Republic of the Philippines

Isabela State University

Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:

Course/Year/Group:

SKILL: Assisting a Patient with Ambulation Using a Walker

PREPARATION 0 1 2 Comments
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 light-
headedness. 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.
Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100
N Name and Signature of Professor

Where: RS = Raw Score Date:

N = Total number of items
ISUE-CON-PEC-096
 Republic of the Philippines
Isabela State University
Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:

Course/Year/Group:

SKILL: Assisting a Patient with Ambulation Using a Crutches

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. Assess the patient’s
knowledge and previous experience regarding the use of crutches.
Determine that the appropriate size crutch has been obtained.
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.
Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100
N Name and Signature of Professor

Where: RS = Raw Score Date:

N = Total number of items
Republic of the Philippines

ISUE-CON-PEC-096
 Isabela State University
Echague, Isabela

PERFORMANCE EVALUATION CHECKLIST

Name: Rating:

Course/Year/Group:

SKILL: Assisting a Patient with Ambulation Using a Cane

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. 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.
Note: You are rated using the criteria below:

0 – Missed/Failed to do the procedure.

1 – Performed procedure but failed to explain the rationale for doing the procedure.
2 – Performed procedure with confidence and explained the reason for doing said procedure.

Rating: RS x 100
N Name and Signature of Professor

Where: RS = Raw Score Date:

N = Total number of items

ISUE-CON-PEC-096