W
Risk for self-directed Violence
Kathleen L. Patusky, MA, PhD, RN, CNC
NANDA-I
At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally and/or sexually harmful to self
Risk Factors
Ages 15 to 19; age 45 or older; behavioral cues (e.g., writing forlorn love notes, directing angry messages at a significant other who has rejected the person, giving away personal items, taking out a large life insurance policy); conflictual interpersonal relationships; emotional problems (e.g., hopelessness, despair, increased anxiety, panic, anger, hostility); employment problems (e.g., unemployed, recent job loss/failure); engagement in autoerotic sexual acts; family background (e.g., chaotic or conflictual, history of suicide); history of multiple suicide attempts; lack of personal resources (e.g., poor achievement, poor insight, affect unavailable and poorly controlled); lack of social resources (e.g., poor rapport, socially isolated, unresponsive family); marital status (single, widowed, divorced); mental health problems (e.g., severe depression, psychosis, severe personality disorder, alcoholism or drug abuse); occupation (executive, administrator/owner of business, professional, semiskilled worker); physical health problems (e.g., hypochondriasis, chronic or terminal illness); sexual orientation (bisexual [active], homosexual [inactive]); suicidal ideation; suicidal plan; verbal cues (e.g., talking about death, “better off without me,” asking questions about lethal dosages of drugs)
NOC,NIC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References
Refer to care plans for Risk for Suicide, Self-Mutilation, and Risk for Self-Mutilation.
Impaired Walking
NANDA-I
Defining Characteristics
Impaired ability to: climb stairs, walk on uneven surface, walk required distances, walk on even surfaces, walk on an incline or decline, navigate curbs
Related Factors (r/t)
Cognitive impairment; deconditioning; depressed mood; environmental constraints (e.g., stairs, inclines, uneven surfaces, unsafe obstacles, distances, lack of assistive devices or person, restraints); fear of falling; impaired balance; impaired vision; insufficient muscle strength; lack of knowledge; limited endurance; musculoskeletal impairment (e.g., contractures); neuromuscular impairment; obesity; pain
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Progressively mobilize clients (gradual elevation of head of bed [HOB], sitting in reclined chair, standing, etc.). Helps clients adapt to and tolerate upright position changes/postures.
• Assist clients to apply orthosis, immobilizers, splints, and braces before walking. Maintain joint stability, immobilization, support, and/or alignment during motion. For example, an ankle-foot orthosis is used to correct insufficient ankle dorsiflexion in stroke clients with the goal of preserving strength and reducing risk of fall (Esquenazi et al, 2009).
• Eat frequent small, low-carbohydrate meals. Low-carbohydrate meals help prevent postprandial hypotension.
• Maintain partial head elevation when resting in bed for orthostatic hypotension. HOB elevation stimulates baroreceptors and decreases nocturnal diuresis (Weimer & Zadeh, 2009).
Compare morning lying/sitting/standing blood pressures. If systolic pressure falls 20 mm Hg or diastolic pressure falls 10 mm Hg from lying to standing within 3 minutes, and/or if lightheadedness, dizziness, syncope, or unexplained falls occur, consult a physician (Weimer & Zadeh, 2009). Assessment for orthostatic hypotension is needed as part of determining the causes of falls (Cameron et al, 2010).
• Apply thromboembolic deterrent (TED) stockings and/or elastic leg wraps and abdominal binders; raise HOB slowly in small increments to sitting, have client move feet/legs up and down, then stand slowly; avoid prolonged standing. Movement enhances circulatory redistribution so blood does not pool in legs/feet, resulting in hypotension.
Give prescribed hydration and medications to treat orthostatic hypotension; also consider leg wraps and abdominal binders; client should perform warm-up bed exercises as well as a medication review for possible contributing factors such as blood pressure medicine (Pierson & Fairchild, 2008). Cerebral hypoperfusion is a common cause of orthostatic intolerance and hypotension (Weimer & Zadeh, 2009). Severe spinal cord injury at cervical or high-thoracic levels is a risk factor for orthostatic hypotension (Furlan & Fehlings, 2009).
• Screen for deep vein thrombosis (DVT), vigilantly apply compression stockings (TEDs), and give medications as prescribed to persons at risk for/with DVT. Refer to care plan for Ineffective peripheral Tissue Perfusion.
Apply compression stockings and assist persons with DVT to walk as ordered. Such stockings stimulate fibrinolysis with acute DVT and should be used long term to help prevent post-thrombotic syndrome (Crowther, 2008).
