Assisting a Patient with Ambulation Using a Cane

Skill 9-9

Assisting a Patient With Ambulation Using a Cane

Canes are useful for patients who can bear weight but need support for balance. They are also useful for patients who have decreased strength in one leg. Canes provide an additional point of support during ambulation. Canes should not be used for bearing weight (Eliopoulos, 2018). Canes are made of wood or metal and often have a rubberized cap on the tip to prevent slipping. Canes come in three variations: single-ended canes with half-circle handles (recommended for patients requiring minimal support and for those who will be using stairs frequently); single-ended canes with straight handles (recommended for patients with hand weakness because the handgrip is easier to hold, but not recommended for patients with poor balance); and canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support (recommended for patients with poor balance). The cane should rise from the floor to the crease in the patient's wrist and the elbow should be bent slightly, flexed about 15 degrees when holding the cane (AAOS, 2015; MFMER, 2019b). The patient holds the cane in the hand opposite the side that needs support (AAOS, 2015; MFMER, 2019b). If the cane is used for stability, the patient may hold it in either hand.

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.

Delegation Considerations

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

Cane of appropriate size with rubber tip
Nonskid shoes or slippers
Nonsterile gloves and/or other PPE, as indicated
Stand-assist aid, if necessary and available
Gait belt, based on assessment

Assessment

Assess the patient's upper body strength, ability to bear weight and 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 cane.

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 outcome to achieve when assisting a patient with ambulation using a cane is that the patient ambulates safely without falls or injury. Additional appropriate outcomes include the following: the patient demonstrates proper use of the cane, and the patient demonstrates increased 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. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for ambulation.	Review of the health record and plan of care validates the correct patient and correct procedure. Identification of equipment and limitations helps reduce the risk for injury.
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. 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 assistive devices 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 reduces 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 firmer grasp for the caregiver if 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 to stand with weight evenly distributed between the feet and the cane.	A stand-assist device reduces strain for caregiver and decreases risk for patient injury. Evenly distributed weight provides a broad base of support and balance.
10. Have the patient hold the cane on their stronger side, close to the body, while the nurse stands to the side and slightly behind the patient (Figure 1).	Holding the cane on the stronger side helps to distribute the patient's weight away from the involved side and prevents leaning. 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.
11. Tell the patient to one small stride ahead (AAOS, 2015) and then, while supporting their weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.	Moving in this manner provides support and balance.
12. While supporting their weight on the weaker leg and the cane, have the patient advance the stronger leg forward to finish the step (AAOS, 2015).	Moving in this manner provides support and balance.
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 the gait belt if used.	Continued ambulation promotes activity. Adhering to the planned distance and time prevents the patient from becoming fatigued.
14. 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.
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.	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 outcomes have been met when the patient has used the cane to ambulate safely without falls or injury, the patient has demonstrated proper use of the cane, and the patient has demonstrated increased independence.

Documentation

Guidelines

Document the activity, any other pertinent observations, the patient's ability to use the cane, the patient's tolerance of the procedure, and the distance walked. Document the use of transfer aids and the 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 cane when the patient says she “can't walk any more”: Call for assistance. Have a coworker obtain a wheelchair to transport the patient back to her room. Assess the patient for possible causes, such as anxiety, fatigue, or a change in her condition. In the future, plan shorter distances to prevent the patient from becoming fatigued. Confer with the health care team regarding the need for referral to physical therapy for muscle strengthening.

Special Considerations

Patients with bilateral weakness should not use a cane. Canes should not be used for bearing weight (Eliopoulos, 2018). Crutches or a walker would be more appropriate.
To climb stairs, the patient should advance the stronger leg up the stair first, followed by the cane and weaker leg. To descend, reverse the process.
When less support is required from the cane, the patient can advance the cane and weaker leg forward simultaneously, while the stronger leg supports the patient's weight.
Teach patients to position their canes within easy reach when they sit down so that they can rise easily.
While a cane might help with mobility, it can also make it more difficult for people to stabilize themselves during a fall.

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Skill 9-9