ASSESSMENT

NURSING
DIAGNOSIS

Subjective:
Objective:
Walked with a
limp
Limited toe
and heel
walking
BP: 142/84
Pulse: 105
Malaise
weakness

Activity
intolerance
related to
generalized
weakness

NURSING INTERVENTION

Independent:
1. Determine cause of activity
intolerance and determine
whether cause is physical,
psychological, or motivational.
2. Assess client daily for
appropriateness of activity and
bed rest orders.
3. Monitor and record client's
ability to tolerate activity.
4. Gradually increase activity,
allowing client to assist with
positioning, transferring, and
self-care as possible. Progress
from sitting in bed to dangling, to
chair sitting, to standing, to
ambulation.
5. When getting clients up,
observe for symptoms of
intolerance such as nausea,
pallor, dizziness, visual
dimming, and impaired
consciousness, as well as
changes in vital signs.
6. Encourage range-of-motion
exercises if client is unable to
tolerate activity.
7. Allow for periods of rest before
and after planned exertion
periods.
8. Observe and document skin
integrity several times a day.
Activity intolerance may lead to
pressure ulcers.
9. Observe for pain before activity.
If possible, treat pain before
activity, and ensure that client is
not heavily sedated.
Dependent:
1. Obtain any necessary assistive

devices or equipment needed

before ambulating client (e.g.,
walkers, canes, crutches,
portable oxygen).
Collaborative:
1. Collaborate with a physical
therapist to help increase
activity levels and strength.