Recognize that ambulating as ordered after diagnosis of DVT as opposed to initial bed rest is recommended when feasible and helps prevent further thromboses (Coss, Geske, & Mueller, 2009; Kearon et al, 2008).
• Reinforce correct use of prescribed mobility devices and remind clients of weight-bearing restrictions. Canes are prescribed to improve gait, balance and alleviate joint pain and are usually used on the contralateral side of the affected limb (Aragaki, 2009, Hoeman, Liszner, & Alverzo, 2008).
• Teach clients with leg amputations to correctly don stump socks, liner, immediate postoperative prostheses (IPOP), or traditional prosthesis before standing/walking. IPOPs often reduce pain, healing time, and knee flexion contractures and promote early ambulation (Olson, 2008). A thin nylon sheath prevents the limb from turning in the socket of the prosthesis. A stump sock establishes proper fit between limb and socket. The liner helps prevent pressure ulcers.
• Teach client with an amputation the importance of avoiding prolonged hip and knee flexion. If contractures occur, the client may experience difficulty with fit of prosthesis and have difficulty using a prosthesis. Limit amount of time the client is permitted to sit to no more than 40 minutes of each hour. Ensure that when client sits, stands, or is recumbent, the hip and knee are in extension and periodic prone lying is recommended (Pierson & Fairchild, 2008).
• Emphasize the importance of wearing properly fitting, low-heeled shoes with nonskid soles, and socks/hose, and of seeking medical care for foot pain or problems with abnormal toenails, corns, calluses, or diabetes. Suggest trying a running shoe that is comfortable and lightweight, as a recent study found participants unable to see the type of shoe (control shoe, running shoe, or orthopedic shoe) chose the running shoe based on comfort and weight (Riskowski, Dufour, & Hannan, 2011).
Use a snug gait belt with handles and assistive devices while walking clients, as recommended by the physical therapist (PT). A gait belt must be applied before and during all ambulation and functional gait activities; it should be applied securely around the waist. Do not use client’s clothing, upper extremity, or personal belt for control, because these items are not strong or secure enough to provide a safe grasp (Pierson & Fairchild, 2008).
• Walk clients frequently with an appropriate number of people; have one team member state short, simple motor instructions. Standing/weight bearing benefits gut motility, spasticity, and respiratory/bowel/bladder function, and promotes muscle stretching (Meyer, 2008).
• Cue and manually guide clients with neglect as they walk. Prevents clients bumping into objects/people. EB: Research subjects with left neglect, when driving a powered wheelchair veered left, whereas when walking, subjects veered right (Turton et al, 2009).
• Document the number of helpers, level of assistance (maximum, standby, etc.), type of assistance, and devices needed on the care plan and room white board. Communication and consistency promote client learning/safety, help prevent staff injury. Utilize all client handling and movement equipment as possible (Cohen et al, 2010).
Take pulse rate/rhythm, respiratory rate, and pulse oximetry before walking clients, and reassess within 5 minutes of walking, then ongoing as needed. If abnormal, have the client sit 5 minutes, then remeasure. If still abnormal, walk clients more slowly and with more help or for a shorter time, or notify physician. If uncontrolled diabetes/angina/arrhythmias/tachycardia (100 bpm or more) or resting SBP at or above 200 mm Hg or DBP at or above 110 mm Hg occur, do not initiate walking exercise. Pulse rate, respiratory rate, and arterial blood oxygenation indicate cardiac/exercise tolerance; tachycardia and low pulse oximetry readings, generally below 88%, are indicators of unstable hemodynamic status. Rest the client and apply oxygen (Perme & Chandrashekar, 2009; Pierson & Fairchild, 2008). Refer to the care plan Activity Intolerance.
Perform initial/ongoing screening for risk of falling and perform postfall assessments including meds and lab results to prevent further falls. Nurses must assess fall risk because literature shows that fewer than 60% of older adults who reported falls in a Medicare review talk to a health care provider about this problem (Matsuda et al, 2011).
• Individualize interventions to prevent falls such as scheduled toileting, monitored rooms, bed alarms, wheelchair alarms, balance/strength training, sleep hygiene, education on risk of medication/alcohol use, removal of hazards, and attention to safe handling during any transfers, toileting, showering/bathing (Cohen et al, 2010). EB: The fall prevention program should include fall prevention interventions as well as assessment of risk and assessment of an actual fall (Ruddick et al, 2009).
