Western Mindanao State University

College of Nursing
Zamboanga City

Level III-SKILL PROCEDURES

NAME: ____________________________ ROTATION: ______________________

SECTION: __________________________ DATE: __________________________

PERFORMANCE EVALUATION CHECKLIST

ASSISTING A PATIENT WITH AMBULATION USING A CANE

LEGEND:

4 – Accomplishes the task excellently

3 – Accomplishes the task very satisfactorily
2 – Accomplishes the task fairly
1 – Accomplishes the task poorly

PROCEDURE 1 2 3 4
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. Help the patient familiarize with the
parts and use of the cane. Tell the patient to report any feelings of dizziness, weakness, or
shortness of breath while walking. Decide how far to walk.
4. Assist the patient to put on appropriate socks and shoes.
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 and sit on the side of the bed.
6. Wrap the gait belt around the patient’s waist, based on assessed need and facility policy.
7. Encourage the patient to make use of the stand-assist device to stand with weight evenly
distributed between the feet and the cane.
8. 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.
9. Ensure appropriate fitting of the cane.
(see fig. 3)
Check the patient’s elbow bend.
Check the patient’s wrist height.
10. 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.
11. 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).
12. Tell the patient to move the weaker leg forward until it is even with the stronger leg, and
then advance the cane again.
13. Continue with ambulation for the planned distance and time.
14. Return the patient to the bed or chair based on the patient’s tolerance and condition. Make
sure call bell and other necessary items are within easy reach.
15. Clean transfer aids per facility policy, if not indicated for single patient use. Remove PPE, if
used. Perform hand hygiene.
EVALUATION:
16. Evaluate
A. if the patient uses the cane to ambulate safely and is free from falls or injury.
B. the patient demonstrates proper use of the cane;
C. the patient exhibits increased muscle strength, joint mobility, and independence; and
D. the patient experiences no injury related to cane use.
17. Document:
A. the activity, any other pertinent observations,
B. the patient’s ability to use the cane,
C. the patient’s tolerance of the procedure, and the distance walked.
D. the use of transfer aids and the number of staff required for transfer.

NAME: ____________________________ ROTATION: ______________________

 Western Mindanao State University
College of Nursing
Zamboanga City

Level III-SKILL PROCEDURES

SECTION: __________________________ DATE: __________________________

PERFORMANCE EVALUATION CHECKLIST

ASSISTING A PATIENT WITH AMBULATION USING CRUTCHES

LEGEND:i
4 – Accomplishes the task excellently
3 – Accomplishes the task very satisfactorily
2 – Accomplishes the task fairly
1 – Accomplishes the task poorly

PROCEDURE 1 2 3 4
1.
Review the medical record and nursing plan of care for conditions that may inuence the patient’s ability to move and ambu
a.Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for ambulation.
b.Assess the patient’s knowledge and previous experience regarding the use of crutches.
2. Determine that the appropriate size crutch has been obtained:
3. Measure the crutch:
Lying:
Have the patient lie supine, arms at sides, wearing a shoe on the unaffected foot.
3.1 Using a tape measure, measure from the axilla. to the heel of the shoe and add two (2) inch.
3.2 Adjust the crutch shaft to this measurement.
Standing:
3.3 Crutch tip 6” from the foot and at a 45degree angle.
3.4 Hand grip at the ulnar styloid process or at the level of the greater trochanter.
3.5 Elbow in about 20-30 degrees of flexion.
3.6 Hand grip Axillary distance to the top of the crutch, 2-3 finger widths.
4. Perform hand hygiene. Put on PPE, if indicated.
5. 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.
6. Assist the patient to put on appropriate socks and shoes.
7. 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
a. the patient holds the crutches 6-12 inches in front of and
b. 6-12 inches to the side of each foot at a 45-degree angle.
8. For the four-point gait:
Begin in the tripod position.
8.1 Have the patient move the right crutch forward 6-12 inches and then move the left foot
forward to the level
of the right crutch.
8.2 Then have the patient move the left crutch forward 6=12 inches and then move the right foot
forward to the
level of the left crutch.
9. For the three-point gait:
Begin in the tripod position.
9.1 Have the patient move the affected leg and both crutches forward about 6- 12 inches.
9.2 Have the patient move the stronger leg forward to the level of the crutches.
10. For the two-point gait:
Begin in the tripod position.
10.1 Have the patient move the left crutch and the right foot forward about 6-12 inches at the same
time.
10.2 Have the patient move the right crutch and left leg forward to the level of the left crutch at the
same time.
11. For the swing-to gait:
Begin in the tripod position.
11.1 Have the patient move both crutches forward about 6-12 inches,
11.2 Have the patient bend and lift the injured leg and swing them at the level of the crutches,
supporting his or
her body weight on the crutches.
12. For the swing-through-gait
 Western Mindanao State University
College of Nursing
Zamboanga City

