Introduction To Nursing Diagnosis: Ambulation Deterioration
Nursing Diagnosis is a domain of health care internationally accepted, that provides nurses and other healthcare professionals with a means for assessing a patient’s progress over the course of their nursing care. Ambulation deterioration is a common symptom in older adults, as well as those suffering from certain chronic illnesses or disabilities. It is important to identify this problem at an early stage to prevent further physical deterioration. By assessing a patient’s mobility, you can determine if they are at risk of further deterioration and design an appropriate treatment plan.
Nursing Diagnosis Definition
Ambulation deterioration is defined as an alteration in a patient's ability to ambulate unaided, which may be due to physical or cognitive deficits. It can refer to decreases in strength, balance, endurance, or range of motion, leading to difficulties with independent mobility. It can also refer to an increase in fatigue, difficulty navigating unfamiliar terrain, or an inability to recall directions.
Defining Characteristics
Subjectives
- Can no longer safely navigate stairs, uneven terrain, or in congested areas
- Complains of feelings of dizziness or lightheadedness upon standing
- Difficulty shifting weight while standing or walking
- Feelings of fatigue after minimal activity
- Reports increased falls or near-falls
- Reports difficulty initiating movement
Objectives
- Diminished range of motion or gait pattern
- Inability to safely execute volitional movement
- Increased use of assistive devices when ambulating
- Inability to maintain upright posture when ambulating or transitioning
- Muscle weakness detected upon assessment
- Reduced speed, distance, or intensity of ambulation compared to baseline
- Adverse effects of medications
- Cognitive impairment
- Lack of opportunities for practice
- Multisystem alterations affecting neural pathways
- Musculoskeletal impairment
- Pain syndromes
- Physical impairments and/or deficits
- Psychosocial factors such as depression
- Recent injury or trauma
Risk Population
Patients at risk for ambulation deterioration include older adults, as well as those suffering from certain chronic illnesses or disabilities, such as stroke, Parkinson’s Disease, Alzheimer’s Disease, Multiple Sclerosis, and muscular dystrophy, as well as orthopedic injuries.
Associated Problems
Difficulties with ambulatory abilities can lead to decreased independence and autonomy; increased risk of falls and injuries; increased risk of pressure ulcers; increased risk of depression; and decreased quality of life.
Suggestions for Use
The nurse must first assess the severity and complexity of the patient’s ambulation needs. Appropriate interventions should then be determined and implemented, specifically tailored to the individual’s needs. Interventions should take into consideration environmental, physical, and psychological components. The nurse should assess the patient’s ambulation needs on a regular basis and make necessary adjustments to the nursing plan of care.
Suggested Alternative Nursing Diagnosis
Alternative NANDA diagnoses associated with ambulation deterioration include Imbalanced Nutrition: Less Than Body Requirements; Impaired Physical Mobility; Activity Intolerance; Readiness for Enhanced Mobility; Deficient Knowledge; Ineffective Self-Health Management; Anxiety; and Risk for Falls.
Usage Tips
When assessing a patient’s ambulation abilities, it is important to consider their living situation, health history, and current physical and emotional state. The nurse should also ask questions to assess their challenges, interests, and goals related to mobility.
NOC Results
- Mobility
- Tissue Integrity
- Activity Tolerance
- Self-Care
- Injury Prevention
Mobility
This outcome measure includes the ability to move from one point to another, with or without the use of assistive devices. The nurse should monitor patient progress in terms of ambulation, functional mobility, internal range of motion, and transfers.
Tissue Integrity
This outcome measure focuses on the patient’s skin, tissue, and wound healing. It involves evaluating the patient’s skin for integrity and signs of injury, as well as assessing the patient’s risk for falls and other types of injuries.
Activity Tolerance
This outcome measure involves assessing the patient’s ability to perform activities of daily living, including self-care and ambulation. The nurse will assess endurance, strength, coordination, balance, and other physical abilities.
Self-Care
This outcome measure involves assessing the patient’s ability to independently perform activities of daily living (ADLs), such as bathing, dressing, grooming, and toileting.
Injury Prevention
This outcome measure involves assessing the patient’s ability to safely move about their environment and minimize the risk of injury. This includes considering the use of appropriate safety equipment, such as grab bars and handrails.
NIC Interventions
- Home Assessment
- Patient & Family Education
- Mobility Assistance
- Remain Alert for Changes Demonstrated in the Patient
- Environmental Management
- Fall Prevention
- Rehabilitation Teaching
Home Assessment
This intervention involves assessing the home environment to ensure that it is safe for the patient. Home assessment focuses on mobility aids and assistive devices such as wheelchairs, walkers, and canes.
Patient and Family Education
This intervention involves teaching the patient and family members about ambulation and mobility aids. The nurse should provide education on fall prevention, proper use of assistive devices, proper body mechanics, and how to safely navigate stairs and other obstacles.
Mobility Assistance
This intervention involves providing the patient with assistance in ambulating by using assistive devices, positioning, or physical support. This includes assisting with transfers, wheelchair maneuvering, and walking and maneuvering obstacles.
Remain Alert for Changes Demonstrated in the Patient
This intervention involves providing emotional and physical support to the patient and their family members, as well as monitoring for changes in ambulation and function.
Environmental Management
This intervention involves modifying the environment to reduce fall hazards and facilitate mobility. This includes ensuring surfaces are level and free of clutter, proper lighting, and appropriate signage.
Fall Prevention
This intervention involves assessing the patient’s risk for falls and taking measures to minimize the risk, such as installing grab bars and handrails, utilizing hip protectors, and providing specialized footwear.
Rehabilitation Teaching
This intervention involves teaching the patient about proper body mechanics, nutritional needs, and exercises for strengthening and flexibility.
Conclusion
Identifying and managing ambulation deterioration is essential for promoting long-term wellness and independence. Although it can be challenging, it is possible to develop an effective plan of care using Nursing Diagnosis and NIC Interventions. With the right assessment and intervention, patients can be successful in reaching their mobility goals.
FAQ:
- What is Nursing Diagnosis? - Nursing Diagnosis is a domain of health care internationally accepted, that provides nurses and other healthcare professionals with a means for assessing a patient’s progress over the course of their nursing care.
- Who is at risk for ambulation deterioration? - Patients at risk for ambulation deterioration include older adults, as well as those suffering from certain chronic illnesses or disabilities, such as stroke, Parkinson’s Disease, Alzheimer’s Disease, Multiple Sclerosis, and muscular dystrophy, as well as orthopedic injuries.
- How can I assess a patient’s ambulation needs? - When assessing a patient’s ambulation abilities, it is important to consider their living situation, health history, and current physical and emotional state. The nurse should also ask questions to assess their challenges, interests, and goals related to mobility.
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