Management of a Patients Needs - Case Study Example

Care study: Management of a Patient’s needs in a communal setting suffering from a diabetic foot Ulcer Table of contents Introduction 3 Presentation of patient’s case 4 Diabetic foot ulcers 5 Theories and models related to nursing 7 RLT Model 8 Nursing Process 9 Assessing 10 Planning 12 Implementation 12 Evaluation 14 Recommendations and Conclusion 15 References 17 Exhibits 19 Introduction Diabetes results in a number of complications and the most distressing to patients is DFUs (diabetic foot ulcers).Foot ulcers affect patient’s quality of living, escalates death incidence and a prolonged stay in the hospice. Diabetes exists in two primary forms that include Type 1 and 2; however, in the United Kingdom, about 10% of patients are affected by Type 1 while approximately 90% suffer Type 2 diabetes. Each year, over 75,000 reported deaths in the UK is associated with diabetes mellitus (Type 1 and 2). Other complications associated with the condition (diabetes mellitus) include, for instance, amputation, kidney failure and blindness. It is estimated that each year, over 6000 people in the UK who are diabetic undergo the amputation of either leg or foot. Researchers in the medical field also contend that if the current trend in the UK continues, the amputation rate will rise (McInnes, 2012). On another note, the expenditure on diabetes care by the NHS is almost reaching the £10billion mark, which is about 10% of NHS total budget. Most of the expenses tend to cater for the management of avoidable complications. Conversely, other than direct costs, there are also indirect costs that increase the figure to approximately £ 23.7 billion. However, among the most costly consequences of diabetes in the UK is the number of hospital admissions. It is estimated that at any one time, averagely 15% of inpatients in the hospitals are recorded as patients with diabetes (NHS, 2012). The government acknowledges the adverse effects of diabetes on its citizens and has come up with a vision that targets the care of diabetes under the NSF (National Service Framework for Diabetes). On the other end of the spectrum, improvements in the care of diabetes are still needed due to its increased prevalence. For instance, there is the need for a multidisciplinary approach in the treatment of complications associated with diabetes such as FDUs (Yazdanpanha, Nasiri & Adarvishi, 2015). In this paper, the focus will be on how a multidisciplinary approach can be used to improve the care of a patient with neuropathic DFU. The guidelines of NMC (2008) on issues regarding confidentiality and consent will inform the use of a pseudonym to protect the identity of the patient presented in this assignment. In addition, this paper will also provide a brief outline of DFUs, pathophysiology and treatment. Other discussions will focus on the significance of applying evidence-based care. An explanation of on the genesis of nursing models will be provided, and including their significance in the nursing practice. This assignment will also emphasise on The RLT model (Roper, Logan and Tierney Activities of Living model) and how it can be used to improve patient care. Further, this paper will also address recommendation for the future of nursing practice. In essence, the patient presented in this paper is suffering from type2 diabetes and has recently complained of mild swelling and ulceration in his left foot. Consequently, this paper intends to explore how evidence-based care can be applied to the presenting case, and in a communal setting in a period of 3weeks. On this note, the four stages of the nursing process will guide the formulation of a care plan that is comprehensive, holistic and person-centred. Presentation of patient’s case David is 65 years old and lives alone on his farm on the outskirts of the city. He is a widower, and his adult children live far away from home. David does not exercise on a regular basis and also admits to occasional dietary discretion. However, he denies experiencing chest discomfort or breathing problem. Recently, David noticed a mild swelling and ulceration on his left foot, and he is concerned regarding the condition. David has struggled with type 2 diabetes mellitus for the past 15 years and hypertension for 10years and dyslipidaemia for 8years. For his hyperglycaemia, he has been receiving a prescription of metformin 1000mg two times a day and 18 units of glargine insulin every hour of sleep, and also takes 5units of lispro insulin prior to taking his meals. For his hypertension, David takes 25mg of hydrochlorothiazide every morning, 5mg of ramipril also every morning and 5mg of amlodipine before sleep. His dyslipidaemia is treated using atorvastatin 10mg before sleep. David was regularly attended to at the local clinic for the management of diabetes by the practice nurse. However, because