Assisting a Patient with Ambulation Using a Walker

Skill 9-7

Assisting a Patient With Ambulation Using a Walker

A walker is a lightweight metal frame with four legs. Walkers improve balance by increasing the patient's base of support, enhancing stability during ambulation, and supporting the patient's weight (Eliopoulos, 2018). There are several kinds of walkers; the choice of which to use is based on the patient's arm strength and balance needs. Regardless of the type used, the patient stands between the back legs of the walker with arms relaxed at the side; the top of the walker should line up with the crease on the inside of the patient's wrist. When the patient's hands are placed on the grips, elbows should be slightly bent, flexed about 15 degrees (MFMER, 2019a). Usually, the legs of the walker can be adjusted to the appropriate height.

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 in Skill 9-6 provides an example of a decision-making tool related to ambulation. Box 9-1 in Skill 9-1 outlines general guidelines related to mobility and safe handling of people with dementia.

Delegation Considerations

Patient teaching regarding use of a walker cannot be delegated to assistive personnel (AP). Reinforcement or implementation of ambulation using a walker may be delegated to AP. Assisting a patient with ambulation using a walker may be delegated 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

Walker, adjusted to the appropriate height
Nonskid shoes or slippers
Nonsterile gloves and/or other PPE, as indicated
Additional staff for assistance, as needed
Stand-assist device, as necessary, if available
Gait belt, based on assessment

Assessment

Assess the patient's ability to walk and the need for assistance. Review the patient's health record for conditions that may affect ambulation. 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. Assess the patient's knowledge regarding the use of a walker. Ensure that the walker is at the appropriate height for the patient.

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:

Fall risk
Impaired walking
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve are that the patient ambulates safely with the walker and is free from falls or injury. Additional outcomes may include: the patient demonstrates proper use of the walker and verbalizes an understanding of the rationale for use of the walker; and the patient demonstrates increasing muscle strength, joint mobility, and independence.

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, and for specific instructions for ambulation, such as distance. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for ambulation. Assess the patient's knowledge and previous experience regarding the use of a walker. Identify any movement limitations.	Reviewing the medical record and care plan validates the correct patient and correct procedure. Checking for equipment and limitations helps minimize the risk for injury.
2. Perform hand hygiene. Put on PPE, if 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. Tell 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, if the patient is in bed.	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.	Use of a stand-assist device encourages independence, reduces strain for staff, and decreases risk for patient injury.
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 they feel secure.	Having the patient sit on the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change. Assessing patient complaints helps prevent injury.
7. Assist the patient to put on skid-proof footwear and a robe, if desired.	Doing so ensures safety and warmth. Skid-proof footwear decreases the 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 and provide for a firmer grasp if patient should lose their balance. A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
9. Place the walker directly in front of the patient (Figure 1). Ask the patient to push themselves off the bed or chair; make use of the stand-assist device to stand. Once the patient is standing, have them hold the walker's handgrips firmly and equally. Stand slightly behind the patient, on one side.	Proper positioning with the walker ensures balance. Standing within the walker and holding the handgrips firmly provide stability when moving the walker and help ensure safety. 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.
10. Remind the patient to keep their back upright, and then lift and position or push the walker forward, about one step ahead, and set it down or stop pushing, making sure all four feet of the walker stay on the floor. The patient should not hunch forward (MFMER, 2019a). Then, tell the patient to step forward with either foot into the walker, supporting themselves on their arms. The patient should not step all the way to the front of the space (AAOS, 2015). Remind the patient to keep the walker still and to push straight down on the grips of the walker and then step forward with the remaining leg into the walker.	Having all four feet of the walker on the floor provides a broad base of support. Moving the walker and stepping forward moves the center of gravity toward the walker, ensuring balance and preventing tipping of the walker.
11. Move the walker forward again, and continue the same pattern. Continue with ambulation for the planned distance and time (Figure 2). Return the patient to the bed or chair based on the patient's tolerance and condition, ensuring that the patient is comfortable. Remove the gait belt if used.	Moving the walker promotes activity. Continuing for the planned distance and time prevents the patient from becoming fatigued.
12. 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 provides for patient comfort and safety. Having the call bell and other essential items within reach promotes safety.
13. 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 used the walker to ambulate safely and has remained free of injury, and the patient has exhibited increased muscle strength, joint mobility, and independence.

Documentation

Guidelines

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

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You are assisting a patient ambulating in the hallway using a walker. She becomes extremely tired and says she cannot pick up the walker anymore (“it's too heavy”). However, she cannot walk without the walker: Call for assistance. Have a coworker obtain a wheelchair to transport the patient back to her room. Assess the patient for other symptoms, if necessary. In the future, plan to ambulate for shorter distances to prevent the patient from becoming fatigued.

Special Considerations

Never use a walker on the stairs or an escalator (American Academy of Orthopaedic Surgeons [AAOS], 2015).
Ensure the patient wears nonskid shoes or slippers.
If the patient has an injured or weaker leg, the injured/weaker leg should be moved into the walker first, followed by the stronger or unaffected leg (AAOS, 2015; MFMER, 2019a).
Some walkers have wheels on the front legs. These walkers are best for patients with a gait that is too fast for a walker without wheels and for patients who have difficulty lifting a walker. This type of walker is rolled forward while the patient walks as normally as possible. Because lifting repeatedly is not required, energy expenditure and stress to the back and upper extremities are less than with a standard walker.
Keep in mind, walkers often prove to be difficult to maneuver through doorways and congested areas.
Advise the patient to check the walker before use for signs of damage, frame deformity, or loose or missing parts.
Teach patients to use the arms of the chair or a stand-assist device for leverage when getting up from a chair. Explain to patients that they should not pull on the walker to get up; the walker could tip over or become unbalanced.

EVIDENCE FOR PRACTICE
Early Ambulation and Prevention of Thrombosis National Institute for Health and Care Excellence (NICE) (UK). (2019). Venous thromboembolism in over 16s: Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE Guideline. https://www.nice.org.uk/guidance/ng89 Refer to the details in Skill 9-6, Evidence for Practice.

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Skill 9-7

EVIDENCE FOR PRACTICE