Geriatric: Assess for swaying, poor balance, weakness, and fear of falling while elders stand/walk. If present, implement fall protection precautions and refer to physical therapy (PT). Fear of falling and repeat falls is common in the elderly. Assess all geriatric clients for falls and have heightened awareness for risk of fall in clients with chronic diseases such as multiple sclerosis, Parkinson’s, and stroke (Matsuda et al, 2011; Radwanski, 2008).
Review medications for polypharmacy (more than five drugs) and medications that increase the risk of falls, including sedatives, antidepressants, and drugs affecting the CNS. Polypharmacy puts the client at risk for adverse drug reactions, including falls, drug-drug interactions, and overall low adherence to drug therapy because of excessive drugs to take (Hovstadius et al, 2010).
• Encourage tai chi, physical therapy, or other exercise for balance, gait, and strength training in group programs or at home.
• Recommend vision assessment and consideration for cataract removal if needed.
Home Care:• Establish a support system for emergency and contingency care (e.g., Lifeline). Impaired walking may pose a life threat during a crisis (e.g., fall, fire, orthostatic episode).
• Assess for and modify any barriers to walking in the home environment. EB: Effective precautions for ambulation safety in the home are removal of small rugs or mats that may slip or slide; use caution when using a bath mat, avoid waxing floors or use a nonskid wax; immediately wipe fluids from noncarpeted floor. Also remove all items from stairways, be certain hand rails are strong and secure, position furniture to create a 36-inch-wide unobstructed pathway when possible, and remove electrical cords or loose objects from walking paths (Pierson & Fairchild, 2008).
Obtain orders for PT home visits for individualized strength, balance retraining, and an exercise plan. EB: Research shows the use of a simple stretching program for geriatric clients counteracts age-related decline in gait function (Watt et al, 2011).
Make referrals for home health services for support and assistance with activities of daily living (ADLs).
Client/Family Teaching and Discharge Planning:
• Teach clients to check ambulation devices weekly for cracks, loose nuts, or worn tips and to clean dust and dirt on tips.
• Teach diabetics that they are at risk for foot ulcers and teach them preventive interventions. See care plan Ineffective peripheral Tissue Perfusion.
Instruct men/women at risk for osteoporosis or hip fractures to bear weight, walk, engage in resistance exercise (with appropriate adjustments for conditions), ensure good nutrition (especially adequate intake of calcium and vitamin D), drink milk, stop smoking, monitor alcohol intake, and consult a physician for appropriate medications. EB: Supplementation with vitamin D3 and calcium reduced the risk of hip fracture by 43%. The National Osteoporosis Foundation recommends daily calcium intake of at least 1200 mg with diet plus supplements, if needed, for postmenopausal women and men age 50 years and older; intake of vitamin D3 800 to 1000 IU per day (Cotton et al, 2011).
References
Aragaki, D.R., et al. Immediate effects of contralateral and ipsilateral cane use on normal adult gait. PM R. 2009;1(3):208–213.
Cameron, I.D., et al, Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev 2010;(1):CD005465.
Cohen, M.H., et al, Patient handling and movement assessments: a white paper, 2010 The Facility Guideline Institute. Retrieved October 12, 2012, from http://www.fgiguidelines.org/pdfs/FGI_PHAMA_whitepaper_042810.pdf
Coss, E., Geske, J.B., Mueller, P.S. 57-year old woman with acute lower extremity pain and swelling. Mayo Clin Proc. 2009;84(10):e1–e4.
Cotton, D., et al. In the clinic: osteoporosis. Ann Intern Med. 5, 2011. [ITCI-1-16].
Crowther, M. Deep vein thrombosis: treatment. In: Ackley B.J., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. St Louis: Mosby, 2008.
Esquenazi, A., et al. The effect of an ankle-foot orthosis on temporal spatial parameters and asymmetry of gait in hemiparetic patients. PM R. 2009;1(11):1014–1018.
Furlan, J.C., Fehlings, M.G. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis and management. Neurosurg Focus. 2008;25(5):E13.
Hoeman, S.P., et al. Functional mobility with activities of daily living. In Hoeman S.P., ed.: Rehabilitation nursing: prevention, intervention, & outcomes, ed 4, St Louis: Mosby, 2008.
Hovstadius, B., et al. Increasing polypharmacy—an individual based study of the Swedish population 2005-2008. BMC Clin Pharmacol. 2010;10(16):1–8.
