COLLEGE OF HEALTH SCIENCES
Procedure Checklist
ASSISTING A CLIENT TO AMBULATE
NAME: _______________________________________________ YEAR & SEC.: _____________
DATE: _______________________________________________ SCORE: _____________
PURPOSE: To provide a safe condition for the client to walk with whatever support is
needed
PREPARATION
Prepare and check functionality of equipment to be used
Assistive devices required for safe ambulation of client (e.g., gait/
transfer belt, walker, cane)
Wheelchair for following client, or chairs along the route if the client
needs to rest 12345
Portable oxygen tank if the client needs it
Robe or appropriate clothing
Slippers or shoes with nonskid soles
Plan the route of ambulation
BEFORE THE PROCEDURE:
Check doctor’s order for contraindications or medications that the
12345
client is receiving.
Introduce self and verify the client’s identity using institution protocol 12345
Explain to the client how you are going to assist, why ambulation is
necessary, and how he or she can participate. Discuss how this
activity relates to the overall plan of care. Stress that the client must 12345
keep the nurse informed as to how the activity is being tolerated as it
progresses.
Perform hand hygiene and observe appropriate infection prevention
12345
procedures
Ensure that the client is appropriately dressed to walk and has shoes
12345
or slippers with nonskid soles..
IMPLEMENTION
Check for encumbrances to movement such as IV or urinary catheter 12345
Asses the patient for the following:
Length of time in bed and the amount and type of activity the
client was last able to tolerate
Baseline vital signs
Range of motion of joints needed for ambulating (e.g., hips, knees,
ankles)
Muscle strength of lower extremities
Need for ambulation aids (e.g., cane, walker, crutches) 12345
Client’s intake of medications (e.g., narcotics, sedatives, tranquilizers,
and antihistamines) that may cause drowsiness, dizziness,
weakness, and orthostatic hypotension.
Presence of joint inflammation, fractures, muscle weakness, or other
conditions that impair physical mobility
Ability to understand directions
Level of comfort
Prepare the client to ambulate 12345
Have the client sit up in bed for at least 1 minute prior to preparing to
dangle legs.
Assist the client to sit on the edge of the bed and allow dangling for at
least 1 minute.
Assess the client carefully for signs and symptoms of orthostatic
hypotension (dizziness, light-headedness, or a sudden increase in heart
rate) prior to leaving the bedside.
Assist the client to stand by the side of the bed for at least 1 minute until
he or she feels secure.
Carefully attend to any IV tubing, catheters, or drainage bags. Keep
urinary drainage bags below level of the client’s bladder.
If the client is a low safety risk (e.g., able to follow commands, medically
stable, and experienced with assistive device), use a gait/transfer belt for
standby assist as needed and assistive devices as needed (e.g.,
crutches, walker, cane) and 1-2 caregivers. Make sure the belt is pulled
snugly around the client’s waist and fastened securely. Grasp the belt at
the client’s back, and walk behind and slightly to one side of the client.
USE OF CANE
Hold the cane with the hand on the stronger side of the body
12345
Position the tip of a standard cane (and the nearest tip of other canes)
about 15 cm (6 in.) to the side and 15 cm (6 in.) in front of the near foot, 12345
so that the elbow is slightly flexed.
When maximum support is required
Move the cane forward about 30 cm (1 ft.), or a distance that is
comfortable while the body weight is borne by both legs
Then move the affected (weak) leg forward to the cane while the weight
is borne by the cane and stronger leg 12345
Next, move the unaffected (stronger) leg forward ahead of the cane and
weak leg while the weight is borne by the cane and weak leg
Repeat the steps. This pattern of moving provides at least two points of
support on the floor at all times
As you become stronger and require less support
Move the cane and weak leg forward at the same time, while the weight is
borne by the stronger leg 12345
Move the stronger leg forward, while the weight is borne by the cane and
the weak leg
USE OF WALKER
When maximum support is required
Move the walker ahead about 15 cm (6 in.) while your body weight is
borne by both legs.
Then move the right foot up to the walker while your body weight is borne 12345
by the left leg and both arms.
Next, move the left foot up to the right foot while your body weight is
borne by the right leg and both arms.
If one leg is weaker than the other
Move the walker and the weak leg ahead together about 15 cm (6 in.)
while your weight is borne by the stronger leg. 12345
Then move the stronger leg ahead while your weight is borne by the
affected leg and both arms.
Ensure client safety while assisting the client to ambulate. 12345
Encourage the client to ambulate independently if he or she is able, but
walk beside the client’s weak side, if appropriate. If the client has a
lightweight IV pole because of infusing fluids, he or she may find that
holding onto the pole while ambulating helps with balance
Remain physically close to the client in case assistance is needed at any
point.
If it is the client’s first time out of bed following surgery, injury, or an
extended period of immobility or if the client is weak or unstable, have an
assistant follow you and the client with a wheelchair in the event that it is
needed quickly.
Encourage the client to assume a normal walking stance and gait as
much as possible. Ask the client to straighten the back and raise the
head so that the eyes are looking forward in a normal horizontal plane.
Protect the client who begins to fall while ambulating.
If a client begins to experience the signs and symptoms of orthostatic
hypotension or extreme weakness, quickly assist the client into a nearby
wheelchair or other chair, and help the client to lower the head between 12345
the knees. Stay with the client.
When the weakness subsides, assist the client back to bed
Ensure client’s comfort and safety
Remove gait belt
Assist in removing slippers or shoes
Position the client to a comfortable position per client’s preference 12345
Re-assess vital signs (Blood pressure, pulse rate and respiratory rate)
Raise side rails
Perform hand hygiene
12345
Document and record all relevant information
Distance and duration of ambulation
Response of the client (dizziness, anxiety, discomfort)
Type of assistive device, if one was used.
12345
Description of the client’s gait (including body alignment) when walking;
pace; activity tolerance when walking (e.g., pulse rate, facial color, any
shortness of breath, feelings of dizziness, or weakness); degree of
support required
Comments:
LEGEND:
1= Procedure not done/ not mentioned
2= Procedure not completely and accurately done; rationale/principle not thoroughly
explained
3= Demonstrated procedure properly; wrong rationale/principle stated or not mentioned
4= Demonstrated procedure properly; rationale/principle not thoroughly explained
5= Demonstrated procedure properly; explained the correct rationale/principle behind the
action
Evaluated by: Conforme:
_________________________________ __________________________
Signature over Printed Name of Instructor Name of Student
Source: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practice 10th Edition
