Skill 9-10 Assisting a Patient with Ambulation using a Cane PDF

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1

Skill Checklists for Taylor’s Clinical Nursing Skills. A Nursing Process Approach, 5th edition

Needs Practice

Satisfactory

Excellent

Name Unit Instructor/Evaluator:

Date Position Position

SKILL 9-10

Assisting a Patient With Ambulation Using a Cane Goal: The patient ambulates safely without falls or injury.

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1. Review the medical record and nursing care plan for conditions that may influence the patient’s ability to move and ambulate. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for ambulation.

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2. Perform hand hygiene. Put on PPE, as indicated.

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4. Place the bed in the lowest position, if the patient is in bed.

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6. Assist the patient to the side of the bed, if necessary. Have the patient sit on the side of the bed. Assess for dizziness or lightheadedness. Have the patient stay seated until he or she feels secure.

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7. Assist the patient to put on footwear and a robe, if desired.

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9. Encourage the patient to make use of the stand-assist device to stand with weight evenly distributed between the feet and the cane.

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10. Have the patient hold the cane on his or her stronger side, close to the body, while the nurse stands to the side and slightly behind the patient.

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11. Tell the patient to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting his or her weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.

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12. While supporting his or her weight on the weaker leg and the cane, have the patient advance the stronger leg forward to finish the step.

Comments

3. Identify the patient. Explain the procedure to the patient. Tell the patient to report any feelings of dizziness, weakness, or shortness of breath while walking. Decide how far to walk.

5. Encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed.

8. Wrap the gait belt around the patient’s waist, based on assessed need and facility policy.

Copyright © 2019 by Wolters Kluwer. Skill Checklists for Taylor’s Clinical Nursing Skills: A Nursing Process Approach, 5th edition, by Pamela Lynn.

2

Skill Checklists for Taylor’s Clinical Nursing Skills. A Nursing Process Approach, 5th edition

Needs Practice

Satisfactory

Excellent

Name Unit Instructor/Evaluator:

Date Position Position

SKILL 9-10

Assisting a Patient With Ambulation Using a Cane (Continued) Comments

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13. Continue with ambulation for the planned distance and time. Return the patient to the bed or chair based on the patient’s tolerance and condition. Remove gait belt.

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14. Ensure the patient is comfortable, with the side rails up and the bed in the lowest position, as necessary. Place call bell and other essential items within reach.

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15. Clean transfer aids per facility policy, if not indicated for single patient use. Remove gloves and any other PPE, if used. Perform hand hygiene.

Copyright © 2019 by Wolters Kluwer. Skill Checklists for Taylor’s Clinical Nursing Skills: A Nursing Process Approach, 5th edition, by Pamela Lynn....