Goal: The patient ambulates safely without falls or injury.
1. Review the medical record and nursing 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.
2. Perform hand hygiene. Put on PPE, as indicated.
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.
4. Encourage the patient to make use of a stand-assist aid, either free-standing or attached to the side of the bed, if available, to move to and sit on the side of the bed.
5. Wrap the gait belt around the patient’s waist, based on assessed need and facility policy.
6. Encourage the patient to make use of the stand-assist device to stand with weight evenly distributed between the feet and the cane.
7. Have the patient hold the cane on his or her stronger side, close to the body, while the nurse stands to the side and slightly behind the patient.
8. Tell the patient to advance the cane 4 to 12 inches (10 to 30 cm) and then, while supporting his or her weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.
9. While supporting his or her weight on the weaker leg and the cane, have the patient advance the stronger leg forward ahead of the cane (heel slightly beyond the tip of the cane).
10. Tell the patient to move the weaker leg forward until it is even with the stronger leg, and then advance the cane again.
11. 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, ensuring the patient’s comfort. Make sure call bell and other necessary items are within easy reach.
12. Clean transfer aids per facility policy, if not indicated for single patient use. Remove PPE, if used. Perform hand hygiene.
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