Kearon, C., et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2008;133(6):S454–S545.
Matsuda, P.N., et al. Falls in multiple sclerosis. PM R. 2011;3(7):624–632.
Meyer, A. Stand for health. Rehabil Manag. 2008;21(7):16–20.
Olson, R.S. Muscle and skeletal function. In Hoeman S.P., ed.: Rehabilitation nursing: prevention, intervention, & outcomes, ed 4, St Louis: Mosby, 2008.
Perme, C., Chandrashekar, R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009;18(3):212–221.
Pierson, F.M., Fairchild, S.L. Ambulation aids, patterns, and activities. In Pierson F.M., Fairchild S.L., eds.: Principles & techniques of patient care, ed 4, St Louis: Saunders, 2008.
Radwanski, M.L. Gerontological rehabilitation nursing. In Hoeman S.P., ed.: Rehabilitation nursing: Prevention, intervention, & outcomes, ed 4, St Louis: Mosby, 2008.
Riskowski, J., et al. Arthritis, foot pain and shoe wear. Curr Opin Rheumatol. 2011;23(2):148–155.
Ruddick, P.R., et al, Using root cause analysis to reduce falls in rural health care facilities, 2009 Retrieved December 12, 2011, from http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Ruddick_61.pdf
Turton, A.J., et al. Walking and wheelchair navigation in patients with left visual neglect. Neuropsychol Rehabil. 2009;19(2):274–290.
Watt, J.R., et al. Effect of a supervised hip flexor stretching program on gait in elderly individuals. PM R. 2011;3(4):324–329.
Weimer, L.H., Zadeh, P. Neurological aspects of syncope and orthostatic intolerance. Med Clin North Am. 2009;93(2):427–449.
Wandering
NANDA-I
Meandering; aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles
Defining Characteristics
Frequent or continuous movement from place to place, often revisiting the same destinations; persistent locomotion in search of “missing” or unattainable people or places; haphazard locomotion; locomotion in unauthorized or private spaces; locomotion resulting in unintended leaving of a premise; long periods of locomotion without an apparent destination; fretful locomotion or pacing; inability to locate significant landmarks in a familiar setting; locomotion that cannot be easily dissuaded or redirected; following behind or shadowing a caregiver’s locomotion; trespassing; hyperactivity; scanning, seeking, or searching behaviors; periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping); getting lost
Related Factors (r/t)
Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, and language (primarily expressive) defects; cortical atrophy; premorbid behavior (e.g., outgoing, sociable personality); separation from familiar people and places; sedation; emotional state, especially fear, anxiety, boredom, or depression (agitation); overstimulating/understimulating social or physical environment; physiological state or need (e.g., hunger/thirst, pain, urination, constipation); time of day
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Maintain psychological well-being
• Decrease the amount of time getting lost
• Engage in meaningful activities daily
• Remain safe and free from falls and elopement
• Maintain physical activity and remain comfortable and free of pain
• Maintain appropriate body weight and be well nourished and well hydrated
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Nursing Care Facilities: Wandering
• Assess and document the amount (frequency and duration), percentage of hours with wandering, and 24-hour distribution of wandering behavior over 3 days. EBN: Assessment over time provides a baseline against which behavioral change can be evaluated and targets the time of day when behavioral interventions are most necessary (Algase et al, 2009).
• Assess and document the quantity and qualities of wandering behaviors (e.g., persistent walking, repetitive walking, eloping behaviors, spatial disorientation, goal directed, negative outcomes). CEB: Such instruments as the Revised Algase Wandering Scale (Nelson & Algase, 2007) can indicate whether the behavior is persistent, spatially disordered, or if the client is prone to elopement. The Everyday Spatial Questionnaire (Chiu et al, 2005) or the Wayfinding Effectiveness Scale (Algase et al, 2007) can be used to assess the nature of navigational deficits. Information from such instruments can direct caregivers toward more appropriate intervention strategies.
• Obtain a history of personality characteristics and behavioral responses to stress. EBN: Premorbid personality traits (e.g., history of a physically active job or leisure activities) and behavioral responses to stress (e.g., history of responding to stress with psychomotor activity) may reveal circumstances under which wandering will occur and can aid in interpreting both positive and negative meanings of wandering behavior of the client (Song & Algase, 2008).
