What should the nurse check when assessing a client balance?

September 28, 2025 •

4 min read

According to the CDC, falls are a leading cause of injury among older adults in the U.S., making a thorough balance assessment a critical nursing responsibility. A nurse must check for a client’s stability through a series of observations and tests that evaluate their neurological, musculoskeletal, and sensory functions.

Quick Summary

A nurse should perform a variety of assessments to check a client's balance, focusing on gait, proprioception, and muscle strength. Key assessments include observing the client's walk and performing the Romberg test, which evaluates their ability to maintain stability with and without visual cues.

Key Points

Gait and Posture: Observe the client's walking pattern for steadiness, symmetry, stride length, and excessive swaying to identify mobility issues.
Romberg Test (Proprioception and Vestibular Function): Have the client stand with feet together and eyes open, then closed; significant swaying with eyes closed indicates a proprioception or inner ear deficit.
Lower Extremity Strength: Assess the muscle strength in the client's legs and ankles, as weakness is a major contributor to poor balance.
Sensory Input Integration: Evaluate how the client uses visual, vestibular (inner ear), and somatosensory (touch/pressure) information, and how they compensate for deficits.
Fall Risk Factors: Review the client's medications, medical history, and home environment for potential hazards that increase their risk of falling.
Functional Mobility: Use tests like the Timed Up-and-Go or the 30-Second Chair Stand to assess the client's ability to perform functional, balance-dependent tasks.
Head and Neck Movements: Check for dizziness or vertigo when the client turns their head, as this can indicate a vestibular issue impacting balance.

Introduction to Balance Assessment in Nursing

Balance is a complex function involving the central nervous system, musculoskeletal system, and sensory inputs (visual, vestibular, and somatosensory). A nurse's assessment goes beyond simple observation, involving a systematic process to identify any deficits that could lead to falls or injury. Understanding the comprehensive nature of this assessment is key to providing safe and effective patient care. For instance, an elderly client's balance can be impacted by conditions like diabetes affecting peripheral sensation or inner ear disorders affecting vestibular function.

Key Components of a Comprehensive Balance Assessment

To ensure a thorough evaluation, nurses use a combination of observation and specific tests to gather both subjective and objective data. This helps create a complete picture of the client's balance abilities and potential risk factors. The assessment should be performed in a safe, clutter-free environment, with the nurse prepared to provide physical support if the client demonstrates instability.

Gait Analysis

Observing the client's gait provides crucial information about their coordination, strength, and neurological function. The nurse should look for the following during a gait assessment:

Initiation of Gait: Does the client have difficulty starting to walk?
Walking Pattern: Is the client's gait steady, or does it appear shuffling, unsteady, or wide-based?
Stride Length and Symmetry: Are the client's steps of equal length and height, or is there asymmetry?
Trunk Sway: Does the client sway excessively to one side while walking?
Use of Assistive Devices: Does the client use a cane or walker, and are they using it correctly?
Tandem Walking: Ask the client to walk in a straight line with the heel of one foot touching the toe of the other. This more challenging task reveals more subtle balance issues.

The Romberg Test

This is a classic neurological test used to differentiate between cerebellar ataxia and sensory ataxia, testing the client's ability to maintain balance with and without visual input.

Procedure: Instruct the client to stand with feet together and arms at their sides, with eyes open. The nurse should stand close by to prevent a fall. After a few moments of observation, instruct the client to close their eyes while maintaining the position.
Interpretation: A small amount of swaying is considered normal. A positive Romberg sign occurs if the client significantly sways or loses balance when their eyes are closed, indicating an issue with proprioception or vestibular function rather than a cerebellar problem.

Assessing Musculoskeletal Strength and Range of Motion

Balance depends heavily on muscle strength, particularly in the lower extremities, and joint flexibility. Weakness or limited range of motion can compromise stability.

Muscle Strength: Test the client's strength in their legs by asking them to push and pull against resistance. Have them walk on their toes and heels to test specific muscle groups.
Functional Strength: The 30-Second Chair Stand Test is a simple, effective way to gauge lower body strength. Ask the client to stand up and sit down as many times as possible in 30 seconds.
Range of Motion: Assess for flexibility in the ankles, hips, and spine. Limitations can alter posture and gait, shifting the center of gravity and increasing fall risk.

