Nursing Diagnosis: Wandering Application of NANDA, NOC, NIC

Nursing Diagnosis: Wandering
Donna Algase

NANDA Definition: 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: 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); premorbid dementia; separation from familiar people and places; sedation; emotional state, especially frustration, 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 Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Safety Status: Falls Occurrence

·         Safety Behavior: Fall Prevention

·         Caregiver Home Care Readiness

Client Outcomes

·         Decreased incidence of falls (preferably free of falls)

·         Decreased incidence of elopements

·         Appropriate body weight maintained

·         Caregiver able to explain interventions can use to provide a safe environment for care receiver who displays wandering behavior

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Dementia Management

Nursing Interventions and Rationales

·         Assess and document the amount (frequency and duration), pattern (random, lapping, or pacing), and 24-hour distribution of wandering behavior over a 3-day interval. Assessment over time provides a baseline against which behavior change can be evaluated (Algase et al, 1997). Such assessment can also reveal the time of day when wandering is greatest and when surveillance or other precautionary measures are most necessary.

·         Obtain a history of personality characteristics and behavioral responses to stress. Information about long-standing behavioral tendencies may reveal circumstances under which wandering will occur and can aid in interpreting both positive and negative meanings of wandering behavior of the patient. (Kolanowski, Strand, Whall, 1997; Monsour, Robb, 1982; Thomas, 1997)

·         Evaluate for neurocognitive strengths and limitations, particularly language, attention, visuospatial skills, and perseveration. Wanderers may have expressive language deficits that hamper ability to communicate needs (Algase, 1992; Dawson, Reid, 1987). Knowledge of attentional and visuospatial deficits, which may account for certain patterns of wandering, 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 (Fischer, Marterer, Danielczyk, 1990; Henderson, Mack, Williams, 1989; Passini et al, 1995; Passini et al, 2000). The presence of perseveration may indicate that the wanderer is unable to voluntarily stop his or her behavior (Passini et al, 1995, Ryan et al, 1995), thus calling for nursing judgment as to when wandering should be interrupted to enhance the wanderer's safety, comfort, or well-being.

·         Assess for physical distress or needs, such as hunger, thirst, pain, discomfort, or elimination. While physical needs have not been documented in relation to wandering, the Need-Driven Dementia-Compromised Model hypothesizes this relationship (Algase et al, 1996).

·         Assess for emotional or psychological distress, such as anxiety, fear, or feeling lost. While emotional needs have not been documented in relation to wandering, the Need-Driven Dementia-Compromised Model hypothesizes this relationship (Algase et al, 1996).

·         Observe wandering episodes for antecedents and consequences. People, events, or circumstances surrounding the onset or conclusion of wandering may provide cues about triggers or rewards that are stimulating or reinforcing wandering behavior (Hirst, Metcalf, 1989; Hussain, 1981, 1982).

·         Assess regularly for the presence of or potential for negative outcomes of wandering, such as weight change, declining social skills, falls, and elopement. Wanderers are at greater risk for falls than other cognitively-impaired persons (Kippenbrock, Soja, 1993; Morse, Tylko, Dixon, 1987). Wanderers have also show greater loss in social skills over time than nonwandering counterparts (Cornbleth, 1977).

·         Provide for safe ambulation with comfortable and well-fitting clothes, shoes with nonskid soles and foot support, and any necessary walking aids (such as a cane, walker, or Merry-walker). Falls in persons with AD are often related to a decline in vigor in persons who had been previously active (Brody et al, 1984).

·         Provide safe and secure surroundings that deter accidental elopements using perimeter control devices or camouflage. Eloping can have hazardous outcomes, even death. Perimeter control devices can effectively reduce or prevent exiting behavior (Negley, Molla, Obenchain, 1990). However, in some circumstances, these devices are viewed as unnecessarily restrictive and more passive means, such as camouflage, have been substituted. Camouflage techniques, such as masking the doorknob or creating striped floor patterns in front of exits, have been used with success (Hussain, Brown, 1987; Namazi, Rosner, Calkins, 1989), particularly in subjects with Alzheimer's disease (Hewewasam, 1996), but the effectiveness may be mitigated by other architectural features of the setting (Chafetz, 1990; Hamilton, 1993).

