M16 · Poor balance
Actual Movement and self-care
Definition
Unsteady standing or walking raises the chance of falling.- Weak legs
- dizziness
- nerve disease
- inner ear problems
- Sways
- holds furniture
- wide steps
- falls
📋 Scenario
An older man sways when standing and holds the wall.
Subjective (S): "I feel like I'm swaying."
Objective (O): Sways when standing; holds the wall; wide steps; positive balance test.
Assessment tools for this scenario: CP-MOVE Movement & Self-Care Score
Validated scales to consider: Barthel Index, Katz ADL
**CarePath diagnosis:** Poor balance related to weak legs and dizziness, as evidenced by swaying when standing, holding the wall, wide steps, and a positive balance test.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Assess balance. | Assessing balance shows how severe the problem is and which causes, such as weak legs or dizziness, need treatment. |
| Use an aid. | A suitable aid widens his base of support and gives him something steady to hold, which lowers the risk of falls. |
| Non-slip shoes. | Non-slip shoes grip the floor and give a stable base, lowering the risk of slipping. |
| Remove hazards. | Clutter, wet floors and loose rugs can trip someone who is unsteady, so removing them cuts the chance of a fall. |
| Teach balance exercises. | Balance exercises strengthen the muscles and reflexes that keep a person upright, improving stability over time. |
| Assist. | Help close by can catch him if he sways, which prevents a fall while his balance is poor. |
**Expected outcomes**
- No falls.
- Balance score improves in 2-4 weeks.
- Walks with the correct aid.
- Patient does balance exercises.
**Linking the data to the diagnosis**
The patient sways when he stands, holds the wall, takes wide steps, and has a positive balance test. These findings are present now, so the correct choice is the actual statement Poor balance (M16) and not a risk statement. It is also different from Likely to fall (S1), which describes the chance of a fall. The plan therefore aims to improve balance and to prevent the fall that his weak legs and dizziness make likely, by using an aid, non-slip shoes, and balance exercises.
CarePath diagnosis
Poor balance related to weak legs and dizziness, as evidenced by swaying when standing, holding the wall, wide steps, and a positive balance test.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Assess balance. | Assessing balance shows how severe the problem is and which causes, such as weak legs or dizziness, need treatment. |
| 2. Use an aid. | A suitable aid widens his base of support and gives him something steady to hold, which lowers the risk of falls. |
| 3. Non-slip shoes. | Non-slip shoes grip the floor and give a stable base, lowering the risk of slipping. |
| 4. Remove hazards. | Clutter, wet floors and loose rugs can trip someone who is unsteady, so removing them cuts the chance of a fall. |
| 5. Teach balance exercises. | Balance exercises strengthen the muscles and reflexes that keep a person upright, improving stability over time. |
| 6. Assist. | Help close by can catch him if he sways, which prevents a fall while his balance is poor. |
Expected outcomes
- No falls.
- Balance score improves in 2-4 weeks.
- Walks with the correct aid.
- Patient does balance exercises.
Linking the data to the diagnosis
The patient sways when he stands, holds the wall, takes wide steps, and has a positive balance test. These findings are present now, so the correct choice is the actual statement Poor balance (M16) and not a risk statement. It is also different from Likely to fall (S1), which describes the chance of a fall. The plan therefore aims to improve balance and to prevent the fall that his weak legs and dizziness make likely, by using an aid, non-slip shoes, and balance exercises.