistive
devices (e.g., crutches, walker, wheelchair, or oxygen tank)
to protect client from injury.
• Promote comfort measures and provide for relief of pain to
enhance ability to participate in activities. (Refer to NDs
acute Pain; chronic Pain.)
• Provide referral to other disciplines, such as exercise physiologist,
psychological counseling/therapy, occupational/
physical therapists, and recreation/leisure specialists, as
indicated, to develop individually appropriate therapeutic
regimens.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/
Discharge Considerations):
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
72 Cultural Collaborative Community/Home Care