Possibly evidenced by
Verbal reports of weakness, fatigue, exhaustion
Exertional dyspnea, tachypnea
Tachycardia in response to activity
Development of, or worsening of, pallor or cyanosis
Desired Outcomes/Evaluation Criteria—Client Will
Report and demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, with vital signs within client’s acceptable range.
Nursing intervention with rationale:
1. Evaluate client’s response to activity. Note reports of dyspnea, increased weakness and fatigue, and changes in vital signs during and after activities.
Rationale: Establishes client’s capabilities and needs and facilitates choice of interventions.
2. Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.
Rationale: Reduces stress and excess stimulation, promoting rest.
3. Explain importance of rest in treatment plan and necessity for balancing activities with rest.
Rationale: Bedrest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual client response to activity and resolution of respiratory insufficiency.
4. Assist client to assume comfortable position for rest and sleep.
Rationale: Client may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on over-bed table with pillow support.
5. Assist with self-care activities as necessary. Provide for progressive increase in activities during recovery phase.
Rationale: Minimizes exhaustion and helps balance oxygen supply and demand.