00154 Vagabundo

Domain 4: activity/rest
Class 3: energy balance
Diagnostic Code: 00154
Nanda label: wandering
Diagnostic focus: wandering
approved 2000 • Revised 2017

NANDA Nursing Diagnosis Definition

The nursing diagnosis « wandering » is defined as: wandering wandering, repetitive or without a defined purpose that makes the person susceptible to injury; It is frequently incongruous with borders, limits or obstacles.

Definite characteristics

  • File behavior
  • Frequent movements from one place to another
  • Fortuitous wandering
  • RESTALE DEAMBULATION
  • Hyperactivity
  • Inmovility interleaved movement
  • Deamulation in unauthorized spaces
  • Deamulation that begins to get lost
  • Desection of which it cannot be easily deterred
  • Long periods of wandering without apparent destination
  • Continuous movement from one place to another
  • Alternated ambulation periods with rest periods
  • Persistent ambulation in search of something
  • Exploration behavior
  • Search behavior
  • Follow the caregiver as a shadow
  • Allanation

Related factors

  • Alteration of the sleep-vigilia cycle
  • Cognitive dysfunction
  • Desire to go home
  • Neurocomportal manifestations
  • Physiological state
  • Separation of the family environment

Risk population

  • People with preordinary behavior

Associated problems

  • Cortical atrophy
  • Psychological disorder
  • sedation

Suggestions of use

Vagabundo can occur as a result of psychological diagnoses such as confusion. If the defining characteristics of the wanderer occur, this label should be used instead of other broader diagnoses such as injury. This label should not be used to describe sleepwalking.

Suggested alternative diagnostics

  • Acute confusion
  • Chronic confusion
  • injury, risk of
  • Deterioration syndrome in the interpretation of the environment

NOC Results

  • Safe at home: physical arrangements to reduce environmental factors that could cause physical damage or injuries to home
  • Behavior for the prevention of falls: personal, family or caregiver actions, to reduce the risk factors that could cause falls in the personal environment
  • leaks: number of times, in the last 24 hours/week/month (select one), that an individual with cognitive impairment escapes a safe area
  • Risk of escape propensity: an individual’s tendency with cognitive impairment to escape a safe area
  • Handling without risk: displacement without apparent, safe and socially acceptable purpose, of an individual with cognitive impairment

Evaluation objectives and criteria

  • • Demonstrates behavior for the prevention of falls, which is manifested by the following indicators (specify from 1 to 5: never, rarely, sometimes, often or usually):
    • Place barriers to prevent falls
    • Use adequate lighting
    • Avoid disorder, spills and floor reflexes
    • Remove the rugs
    • Makes arrangements to remove snow and ice from passable areas
    • Control the restlessness
  • Other examples

    The patient will be able to:

    • • Do not wander for private or unauthorized sites
    • • Do not miss
    • • Do not abandon the facilities (if you are admitted)
    • • Walk only on a previously established route

    NIC Interventions

    • Dementia management: Provision of a modified environment for the patient who suffers a chronic confusional state
    • Environment management: Security: Control and manipulation of the physical environment to increase security
    • Fall prevention: Use of special precautions with a patient at risk of drops lesions
    • leak prevention: Reduction of the risk of a patient abandoning a therapeutic environment without authorization, when their departure represents a threat to patient or other people’s safety
    • Anxiety reduction: minimum reduction of apprehension, fear, omen or discomfort, related to the feeling of an unknown danger of origin
    • Restriction of an area: Use of the less restrictive limitation of patient mobility in a specific area for security or behavioral management purposes
    • Surveillance: Security: Collection and analysis, continuous and with an end, of information about the patient and the environment to promote and maintain their safety

    Nursing Activities

    Valuations

    • • Evaluate the factors that create a risk for wandering (such as confusion, agitation, anxiety)
    • • (NIC) Environment Management: Security:
      • Identify patient safety needs, based on the level of physical and cognitive functioning, as well as behavior history
    • • (NIC) leak prevention:
      • Monitor potential escape indicators (for example, verbal expressions, proximity of places to vagage, many layers of clothing, disorientation, separation anxiety and longing for home)
    • • (NIC) Dementia management:
      • Determine the type and extension of cognitive deficiencies through standardized evaluation tools

    Patient and family education

    • • Explain to family and friends the best way to interact with a confused person, or with someone who suffers from delirium or dementia
    • • Explain to the family the purpose of precautions such as the restriction of an area, the use of identification bands, the increase in supervision, the use of physical bars and restrictions, etc.
    • • Provide information on ways to create a safe home for the patient

    Collaboration activities

    • • (NIC) leak prevention:
      • Clarify the patient’s legal status (for example, if he is less or adult, if he is in voluntary treatment or by order of a court)
      • Communicate the risk of other caregivers

    Others

    • • Use locks or locks on doors and windows, or automatic goalkeepers in the limits of property
    • • If available, use electronic identification bracelets linked to a national database to locate patients. (In the near future microchips will be implemented for these purposes to patients who do not have the ability to communicate).
    • • Notify the neighbors about the patient’s vagabundo and give them instructions to provide reports if they see the person
    • • If possible, avoid restrictions; Instead, use pressure sensitive alarms (such as chair or bed sensors)
    • • Provide a consistent family environment (for example, avoid room changes and unknown people)
    • • Clearly mark the limits of the patient (a bright color tape on the floor, signs on the doors, etc.)
    • • (NIC) Dementia management:
      • Provide space for a vagabundo and walking walking
      • Place the patient an identification bracelet
    • • (NIC) leak prevention:
      • familiarize the patient with the environment and routine to reduce anxiety
      • Place the patient in a physically safe environment (for example, closed doors or with alarms in the outputs, and blocked windows), as required
      • Increase supervision or surveillance when the patient is in a safe exterior environment (such as sustaining the hand and increasing the amount of personnel to monitor it)
      • Record a physical description (height, weight, eye, hair and skin, and any distinctive characteristic [for a reference in case of escape])
    • • (NIC) environment management: eliminate environmental hazards (for example, loose rugs, and small and mobile furniture)

    At home

    • • Previous activities can be used or adapted for home care