DECREASED ACTIVITY TOLERANCE

Risk for Decreased Activity Tolerance

Insufficient endurance to complete required or desired daily activities

NANDA-I approved*

Generalized weakness*

Expresses fatigue*

Exertional discomfort*

Verbal reports of vertigo

Confusion

An Altered Physiologic Response to Activity as:

Respiratory

Exertional dyspnea*

Exertional discomfort*

Excessively increased respiratory rate

Shortness of breath

Decreased rate

Pulse/Heart Rate

Weak/rhythm change

Abnormal heart rate response to activity*

Failure to return to preactivity level after 3 minutes

Electrocardiogram change*

Blood Pressure

Abnormal blood pressure response to activity*

Failure to increase with activity

Increased diastolic pressure greater than 15 mm Hg

NANDA-I approved*

Any factors that compromise oxygen transport, physical conditioning, or create excessive energy demands that outstrip the individual's physical and psychological abilities can cause activity intolerance. Some common factors follow.

Pathophysiologic

Related to physical deconditioning*

Related to pain

Related to imbalance between oxygen supply/demand*

Related to impaired physical mobility*

Related to compromised oxygen transport system secondary to:

Cardiac condition (specify)

Respiratory condition (specify)

Circulatory insufficiency (specify)

Hypovolemia

Related to increased metabolic demands secondary to:

Acute or chronic infections

Autoimmune or metabolic disorders (specify)

Chronic disease (specify)

Related to inadequate energy sources secondary to inadequate diet

Treatment Related

Related to inactivity secondary to assistive equipment (walkers, crutches, braces)

Related to compromised oxygen transport secondary to immobility*

Situational (Personal, Environmental)

Related to inactivity secondary to:

Depression

Inadequate social support

Sedentary Lifestyle *

Related to increased metabolic demands secondary to:

Inexperience with an activity*

Environmental barriers (e.g., stairs)

Climate extremes (especially hot, humid climates)

Air pollution (e.g., smog)

Atmospheric pressure (e.g., recent relocation to high-altitude living)

Maturational

Older adults may have decreased muscle strength and flexibility, as well as sensory deficits. They are at high risk for falls. These factors can undermine body confidence and may contribute directly or indirectly to activity intolerance.

Individuals with history of decreased activity tolerance

Older adults

Neoplasms

Neurodegenerative diseases

Respiration disorders

Traumatic brain injuries

Vitamin D deficiency

AUTHOR'S NOTE

Decreased Activity Intolerance is a diagnostic judgment that describes an individual with compromised physical conditioning. This individual can engage in therapies to increase strength and endurance. Decreased Activity Intolerance is different than Fatigue; Fatigue is a pervasive, subjective draining feeling. Rest does treat Fatigue, but it can also cause tiredness. Moreover, in Decreased Activity Intolerance, the goal is to increase tolerance and endurance to activity; in Fatigue, the goal is to assist the individual to adapt to the fatigue, not to increase endurance.

The individual will progress activity to (specify level of activity desired), evidenced by these indicators:

• Identifies factors that aggravate activity intolerance.
• Identifies methods to reduce activity intolerance.
• Maintains blood pressure within normal limits 3 minutes after activity.

Level 2 Interventions (postacute, rehabilitation, specialty, community)

Explain the risks of inactivity.

R:Exercise is prescribed to increase oxygen consumption by muscle tissues to increase the cardiovascular, respiratory, hematological, the musculoskeletal, and neurological systems to support increasing levels of physiologic work demands (Norris, 2019).

Elicit from individual their goals for activity.

Monitor Response to Activity and Record Response

• Take resting pulse, blood pressure, and respirations.
• Consider rate, rhythm, and quality (if signs are abnormal—e.g., pulse above 100—consult with physician/nurse practitioner/physician assistant about the responses to increasing activity).
• If vital signs are within normal range, have the person perform the activity.
• Take vital signs immediately after activity.
• Instruct to rest for 3 minutes; take vital signs again.
• Discontinue the activity if there is:
  • Complaints of chest pain, vertigo, or confusion
  • Decreased pulse rate
  • Failure of systolic blood pressure to increase
  • Decreased systolic blood pressure
  • Increased diastolic blood pressure by 15 mm Hg
  • Decreased respiratory response

R:Clinical responses that require discontinuation or reduction in the activity level are evidence of compromised cardiac or respiratory ability (Norris, 2019).

• Reduce the intensity or duration of the activity if:
  • The pulse takes longer than 3-4 minutes to return to within 6 beats of the resting pulse.
  • The respiratory rate increase is excessive after the activity.

R:The cardiopulmonary responses to activity involve the circulatory functions of the heart and blood vessels and the gas exchanges in the respiratory system (Norris, 2019). Response to activity can be evaluated by comparing preactivity blood pressure, pulse, and respiration with postactivity results. These, in turn, are compared with recovery time.