he has been experiencing reduced mobility in recent times, he was referred to an interdisciplinary team based at the local hospital. Diabetic foot ulcers Diabetes Mellitus has many complications and among them is a diabetic foot ulcer that is considered to affect approximately 15% of individuals with diabetes. On the other hand, the recurrent nature of DFUs can affect the patient’s mental health. For example, an ulcer that appears benign in a patient may in the end lead to amputation (Cundell, 2011). In the UK, a significant number of amputations are often associated with diabetes mellitus. Consequently, this contributes to severe morbidity and mortality rate. Further, the financial burden of DFUs is substantial for both the patient and NHS (McInnes, 2012).In most instances, diabetic foot ulcer is associated with peripheral neuropathy that is a disorder prevalent among patients suffering from diabetes. The condition often affects the nerves in the lower leg, resulting in muscle weakness and numbness. In addition, the condition is also associated with a decrease in sensation, for example, to temperature and pain. However, most people suffering from diabetes are unaware regarding the genesis of these complications. As a result, they end up developing chronic and non-healing wounds. On the other hand, the areas of the foot where DFUs are common include, for instance, areas exposed to sustained pressure. In this sense, the common sites include the lower side of the toes, the heel and the tips of either first or second toe (Leung, 2007). There are many factors associated with the development of DFUs. For example, poor blood supply and loss of sensation is one of the major contributing factors. A progressive damage to nerves and lack of protective sensation is the reason diabetes patients are not able to feel any pain. In most of the times, patients with diabetes fail to notice foot injuries, and this may worsen their condition. In addition, nerve damage on the foot also affects diabetic patient’s mobility because of lack of nerve signals in small muscles of the foot. This leads to abnormal pressures in the foot sites that are not exposed to pressures in normal circumstances. The consequence in this sense is the formation of callus and ulcers (Myles, 2007).On the other end, the reluctance to identify fractures in the foot can increase foot deformities. As a result, the pressure is exerted on the foot sites that were not affected previously, and this also increases the formation of callus and ulcer. Arterial disease among diabetes patients tends to vary, and the danger of contracting PVD (peripheral vascular disease) is greater among diabetes patients. In addition, the acuteness of PVD in diabetic patients has a greater influence on the development of ulcers and their ability to heal. Poor blood flow also affects the healing of wounds among patients with diabetes. The delayed healing is because the wound lacks sufficient supply of oxygen, nutrients and white blood cells. Insufficient blood supply also exposes the patients with diabetes to the risk of developing gangrene, and the possibility of facing amputation if proper treatment is not provided on time (Pham, Rich & Veves, 2000). With regard to the management of diabetes, primary prevention is crucial; however, secondary prevention is also necessary for effective care of FDUs. Since the rate of recurrence is often high, it is important to develop an effective care. This includes, for example, identifying prevention strategies such as optimal glycaemic control to help minimize the recurrence of DFUs. In addition, the management of foot ulcers also requires the patient to inspect his feet on a daily basis and cleanse the wound. Using topical moisturisers is also necessary for maintaining a healthy skin and reducing the risk of breakdown and injury (Pham et al., 2000). Diabetes patients with DFUs also need to wear the correct footwear that can provide adequate support, and avoid walking barefoot. Managing a patient with diabetes also requires a holistic approach that involves, for example, identifying all the complications associated with diabetes. Some of the issues that needs to be addressed prior to initiating treatment include identifying where the ulcer is located, whether there has been a recurrence and the period, the course of the previous and current ulcer, how the ulcer look like and whether the bone is visible (Pham et al., 2000). Addressing these issues help in the development of an effective treatment plan. Some of the underlying reasons for recurrence or development of a new ulcer at the same site include, for example, osteomyelitis or existence of a foreign body. It is also important to refer a patient to a multidisciplinary team for further treatment and care. On the other hand, where the wound appears superficial, and there is no presence of underlying