Weakness is a common nursing diagnosis characterized by decreased muscle strength, reduced physical capacity, and difficulty performing daily activities. This nursing diagnosis focuses on identifying underlying causes, managing symptoms, and helping patients regain their strength and independence.
Causes (Related to)
Weakness can affect patients for various reasons, with several factors contributing to its development and progression:
- Medical conditions such as:
- Neurological disorders
- Muscular diseases
- Multiple sclerosis
- Guillain-Barré syndrome
- Myasthenia gravis
- Systemic factors including:
- Prolonged bed rest
- Malnutrition
- Chronic fatigue syndrome
- Post-operative recovery
- Cancer and cancer treatments
- Psychological factors such as:
- Depression
- Anxiety
- Stress
- Sleep disorders
- Environmental factors including:
- Limited mobility
- Lack of exercise
- Poor conditioning
- Environmental barriers
Signs and Symptoms (As evidenced by)
For proper diagnosis and treatment, weakness presents with distinctive signs and symptoms that nurses must recognize.
Subjective: (Patient reports)
- The feeling of decreased strength
- Difficulty performing daily activities
- Increased effort required for movement
- Fatigue with minimal exertion
- Decreased endurance
- Poor grip strength
- Difficulty maintaining posture
Objective: (Nurse assesses)
- Decreased muscle strength on assessment
- Reduced range of motion
- Impaired mobility
- Decreased activity tolerance
- Poor posture
- Muscle atrophy
- Decreased coordination
- Abnormal gait pattern
Expected Outcomes
The following outcomes indicate successful management of weakness:
- The patient will demonstrate improved muscle strength
- The patient will perform ADLs with minimal assistance
- The patient will maintain proper posture
- The patient will show increased endurance
- The patient will participate in a prescribed exercise program
- The patient will utilize assistive devices appropriately
- The patient will maintain safety during activities
- The patient will report decreased fatigue
Nursing Assessment
Evaluate Muscle Strength
- Perform manual muscle testing
- Assess grip strength
- Evaluate the range of motion
- Document strength changes
- Note bilateral differences
Monitor Functional Status
- Assess ability to perform ADLs
- Evaluate transfer capabilities
- Check ambulation status
- Document activity tolerance
- Assess the need for assistive devices
Review Contributing Factors
- Evaluate nutritional status
- Check medication effects
- Assess sleep patterns
- Review medical history
- Document activity level
Assess Safety Risks
- Evaluate fall risk
- Check home environment
- Assess cognitive status
- Document safety awareness
- Review support system
Monitor Progress
- Track strength improvements
- Document endurance changes
- Assess participation level
- Note functional gains
- Record exercise compliance
Nursing Care Plans
Nursing Care Plan 1: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to muscle weakness as evidenced by decreased muscle strength and difficulty performing ADLs.
Related Factors:
- Decreased muscle strength
- Reduced endurance
- Neurological impairment
- Prolonged immobility
Nursing Interventions and Rationales:
- Assess current mobility status
Rationale: Establishes baseline for care planning - Implement a progressive mobility program
Rationale: Gradually improves strength and endurance - Teach proper body mechanics
Rationale: Prevents injury and promotes safe movement
Desired Outcomes:
- The patient will demonstrate improved mobility
- The patient will maintain safety during movement
- The patient will show increased independence in ADLs
Nursing Care Plan 2: Risk for Falls
Nursing Diagnosis Statement:
Risk for Falls related to muscle weakness and impaired balance as evidenced by unsteady gait and decreased muscle strength.
Related Factors:
- Muscle weakness
- Impaired balance
- Environmental hazards
- Medication effects
Nursing Interventions and Rationales:
- Implement fall precautions
Rationale: Prevents injury from falls - Provide appropriate assistive devices
Rationale: Supports safe mobility - Modify the environment for safety
Rationale: Reduces fall risks
Desired Outcomes:
- The patient will remain free from falls
- The patient will demonstrate proper use of assistive devices
- Patient will identify and avoid fall hazards
Nursing Care Plan 3: Self-Care Deficit
Nursing Diagnosis Statement:
Self-Care Deficit related to muscle weakness as evidenced by inability to complete ADLs independently.
Related Factors:
- Decreased strength
- Fatigue
- Limited mobility
- Reduced coordination
Nursing Interventions and Rationales:
- Assist with ADLs as needed
Rationale: Maintains dignity while ensuring needs are met - Teach energy conservation techniques
Rationale: Maximizes independence in self-care - Provide adaptive equipment
Rationale: Facilitates independent self-care
Desired Outcomes:
- The patient will demonstrate increased independence in ADLs
- The patient will use adaptive equipment effectively
- The patient will maintain personal hygiene
Nursing Care Plan 4: Activity Intolerance
Nursing Diagnosis Statement:
Activity Intolerance related to muscle weakness as evidenced by fatigue with minimal exertion.
Related Factors:
- Muscle weakness
- Deconditioning
- Poor endurance
- Systemic illness
Nursing Interventions and Rationales:
- Establish activity schedule
Rationale: Balances activity and rest - Monitor vital signs during activity
Rationale: Ensures safe activity progression - Implement a graduated exercise program
Rationale: Builds endurance safely
Desired Outcomes:
- The patient will demonstrate improved activity tolerance.
- The patient will participate in prescribed exercises
- The patient will report decreased fatigue
Nursing Care Plan 5: Risk for Disuse Syndrome
Nursing Diagnosis Statement:
Risk for Disuse Syndrome related to muscle weakness and decreased mobility as evidenced by muscle atrophy and reduced joint mobility.
Related Factors:
- Prolonged immobility
- Muscle weakness
- Limited range of motion
- Decreased activity
Nursing Interventions and Rationales:
- Perform range of motion exercises
Rationale: Maintains joint mobility - Implement positioning schedule
Rationale: Prevents complications of immobility - Encourage active participation in care
Rationale: Promotes muscle strength and function
Desired Outcomes:
- The patient will maintain joint mobility
- The patient will show improved muscle strength
- The patient will avoid complications of immobility
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Almoallim H, Albar H, Mehdawi F. Diagnostic Approach to Proximal Myopathy. 2021 Jan 6. In: Almoallim H, Cheikh M, editors. Skills in Rheumatology [Internet]. Singapore: Springer; 2021. Chapter 9. Available from: https://www.ncbi.nlm.nih.gov/books/NBK585737/ doi: 10.1007/978-981-15-8323-0_9
- Beckwée, D., Delaere, A., Aelbrecht, S., Baert, V., Beaudart, C., Bruyere, O., De Saint-Hubert, M., & Bautmans, I. (2019). Exercise Interventions for the Prevention and Treatment of Sarcopenia. A Systematic Umbrella Review. The Journal of Nutrition, Health and Aging, 23(6), 494-502. https://doi.org/10.1007/s12603-019-1196-8
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Xu Q, Tan J, Wang Y, Tang M. Theory-based and evidence-based nursing interventions for the prevention of ICU-acquired weakness in the intensive care unit: A systematic review. PLoS One. 2024 Sep 13;19(9):e0308291. doi: 10.1371/journal.pone.0308291. PMID: 39269947; PMCID: PMC11398680.
