Taxonomy II: Activity/Rest—Class 2 Activity/Exercise (00088)
[Diagnostic Division: Activity/Rest]
Submitted 1998
Definition: Limitation of independent movement within the environment on foot
Related Factors
To be developed
[Condition affecting muscles/joints impairing ability to walk]
To be developed
[Condition affecting muscles/joints impairing ability to walk]
Defining Characteristics
SUBJECTIVE OR OBJECTIVE
Impaired ability to walk required distances, walk on an incline/ decline, or on uneven surfaces, to navigate curbs, climb stairs
[Specify level of independence—refer to ND impaired physical Mobility, for suggested functional level classification]
SUBJECTIVE OR OBJECTIVE
Impaired ability to walk required distances, walk on an incline/ decline, or on uneven surfaces, to navigate curbs, climb stairs
[Specify level of independence—refer to ND impaired physical Mobility, for suggested functional level classification]
Desired Outcomes/Evaluation
Criteria—Client Will:
• Be able to move about within environment as needed/desired within limits of ability or with appropriate adjuncts.
• Verbalize understanding of situation/risk factors and safety measures.
Criteria—Client Will:
• Be able to move about within environment as needed/desired within limits of ability or with appropriate adjuncts.
• Verbalize understanding of situation/risk factors and safety measures.
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, recent surgery, trauma, arthritis, brain injury, vision impairments, pain, fatigue, cognitive dysfunction).
• 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.
• Note emotional/behavioral responses of client/SO 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 needed/indicated by individual situation.
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, recent surgery, trauma, arthritis, brain injury, vision impairments, pain, fatigue, cognitive dysfunction).
• 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.
• Note emotional/behavioral responses of client/SO 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 needed/indicated by individual situation.
• Consult with PT/OT to develop individual mobility/walking program and identify appropriate adjunctive devices.
• Demonstrate use of adjunctive devices (e.g., walker, cane, crutches, prosthesis).
• Schedule walking/exercise activities interspersed with adequate rest periods to reduce fatigue.
• Provide ample time to perform mobility-related tasks.
• Advance levels of exercise as able.
• Provide safety measures as indicated, including environmental management/fall prevention.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Involve client/SO in care, assisting them to learn ways of managing deficits to enhance safety for client and SO(s)/caregivers.
• Identify appropriate resources for obtaining and maintaining appliances, equipment, and environmental modifications to promote mobility.
• Instruct client/SO in safety measures as individually indicated (e.g., maintaining safe travel pathway, proper lighting/ handrails on stairs, etc.) to reduce risk of falls.
• Demonstrate use of adjunctive devices (e.g., walker, cane, crutches, prosthesis).
• Schedule walking/exercise activities interspersed with adequate rest periods to reduce fatigue.
• Provide ample time to perform mobility-related tasks.
• Advance levels of exercise as able.
• Provide safety measures as indicated, including environmental management/fall prevention.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Involve client/SO in care, assisting them to learn ways of managing deficits to enhance safety for client and SO(s)/caregivers.
• Identify appropriate resources for obtaining and maintaining appliances, equipment, and environmental modifications to promote mobility.
• Instruct client/SO in safety measures as individually indicated (e.g., maintaining safe travel pathway, proper lighting/ handrails on stairs, etc.) to reduce risk of falls.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, including level of function/ability to participate in specific/desired activities.
PLANNING
• Plan of care and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge/long-range needs, noting who is responsible for each action to be taken.
• Specific referrals made.
• Sources of/maintenance for assistive devices.
ASSESSMENT/REASSESSMENT
• Individual findings, including level of function/ability to participate in specific/desired activities.
PLANNING
• Plan of care and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge/long-range needs, noting who is responsible for each action to be taken.
• Specific referrals made.
• Sources of/maintenance for assistive devices.