structures, the management of local wound environment requires the adoption of good local wound bed preparation principles (Leung, 2007). In the UK, statistics shows that approximately 7% of people with diabetes also have diabetic foot ulcer. However, most complications can be avoided with proper management (McInnes, 2012). Theories and models related to nursing According to Johnson and Webber (2005), nursing models emerged in the 1950s with a shift from traditional handmaiden approach to a wider focus on human necessities. Among the foremost originators of nursing include Hildegard Peplau who is recognised for reconceptualising the therapeutic relationship. Peplau saw the practice nurse as an agent of change; however, while she specialised in psychiatric nursing, her model was applied by all nurses. On the other hand, Virginia Henderson described nursing as a profession that involved responding to functional human needs (Johnson & Webber, 2005). As an evolving profession, the theories diversified and each focused on assumptions regarding human health. For example, Sister Callista Roy’s model (1980) was influenced by systems thinking. She described human beings as having a natural tendency to meet biological, psychological and social needs. However, she also reiterated that where there was a maladaptive response, a nursing intervention was necessary. The development of nursing theory reflects on the improvement of intellectual culture associated with nursing. For instance, Roper, Logan and Tierney (1980) oriented nursing to twelve activities. Their model was similar to Henderson, but they explicitly focused on the nursing process that included assessment, planning, implementation and evaluation. Further, theorists have also attempted to develop an approach to nursing that is comprehensive, rational and systematic. Due to the existence of various models, different categorizations are provided. For instance, Aggleton and Chambers (2000) view models as either interactional or developmental. However, such discussion bring confusion as explained by McKenna and Slevin(2008) who noted that, the work of Callista Roy (1980) was viewed by Williams, Kim, Beckstrand and Webb as a conceptual framework, abstract theory and an ideology. However, Riehl and Roy (1980) definition of nursing tends to clear the confusion noted by McKenna and Slevin (2008). According to Riehl and Roy (1980), a nursing model needs to be systematic, scientifically oriented and relates to a logical set of concepts that identifies important components of nursing practice. Conversely, Fawcett (2005) provided a hierarchical classification that ranges from meta-paradigms to empirical indicators. Most nursing theorists expected that models related to the nursing practice would help practitioners to develop autonomy and accountability with regard to clinical decisions, establishing an organised care and improving the nursing profession. On the contrary, models are also seen as a diversion from intuitive care. In this sense, developing, teaching and the application of a particular nursing theory is a challenging task. Further, practical application is impeded by a number of challenges, but these can be addressed. In essence, discipline is pivotal in the construction of nursing’s theoretical knowledge. However, regardless of the protracted debate, the exact definition of nursing is still elusive. Consequently, as a way of accommodating the diversity of the nursing profession, the term holistic care tends to be the defining statement. On the other hand, Clarke (1999) notes that, the notion of holism is often confused by the practice nurse to mean an eclectic approach, but its real meaning is the integration of body and psyche. It is important for nurses to focus nursing theory on holistic care. Theory in this sense should serve the purpose of informing practice in an iterative process. RLT Model This model as applied in nursing practice emerged in the 70s and is considered as the first nursing model to originate from Britain and forms the basis of nursing care in the UK. Compared to other models, for example, this model focuses on a holistic and person-centred care. In this regard, the patient’s wholeness prevails over labelling their state of health. The RLT model focuses on 12 activities of living and also recognises the importance of linking medical and nursing goals. Further, this model plays an important role in terms of supporting a multidisciplinary approach to care. In essence, linking nursing with ALs is influenced by the understanding that health and ill-health are intertwined with lifestyle (Williams, 2015). The 12 activities posited by Roger, Logan and Tierney (2001) include: eating, drinking, controlling the body temperature, working, playing, expressing sexuality, keeping a safe environment, breathing, communicating, sleeping and dying. Additional