• Evaluate for neurocognitive strengths and limitations, particularly language, attention, and visuospatial skills. CEB: Wanderers may have expressive language deficits that hamper their ability to communicate needs (Algase, 1992). CEB: Knowledge of attentional and visuospatial deficits, which may account for certain patterns of wandering or way-finding deficits, can lead to identification of appropriate environmental modifications that could enhance functional ambulation, such as elimination of distractions and enhancement of cues marking desired destinations (Chiu, Algase, & Whall, 2004).
• Assess for changes in cognition and signs and symptoms of medical illness such as pneumonia or cardiovascular disease. EB: A large longitudinal study found advancing dementia and/or an undiagnosed medical event that affects cognition but spares mobility are associated with the onset of wandering (King-Kallimanis et al, 2009).
• Assess and monitor for drug-induced akathisia (motor restlessness). CEB: Although wandering has not been specifically linked to akathisia, medications such as antipsychotics, selective serotonin reuptake inhibitors, antiemetics, and dopamine antagonist drugs may increase restlessness, pacing, and the urge to move (Molinari et al, 2008; Schneider, Dagerman, & Insel, 2006). CEB: The occurrence of akathisia can be assessed with the Barnes Akathisia Rating Scale (Barnes, 1989).
• Discontinue use of medications and physical restraints that are used for the sole purpose of controlling wandering behavior. CEB: The Omnibus Budget Reconciliation Act (OBRA) of 1978 requirements specify that wandering behavior is not an appropriate target symptom for the use of psychotropic medications or physical restraints. In addition, there is no evidence that psychotropic medications should be used to treat any type of wandering behavior (Sink et al, 2005).
• Assess for emotional or psychological distress, such as anxiety, fear, or feeling lost. EB: Anxiety, loneliness, and separation may be related to restlessness and wandering (Ata et al, 2010).
• Assess for physical distress or unmet needs (e.g., hunger, thirst, pain discomfort, elimination) with the Need-Driven Dementia-Compromised Behaviors (NBD) model. CEB: (Algase et al, 1996). EBN: The NBD model may help explain reasons for wandering and offers direction in the development of management strategies (Futrell et al, 2010; Miranda-Castillo, Woods, & Gaboda, 2010).
• Observe wandering episodes for antecedents and consequences. CEB: Triggers for wanderers include being placed in an unfamiliar environment, seeing a coat and hat, experiencing an argumentative or confronting situation, a change in schedule or routine, and recent relocation to a care facility (Silverstein & Flaherty, 2003).
• Observe the location where and environmental conditions in which wandering is occurring and modify those that appear to induce wandering. EBN: In a recent observational study, wanderers were less likely to wander from where the likelihood of social interaction was greater (i.e., activities room, dayroom, staff area); where the environment was more soothing (i.e., their own room); or where rooms had a designated purpose (e.g., dayrooms, the wanderer’s own room, activities and staff areas), and wandering was less likely when lighting was low and variation in sound levels was small (Algase, Beattie, & Antonakos, 2010).
• Assess regularly for the presence of or potential for negative outcomes of wandering (e.g., elopement, declining social skills, onset of falls, becoming lost, and injuries). CEB: Wanderers are at great risk for falls and other adverse events (Nelson & Algase, 2007).
• Weigh the client at defined intervals to detect onset of weight loss, and watch for symptoms associated with inadequate food intake, including constipation, dehydration, muscle wasting, and starvation. CEB: Wandering behavior can affect the client’s ability to eat, when the client is unable to sit at a table for the time needed to eat a meal (Beattie & Algase, 2002).
• For the client who displays wandering behavior during mealtimes, use behavioral interventions to shape behavior, including verbal statements, nonverbal social behavior, and systematic extinguishing of undesirable client behavior. CEB: Results of a study using behavior interventions demonstrated that they were effective in increasing the time the client sat at the table, and the amount of food the client ate (Beattie, Algase, & Song, 2004).
• Provide for safe ambulation with comfortable and well-fitting clothes, shoes with nonskid soles and foot support, and any necessary walking aids (e.g., a cane or walker). CEB: Wanderers are at increased risk for falls (Katz et al, 2004).
• Refer to physical therapy for core therapeutic exercise, balance, gait, and assistive device training. EB: In a case study, physical therapy demonstrated positive functional outcomes using fall prevention interventions modified for the client’s cognition, communication deficits, and behavior problems (Mirolsky-Scala & Kraemer, 2009).
