Problems/Needs | |
Examples of Problems/Needs | Nursing Considerations |
The resident has difficulty with walking due to …. e.g. Parkinson’s disease, CVA, arthritis, etc. | Identify and document the resident’s abilities regarding sit to stand, stand to sit and getting in and out of bed. Include the level of assistance the resident required e.g. prompting, supervision, assistance of one person or two people. Where a standing hoist is being used, document the sling size to be used. Identify and document the distance the resident can walk e.g. from bed to en-suite, from bedroom to siting/dining room, etc. Include the level of assistance that is required e.g. prompting, supervision, assistance of one person or two people. Document the resident’s ability to follow instructions or cognitive ability to understand what is being asked of him/her. Document any aids of equipment the resident requires when mobilising such as walking stick, rollator, zimmer frame, and the residents ability to use same. Document any multidisciplinary team member’s recommendations e.g. physiotherapist, and how this affects the resident on a day to day basis. Document any fixed/scheduled walks the resident may require to maintain walking ability. Identify and document the resident’s ability to use the stairs or elevator and the level of assistance required (if applicable). Identify and document the resident’s needs with walking when outdoors /grounds. |
Examples of Problems/Needs | Nursing Considerations |
The resident is unable to weight bear or walk due to …. e.g. CVA, cognitive impairment / dementia. . | Document the residents need to use the full body hoist and include the sling size required. Identify and document any risks to the resident that may exist when using the hoist and how these risks will be addressed such as, risk of injury to feet or lower limbs from knocking off the hoist frame when in use. Document the resident’s ability to follow instructions and understand that he/she is being hoisted. Where the resident is unable to understand, document any other method other than verbal communication that may be used to aid in the residents understanding. Document any psychological support or reassurance the resident may require when being hoisted. Identify and document any individual risks the resident may have that may impact on the hoisting procedure such as, any sensory difficulties the resident resists care, amputation (particularly lower limb(s), the presence of a wound, the presence of drips or catheters, presence of pain. Document how these risks will be addressed. |
Examples of Problems/Needs | Nursing Considerations |
The resident spends long periods of time walking/pacing. | Document the resident’s usual walking patterns including where they tend to walk, for how long and times of the day. Document any methods used to encourage the resident to take rest breaks during the day, such as leaving chairs along the corridor to encourage the resident to sit for a few minutes. Document any distraction techniques used to distract the resident from walking. Document any techniques used to stimulate the resident when walking e.g., items of interest placed on the corridor Document any additional nutritional requirements the resident may have to prevent weight loss due to additional calorie requirements needed as a result of excess walking (This may be added to the nutrition and hydration care plan instead). |
If the resident has no problems or needs with mobility, document the resident’s abilities | |
Document any specific interventions that will be provided to the resident to reduce the likelihood of fractures should a fall occur. Where the resident is wearing hip protectors, document any specific needs the resident may have regarding these e.g. managing clothing when using the toilet. Document interventions that may be required to assist the resident with everyday activities which may be affected as a result of the risk of falling e.g. manual handling needs, toileting. Document any specific foot care and/or footwear the resident may require. Document any individualised exercise programme the physiotherapist may be doing with the resident e.g. Resistance (strength) training, gait, balance, and co-ordination training. Where the resident has a fear of falling document how this fear will be addressed to provide the resident with reassurance and psychological support as well as physical assistance to promote walking and independence. |
If the resident has no risks related to mobility, enter ‘no risks’ in this section. |
References
- Health Service Executive (2008). Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population.
- National Institute for Clinical Excellence (2004). Clinical Practice Guidelines for the Assessment and Prevention of Falls in Older People. http://guidance.nice.org.uk
- Victorian Government Department of Human Service (2004). Minimising the Risk of Falls and Falls Related Injuries. Guideline for acute, sub-acute and residential care settings.
- New South Wales Health Department (2001) Preventing Injuries from Falls in Older People