Taxonomy II: Activity/Rest—Class 2 Activity/Exercise (00154)
[Diagnostic Division: Safety]
Submitted 2000
Definition: Meandering, aimless, or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles
[Diagnostic Division: Safety]
Submitted 2000
Definition: Meandering, aimless, or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles
Related Factors
Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, language (primarily expressive) defects
Cortical atrophy
Premorbid behavior (e.g., outgoing, sociable personality; premorbid dementia)
Separation from familiar people and places
Emotional state, especially frustration, anxiety, boredom, or depression (agitation)
Physiological state or need (e.g., hunger/thirst, pain, urination, constipation)
Over/understimulating social or physical environment; sedation
Time of day
Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, language (primarily expressive) defects
Cortical atrophy
Premorbid behavior (e.g., outgoing, sociable personality; premorbid dementia)
Separation from familiar people and places
Emotional state, especially frustration, anxiety, boredom, or depression (agitation)
Physiological state or need (e.g., hunger/thirst, pain, urination, constipation)
Over/understimulating social or physical environment; sedation
Time of day
Defining Characteristics
OBJECTIVE
Frequent or continuous movement from place to place, often revisiting the same destinations
Persistent locomotion in search of “missing” or unattainable people or places; scanning, seeking, or searching behaviors
Haphazard locomotion; fretful locomotion or pacing; long periods of locomotion without an apparent destination
Locomotion into unauthorized or private spaces; trespassing
Locomotion resulting in unintended leaving of a premise
Inability to locate significant landmarks in a familiar setting; getting lost
Locomotion that cannot be easily dissuaded or redirected; following behind or shadowing a caregiver’s locomotion
Hyperactivity
Periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping)
OBJECTIVE
Frequent or continuous movement from place to place, often revisiting the same destinations
Persistent locomotion in search of “missing” or unattainable people or places; scanning, seeking, or searching behaviors
Haphazard locomotion; fretful locomotion or pacing; long periods of locomotion without an apparent destination
Locomotion into unauthorized or private spaces; trespassing
Locomotion resulting in unintended leaving of a premise
Inability to locate significant landmarks in a familiar setting; getting lost
Locomotion that cannot be easily dissuaded or redirected; following behind or shadowing a caregiver’s locomotion
Hyperactivity
Periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping)
Desired Outcomes/Evaluation
Criteria—Client Will:
• Be free of injury, or unplanned exits.
Caregiver(s) Will:
• Modify environment as indicated to enhance safety.
• Provide for maximal independence of client.
Criteria—Client Will:
• Be free of injury, or unplanned exits.
Caregiver(s) Will:
• Modify environment as indicated to enhance safety.
• Provide for maximal independence of client.
Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impairment/stage of disease process:
• Ascertain history of client’s memory loss and cognitive changes.
• Note results of diagnostic testing, confirming diagnosis and type of dementia.
• Evaluate client’s mental status during daytime and nighttime, noting when client’s confusion is most pronounced, and when client sleeps.
• Monitor client’s use/need for assistive devices such as glasses, hearing aids, cane, and so forth.
• Assess frequency and pattern of wandering behavior to determine individual risks/safety needs.
• Identify client’s reason for wandering if possible (e.g., looking for lost item, desire to go home, boredom, need for activity, hunger, thirst, or discomfort).
• Ascertain if client has delusions due to shadows, lights, and noises.
NURSING PRIORITY NO. 1. To assess degree of impairment/stage of disease process:
• Ascertain history of client’s memory loss and cognitive changes.
• Note results of diagnostic testing, confirming diagnosis and type of dementia.
• Evaluate client’s mental status during daytime and nighttime, noting when client’s confusion is most pronounced, and when client sleeps.
• Monitor client’s use/need for assistive devices such as glasses, hearing aids, cane, and so forth.
• Assess frequency and pattern of wandering behavior to determine individual risks/safety needs.
• Identify client’s reason for wandering if possible (e.g., looking for lost item, desire to go home, boredom, need for activity, hunger, thirst, or discomfort).
• Ascertain if client has delusions due to shadows, lights, and noises.
