CUES

Subjective:
I cant move my
body as much
because of the pain
in my left knee as
verbalized by patient.

Objective:
- slow movement
- need supports in
transferring
-experiences
difficulty in doing
certain actions
because of pain
-pain to L knee 8/10

NURSING
DIAGNOSIS
Activity intolerance
related to pain

SCIENTIFIC BASIS
Most activity
intolerance is related
to generalized
weakness and
debilitation
secondary to acute
or chronic illness and
disease. Activity
intolerance may also
be related to factors
such as pain,
obesity,
malnourishment, side
effects of
medications or
emotional states
such as depression
or lack of confidence
to exert ones self.
(Doenges, 2006).

GOAL & OUTCOME

CRITERIA
Within 8 hours of
nursing intervention,
the patient will
maintain activity level
within capabilities.

ACTIONS &
NURSING ORDERS
Independent:

RATIONALE OF
NURSING ORDERS

1. Monitor
vital/cognitive signs,
watching for changes
in blood pressure,
heart and respiratory
rate, and presence of
confusion.

1. Vital signs may be

altered in response to
activity
(Doenges, 2006).

b) Patient will
demonstrate a
decrease in
physiological signs of
intolerance (pulse,
respirations, and
blood pressure within
normal range).

2. Increase
exercise/activity
gradually.

2. To conserve energy
(Doenges, 2006).

3. Promote comfort
measures and
provide for relief of
pain.

3. To enhance ability to
participate in activities.
(Doenges, 2006).

c) Patient will use

identified energy
conservation
techniques to
enhance activity
tolerance.

4. Plan care with rest

periods between
activities.

4. To reduce fatigue
(Doenges, 2006).

a) Patient will
participate willingly in
necessary activities.

5. Assist with
activities as needed.
Collaborative:
1. Provide referral to
other disciplines as
indicates ( eg.
Physical therapists
and occupational
therapists.

EVALUATION
After 8 hours, the goal not
partially met.

5. To protect patient
from injury.
(Doenges, 2006).
1. To develop
individually appropriate
therapeutic regimens
(Doenges, 2006).

- Patient participated willingly

with bathing and dressing with
appropriate vitals changes.
Her vitals were checked before
and after activity and there
were no indications of unstable
vitals.
-Patient utilized energy
conservation techniques by
taking rest periods in between
activities.