·         During periods of inactivity, position the wanderer so that desirable destinations, such as the bathroom, are within line of vision and undesirable destinations (such as exits or stairwells) are out of sight. Functional, nonwandering ambulation is possible even into late-stage dementia and may be facilitated by keeping appropriate visual cues accessible (Algase, 1999; Martino-Saltzman et al, 1991; Passini et al, 2001).

·         If wandering takes a random or haphazard route, reduce environmental distractions and increase relevant environmental cues. Note and eliminate stimuli that distract the wanderer while in route. Random pattern wandering may be affected by environmental stimuli (Algase, 1999).

·         Provide afternoon rest periods if assessment reveals that random pattern wandering worsens as the day progresses. The proportion of wandering that is random increases as the day progresses (Algase et al, 1997; Algase, 1999) and may indicate fatigue.

·         Engage wanderers in social interaction and structured activity, especially when wanderers appear distressed or otherwise uncomfortable or their wandering presents a challenge to others in the setting. Wandering and social interaction are inversely related. Wanderers often have an outgoing or sociable personality and also have deficits in expressive language skills. Thus while they may prefer social interaction, their ability to initiate it may be compromised (Algase, 1992; Thomas, 1997).

·         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. Pacing, as a wandering pattern, is not associated with level of cognitive impairment and may reflect anxiety, agitation, pain or another internal process (Algase, Beattie, Therrien, 2001; Gerdner, 2000; Snyder, Olson, 1996).

·         If wandering is a new or recently acquired behavior, or if it increases in intensity over previous levels, evaluate for constipation, pneumonia, or acute physical problems. Persons who first exhibit wandering within 3 months after admission to a nursing home are more likely than others to have developed physical problems that stimulate wandering (Keily, Morris, Algase, 2000).

·         If wandering has a lapping or circuitous pattern, signs or labels may be effective. Substitute another repetitive activity such as folding or rocking if lapping becomes problematic or excessive. Not all wanderers display lapping pattern wandering and, when it does occur, it tends to occur early in the day or to follow rest periods. Thus it may be a more functional pattern than random wandering and may indicate a slightly better level of cognitive function for the individual, even if transient. Thus wanderers who lap may be better able to make use of information in the environment (Algase, Beattie, Therrien, 2001). However, this pattern of wandering may also be a form of perseveration and therefore the person may be unable to disengage voluntarily (Passini et al, 1995; Ryan et al, 1995).

·         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. While exercise or walking programs do not reduce daytime wandering, they have been shown to reduce or eliminate nighttime wandering (Robb, 1987) and to decrease general agitation levels (Holmberg, 1997).

Multicultural

·         Assess for the influence of cultural beliefs, norms, and values on the family's understanding of wandering behavior. What the family considers normal and abnormal health behavior may be based on cultural perceptions (Leininger, 1996).

·         Refer family to social services or other supportive services to assist with the impact of caregiving for the wandering client. African-American caregivers of dementia clients may evidence less desire than other caregivers to institutionalize their family members and are more likely to report unmet service needs (Hinrichsen, Ramirez, 1992). African-American and Caucasian families of dementia clients may report restricted social activity (Haley et al, 1995).

·         Encourage family to use support groups or other service programs. Studies indicate that minority families of clients with dementia use few support programs even though these programs could have a positive impact on caregiver well-being (Cox, 1999).

·         Validate the family's feelings regarding the impact of client wandering on family lifestyle. Validation lets the client know that the nurse has heard and understands what was said (Stuart, Laraia, 2001).

Home Care Interventions

·         Help the caregiver set up a plan to deal with wandering behavior using the interventions mentioned in Nursing Interventions and Rationales.

·         Help the caregiver develop a plan of action to use if the client elopes.

Client/Family Teaching

·         Inform client family of meaning of and reasons for wandering behavior. An understanding of wandering behavior will enable the client 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.