aspects of RTL model include, for example, the dependence and independence continuum, the progression of an individual along a lifespan continuum and the idea of individuality. On the other hand, a consideration of biological, psychological, socio- economic, environmental and political factors allows nurses to improve individualised and person-centred care (Williams, 2015). In addition, it is also imperative to note that these aspects should be applied in the assessment of the patient to avoid any flaws. However, despite the widespread application of RLT model, it also faces criticism due to its simplicity and disassociation. Other antagonists of the model insist that the ALs are physically oriented and tends to hinder care that focuses on performing all the activities. Similarly, nurses also face a challenge in terms of fitting patients into all the categories of ALs. As such, the effectiveness of the model depends on its appropriate utilisation (Mooney & O’Brien, 2006). As stated in the guidelines of NMC (2008), establishing an individualised care is necessary on enhancing a patient’s well-being; however, critics are convinced that a focus on ALs only supports generic care. Other critics also raise concerns regarding the lack of a focus on a patient’s social and psychological needs that also impact on health. However, while the model faces criticism, it is also recognised for being simple and adaptable. On the same note, the model lacks ambiguity and tends to promote a multidisciplinary approach to patient care (Mooney & O’Brien, 2006). Nursing Process Nursing process denotes a structured and systematic decision-making process in the provision of health care. This process was developed by Yura and Walsh in 1967, and used in the United States. The process enables nurses to provide individualised and evidence-based care. In addition, this process plays an important role in terms of promoting critical thinking in the health care settings. Before it was introduced for application in the nursing field, care delivery to an extent relied, for instance, on instinct or intuition. In essence, the nursing process consists of four overlapping steps. They include assessment, planning, implementation and evaluation (Basford & Slevin, 2003). In the UK, the focus is on the four stages is in tandem with the competency standards for nursing students (NMC, 2010).On another note, the nursing process is different from the medical process because, the focus is on both the presenting medical problem and its impact or human response. Consequently, nursing process emphasises a holistic approach to health care provision. The all-rounded nature of the nursing process has led to its application in different countries around the world, and it eliminates any conflict of interest with regard to either culture or professionalism. Conversely, the nursing process cannot work on its own and requires a framework to realise its effectiveness (Basford & Slevin, 2003). According to Williams (2015), the nursing process may have faced challenges in its initial inception in the UK. Resistance to the nursing process in the UK may also have emerged in the initial stages due to the view that it increased workload and the related paperwork. On the other end of the spectrum, nursing process is considered as a problem-solving method for the provision of care, and this can create the risk of nurses focusing only on the patient’s problems. However, when integrated with a nursing model, the promotion of health and management tends to be the focus of the process (Baford & Slevin, 2003). Assessing Assessment as a stage in the nursing process focuses on the holistic needs of the patient with diabetes. Further, assessment requires nurses to develop effective communications skills that include, for instance, the skill of active listening to understand the patient’s problem. The NMC (2008) further identifies other skills that are necessary in the assessment process that include, for example, critical thinking and professional judgement. On the other hand, assessment involves a process of information gathering to derive both objective and subjective data. While objective data can be measured, subjective data, on its part provides important information that facilitates the development of an individualised care plan. The source of subjective data is often the patient; however, other necessary information can be collected through secondary sources that include, for instance, caregivers, health providers or family members (Munroe, Curtis, Considine & Buckley, 2013). David’s capillary blood glucose was 9.94 mmol/L; however, individuals with type 2 diabetes are required to record a BG of about 5.5 mmol/L before a meal and not more than 7.8mmol/L two hours after a meal (Graffigna et al., 2014).David also admitted to sleep on the couch since his mobility problems hindered him from