Catanduanes State University

College of Health Sciences

NCM 103 RLE – Fundamentals of Nursing Practice

Name ____________________________Block _____ Group_____ Date ________

PERFORMANCE CHECKLIST – ASSISTING A CLIENT TO AMBULATE

PURPOSE
• To provide a safe condition for the client to walk with whatever support is needed

ASSESSMENT
Assess
• 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, lift with ambulation sling)
• Client’s intake of medications (e.g., narcotics, sedatives, tranquilizers, and
antihistamines) that may cause drowsiness, dizziness, weakness, and orthostatic
hypotension and seriously hinder the client’s ability to walk safely
• Presence of joint inflammation, fractures, muscle weakness, or other conditions that
impair physical mobility
• Ability to understand directions
• Level of comfort

EQUIPMENT
• Assistive devices required for safe ambulation of client (e.g., gait/ transfer belt, walker,
cane, sit to stand assist device, lift with ambulation sling)
• Wheelchair for following client, or chairs along the route if the client needs to rest
• Portable oxygen tank if the client needs it

DIRECTIONS:Mark each step of the procedure following the rubric below denoting the
skill performance of the student. Total the scores and look for the equivalent grade on
the transmutation table. The Remark section is for suggestions that will help improve the
skills of students.

(3) – Skill performed with mastery using the recommended technique.

SCORE
STEPS 3 2 1 0 REMARKS
1. Prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client how
you are going to assist, why ambulation is necessary, and how
he or she can participate.
2. Perform hand hygiene and observe appropriate infection
Prevention procedures.
3. Ensure that the client is appropriately dressed to walk and has
shoes or slippers with nonskid soles.
4. Prepare the client for ambulation.
• 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 high safety risk (e.g., cannot follow commands,
medical instability, lack of experience with assistive device,
neurologic deficits), use a lift with ambulation sling and 1-2
caregivers.
• If the client is a high safety risk and has upper extremity
strength and is able to grasp with at least one hand, use a lift with
ambulation sling or a sit-to-stand lift with ambulation capability
and 1-2 caregivers.
• 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.
5. Ensure client safety while assisting the client to ambulate.
• 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. If the pole or other equipment is cumbersome in
any way, the nurse must push it to match the client’s pace,
securing any assistance necessary in order to move smoothly
with the client.
• 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.
6. 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 the knees.
• Stay with the client
• When the weakness subsides, assist the client back to bed.
• If a chair is not close by, assist the client to a horizontal position
on the floor before fainting occurs.
a. Assume a broad stance with one foot in front of the other.
b. Bring the client backward so that your body supports the
person.
c. Allow the client to slide down your leg, and lower the person
gently to the floor, making sure the client’s head does not hit any
objects.
Variation: Two Nurses
• Place a gait/transfer belt around the client’s waist. Each nurse
grasps the side handle with the near hand and the lower aspect
of the client’s upper arm with the other hand.
• Walk in unison with the client, using a smooth, even gait, at
the same speed and with steps the same size as the client’s.
7. Document distance and duration of ambulation and assistive
devices, if used, in the client record using forms or checklists
supplemented by narrative notes when appropriate. Include
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; and respiratory rate and
blood pressure after initial ambulation to compare with baseline
data.
Total
Equivalent Grade

___________________ _______________________________
Student’s Signature Name & Signature of Clinical Instructor