Skill 9-6

Assisting a Patient With Ambulation

Walking exercises most of the body's muscles and increases joint flexibility. It improves respiratory and gastrointestinal function. Ambulating also reduces the risk for complications of immobility. Early mobility plays an important role in the patient's physical and psychological well-being (Arnold et al., 2018). Use a screening or assessment tool to assess the patient's ability to walk and the need for SPHM devices and assistance to guide decision making (VA Mobile Health, n.d.; VHACDOSH, 2016). One example of a decision-making tool and associated SPHM equipment are outlined in Fundamentals Review 9-4. Figure 1 provides another example of a decision-making tool related to ambulation. Fundamentals Review 9-3 provides examples of assistive equipment and devices. Box 9-1 in Skill 9-1 outlines general guidelines related to mobility and safe handling of people with dementia. The procedure below describes general guidelines for ambulating a patient who is able to bear weight, balance, and raise and advance both feet while standing. Refer to facility policy and procedures and specific manufacturer guidelines related to other available devices and equipment.

Delegation Considerations

Assisting a patient with ambulation may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Gait belt, as necessary
Nonskid shoes or slippers
Nonsterile gloves and/or other PPE, as indicated
Stand-assist device, based on assessment
Additional staff for assistance, as needed

Assessment

Review the health record for conditions that may influence the patient's ability to walk. Assess the patient's ability to walk and the need for assistance (one nurse, two nurses, walker, cane, walking belt, or crutches). Check for tubes, IV lines, incisions, or equipment that may require modifying the transfer procedure. Perform a pain assessment before the time for the activity. If the patient reports pain, administer the prescribed medication in sufficient time to allow for the full effect of the analgesic. Take vital signs and assess the patient for dizziness or lightheadedness with position changes. Use available algorithms or other decision-making tools to aid in assessment and decision making.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Activity intolerance
Fall risk
Impaired walking

Outcome Identification and Planning

The expected outcome to achieve when assisting a patient with ambulation is that the patient ambulates safely, without falls or injury. Additional appropriate outcomes include the patient demonstrates improved muscle strength and joint mobility, and the patient's level of independence increases.

Implementation

Action	Rationale
1. Review the health record and plan of care 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. Identify any movement limitations. Consult a patient handling algorithm or other decision-making tool to plan an appropriate approach to moving the patient (refer to Figure 1 for an example).	Reviewing the medical record and care plan validates the correct patient and correct procedure. Checking for equipment and limitations reduces the risk for patient injury. Identification of limitations and ability and use of an algorithm help to prevent injury and aid in determining best plan for patient movement.
2. Perform hand hygiene. Put on PPE, as indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain the procedure to the patient. Ask the patient to report any feelings of dizziness, weakness, or shortness of breath while walking. Decide how far to walk.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. Place the bed in a position that allows the patient's feet to reach the floor.	Proper bed height ensures safety when getting the patient out of bed.
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. Assist the patient to the side of the bed, if necessary.	Encourages independence, reduces strain for staff, and decreases risk for patient injury.
6. Have the patient sit on the side of the bed for several minutes and assess for dizziness or lightheadedness. Have the patient stay sitting until they feel secure.	Having the patient sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change. Allowing the patient to sit until they feel secure reduces anxiety and helps prevent injury.
7. Assist the patient to put on skid-proof footwear and a robe, if desired.	Doing so ensures safety and patient warmth. Skid-proof footwear decreases risk of falls.
8. Wrap the gait belt around the patient's waist, based on assessed need and facility policy.	Gait belts improve the caregiver's grasp, reducing the risk of musculoskeletal injuries to staff and the patient. The belt also provides a firmer grasp for the caregiver if the patient should lose their balance. A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
9. Encourage the patient to make use of the stand-assist device. Cue the patient to stand. Assess the patient's balance and leg strength. If the patient is weak or unsteady, return the patient to the bed or assist to a chair.	Use of a stand-assist device decreases the risk of injury to the nurse and to the patient. Assessing balance and strength helps to identify the need for additional assistance to prevent falling.
10. If you are the only person assisting, position yourself to the side and slightly behind the patient. Steady the patient by the waist or gait belt (Figure 2).	Positioning to the side and slightly behind the patient encourages the patient to stand and walk erect. It also places the nurse in a safe position if the patient should lose their balance or begin to fall.
When two caregivers assist, position yourself to the side and slightly behind the patient, supporting the patient by the waist or gait belt. Have the other caregiver carry or manage equipment or provide additional support from the other side.	Gait belts improve the caregiver's grasp, reducing the risk of musculoskeletal injuries to staff and the patient, and allow for a firmer grasp for the caregiver if the patient should lose their balance. A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
Alternatively, when two caregivers assist, stand at the patient's sides (one nurse on each side) with near hands grasping the gait belt and far hands holding the patient's lower arm or hand.	Gait belts improve the caregiver's grasp, reducing the risk of musculoskeletal injuries to staff and the patient, and allow for a firmer grasp for the caregiver if the patient should lose their balance. A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
11. Take several steps forward with the patient. Continue to assess the patient's strength and balance. Remind the patient to stand erect.	Taking several steps with the patient and standing erect promote good balance and stability. Continued assessment helps maintain patient safety.
12. 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 the gait belt.	Ambulation as prescribed promotes activity and prevents fatigue.
13. Ensure the patient is comfortable, with the side rails up and the bed in the lowest position, as necessary. Place the call bell and other essential items within reach.	Proper positioning with raised side rails and proper bed height provide for patient comfort and safety. Having the call bell and other essential items within reach promotes safety.
14. Clean transfer aids per facility policy, if not indicated for single-patient use. Remove gloves and any other PPE, if used. Perform hand hygiene.	Proper cleaning of equipment between patient use prevents the spread of microorganisms. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcome has been met when the patient has ambulated safely for the prescribed distance and time and has remained free from falls or injury, and the patient has exhibited increasing muscle strength, joint mobility, and independence.

Documentation

Guidelines

Document the activity, any other pertinent observations, the patient's tolerance of the procedure, and the distance walked. Document the use of SPHM aids and number of staff required for ambulation.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You are walking with a patient in the hallway. She tells you she feels faint and begins to lean over as if she is going to fall: Place your feet wide apart, with one foot in front. Rock your pelvis out on the side nearest the patient. This widens and stabilizes the base of support. Grasp the gait belt. This ensures a safe hold on the patient. While grasping the gait belt, guide the patient slowly to the floor, supporting them on your thigh and your large quadriceps muscle and protecting the patient's head (Wintersgill, 2019). This enables you to support the patient's weight with large muscle groups and protects you from back strain. Stay with the patient. Call for help. If another staff member was assisting you with ambulation, each of you should use one hand to grasp the gait belt and grasp the patient's hand or wrist with your other hand. Slowly lower them to the floor.

Special Considerations

Secure all equipment, such as indwelling urinary catheters, drains, or IV infusions, to a pole for ambulation. Do not carry equipment while helping the patient. Your hands should be free to provide support.
Consider use of a gait belt for any patient who is not independent to promote safety (Wintersgill, 2019). A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
Gait belts should also not be used with patients exhibiting behavioral aggression, as the belt might be used as a weapon and for patients at risk for suicide, as the belt might be used for self-harm (Wintersgill, 2019).

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Skill 9-6

EVIDENCE FOR PRACTICE