getting in and out of the bed. The ulcer on his feet located on the second toe measured 4mm×5mm a was classified as neuropathic by the expert team for foot care. It is always critical to know the type of the ulcer so as to develop an appropriate treatment (Yotsu et al., 2014). The common areas where neuropathic DFUs are located include, for example, the metatarsal heads and the heel. The wound on David’s feet did not seem infected, but there was the minimal presence of exudate. In relation to the Texas system used to classify diabetic foot ulcers (see Exhibit 1), David’s ulcer is classified as 1A. The Texas system is advantageous in the sense that it provides a better prediction regarding the outcome of DFU. After the wound is accurately assessed, there is need to document the finding as a way of establishing the basis for treatment and monitoring of changes. As explained by NICE (2013), older people are at higher risk of falls and as such, a comprehensive assessment was necessary to assess David’s risk of falling. In this regard, the Tinetti Balance Assessment Tool (1986) (See Exhibit 2) is necessary for assessing balance and movement of limbs. David scored 14, and, as a result, was considered to be at a high risk of falling. Other recordings taken include his weight and height that was used to calculate his BMI. His BMI was 33.5 thus indicating that he was overweight (RCN, 2014). For the assessment of malnutrition, the Malnutrition Universal Screening Tool was used, where David scored 0. The score indicated a low risk of malnutrition; however, David; admitted to occasional dietary indiscretion which may have had a negative impact on his nutritional intake. According to Wild et al. (2010), malnutrition is a common problem among older patients and tends to occur rapidly. Further, those living alone like David are at a greater risk of becoming malnourished. In essence, a diet that is rich in nutrients is vital in the healing of wounds. Adequate hydration is also necessary because dehydration tends to reduce the blood volume and as a result, prevent the supply of nutrients and oxygen to the wound site. In dealing with David’s overweight, the priorities from the RLT model that needs to be emphasised for his care include ensuring he stays in a safe environment, embrace a healthy diet and improve on his water intake (Williams, 2015). Planning The needs emphasised in the assessment phase are transformed into short and long term goals as a way of enhancing the recovery process. According to Hogston and Marjoram (2011) goals can be set by relying on the MACROS criteria; however, the goals should focus on PRODUCT. When setting goals, it is important to involve the patient as a way of enhancing their involvement in the care plan. In David’s case, the aim is to improve the healing process of the wound using appropriate techniques over a period of three weeks. David also needs a short term goal, and this involves, for instance, achieving appropriate glycaemic control. David also need pressure offloading to help in wound healing and prevent further complications. In addition, different interventions will be necessary to help David achieve the desired outcomes (Chow, Lemos & Einarson, 2008). Implementation Implementation involves taking action with regard to the established plans and goals. On another note, a multidisciplinary approach is appropriate for a patient with a foot ulcer. In this regard, effective communication skills between the health care providers and the patient are important in ensuring that the patient’s needs are met (Braun et al., 2014). The initial goal for David was to heal the wound, which requires TIME framework for managing the healing process. According to the European Wound Management Association (2004), TIME framework denotes a structured process in the clinical assessment and optimisation in the management of wound healing using, for instance, epithelialisation or secondary intention. The management in this sense involves the control of infection and inflammation, moisture balance, epithelial advancement and tissue management. For David’s wound, debridement is also necessary to remove damaged tissue and restore the wound base (Lebrun, Tomic-Canic & Kirsner, 2010). Further, the type of wound dressing that is used for foot ulcers has an impact on the growth of new tissues (Wounds International, 2013). David also reported not being allergic to any form of dressings or treatments. His wound was cleansed using the wet to dry dressing method. This type of dressing is ideal for debriding procedure and also improves wound bed preparation creating an ample environment for its healing. Further, this dressing mode is considered to be absorptive and adherent; in addition, it is cost effective compared to other aseptic techniques and is commonly used around the world. However, its drawback is that dressing changes are