Policy & Procedure
Shiawassee County Medical Care Facility
Approved by Social Services Board
Date: 12/31/99
Revised:
Ambulation
Basic Responsibility: Licensed Nurse, Nursing Assistant, Restorative Nursing Assistant,
Physical Therapist and Occupational Therapist
If performed by individuals other than those listed in Basic Responsibility, check all that apply.
Procedure Performed by: CENA LPN RN
Purpose
1. To assist resident to achieve maximum function.
2. To provide assistance to resident as necessary.
3. To supervise and assess resident function in order to plan care to maintain optimum
ambulation function as long as possible.
4. To re-educate resident in ambulation techniques.
5. To teach resident use of assistive devices to maintain optimum ambulation function as
long as possible.
6. To reduce risk of falls and injury.
General Resident Rights Guidelines
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If resident is in his/her room, knock on the door, wait for a response and identify yourself.
Identify resident and explain reason for the procedure.
Explain benefits of the procedure to the resident.
Explain safety measures of the procedure to the resident.
Explain the adverse effects and/or complications of the procedure to the resident, when
appropriate.
Place call light within reach and instruct resident to call for assistance, if needed.
Encourage resident to participate in care as much as possible.
Include resident’s family and surrogate health care decision-makers in explanation of the
procedure and in care planning when possible.
Demonstrate purpose and use of all assistive devices to be used.
General Guidelines for Assessment may included, but are not limited to:
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Change in physical and/or mental function.
Pain.
Level of function and endurance.
Rigidity.
Change in cardiac or respiratory function.
Loss of balance.
Dizziness.
Unsteady gait.
Tremors.
Range of motion limitations.
Potential for improvement of function.
General Infection Control Guidelines
1. Observe (standard) universal precautions or other infection control standards as approved
by the appropriate facility committee.
2. Wash your hands before and after all procedures.
3. Gather equipment.
4. Cleanse the area to be treated when necessary.
5. Dry area well.
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Policy & Procedure
Date: 12/31/99
6. Dispose of disposable equipment appropriately.
7. Thoroughly clean all equipment used and return to appropriate storage area.
8. Dispose of soiled linen appropriately.
Equipment
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Appropriate clothing.
Appropriate footwear.
Appropriate assistive devices.
Brace or splint, if needed.
Ambulation (gait) belt (per facility policy).
Procedure
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Check resident’s medical record for ambulation order; note equipment ordered if any.
Check care plan for specific instructions.
Assist the resident to a sitting position.
Be sure the resident is properly dressed with proper footwear (shoes tied). Use
ambulation belt per facility policy.
Assist resident to standing position with feet firmly on the floor and properly positioned.
Encourage resident to stand until good balance is established.
Apply gait belt.
Stand facing the resident with your feet shoulder width apart.
Have the resident place his/her hands on your shoulders.
Grasp the gait belt firmly at each side of the resident.
Brace your knees against the resident’s knees.
Block the resident’s feet from sliding with your feet.
Pull the resident up into a standing position as you straighten your knees.
Move behind and slightly to one side of the resident.
Grasp the gait belt with one hand and support the resident as needed with the other
hand. Do not let go of the gait belt.
Walk with the resident with your gait matching the resident’s gait.
Possible Related Minimum Data Set Triggers
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Delirium.
Visual function related to ambulation.
Communication related to ambulation.
ADL function/rehabilitation potential.
Psychosocial well-being.
Falls.
Pressure ulcers.
Psychotropic drug use.
Physical restraints.
General Documentation Guidelines
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Date, time (or shift), as appropriate.
Resident’s level of function.
Resident’s level of endurance.
Amount of resident cooperation and motivation.
Refusal of treatment.
Pain, type, amount, duration, site and cause, if present.
Type of assistive device used, if any.
Amount of assistance required.
Balance and steadiness of gait.
Any complications, if present.
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Policy & Procedure
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Signature, title and date.
General Resident Care Plan Documentation Guidelines
Problem
 Identify reason resident requires assistance with ambulation.
 Consider listing possible risks and complications.
Goal
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List MEASURABLE goal(s) to be accomplished.
List target date.
Approaches
 List responsible discipline for each approach.
 List instructions, unique to this resident, for ambulation.
 List necessary monitoring and observation of condition during procedure.
 Indicate frequency of treatment and assistive devices to be used.
 List safety measures.
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Date: 12/31/99