NURSING PRIORITY NO. 2. To assist client/caregiver to deal with situations:
• Provide a structured daily routine. Decreases wandering behavior and minimizes caregiver stress.
• Encourage participation in family activities and familiar routines such as folding laundry, listening to music, walking outdoors. Activities and exercises may reduce anxiety and restlessness.
• Bring client to bathroom on a regular schedule.
• Provide safe place for client to wander, away from safety hazards (e.g., hot water/kitchen stove, open stairway) and other noisy clients. Arrange furniture and other items to accommodate wandering.
• Make sure that doors have alarms and that alarms are turned on. Provide door and window locks that are not easily opened to prevent unsafe exits.
• Provide 24-hour reality orientation. (Client can be awake at any time and fail to recognize day/night routines.)
• Provide a structured daily routine. Decreases wandering behavior and minimizes caregiver stress.
• Encourage participation in family activities and familiar routines such as folding laundry, listening to music, walking outdoors. Activities and exercises may reduce anxiety and restlessness.
• Bring client to bathroom on a regular schedule.
• Provide safe place for client to wander, away from safety hazards (e.g., hot water/kitchen stove, open stairway) and other noisy clients. Arrange furniture and other items to accommodate wandering.
• Make sure that doors have alarms and that alarms are turned on. Provide door and window locks that are not easily opened to prevent unsafe exits.
• Provide 24-hour reality orientation. (Client can be awake at any time and fail to recognize day/night routines.)
• Sit with client and talk. Provide TV/radio/music.
• Avoid overstimulation from activities or new partners/roommate during rest periods when client is in a facility.
• Use pressure-sensitive bed/chair alarms to alert caregivers of movement.
• Avoid using physical or chemical restraints (sedatives) to control wandering behavior. May increase agitation, sensory deprivation, and falls, and may contribute to wandering behavior.
• Provide consistent staff as much as possible.
• Provide room near monitoring station; check client location on frequent basis.
• Avoid overstimulation from activities or new partners/roommate during rest periods when client is in a facility.
• Use pressure-sensitive bed/chair alarms to alert caregivers of movement.
• Avoid using physical or chemical restraints (sedatives) to control wandering behavior. May increase agitation, sensory deprivation, and falls, and may contribute to wandering behavior.
• Provide consistent staff as much as possible.
• Provide room near monitoring station; check client location on frequent basis.
NURSING PRIORITY NO. 3. To Promote Wellness (Teaching/ Discharge Considerations):
• Identify problems that are remediable and assist client/SO to seek appropriate assistance and access resources. (Encourages problem solving to improve condition rather than accept the status quo.)
• Notify neighbors about client’s condition and request that they contact client’s family or local police if they see client outside alone. Community awareness can prevent/reduce risk of client being lost or hurt.
• Use community resources, such as Alzheimer’s Association Safe Return Program, to assist in identification, location, and safe return of individual with wandering behaviors.
• Help client/SO develop plan of care when problem is progressive.
• Refer to community resources such as day care programs, support groups, and so forth.
• Refer to NDs: acute Confusion; disturbed Sensory Perception, (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory); risk for Injury, risk for Falls.
• Identify problems that are remediable and assist client/SO to seek appropriate assistance and access resources. (Encourages problem solving to improve condition rather than accept the status quo.)
• Notify neighbors about client’s condition and request that they contact client’s family or local police if they see client outside alone. Community awareness can prevent/reduce risk of client being lost or hurt.
• Use community resources, such as Alzheimer’s Association Safe Return Program, to assist in identification, location, and safe return of individual with wandering behaviors.
• Help client/SO develop plan of care when problem is progressive.
• Refer to community resources such as day care programs, support groups, and so forth.
• Refer to NDs: acute Confusion; disturbed Sensory Perception, (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory); risk for Injury, risk for Falls.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, including individual concerns, family involvement, and support factors/availability of resources.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses of client/SO(s) to plan interventions and actions performed.
ASSESSMENT/REASSESSMENT
• Assessment findings, including individual concerns, family involvement, and support factors/availability of resources.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses of client/SO(s) to plan interventions and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-range needs and who is responsible for actions to be taken.
• Specific referrals made.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-range needs and who is responsible for actions to be taken.
• Specific referrals made.
