Nursing Diagnosis: Activity Intolerance related to imbalance between oxygen supply and 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—Client Will
Endurance
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 intervention with rationale:
1. Check vital signs before and immediately after activity during acute episode or exacerbation of HF, especially if client is receiving vasodilators, diuretics, or beta blockers.
Rationale: Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.
2. Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, and pallor.
Rationale: Compromised myocardium and inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating
weakness and fatigue.
3. Assess level of fatigue, and evaluate for other precipitators and causes of fatigue, for example, HF treatments, pain, cachexia, anemia, and depression.
Rationale: Fatigue because of advanced HF can be profound and is related to hemodynamic, respiratory, and peripheral muscle abnormalities. Fatigue is also a side effect of some medications (e.g., beta blockers). Other key causes of fatigue should be evaluated and treated as appropriate and desired.
4. Evaluate accelerating activity intolerance.
Rationale: May denote increasing cardiac decompensation rather than overactivity.
5. Provide assistance with self-care activities, as indicated. Intersperse activity with rest periods.
Rationale: Meets client’s personal care needs without undue myocardial stress or excessive oxygen demand.
6. Implement graded cardiac rehabilitation and activity program.
Rationale: Strengthens and improves cardiac function under stress if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen
consumption.
Other possible Nursing Diagnosis for Heart Failure:
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