Assisting a Patient With Ambulation

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. Identify any movement limitations.

2. Perform hand hygiene. Put on PPE, as indicated.

3. Identify the patient. Explain the procedure to the patient. Ask the patient to report any feelings of dizziness, weakness, or shortness of breath while walking. Decide how far to walk.

4. Place the bed in the lowest position.

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. Assist the patient to the side of the bed, if necessary.

6. Have the patient sit on the side of the bed for several minutes and assess for dizziness or lightheadedness. Have the patient stay sitting until he or she feels secure.

7. Assist the patient to put on footwear and a robe, if desired.

8. Wrap the gait belt around the patient’s waist, based on assessed need and facility policy.

9. Encourage the patient to make use of the stand-assist device. Assist the patient to stand, using the gait belt, if necessary. Assess the patient’s balance and leg strength. If the patient is weak or unsteady, return the patient to the bed or assist to a chair.

10. If you are the only nurse assisting, position yourself to the side and slightly behind the patient. Support the patient by the waist or transfer belt. When two nurses assist, position yourself to the side and slightly behind the patient, supporting the patient by the waist or gait belt. Have the other nurse carry or manage
equipment or provide additional support from the other side. Alternatively, when two nurses assist, stand at the patient’s sides (one nurse on each side) with near hands grasping the gait belt and far hands holding the patient’s lower arm or hand.

11. Take several steps forward with the patient. Continue to assess the patient’s strength and balance. Remind the patient to stand erect.

12. 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.

13. Remove gait belts. Clean transfer aids per facility policy, if not indicated for single patient use. Remove gloves and any other PPE, if used. Perform hand hygiene.