ADVENTIST MEDICAL CENTER COLLEGE

San Miguel, Iligan City

SCHOOL OF NURSING

FUNDAMENTALS OF NURSING PRACTICE

Related Learning Experience (Skills Lab)
Second Semester, AY 2021 – 2022

ASSISTING THE CLIENT TO AMBULATE USING THE GAIT/TRANSFER BELT RUBRIC

Name _____________________________________________________ Section _________ Date __________________ Score _______

Purpose: To provide a safe condition for the client to walk with whatever support is needed.

CRITERIA AND PROCEDURE EXCELLENT VERY SATISFACTORY POOR SCORE

4 SATISFACTORY 2 1
3
I. ASSESSMENT Demonstrated Demonstrated Demonstrated five Demonstrated
Before assisting a client to ambulate, assess the following: all (9) seven to eight of to six of the four or less of
1. Length of time in bed and the amount and type of activity the client was assessment the assessment assessment the assessment
last able to tolerate activities activities activities activities
2. Baseline vital signs
3. Range of motion of joints needed for ambulating (e.g., hips, knees, ankles)
4. Muscle strength of lower extremities
5. Need for ambulation aids (e.g., gait/transfer belt, cane, walker, crutches, lift
with ambulation sling)
6. Client’s intake of medications (e.g., narcotics, sedatives, tranquilizers, and
antihistamines) that may cause drowsiness, dizziness, weakness, and
orthostatic hypotension and seriously hinder the client’s ability to walk
safely.
7. Presence of joint inflammation, fractures, muscle weakness, or other
conditions that impair physical mobility.
8. Ability to understand directions
9. Level of comfort
II. PLANNING EXCELLENT VERY SATISFACTORY POOR
1. Implement pain relief measures so that they are effective. Exhibited SATISFACTORY Exhibited four of Exhibited three
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2. The amount and assistance needed while ambulating will depend on the complete (6) Exhibited five of the planning or less of the
client’s condition (e.g., age, health status, length of inactivity, and emotional planning the planning activities planning
readiness. activities activities activities
3. Review any previous experiences with ambulation and success of such efforts.
4. Plan the length of the walk with the client, considering the nursing or primary
care practitioner’s order and the medical condition of the client.
5. Be prepared to shorten the walk according to the client’s activity tolerance.
6. Determine the type of equipment needed: gait/transfer belt, bathrobe or
appropriate clothing, nonskid shoes or nonskid slippers
III. IMPLEMENTATION EXCELLENT VERY SATISFACTORY POOR
Preparation and other Preliminary Activities Complete and SATISFACTORY Missed three to Missed five or
Determine: comprehensive Missed one to two four steps of more steps of
- Plan what to do and how to do it. Be sure that others are available to assist implementatio steps of assisting assisting the client assisting the
you, if needed. n of assisting the client to to ambulate by client to
- Obtain essential equipment before starting. the client to ambulate by using using the ambulate by
- Encumbrances to movement such as an IV or an indwelling urinary ambulate by the gait/transfer gait/transfer belt using the
catheter. using the belt gait/transfer belt
- Remove obstacles from the area so the client do not trip. Make sure there gait/transfer
are no spills or liquids on the floor on which the client could slip. belt
- Perform hand hygiene and observe other appropriate infection prevention
procedures.
- Provide for client privacy by drawing the curtains around the bed or closing
the door to the room.
Rationale: This is a personal matter.
- Demonstrate courtesy, introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it is necessary, and how
the client can cooperate or participate. Stress that the client must keep the
nurse informed as to how the activity is being tolerated as it progresses.
Rationale: To establish rapport and allay fear and anxiety.

Performance
 Prepare the client for ambulation.
- Have the client sit up in bed for at least 1 minute prior to preparing to
dangle legs.
- Follow the procedure in assisting the client to sit on the edge of the bed
and allow dangling for at least 1 minute.
- Assess the client for orthostatic hypotension or a sudden increase of heart
rate before moving the client from the bed.

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 Rationale: Allowing for gradual adjustment can minimize drops in blood
pressure (and fainting) that occur with shifts in position from lying to
sitting, and sitting to standing.
- Give explicit instructions to the client. Ask the client to move forward and
sit on the edge of the bed (or surface in which the client is sitting) with feet
placed flat on the floor.
- Assist the client in putting on a bathrobe or appropriate clothing and
nonskid slippers or shoes.
- Place a gait/transfer belt snugly around the client’s waist. Check to be
certain that the belt is securely fastened.

- Lean forward slightly from the hips.

Rationale: This brings the client’s center of gravity more directly over the
base of support and positions the head and trunk in the direction of the
movement.

