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6 Assisting with Ambulation

Assessment

  • Reviewed client’s chart for ambulation orders.
  • Assessed client’s physical readiness.
  • Assessed client understanding of ambulation technique.
  • Determined optimal time for ambulation.
  • Assessed degree of assistance client needed.

Nursing Diagnosis

  • Developed appropriate nursing diagnosis based on assessment data.

Planning

  • Developed individualized goals for client based on nursing diagnosis and identified expected outcomes.
  • Prepared client and room- appropriate footwear, adequate lighting and a clear path.

Evaluation

  • Assessed client’s response to ambulation, including vital signs and energy level.
  • Assessed subjective response regarding ambulation.
  • Assessed gait and body alignment.
  • Identified unexpected outcomes.
  • Immediately reported any injury sustained during procedure, alteration in vital signs, or inability to ambulate.
  • Recorded on client chart: type of gait used, amount of assistance required, distance walked and tolerance of activity.

Assisting with Ambulation

Implementation

  1. Performed hand hygiene.
  2. Applied ambulation belt if necessary. Assisted client to standing position and observed balance.
  3. Positioned self on client’s weaker side.
  4. Assisting using a walker -Non Weight Bearing (NWB) & Partial Weight Bearing (PWB):
    1. Ensured handle is at client’s wrist level and elbows are flexed at 15-30 degree angle.
    2. Had client lift (roll) walker forward 15-20 cm. (6-8 inches), put it down and take a step.
    3. Continued according to orders and client tolerance.
  5. Assisted using crutches – Partial Weight Bearing (PWB) & Full Weight Bearing (FWB one leg):
    1. Ensured that the axillary pad is 3 finger breaths below axilla.
    2. Had client place crutches 15 cm (6 in.) ahead and 15 cm. (6 in.) to the sides.
    3. For “swing to”, had client swing feet to crutches (PWB).
    4. For “swing through”, had client swing feet past crutches (PWB)
    5. For “2-point gait” (PWB each leg), had client move crutch ahead at the same time as opposite leg
    6. For “3-point gait” (wt. bearing on one leg), had client start with strong leg, then crutches and affected leg.
    7. For “4-point gait” (wt. bearing on both legs), had client move each leg with alternating crutch.
    8. Continued according to orders and client tolerance.
    9. For stairs, had the client place the unaffected foot higher than the affected foot.
  6. Assisting using a cane:
    1. Had client hold cane on unaffected side, 10-15 cm. (4-6 in.) to side of foot with 15-30° of elbow flexion.
    2. Had client move cane forward 15-25 cm. (6-10 in.)
    3. Continued according to orders and client tolerance.
  7. Assisting ambulation with one nurse:
    1. Had client take a few steps while supporting at waist – ambulation belt.
    2. Took a few steps forward with client and assessed for strength and balance.
    3. Continued according to orders and client tolerance.
    4. Allowed client to return to bed or chair if weak or dizzy.
  8. Assisting ambulation with two nurses:
    1. Nurse stood on each side of the client while holding on to ambulation belt.
    2. Stepped in unison with client.
    3. Continued according to orders and client tolerance.
  9. Returned client to bed or chair, ensuring safety and comfort.
  10. Washed hands.

Faculty Comments
Assessment Nursing Diagnosis Planning Implementation Evaluation
Attempt Number &
Outcome Number
Student Signature  
 

 Faculty Signature
 
 		 Date
 
 
The student was unable to perform the skill competently and will be retested.
 
 

 Faculty Signature
 
 		 Date
 
 

License

Practical Nursing Program Skills Checklist Copyright © 2023 by Nova Scotia Community College. All Rights Reserved.

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