Domain 4. Activity-rest
Class 2. Activity-exercise
Diagnostic Code: 00238
Nanda label: Impaired standing
Diagnostic focus: Standing
Introduction to Nursing Diagnosis: Impaired Standing
What is Impairment of Standing?
Impaired standing, also known as an activity limitation— is a type of nursing diagnosis indicating a patient’s inability to maintain an upright posture. It is usually caused by physical or mental limitations, circumstances of illness or injury, or a combination of these. This can lead to reduced ability to maintain balance and to support their own body weight.
NANDA Nursing Diagnosis Definition
NANDA International's definition of this nursing diagnosis is: "Impaired Standing related to muscle weakness, pain, altered joint mobility, fatigue, or neuropathy."
Defining Characteristics
Subjective Characteristics:
- Altered body sensations, such as tingling, numbness or pain
- Feeling of unsteadiness or instability
- Ineffective balance
- Lack of strength or coordination when attempting to stand
Objective Characteristics:
- Abnormal curvatures of the spine
- Difficulty maintaining posture in upright position
- Diminished mobility in legs and feet
- Limited range of motion
- Muscular weakness
- Postural deformity
Certain factors can cause Impairment of Standing, including:
- Muscle Weakness: A weakened muscle reduces its ability to provide stability and support to the body while standing.
- Pain: Pain may cause difficulty in standing and moving normally.
- Altered Joint Mobility: Restrictions in joint movement, such as joint stiffness, can limit a person’s capability to stand and move normally.
- Fatigue: Tiredness or exhaustion can reduce the muscles' capacity to support bodyweight.
- Neuropathy: Nerve damage can affect the nerve signals to various parts of the body, increasing a person’s risk of falling.
Associated Conditions
Some medical conditions may make a person more likely to experience Impaired Standing. These conditions include:
- Parkinson’s disease
- Stroke
- Multiple sclerosis
- Spinal cord injuries
- Excessive alcohol consumption
- Arthritis
- Osteoporosis
- Cardiovascular diseases
Suggestions of Use
Nursing diagnosis for Impaired Standing can be applied in many clinical settings, such as:
- Hospitals
- Rehabilitation facilities
- Outpatient clinics
- Long-term care facilities
Suggested Alternative NANDA Nursing Diagnosis
Alternative NANDA Nursing Diagnoses for situations where Impaired Standing is not an appropriate diagnosis include:
- Impaired Physical Mobility: Unilateral or bilateral limitation of the patient's ability to move independently from one place to another.
- Risk for Falls: An individual is at risk for injury if they lose balance while standing or walking.
- Risk for Injury: A decrease in the capability to protect oneself from physical injury.
Usage Tips
When assessing Impaired Standing, it is important to approach the patient with respect and sensitivity. Ask about their overall physical health, joint mobility, and any injuries or illnesses that could affect their ability to stand. Observe their posture and the way they walk, as well as any objects they use for balance.
NOC Outcomes
NOC (Nurse Outcome Classification) outcomes that are expected when Impaired Standing has been addressed include:
- Balance: The patient’s ability to move from one position to another without losing balance.
- Gait and Mobility: Ability to walk, shift positions, and transfer from bed to wheelchair or chair to bed.
- Joint Movement: Ability to move and exercise joints freely and with minimal discomfort.
- Mobility Level: A person's ability to stand up, walk, or maneuver around by themselves.
Evaluation Objectives and Criteria
When evaluating a patient’s progress in overcoming Impaired Standing, objectives and criteria of success include:
- Awareness of own body's positioning and movements when standing
- Ability to stand upright on their own without the need for using objects for balance
- Increase in joint mobility and improved strength in supporting body weight
- Normal gait when walking and no symptoms of discomfort
NIC Interventions
NIC (Nursing Interventions Classification) interventions for managing Impaired Standing include:
- Exercise: Providing exercises such as stretching and strengthening of the supportive muscles for improved balance and gait.
- Assistance with Walking: Supervising and assisting the patient with daily activities such as walking.
- Positioning: Repositioning the person throughout the day in positions that promote their body awareness, healthy joint movements, and balance.
- Safety Teaching: Teaching patients how to assess risks of injury and how to protect themselves when performing activities that require balance.
Nursing Activities
Nursing activities that can be used to address Impaired Standing include:
- Observing patient while standing, walking, transferring, and changing positions
- Instructing patient in the proper posture and exercising techniques
- Helping patient to identify useful aids for balance, such as braces and canes
- Providing instruction to families on helping with transfers and movement
- Explaining the importance of appropriate task selection and modifications
Conclusion
Impaired Standing is a commonly diagnosed nursing diagnosis that commonly results from numerous conditions and causes. If a patient is found to have difficulty in maintaining an upright posture, the proper nursing interventions and treatments must be provided in order to help the patient. Nursing activities such as exercise, repositioning, safety teaching, and assistance with walking can be used to effectively address Impaired Standing.
FAQs
How can nurses help with Impaired Standing?
Nurses can assist with Impaired Standing by providing instruction, guidance, and support. This may include offering exercise programs and helping with transfers, positioning, and task selection.
What is the NANDA definition of Impaired Standing?
NANDA's definition of this nursing diagnosis is: "Impaired Standing related to muscle weakness, pain, altered joint mobility, fatigue, or neuropathy."
What are common associated conditions with Impaired Standing?
Common associated conditions with Impaired Standing include Parkinson’s disease, stroke, multiple sclerosis, spinal cord injuries, excessive alcohol consumption, arthritis, osteoporosis, and cardiovascular diseases.
What are some NOC Outcomes related to Impaired Standing?
NOC outcomes related to Impaired Standing include Balance, Gait and Mobility, Joint Movement, and Mobility Level.
What are some NIC Interventions for Impaired Standing?
Common NIC interventions for Impaired Standing include Exercise, Assistance with Walking, Positioning, and Safety Teaching.
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