Activity Intolerance

 

Instructions: Fill out this form, print it, and hand it in with your assessment to your instructor. When you click on Next at the bottom of the page, you see the data you submitted. Please follow the instructions on how to save the data on the next page.

AOL users: Read this instruction.

Definition: a state in which an individual has insufficient physiological or psychological energy to endure or complete required or desired daily activities.

1. Your initials (required): 

2. Defining Characteristics- check those that apply to your client:

None- high risk diagnosis  dyspnea,  fatigue,  weakness,  exertional discomfort, 
abnormal heart rate,  blood pressure or EKG changes in response to activity 

3. Related Factors- check those that apply to your client:

bedrest,  immobility,  pain,  surgery,  chemotherapy,  radiation therapy,  sleep disturbances,  environmental barriers such as stairs, generalized weakness,  imbalance between oxygen supply and demand,  sedentary lifestyle 
 


4. Goal (ultimate, long term) 

5. Outcome Criteria (short term) 

6. Evaluation: Was the outcome criteria met? 

Yes- Give Evidence: 

No- Explain how you would change the plan: 

7A. Interventions 

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7B. Rationale for each intervention

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