Sensory Input Evaluation

Balance relies on three primary sensory systems: visual, vestibular (inner ear), and somatosensory (touch, pressure, and proprioception). A nurse must evaluate how a client's impairment in one system might affect their balance and how other systems compensate.

Comparison of Balance-Related Sensory Systems


Sensory System	Primary Function	How the Nurse Assesses	Impact of Impairment
Visual	Spatial orientation and environmental awareness	Observe gait and Romberg test with eyes open; notice how balance changes with eyes closed.	Decreased depth perception, visual field loss, or poor acuity can impair balance.
Vestibular	Detects head motion, rotation, and linear movement	Romberg test with eyes closed; observe for vertigo or nystagmus with head position changes.	Vertigo, dizziness, and a spinning sensation can cause extreme instability.
Somatosensory	Touch, pressure, proprioception from feet and joints	Test sensation in the feet and lower extremities; Romberg test with eyes closed highlights dependency.	Impaired sensation can delay muscle responses to balance loss, creating instability.

Fall Risk Screening

Beyond physical assessment, nurses use specific tools to screen for fall risk, often involving a comprehensive look at the client's history and overall health.

Medication Review: Some medications can cause dizziness, confusion, or slowed reflexes, increasing fall risk.
Medical History: A history of previous falls, neurological conditions, or cardiovascular issues can indicate a higher risk.
Home Environment: A client's home environment, including potential tripping hazards, poor lighting, or lack of grab bars, can be a major factor.

The Nurse's Role in Action

Putting the assessment into practice involves more than just observation. It requires communication, education, and collaboration. A nurse must explain the purpose of the assessment to the client, ensuring they understand each step and feel safe. If deficits are found, the nurse's role is to document the findings accurately and communicate them to the interdisciplinary team, which may include physical therapists, occupational therapists, and physicians. This collaborative approach ensures the client receives a holistic treatment plan tailored to their needs. For example, a nurse might identify a client who relies heavily on visual cues for balance and recommend physical therapy to improve somatosensory and vestibular function, along with strategies to minimize visual conflicts in their home.

An excellent resource for learning more about comprehensive balance assessment and fall prevention strategies is the CDC's STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative.

Conclusion

In conclusion, when a nurse assesses a client's balance, they are conducting a complex evaluation of multiple interconnected systems. This includes observing their gait, performing specific tests like the Romberg test, assessing muscle strength, and considering sensory inputs. The goal is to identify balance impairments and fall risk factors to implement interventions that promote patient safety and independence. By taking a thorough and systematic approach, nurses play a vital role in preventing falls and improving overall client outcomes.

Frequently Asked Questions

The Romberg test is a neurological exam to assess balance. The client stands with feet together, first with eyes open and then with eyes closed. A positive result, where the client sways or falls with eyes closed, indicates a problem with proprioception (sense of body position) or vestibular function rather than cerebellar function.

Nurses perform gait analysis, observing the client's walking pattern, stride, and any unsteadiness. They may also use functional tests like the Timed Up-and-Go, which assesses mobility and fall risk, or the 30-Second Chair Stand Test, which measures lower body strength.

A client's medication can significantly impact balance. Some drugs cause side effects like dizziness, confusion, or slowed reflexes, which can increase the risk of falling. A nurse should always perform a medication review as part of a comprehensive balance assessment.

The inner ear houses the vestibular system, which is critical for balance and spatial orientation. When assessing balance, the nurse is effectively checking the health of this system, especially during the Romberg test when visual cues are removed. Impairments can lead to vertigo and dizziness.

Observing a client's gait provides essential clues about their coordination, strength, and neurological status. An unsteady, shuffling, or asymmetrical walk can indicate underlying balance issues that the nurse should investigate further. Changes in gait are often early signs of instability.

Common fall risk factors include muscle weakness, visual impairments, certain medications, a history of previous falls, neurological conditions, and environmental hazards like poor lighting or clutter in the home.

Static balance involves maintaining stability while standing still (assessed by tests like the Romberg), while dynamic balance is the ability to maintain stability during movement (assessed during gait analysis or functional reach tests).