Client Will (Specify Time Frame)

• 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).