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Ambulation

The document provides guidance for nurses on assisting patients with ambulation. It describes preparing the patient and equipment, techniques for dangling the patient to assess stability, proper gait and use of ambulation devices like canes and walkers. Key steps include preventing injury, having the patient maintain proper posture and gaze forward, and providing the appropriate level of assistance, such as one or two nurses, based on the patient's needs and abilities. Special considerations are given for patients with weakness on one side.

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Didik Susetiyanto
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4K views18 pages

Ambulation

The document provides guidance for nurses on assisting patients with ambulation. It describes preparing the patient and equipment, techniques for dangling the patient to assess stability, proper gait and use of ambulation devices like canes and walkers. Key steps include preventing injury, having the patient maintain proper posture and gaze forward, and providing the appropriate level of assistance, such as one or two nurses, based on the patient's needs and abilities. Special considerations are given for patients with weakness on one side.

Uploaded by

Didik Susetiyanto
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd

Assisting with Ambulation

Ns.Didik Susetiyanto A., M.Kep


Before Assisting with Ambulation
 Make sure bed is lowered and locked.
 Make sure wheel chair is locked.
 Make sure patient has on non-skid socks
or supportive shoes
Dangling a Client
 Prevent injury
 Seated position at side of bed with feet
touching the floor
 Gaze looking forward
 What is orthostatic hypotension?
Ambulation
 Stand erect
 Gaze forward
 Heel to toe
 Opposite arm swing to opposite leg
Gait Belt
Gait Belt: a device used by caregivers to transfer
patients with mobility issues from one position to
another.
For example, a gait belt is used to move a patient
from a standing position to a wheelchair.

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Nursing Assistance
 One Nurse Assist

 Two Nurse Assist


Special Consideration
 Client has one-sided weakness or paralysis
 Nurse stands on the weaker or affected side
 With arm around waist to stabilize the client
Preventing Injury: Falls
 Client begins to fall or feels faint

 What are you going to do?


Nurse Guides to Floor
 Move hip forward closest to client with a
wide base of support and have client slide
down your leg into a sitting or lying
position
Walking Assistive Devices
 Canes
 Walkers
 Braces
 Walking belts
Canes
 Single-ended curve ended ideal for use with
stairs
 Single-ended straight ended used when
balance is intact and hand weakness exists
 Multi-prong used when there is balance
problems because it has a wide base of
support
Canes
 Rubber tipped
 Sizing: bottom 4 inches to side of foot
 Sizing: top reaches hip joint
 Held with stronger side with elbow bent at 30
degree angle
 Weight evenly distributed
 Advance weaker leg and cane simultaneously
 Swing stronger leg
 Avoid leaning forward
Walkers
 Client picks up walker and advances as
steps ahead
 Impaired side advances first ahead after
picks up walker
Braces
 Support joints and muscles that can not
support body weight
Crutches
 Reliance on strength of arms and shoulders
 Limit or eliminate weight bearing
 Forearm Support Crutches used for
permanent limitations
 Axillary Crutches used for short
or long term
Axillary Crutches
 Body weight carried on arms and hands and not
axilla
 2 Point Gait and 4 Point Gait used for partial
weight bearing
 3 Point Gait non-weight bearing
 Swing to and Swing through for weight bearing
 Upstairs lead with unaffected and going down
stairs lead with effected
Crutches
 Measure by lying flat in bed with shoes
used for walking
 Measure from anterior fold of axilla to the heel
and add 1 inch = 2.5 cm
 Standing position: crutch pad should be three
finger breaths from anterior fold of axilla
Possible Nursing Diagnoses with inactive
clients
 Impaired physical mobility
 Risk for disuse syndrome
 Unilateral neglect
 Risk for trauma
 Risk for peripheral neurovascular dysfunction
 Risk for activity intolerance

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