• Provide safe and secure surroundings that deter accidental elopements, using perimeter control devices or electronic tracking systems. CEB: A review of technology identified boundary alarms activated by wrist bands, alarms alerting caregivers of wandering behavior, and electronic monitoring and tracking systems, such as global positioning systems (GPS), as effective in improving client safety (Lauriks et al, 2007).
• During periods of inactivity, position the wanderer so that desirable destinations (e.g., bathroom) are within the client’s line of vision and undesirable destinations (e.g., exits or stairwells) are out of sight. CEB: Functional, nonwandering ambulation is possible even into late-stage dementia and may be facilitated by keeping appropriate visual cues accessible (Passini et al, 2000).
• Facilitate way-finding through therapeutic environmental design. EB: Thirty nursing homes were analyzed for architectural characteristics, and the significant characteristics that impact spatial orientation included limiting the number of people with dementia per living area, providing straight layouts without changes in direction to important locations, and providing only one living/dining room (Marquardt & Schmieg, 2009).
• Enhance the physical environment by increasing visual appeal and provide interesting views and opportunities to sit. CEB: In a cross-sectional study, environmental ambience influenced walking frequencies, walking duration, and sitting duration (Yao & Algase, 2006).
• Engage wanderers in social interaction and structured activity such as painting or coloring, especially when wanderers appear distressed or otherwise uncomfortable, or their wandering presents a challenge to others in the setting. EB: In a case study, simple leisure activities such as picture coloring significantly reduced wandering behavior (Giulio et al, 2011).
• Provide headphones and iPod with individualized preferred music while the person with dementia is wandering, or encourage the person to participate in a music group. EBN: In an intervention nursing home study in Taiwan, researchers found preferred music listening had a positive impact by reducing the level of anxiety in older residents with dementia (Sung, Chang, & Lee, 2010).
• If wandering has a pacing quality, attempt to identify and address any underlying problems or concerns. Offer stress-reducing approaches, such as music, massage, or rocking. Attempts to distract or redirect the pacing wanderer may worsen wandering. EB: In a field study, the researchers found a close relationship between wandering and restlessness (Ata et al, 2010).
• Provide a regularly scheduled and supervised exercise or walking program, particularly if wandering occurs excessively during the night or at times that are inconvenient in the setting. CEB: Although exercise or walking programs do not reduce daytime wandering, they have been shown to reduce or eliminate nighttime wandering (Carillon Nursing and Rehabilitation Center, 2000).
• Use soft tactile hand massage before the times of day or events that induce wandering. EB: In an intervention study, soft hand message for 20 minutes reduced aggressiveness and stress in clients with dementia (Suzuki et al, 2010).
Multicultural:• Recognize that wandering occurs with little variation in expression among individuals with dementia regardless of culture or ethnicity. CEB & EB: Wandering has been reported in multiple populations and varies little by cultural group (Greiner et al, 2007; Young et al, 2008).
• Assess for the influence of cultural beliefs, norms, and values on the family’s understanding of wandering behavior. CEB: Latina caregivers of people with dementia delay institutionalization significantly longer than female Caucasian caregivers because of Latino cultural values and positive views of the caregiving role (Mausbach et al, 2004; Sink et al, 2004).
Refer the family to social services or other supportive services to assist with the impact of caregiving for the wandering client.
• Encourage the family to use support groups or other service programs.
• Help the caregiver set up a plan to deal with wandering behavior using the interventions mentioned earlier.
• Assess the home environment for modifications that will protect the client and prevent elopement. Security devices are available to notify the caregiver of the client’s movements (e.g., alarms at doors, bed alarms).
• Assist the family to set up a plan of exercise for the client, including safe walking. Walking is a valuable source of exercise, even for clients with dementia.
• Enroll wanderers in the Safe Return Program of the Alzheimer’s Association, and help the caregiver develop a plan of action to use if the client elopes. CEB: The Safe Return Program has assisted in locating numerous persons who have eloped from their homes or other residential care settings. Mortality rates are high if there is failure to locate elopers within the first 24 hours (Rowe & Glover, 2001).
• Help the caregiver develop a plan of action to use if the client elopes.
Refer for homemaker or psychiatric home health care services for respite, client reassurance, and implementation of a therapeutic regimen. Refer to the care plan for Caregiver Role Strain. Responsibility for a person at high risk for wandering provides high caregiver stress. Respite care decreases caregiver stress. The presence of caring individuals is reassuring to both the client and caregivers, especially during periods of client anxiety. Wandering behavior can make use of the interventions described previously, modified for the home setting.
