Assisting with ambulation is a routine nursing task.
Before assisting with ambulation, you need this information from the nurse and the care plan.
• How much help the person needs
• If the person uses a cane, walker, crutches (p.
543), or an orthotic device (p. 545)
• Areas of weakness—right arm or leg, left arm or leg
• How far to walk the person
• What observations to report and record:
• How well the person tolerated the activity
• Shuffling, sliding, limping, or walking on tip-toes
• Complaints of pain or discomfort
• Complaints of postural hypotension—
weakness, dizziness, spots before the eyes, feeling faint
• The distance walked
• When to report observations
• What patient or resident concerns to report at once
Promoting Safety and Comfort
Assisting With AmbulationSafety
Practice the safety measures to prevent falls (Chapter 14). Use a gait belt to help the person stand and during ambulation.
If a walker is used, remind the person not to pull on the walker to stand. The walker can tip. The person pushes on the ma ress or the chair’s armrests to stand (Chapter 20).
Remind the person to walk normally. Encourage the person to stand erect (upright) with the head up and the back straight. Discourage shuffling, sliding, and walking on tip-toes.
Comfort
The fear of falling affects mental comfort. Explain the purpose of the gait belt. Also explain how you will help the person if he or she starts to fall (Chapter 14).
Assisting With Ambulation
Quality of Life• Knock before entering the person's room.
• Address the person by name.
• Introduce yourself by name and title.
• Explain the procedure before starting and during the procedure.
• Protect the person's rights during the procedure.
• Handle the person gently during the procedure.
Pre-Procedure
1 Follow Delegation Guidelines: Assisting With Ambulation, p. 541. See Promoting Safety and Comfort: Assisting With Ambulation, p. 541.
2 Practice hand hygiene.
3 Collect the following.
• Slip-resistant shoes or footwear
• Paper or towel to protect bo om linens
• Gait (transfer) belt
• Walker or cane (if needed)
4 Identify the person. Check the ID bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
5 Provide for privacy.
Procedure
6 Lower the bed to a safe and comfortable level.
Follow the care plan. Lock (brake) the bed wheels. Lower the bed rail if up.
542
7 Fan-fold top linens to the foot of the bed.
8 Place the paper or towel under the person's feet to protect bo om linens. Put the shoes on and fasten.
9 Help the person sit on the side of the bed. (See procedure: Si ing on the Side of the Bed [Dangling] in Chapter 19.)
10 Make sure the person's feet are flat on the floor.
11 Make sure that the person is properly dressed.
12 Apply the gait belt at the waist over clothing.
(See procedure: Using a Transfer/Gait Belt in Chapter 14.)
13 Position the walker (if used) in front of the person. Or have the person hold the cane (if used) on the strong side.
14 Help the person stand. (See procedure:
Transferring the Person to a Chair or Wheelchair in Chapter 20.) Grasp the gait belt at each side.
15 Stand at the weak side while the person gains balance. Hold the belt at the side and back.
16 Encourage the person to stand erect with the head up and the back straight.
17 Positioning a walker or cane:
a Walker—the walker is 6 to 8 inches in front of the person.
b Cane—the cane is held on the strong side.
1) The cane tip is 6 to 10 inches to the side of the strong foot.
2) The cane tip is 6 to 10 inches in front of the strong foot.
18 Help the person walk. Walk to the side and slightly behind the person on the person's weak side. Provide support with the gait belt (Fig. 34- 28). Have the person use the hand rail on his or her strong side (unless using a walker or cane).
FIGURE 34-28 Assisting with ambulation. The nursing assistant walks at the person's side and slightly behind her. A gait belt is used for safety.
19 For a walker or cane:
a Walker—with both hands, the person pushes the walker 6 to 8 inches in front of the feet.
b Cane:
1) The cane (on the strong side) is moved forward 6 to 10 inches (see Fig. 34-25, A).
2) The weak leg (opposite the cane) is moved forward even with the cane (see Fig. 34-25, B).
3) The strong leg is moved forward and ahead of the cane and the weak leg (see Fig. 34-25, C ).
20 Encourage the person to walk normally. The heel strikes the floor first. Discourage shuffling, sliding, or walking on tip-toes.
21 Walk the ordered distance if the person tolerates the activity. Do not rush the person.
22 Help the person return to bed. Remove the gait belt. (See procedure: Transferring the Person From a Chair or Wheelchair to Bed in Chapter 20.) 23 Lower the head of the bed. Help the person to
the center of the bed.
24 Remove the shoes. Remove the paper or towel over the bo om sheet. Discard the paper or follow agency policy for used linens.
Post-Procedure
25 Provide for comfort. (See the inside of the back cover.)
26 Place the call light and other needed items within reach.
27 Raise or lower bed rails. Follow the care plan.
28 Return the shoes to their proper place.
29 Unscreen the person.
30 Complete a safety check of the room. (See the inside of the back cover.)
31 Practice hand hygiene.
32 Report and record your observations (Fig. 34- 29).
FIGURE 34-29 Charting sample.