A crucial part of the geriatric nursing assessment is the observational gait analysis performed as the client enters the room. While some changes, such as slightly slower walking speed, may be a normal part of aging, significant deviations are abnormal and warrant documentation and further investigation. The nurse’s keen observation can be the first step in identifying a serious health issue and implementing fall prevention strategies.
Observing the Client's Ambulation
When an older client walks into the examination room, the nurse should assess several key components of their gait. These observations provide valuable clues about the client's neurological, musculoskeletal, and overall functional status. The assessment is not just about observing the feet, but the entire body's coordination, balance, and rhythm.
Abnormal Gait Findings to Document
Abnormal findings are those that deviate from a smooth, rhythmic, and well-coordinated pattern. The specific characteristics to note include:
- Shuffling or Festinating Gait: This is characterized by small, shuffling steps where the client's feet do not lift completely off the ground. This can be a sign of Parkinson's disease or other neurological disorders affecting the basal ganglia. The client may also have difficulty initiating movement or appear "frozen" in place.
- Balance Difficulties or Ataxia: The client may appear unsteady, sway from side to side, or have a wide-based stance as they walk. An ataxic gait is often irregular and uncoordinated and can be a sign of cerebellar dysfunction, sensory issues, or even alcohol use.
- Asymmetry: A normal gait is symmetrical, with equal movements on both sides of the body. An obvious limp or inconsistency in step length and timing between the left and right sides is abnormal. This can indicate pain, weakness on one side (hemiparesis from a stroke), or musculoskeletal problems like a hip or knee issue.
- Foot Drop or Steppage Gait: If the client has difficulty lifting the front part of their foot, they may compensate by lifting their leg higher than normal to avoid dragging their toe. The foot may appear to slap the ground as it lands. This can be caused by nerve damage or muscle weakness.
- Circumduction: This involves swinging one leg out in a semi-circular arc rather than walking it forward in a straight line. It often occurs in clients with weakness or spasticity on one side of their body, such as following a stroke.
- Changes in Posture and Arm Swing: A stooped posture, reduced or absent arm swing, or a forward-leaning stance can be abnormal findings. These can indicate a variety of neurological conditions and may increase the risk of falling forward.
Normal vs. Abnormal Gait in Older Adults
It is important for nurses to distinguish between expected age-related changes and findings that signal a pathological issue. The following table provides a comparison:
| Feature of Gait | Normal Age-Related Change | Abnormal Finding to Document |
|---|---|---|
| Speed | Slightly slower walking pace. | Marked, progressive slowness or a hurried, shuffling pace (festination). |
| Base of Support | Slightly wider stance to increase stability. | Excessively wide base or significant side-to-side swaying (ataxia). |
| Double Stance Time | Increased time spent with both feet on the ground. | Freezing or hesitancy when starting or turning. |
| Step Symmetry | Symmetrical movement is maintained. | Asymmetrical step length or uneven rhythm. |
| Foot Clearance | Smooth lifting of feet off the floor. | Foot dragging, scuffing, or a high-stepping (steppage) gait. |
| Arm Swing | Reduced but symmetrical arm swing. | Asymmetrical or completely absent arm swing. |
| Posture | Mild flexion of hips and knees. | Significant forward lean or stooped, rigid posture. |
Causes of Abnormal Gait
Abnormal gait in older adults is often multifactorial and can be caused by a combination of underlying medical issues. The nurse's role includes identifying these potential root causes and referring the client for further assessment. Common etiologies include:
- Neurological Conditions: Disorders like Parkinson's disease, dementia (including Normal Pressure Hydrocephalus), stroke, and peripheral neuropathy often manifest as gait abnormalities.
- Musculoskeletal Disorders: Conditions such as osteoarthritis of the hip or knee can cause pain and stiffness that lead to an antalgic (pain-avoiding) gait. Muscle weakness, particularly in the lower extremities, can also contribute.
- Sensory Deficits: Vision problems, vestibular dysfunction (inner ear issues), and reduced proprioception (sense of body position) can all lead to unsteady walking and balance issues.
- Cardiopulmonary Issues: Heart or lung conditions can cause fatigue, shortness of breath, and decreased endurance, all of which affect a client's ability to walk normally.
- Adverse Drug Effects: Certain medications, including sedatives, antidepressants, and blood pressure medications, can cause dizziness, altered balance, or orthostatic hypotension (a drop in blood pressure when standing).
- Psychological Factors: A fear of falling, often stemming from a previous fall, can cause a cautious or hesitant gait pattern.
Conclusion
When an older client walks into the examination room, a shuffling, asymmetrical, or unsteady gait is an abnormal finding that a nurse must document. While some changes in gait are expected with aging, significant deviations often signal an underlying health problem, such as a neurological disorder, musculoskeletal issue, or side effect from medication. Observing the client's ambulation provides essential, early clues that can prompt further evaluation and intervention. By meticulously documenting these abnormal findings, nurses play a critical role in proactive geriatric care, helping to reduce the risk of falls and address the underlying health issues that compromise their clients' mobility and independence.
What to Document for Abnormal Gait
- Specifics of the Gait: Document the type of abnormality observed (e.g., shuffling, wide-based, ataxic, asymmetrical, foot drop).
- Use of Assistive Devices: Note if the client uses a cane or walker and if it provides adequate support or if the client still appears unsteady.
- Turning Behavior: Record how the client turns; normal is a fluid motion, while abnormal includes an "en bloc" turn (turning like a statue) or multiple hesitant steps.
- Safety Risk: Describe any noticeable balance issues, staggering, or signs that indicate a high fall risk.
- Associated Symptoms: Include any other related observations, such as diminished arm swing, flexed posture, or facial expressions that indicate pain.