Level III-SKILL PROCEDURES

Begin in the tripod position. the client stands on the strong leg, bending the knee of injured
leg.
12.1 Moves both crutches forward the same distance,
12.2 Rests his or her weight on the palms, and swings forward slightly ahead of the crutches.
13. Continue with ambulation for the planned distance and time.
14. 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
15. Remove PPE, if used. Perform hand hygiene

Continued
1 2 3 4
Steps in Sitting down and Getting up of the chair
Stand to Sit/ Sitting down:
16. Stand in front of the chair with the seat of the chair touching the back of your legs.

17. Place both crutches in the hand on the side of your injured leg.

18. Place the other hand on the arm rest or side of the chair.

19. Sit down and slide back.

Sit to Stand/ Getting up:

20. Hold both crutches in the hand on the side of your good leg.

21. Slide to the front edge of seat. Both feet flat on the floor (injured leg NWB).

22. Place your other hand on the armrest or side of the chair or side of the chair.
23.

24. Push yourself up, placing weight on the good leg and the crutches.
25.

26. Transfer one crutch to the side of affected leg. Stand in tripod position, before walking.
27.

CLIMBING UP THE STAIRS

27. The patient places the unaffected leg on the rst stair tread.

28. The patient transfers his or her weight to the crutches.

29. The patient moves the crutches and affected leg up to the stair tread and continues to the top of the
stairs.

30. Have the patient stand in the tripod position facing the stairs.

31. The patient then transfers his or her weight to the unaffected leg, moving up onto the stair tread.

GOING DOWN THE STAIRS

32.The patient transfers his or her weight to the crutches.

33. Have the patient stand in the tripod position facing the stairs.
34.The patient moves the unaffected leg down to the stair tread and continues down the stairs.
35.The patient moves the crutches and affected leg down to the stairs tread.

36. The patient transfers weight to unaffected leg.

37.Evaluation:
The patient demonstrates correct use of crutches to ambulate safely and without injury.
37.1 The patient demonstrates increased muscle strength and joint mobility
37.2 Exhibits no evidence of injury related to crutch use.
38.Documentation:
The patient’s ability to use the crutches, the patient’s tolerance of the procedure, and the distance
walked.
38.1 Document the use of transfer aids and number of staff required for transfer.
and other appropriate interventions

S
 Western Mindanao State University
College of Nursing
Zamboanga City

Level III-SKILL PROCEDURES

CORE

309 – 312 = 1.0 Rating:_______________________________

305 – 308 = 1.25
301 – 304 = 1.5 Student’s Signature: _____________________
297 – 300 = 1.75
293 – 296 = 2.0 C.I.’s Signature: _________________
289 – 292 = 2.25
285– 288 = 2.5
281 – 284 = 2.75 Prepared By: LEVEL III-FACULTY
277 – 280 = 3.0
273 – 276 = 3.25 Noted By: Nerissa C. Mariga, MAN, RN
269 – 272 = 3.5 Level III- Coordinator
265 – 268 = 3.75
261 – 264 = 4.0 Recommending Approval: Desdimona C. Sakandal, RN, RM, MN
257 – 260 = 4.25 Clinical Coordinator
253 – 256 = 4.5
249 – 252 = 4.75 Approved By: Hashim N. Alawi Jr., RN, MAN
245 - 248 = 5.0 OIC- Dean