A patient has been admitted for exacerbation of a chronic pulmonary disease. The nurse would assign the nursing diagnosis Activity Intolerance when which assessment is made?
1. The patient's heart rate increases by 20 beats per minute when she ambulates to the bathroom in her hospital room.
2. The patient's husband reports that she sits in a recliner chair most of the day.
3. The patient complains of cramping in her legs at night.
4. The patient's ankles demonstrate 3+ edema bilaterally.
1
Rationale 1: Increasing heart rate on exertion is a finding associated with intolerance of activity.
Rationale 2: This is not enough evidence to support activity intolerance as a nursing diagnosis. The patient may be depressed or simply desire to stay in the chair.
Rationale 3: Night leg cramps may or may not be associated with activity intolerance.
Rationale 4: Ankle edema may or may not be associated with activity intolerance.
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