done frequently depending on the severity of the wound. Before removing the dressing, it should be moistened to reduce the risk of bleeding. In addition, the use of a gentle cleanser is necessary to reduce wound irritation (Turns, 2015). David had no complaints regarding the choice of the wound dressing. Further, the district nurse also visited him at his home every day and assessed and monitored his wound. Conversely, in the healing process of foot ulcers, pressure relieving is important. In addition, removable offloading devices that include, for example, healing sandals, are also considered effective in enhancing pressure distribution (Eddy & Price, 2009). According to Perry (2013), the patient’s preference regarding the choice of treatment rather than the device chosen contributes to successful offloading. As such, it is important to involve the patient in the process of deciding on the treatment choice. This is because; the treatment may turn ineffective especially when the patient is uncomfortable with the choice of treatment. In this sense, David was made aware regarding the significance of offloading and the various devices used. David admitted that initially he was uncomfortable using pressure relieving device because he believed it would worsen his mobility problems. He preferred off-loading shoe which was provided by the MDFT. David was also equipped with both written and verbal information regarding good foot care. Additional information that he received focused on how to keep his weight in check (Clair, 2011). As a result of the challenges that David is facing such as mobility and balance problems; the team involved with falls prevention visited him at his home to carry out a risk assessment. This team also included physiotherapists and occupational therapists whose role was to help David reduce the risk of falls. Their work involved making changes in David’s house and providing him with relevant information regarding falls prevention. The team also taught David a few exercises that could help to improve his mobility challenges, for instance, within the house (Iraj et al., 2013). David was also visited by a practice nurse specialising in diabetes cases, who advised him on the importance of a healthy diet and how to manage his sugar levels. However, while advising David on the ideal diet, the nurse also took into consideration socio-economic factors to ensure the diet advised is within the limit of his budget. Dietary intervention is necessary in terms of improving glycaemic control and healing of the wound. (Turns, 2015). According to a UK survey, patients contend that consulting a diabetes specialist nurse on occasional basis helps them to improve their diabetes management (Leung, 2007). David was also given a glucometer to help him manage his blood sugar levels. The nurse also assured David of assistance in case he encountered a challenge in managing his blood sugar levels. In this regard, David was provided with a hotline number where he could call for help. Evaluation Evaluation is necessary because it helps to ascertain whether the interventions used are effective. In addition, thorough evaluation helps to avoid errors that may impact negatively on the care provided (Williams, 2015). The nurses should also observe and measure the progress made; however, patients should also provide feedback regarding the interventions used (Braun et al., 2014). After a specific period of time (three weeks), David felt healthier, and this is as a result of the changes he made to his diet. However, while MUST identified David not to be at risk of malnutrition, it was also evident that his diet lacked the required nutrients. The results derived from the assessment tools are vital in making clinical decisions (Eddy & Price, 2009). David reported doing regular exercises and wearing his offloading shoe. The progress of his recovery was on track as evident on the healing of the wound. His blood sugar level also improved and he reported feeling comfortable moving around in his house. He also appreciated the education he received on good foot care and nutrition respectively. Recommendations and Conclusion The management of DFUs is challenging, and as such, it is important to refer patients for specialised care. In addition, it is important to consider patient education in the management of diabetes patients with DFUs. This is because; initiating an effective treatment plan requires the patient to grasp the rationale behind his or her treatment. The patient also needs to develop awareness regarding what to do to prevent further complications associated with DFUs (Perry, 2013). This paper has shown how a properly planned care system can enhance the provision of a comprehensive and person-centred care. The approach that this paper emphasises is a structured and evidence-based care plan to treat complications such as DFUs. Further, the