Increase the Activity Gradually

• Increase tolerance for activity by having the individual perform the activity more slowly, for a shorter time, with more rest pauses, or with more assistance.
• Minimize the deconditioning effects of prolonged bed rest and imposed immobility:
  • Begin active range of motion (ROM) at least twice a day. For those who are unable, the nurse should perform passive ROM.
  • Encourage isometric exercise.
  • Encourage the individual to turn and lift self actively unless contraindicated.
  • Gradually increase tolerance by starting with 15 minutes the first time out of bed.
  • Choose a safe gait. (If the gait appears awkward but stable, continue; stay close by and give clear coaching messages, e.g., "Look straight ahead, not down.")
  • Allow the individual to gauge the rate of ambulation.
  • Provide sufficient support to ensure safety and prevent falling.
  • Encourage to wear comfortable walking shoes (slippers do not support the feet properly).

R:Activity tolerance develops cyclically through adjusting frequency, duration, and intensity of activity until the desired level is achieved. Increasing activity frequency precedes increasing duration and intensity (work demand). Increased intensity is offset by reduced duration and frequency. As tolerance for more intensive activity of short duration develops, frequency is once again increased (Norris, 2019).

Plan Rest Periods According to the Person's Daily Schedule

R:They should occur throughout the day and between activities to allow time for recovery.

Promote a Sincere "Can Do" Attitude

• Allow the individual to set the activity schedule and functional activity goals. If the goal is too low, negotiate (e.g., "Walking 25 feet seems low. Let's increase it to 50 feet. I'll walk with you.").
• Plan a purpose for the activity, such as sitting up in a chair to eat lunch, walking to a window to see the view, or walking to the kitchen to get some juice.
• Praise the individual for progress, no matter how small.

R:Do not underestimate the value of praise and encouragement as effective motivational techniques.

Interventions for Individuals with Chronic Pulmonary Insufficiency (COPD Foundation, 2021; Troosters, van der Molen, Polkey et al., 2013)

R:Muscle deconditioning, associated with reduced physical activity, contributes to further inactivity and as a result patients get trapped in a vicious cycle of declining physical activity levels and increasing symptoms with exercise (Troosters, van der Molen, Polkey et al., 2013).

• Encourage conscious controlled-breathing techniques during increased activity and times of emotional and physical stress (techniques include pursed-lip and diaphragmatic breathing).
• Teach pursed-lip breathing. The person should breathe in through the nose, then breathe out slowly through partially closed lips while counting to 7 and making a "pu" sound. (Often, people with progressive lung disease learn this naturally.)

R:Pursed-lip breathing slows breathing down, thus keeping airways open longer so trapped air can be exhaled. This improves the exchange of oxygen and carbon dioxide (COPD Foundation, 2021).

• Teach diaphragmatic breathing: (COPD Foundation, 2021).
  • Place your hands on their abdomen below the base of the ribs and keep your hands there while he or she inhales.
  • To inhale, the person relaxes the shoulders, breathes in through the nose, and pushes the stomach outward against your hands. Then holds the breath for 1-2 seconds to keep the alveoli open, then exhales.
  • To exhale, the person breathes out slowly through the mouth while you apply slight pressure at the base of the ribs.
  • Have the person practice this breathing technique several times with you; then, the person should place his or her own hands at the base of the ribs to practice alone.
  • Once the technique has been learned, have them practice it a few times each hour.
  • Encourage the person to use adaptive breathing techniques to decrease the work of breathing.

R:The diaphragm is the main muscle of breathing. In an individual with COPD, when the diaphragm weakens, the muscles in the neck, shoulders, and back are used instead (COPD Foundation, 2021).

• "Explain that the tripod position, in which the individual sits or stands leaning forward with the arms supported, forces the diaphragm down and forward, and stabilizes the chest while reducing the work of breathing. Point out that this reduces competing demands of the arm, chest, and neck muscles needed for breathing." (Bauldoff, 2015; *Bauldoff et al., 2006; *Breslin, 1992).
• Providing arm support (e.g., resting elbows on a tabletop while shaving or eating) may enhance independence and improve functional capacity.

R:Research has shown that arm support during performance of arm tasks reduces diaphragmatic recruitment, increases respiratory endurance (*Bauldoff et al., 2006; Bauldoff, 2015), and increases arm exercise endurance.

• While in the hospital, discuss the effects of smoking, with a focus on the specific health problems of the individual, e.g., frequent infections, leg cramps, worsening of COPD, and cardiac problems.

R:A Cochrane review of over 50 clinical trials has found that high-intensity behavioral interventions that begin during a hospital stay and include at least 1 month of supportive contact after discharge promote smoking cessation among hospitalized individuals (Rigotti et al., 2012).