- Place the foot of the stronger leg beneath the edge of the bed and put the
other foot forward.

Rationale: In this way, the client can use the stronger leg muscles to stand
and power the movement. A broader base of support makes the client more
stable during the transfer.
- Place the client’s hand on the bed surface (or available stable area) so that
the client can push while standing.

Rationale: This provides additional force for the movement and reduces
the potential for strain on the nurse’s back. The client should not grasp
your neck for support. Rationale: Doing so can injure the nurse.

 Position yourself correctly.

- Stand directly in front of the client and to the side requiring the most
support. Hold the gait/transfer belt with the nearest hand; the other hand
supports the back of the client’s shoulder. Lean your trunk forward from
the hips. Flex your hips, knees, and ankles. Assume a broad stance, placing
one foot forward and one back. Brace the client’s feet with your feet to
prevent the client from sliding forward or laterally. Mirror the placement of
the client’s feet, if possible.

Rationale: This helps prevent loss of balance.

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  Assist the client to stand.
- On the count of three or the verbal instructions of “Ready, steady, stand”
and on the count of three or the word “Stand,” ask the client to push down
against the mattress/side of the bed while you transfer your weight from
one foot to the other (while keeping your back straight) and stand upright
moving the client forward (directly toward your center of gravity) into a
standing position.

- Support the client in an upright standing position for at least 1 minute until
he or she feels secure.
Rationale: This allows the nurse and the client to extend the joints and
provides the nurse with an opportunity to ensure that the client is stable
before moving away from the bed.

- Carefully attend to any IV tubing, catheters or drainage bags, Keep urinary

drainage bags below level of client’s bladder.

Rationale: To prevent backflow of urine into bladder and risk of infection.

- Assist the client to ambulate by grasping the belt at the client’s back, and
walk behind and slightly to one side of the client.

 Ensure client safety.

- Encourage the client to ambulate independently if he or she is able, but
walk beside the client’s weak side, if appropriate.
- Remain physically close to the client in case assistance is needed at any
point.
- Encourage the client to assume a normal walking stance and gait as much
as possible. Ask the client to straighten the back and raise the head so that
the eyes are looking forward in a normal horizontal plane.

Rationale: Clients who are unsure of their ability to ambulate tend to look
down at their feet, which makes them more likely to fall.

- After ambulation, return the client to the bed and assist him to sit down
then remove the gait/transfer belt.

Aftercare and Documentation EXCELLENT VERY SATISFACTORY POOR

 Appreciate your client for his/her cooperation. Demonstrated SATISFACTORY Demonstrated five Demonstrated
all (7) aftercare Demonstrated six aftercare and four or less of
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  Perform hand hygiene. and aftercare and documentation aftercare and
 Place the call bell. documentation documentation activities documentation
 Document activities activities activities
- Distance and duration of ambulation and assistive device used.
- Include description of the client’s gait (including body alignment) when
walking; pace; activity tolerance when walking (e.g., pulse rate, facial
color, any shortness of breath, feelings of dizziness, or weakness).
- Degree of support required
- Vital signs to be compared to baseline data.

IV. QUALITY OF PERFORMANCE EXCELLENT VERY SATISFACTORY POOR

- Spontaneity (spontaneous in communication) Demonstrated SATISFACTORY Demonstrated Demonstrated
- Articulation: diction and grammar all (5) qualities Demonstrated four three qualities of two or less
- Mastery of the subject matter of performance qualities of performance qualities of
- Application of the principles of body mechanics performance performance
- Video: well-edited, good transitions, appropriate graphics, good shots, and
audible audio
V. CONFIDENCE EXCELLENT VERY SATISFACTORY POOR
Performed SATISFACTORY Performed entire Not able to
entire Performed entire procedure with perform entire
procedure with procedure with minimal procedure with
great moderate confidence confidence
confidence confidence
VI. TIMING (AT LEAST 20 MINUTES) EXCELLENT VERY SATISFACTORY
Performed SATISFACTORY Performed entire POOR
entire Performed entire procedure with 10 Performed the
procedure procedure with 5 minutes excess on entire procedure
within the minutes excess on the allotted time with 15 minutes
allotted time the allotted time or more excess
of the allotted
time.
TOTAL

Perfect Score: 28 points

Range of Scores:
26 – 28 --------------------------------------- Excellent
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23 – 25--------------------------------------- Very Satisfactory
20 – 22 --------------------------------------- Satisfactory
19 and below ------------------------------- Poor

Assessed by:
___________________________________
Name and Signature of RLE Instructor
/rsp
5/16/21