Nurse's Pocket Guide

Actions/Interventions
NURSING PRIORITY NO.1.To assess causative/contributing factors:
• Identify condition/diagnoses that contribute to difficulty walking
(e.g., advanced age; acute illness; weakness/chronic illness
[e.g., cardiopulmonary disorders, cancer, kidney disease]; recent
surgery/trauma; osteo/rheumatoid/gouty arthritis; leg/hip/knee
trauma/other disorders [e.g., fractures, tendon or ligament
injury, amputation]; balance problems [e.g., inner ear infection/brain
injury/stroke]; nerve disorders [e.g., MS, Parkinson’s
disease, cerebral palsy]; spinal abnormalities [disease, trauma,
degeneration]; neuropathies [e.g., peripheral, diabetic, alcoholic];
degenerative muscle disorders [e.g., muscular dystrophy,
myositis]; vision impairments; foot conditions [e.g., plantar
warts, bunions, ingrown toenails, pressure ulcers]; cognitive dysfunction).
• Note client’s particular symptoms related to walking (e.g.,
unable to bear weight, can’t walk usual distance, limping, staggering,
stiff leg, leg pain, shuffling, asymmetric or unsteady gait).
• Determine ability to follow directions and note emotional/
behavioral responses that may be affecting the situation.
NURSING PRIORITY NO.2.To assess functional ability:
• Determine degree of impairment in relation to suggested
functional scale (0 to 4), noting that impairment can be either
temporary/permanent or progressive.
• Assist with/review results of mobility testing (e.g., timing of
walking over fixed distance, distance walked over set period of
time [endurance], limb movement analysis, leg strength and
speed of walking, ambulatory activity monitoring) for differential
diagnosis and to guide treatment interventions.
• Note emotional/behavioral responses of client/SO(s) to problems
of mobility.
NURSING PRIORITY NO. 3.To promote safe, optimal level of independence
in walking:
• Assist with treatment of underlying condition causing dysfunction,
as indicated by individual situation.
• Consult with PT/OT/rehabilitation team for individualized
mobility/walking program, and identify/develop appropriate
devices (e.g., shoe insert, leg brace to maintain proper
foot alignment for walking, quad cane, hemiwalker).
• Demonstrate use of/help client become comfortable with
adjunctive devices (e.g., cane, crutches, walking cast/boot,
walker, limb prosthesis, mobility scooter).
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 775
impaired WALKING