Client/Family Teaching and Discharge Planning:
• Inform the client and family of the meaning of and reasons for wandering behavior. An understanding of wandering behavior will enable the client and family to provide the client with a safe environment.
• Teach the caregiver/family methods to deal with wandering behavior using the interventions mentioned in Nursing Interventions and Rationales.
References
Algase, D.L. Cognitive discriminants of wandering among nursing home residents. Nurs Res. 1992;41(2):78–81.
Algase, D.L., Beattie, E., Antonakos, C. Wandering and the physical environment. Am J Alzheimers Dis Other Demen. 2010;25(4):340–346.
Algase, D.L., et al. Need-driven dementia-compromised behaviors: an alternative view of disruptive behavior. Am J Alzheimers Dis Other Demen. 1996;11(6):10–19.
Algase, D.L., et al. Initial psychometric evaluation of the wayfinding effectiveness scale. West J Nurs Res. 2007;29(8):1015–1032.
Algase, D.L., et al. New parameters for daytime wandering. Res Gerontol Nurs. 2009;2(1):58–68.
Ata, T., et al. Wandering and fecal smearing in people with dementia. Int Psychogeriatr. 2010;22(3):493–500.
Barnes, T.R.E. A rating scale for drug-induced akathisia. Br J Psychiatry. 1989;154:672–676.
Beattie, E.R.A., Algase, D.L. Improving table-sitting behavior of wanderers via theoretic substruction. J Gerontol Nurs. 2002;28(10):6–11.
Beattie, E.R.A., et al. Keeping wandering nursing home residents at the table: improving food intake using a behavior communication intervention. Aging Ment Health. 2004;8(2):109–116.
Carillon Nursing and Rehabilitation Center. Nature walk: from aimless wandering to purposeful walking. Nurs Homes Long Term Care Manage. 2000;49(11):50–55.
Chiu, Y.C., Algase, D., Whall, A. Getting lost: directed attention and executive functions in early Alzheimer’s disease patients. Dement Geriatr Cogn Disord. 2004;17(3):174–180.
Chiu, Y.C., et al. Conceptualization and measurement of getting lost behavior in persons with early dementia. Int J Geriatr Psychiatry. 2005;20(8):760–768.
Futrell, M., et al. Evidence-based guideline. Wandering. J Gerontol Nurs. 2010;36(2):6–16.
Greiner, C., et al. Feasibility study of the integrated circuit tag monitoring system for dementia residents in Japan. Am J Alzheimers Dis Other Demen. 2007;22(2):129–136.
Giulio, L., et al. A man with severe Alzheimer’s disease stops wandering during a picture colouring activity. Dev Neurorehabil. 2011;14(4):242–246.
Katz, I.R., et al. Risperidone and falls in ambulatory nursing home residents with dementia and psychosis or agitation: secondary analysis of a double-blind, placebo-controlled trial. Am J Geriatr Psychiatry. 2004;12(5):499–508.
King-Kallimanis, B., et al. Longitudinal investigation of wandering behavior in department of veterans affairs nursing home care units. Int J Geriatr Psychiatry. 2010;25:166–174.
Lauriks, S., et al. Review of ICT-based services for identified unmet needs in people with dementia. Ageing Res Rev. 2007;6(3):223–246.
Marquardt, G., Schmieg, P. Dementia-friendly architecture: environments that facilitate wayfinding in nursing homes. Am J Alzheimers Dis Other Demen. 2009;24(4):333–340.
Mausbach, B.T., et al. Ethnicity and time to institutionalization of dementia patients: a comparison of Latina and Caucasian female family caregivers. J Am Geriatr Soc. 2004;52(7):1077–1084.
Miranda-Castillo, C., et al. Unmet needs, quality of life and support networks of people with dementia living at home. Health Qual Life Outcomes. 2010;8:132.
Mirolsky-Scala, G., Kraemer, T. Fall management in Alzheimer-related dementia: a case study. J Geriatr Phys Ther. 2009;32(4):181–189.
Molinari, V., et al. Wandering behavior in veterans with psychiatric diagnoses residing in nursing homes. Int J Geriatr Psychiatry. 2008;23(7):748–753.
Nelson A.L., Algase A., eds. Evidence-based protocols for managing wandering behaviors. New York: Springer, 2007.
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