presentation also focused on the various nursing models that guide the nursing profession. However, while there are many nursing models that are used in different regions around the world, this paper focused on RLT model that is commonly used in the UK for patient care. The RLT model was used as a framework for the four steps involved in the nursing process that include: assessing, planning, implementation and evaluation. As a result, the process ensured that David’s care was managed appropriately, which contributed to a positive outcome. In implementing David’s care, the adoption of a multidisciplinary approach played an important role in ensuring that David had access to a comprehensive care plan. After the evaluation of David’s care, among the recommendation that was provided include, for instance, patient education. Patients need to learn more about their condition as a way of improving interventions and prompt treatment of complications that are associated with diabetes mellitus (NMC, 2008). The high prevalence of complications associated with diabetes mellitus is because of lack of awareness. As a result, patient education will help, for instance, to reduce cases of amputations that are as a result of delays in seeking early treatment for DFUs. David was also provided with informative material regarding diet management to ensure his immunity improves. Initially, David admitted to dietary indiscretion, and this may have contributed to his complications. While the MUST tool showed David was not at risk of malnutrition, advice on healthy eating provided by the diabetes specialist nurse was still necessary. Other than seeking appropriate and prompt treatment of complications associated with diabetes, the management of the condition should also involve healthy eating, doing regular exercises and weight management. References Aggleton P. & Chalmers H., 2000. Nursing Models and Nursing Practice, 2nd edn. Basingstoke: Macmillan. Basford, L., & Slevin, O., 2003.Theory and Practice of Nursing: An Integrated Approach to Caring Practice. Cheltenham: Nelson Thornes Ltd. Braun, L., Fisk, W., Lev-Tov, H., Kirsner, R., & Isseroff, R., 2014.Diabetic foot ulcer: an evidence-based treatment update. American Journal of Clinical Dermatology, 15(3), 267-281. 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Comparison of characteristics and healing course of diabetic foot ulcers by etiological classification: Neuropathic, ischemic, and neuro-ischemic type. Journal of Diabetes & its Complications, 28(4), 528-535. Exhibits Exhibit 1: University of Texas Classification of Diabetic Foot Wound Exhibit 2: TINETTI BALANCE ASSESSMENT TOOL Tinetti ME, Williams TF, Mayewski R, Fall Risk Index for elderly patients based on number of chronic dis-abilities. Am J Med 1986:80:429-434 PATIENTS NAME ______________________ D.o.b. ___________ Ward ______ BALANCE SECTION Patient is seated in hard, armless chair; Date Sitting Balance Leans or slides in chair = 0 Steady, safe = 1 Rises from chair Unable to without help = 0 Able, uses arms to help = 1 Able without use of arms = 2 Attempts to rise Unable to without help = 0 Able, requires > 1 attempt = 1 Able to rise, 1 attempt = 2 Immediate standing Unsteady (staggers, moves feet, trunk sway) = 0 Steady but uses walker or other support = 1 Balance (first 5 seconds) Steady without walker or other support = 2 Standing balance Unsteady = 0 Steady but wide stance and uses support = 1 Narrow stance without support = 2 Nudged Begins to fall = 0 Staggers, grabs, catches self = 1 Steady = 2 Eyes closed Unsteady = 0 Steady = 1 Discontinuous steps = 0 Turning 360 degrees Continuous = 1 Unsteady (grabs, staggers) = 0 Steady = 1 Sitting down Unsafe (misjudged distance, falls into chair) = 0 Uses arms or not a smooth motion = 1 Safe, smooth motion = 2 Balance score /16 /16 . TINETTI BALANCE ASSESSMENT TOOL GAIT SECTION Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace. Date Indication of gait Any hesitancy or multiple attempts = 0 (Immediately after told to ‘go’.) No hesitancy = 1 Step length and height Step to = 0 Step through R = 1 Step through L = 1 Foot clearance Foot drop = 0 L foot clears floor = 1 R foot clears floor = 1 Step symmetry Right and left step length not equal = 0 Right and left step length appear equal = 1 Step continuity Stopping or discontinuity between steps = 0 Steps appear continuous = 1 Path Marked deviation = 0 Mild/moderate deviation or uses w. aid = 1 Straight without w. aid = 2 Marked sway or uses w. aid = 0 Trunk No sway but flex. knees or back or uses arms for stability = 1 No sway, flex., use of arms or w. aid = 2 Walking time Heels apart = 0 Heels almost touching while walking = 1 Gait score /12 /12 Balance score carried forward /16 /16 Total Score = Balance + Gait score /28 /28 Risk Indicators: Tinetti Tool Score Risk of Falls ≤18 High 19-23 Moderate ≥24 Low Read More