RESIDENT_____________________________________

DATE

PROBLEM

GOAL

TO DATE

INTERVENTIONS

RESP

DISC

Ambulation with cane / quad cane to:

Assist balance

Widen base of support

Decrease weight bearing

Resident is on restorative nursing program to improve ambulation

Related to:

Balance problem

Unsteady gait

Weakness

Limited endurance

Lack of safety awareness

Knowledge deficit

Dizziness

Pain

Fracture

Cognitive impairment

Sensory impairment
Uncontrolled movements

Loss of voluntary movement

Full weight bearing

Partial weight bearing

Resident will ambulate with

Cues / reminders

Supervision

Stand-by assist

Assist of one

Assist of two

Resident will ambulate

Daily

Twice per day

Three times per day

Resident will ambulate

2 / 5 / 10 / 15 / 20 feet

To dining room

To bathroom

Resident will demonstrate correct and safe use of assistive device

Resident will be free of falls or injury

PT, OT evaluation as indicated

Provide appropriate level of assistance to promote safety of resident

Encourage resident to participate in ambulation, and praise accomplishments

See Falls care plan

Assist resident to sit on the edge of the bed for two minutes to assess for dizziness

Assist resident in putting on socks and well-fitting nonskid shoes

Walk on resident’s weaker side, and encourage resident to hold cane with strong hand

Walk in the same pattern as resident (both step with left foot at the same time)

Walk resident only distance instructed by care plan

Ask how resident is doing, and observe closely for dizziness, unsteady gait, impaired balance, or fatigue

Instruct and assist resident to:

Hold cane in hand opposite weaker leg

Slightly bend elbow when hold   ing cane

Keep cane close to body for support and balance

Place cane about 4 inches to side of stronger leg

Put weight on stronger side

Move cane about 4 inches in front of stronger leg, bringing weaker leg forward at the same time

Use cane to help keep weight off weaker leg, and move stronger leg ahead until heel is slightly beyond tip of cane

Look straight ahead when walking

When turning, take small steps – do not pivot

Caution resident to:

Not take a step unless cane is firmly on ground

Not place cane too far forward

Not take steps that are too big

Not to carry heavy things when using cane

Not use cane on stairs