NCM 114 – Related Learning Experience
Performance Checklist
Student’s Name: _______________________________________________________________ Date: __________________________________
ASSISTING A PATIENT WITH AMBULATION USING A WALKER
Qualitative Description of Rating:
Points Level of Performance Evaluation Criteria
2 Satisfactory Achieves performance and demonstrates competencies at a consistent level
1 Needs Improvement Needs further development and guidance to fully meet expectations
0 Unsatisfactory Lacks or fails to utilize skills, knowledge, and/or competencies
Performance Criteria Competency Level
The student nurse has: Satisfactory Needs Unsatisfactory
2 Improvement 0
1
1. Review the medical record and nursing plan of care for conditions that may
influence the patient’s ability to move and ambulate, and for specific
instructions for ambulation such as distance. Assess for tubes, IV lines,
incisions, or equipment that may alter the procedure for ambulation. Assess
the patient’s knowledge and previous experience regarding the use of a
walker. Identify any movement limitations.
2. Perform hand hygiene. Put on PPE, if 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. Place the bed in the lowest position, if the patient is in bed.
5. 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 the side of the bed.
6. Assist the patient to the side of the bed, if necessary. Have the patient sit on
the side of the bed. Assess for dizziness or lightheadedness. Have the patient
stay seated 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. Place the walker directly in front of the patient. Ask the patient to push him-
or herself off the bed or chair; make use of the stand-assist device, or assist
the patient to stand. Once the patient is standing, have him or her hold the
walker’s hand grips firmly and equally. Stand slightly behind the patient, on
one side.
10.Have the patient move the walker forward 6 to 8 inches and set it down,
making sure all four feet of the walker stay on the floor. Then, tell the patient
to step forward with either foot into the walker, supporting him- or herself on
his or her arms. Follow through with the other leg.
11.Move the walker forward again, and continue the same pattern. 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 that the patient
is comfortable. Make sure call bell and other necessary items are within easy
reach.
12.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.
Total Score
Evaluator:____________________________________________________ Date: ____________________________
Remarks:
_________________________________________________________________________________________________________________________________________________________
NCM 103 – Related Learning Experience
Performance Checklist
Student’s Name: _________________________________________________________ Date: ___________________________________________
ASSISTING A PATIENT WITH AMBULATION USING CRUTCHES
Qualitative Description of Rating:
Points Level of Performance Evaluation Criteria
2 Satisfactory Achieves performance and demonstrates competencies at a consistent level
1 Needs Improvement Needs further development and guidance to fully meet expectations
0 Unsatisfactory Lacks or fails to utilize skills, knowledge, and/or competencies
Goal: The patient ambulates safely without experiencing falls or injury.
Performance Criteria
The student nurse has: Satisfactor Needs Unsatisfactory
y Improvemen 0
2 t
1
1. Review the medical record and nursing plan of care for conditions that may
influence the patient’s ability to move and ambulate, and for specific instructions
for ambulation such as distance. Assess for tubes, IV lines, incisions, or equipment
that may alter the procedure for ambulation. Assess the patient’s knowledge and
previous experience regarding the use of a walker. Identify any movement
limitations.
2. Perform hand hygiene. Put on PPE, if 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 the stand-assist device, if available. Assist
the patient to stand erect, face forward in the tripod position. This means the
patient holds the crutches 12 inches in front of and 12 inches to the side of each
foot.
5. For the four-point gait:
a. Have the patient move the right crutch forward 12 inches and then move the
left foot forward to the level of the right crutch.
b. Then have the patient move the left crutch forward 12 inches and then move
the right foot forward to the level of the left crutch
6. For the three-point gait:
a. Have the patient move the affected leg and both crutches forward about 12
inches.
b. Have the patient move the stronger leg forward to the level of the crutches.
7. For the two-point gait:
a. Have the patient move the left crutch and the right foot forward about 12
inches at the same time.
b. Have the patient move the right crutch and left leg forward to the level of the
left crutch at the same time.
8. For the swing-to gait:
a. Have the patient move both crutches forward about 12 inches.
b. Have the patient lift the legs and swing them to the crutches, supporting his
or her body weight on the crutches.
9. 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 that the
patient is comfortable. Make sure call bell and other necessary items are within
easy reach.
10.Remove PPE, if used. Perform hand hygiene.
Total Score
Evaluator:____________________________________________________ Date: ______________________________________
Remarks:
_________________________________________________________________________________________________________________________________________________________
NCM 103 – Related Learning Experience
Performance Checklist
Student’s Name: _______________________________________________________________ Date: __________________________________
ASSISTING A PATIENT WITH AMBULATION USING A CANE
Qualitative Description of Rating:
Points Level of Performance Evaluation Criteria
2 Satisfactory Achieves performance and demonstrates competencies at a consistent level
1 Needs Improvement Needs further development and guidance to fully meet expectations
0 Unsatisfactory Lacks or fails to utilize skills, knowledge, and/or competencies
Performance Criteria
The student nurse has: Satisfactory Needs Unsatisfactory
2 Improvement 0
1
1. Review the medical record and nursing plan of care for conditions that
may influence the patient’s ability to move and ambulate, and for specific
instructions for ambulation such as distance. Assess for tubes, IV lines,
incisions, or equipment that may alter the procedure for ambulation.
Assess the patient’s knowledge and previous experience regarding the use
of a walker. Identify any movement limitations.
2. Perform hand hygiene. Put on PPE, if 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.
Total Score
Evaluator:____________________________________________________ Date: ______________________________________
Remarks:
_________________________________________________________________________________________________________________________________________________________
