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NCP Activity Intolerance — Heart Failure (CHF)

NURSING DIAGNOSIS: Activity intolerance

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May be related to

  • Imbalance between oxygen supply/demand
  • Generalized weakness
  • Prolonged bedrest/immobility

Possibly evidenced by

  • Weakness, fatigue
  • Changes in vital signs, presence of dysrhythmias
  • Dyspnea
  • Pallor, diaphoresis

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Endurance (NOC)

  • Participate in desired activities; meet own self-care needs.
  • Achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity.

Nursing Interventions & Rationale

Nursing Interventions Rationale
 Check vital signs before and immediately after activity, especially if patient is receiving vasodilators, diuretics, or beta-blockers.  Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.
 Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor.  Compromised myocardium/inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue.
 Assess for other precipitators/causes of fatigue, e.g., treatments, pain, medications.  Fatigue is a side effect of some medications (e.g., beta-blockers, tranquilizers, and sedatives). Pain and stressful regimens also extract energy and produce fatigue.
 Evaluate accelerating activity intolerance.  May denote increasing cardiac decompensation rather than overactivity.
 Provide assistance with self-care activities as indicated. Intersperse activity periods with rest periods.  Meets patient’s personal care needs without undue myocardial stress/excessive oxygen demand.
 Implement graded cardiac rehabilitation/activity program.  Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption.
 Source:
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