60. CCA Study Notes: Safe Mobility, Ambulation, Walking Aids, and Falls

The Big Picture

Safe mobility support includes helping clients move their joints, stand, walk, use walking aids, and respond safely if a fall starts.

The care plan guides how you support each client. Some clients need temporary help while regaining strength. Others continue to need assistance. Safety also depends on correct body mechanics, proper footwear, a clear walking path, and following directions for equipment and exercises.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Ambulation and Returning to Walking

Ambulation is the act of walking. Regular ambulation helps prevent deconditioning, which is the loss of muscle size, strength, and function caused by immobility and inactivity.

After bed rest, activity usually increases gradually:

1. Dangle the legs over the side of the bed.
2. Sit in a bedside chair.
3. Walk in the room.
4. Walk in the hallway.

Proper positioning and exercise help prevent problems such as contractures and muscle atrophy that interfere with mobility.

A contracture is loss of joint mobility caused by abnormal muscle shortening. Muscle atrophy is a decrease in muscle size or wasting away of muscle.

Preparing a Client for Ambulation

Before walking:

• Check the client for orthostatic hypotension, also called postural hypotension. It is a drop in blood pressure when the client stands.
• Remove obstacles from the walking path.
• Place a chair nearby when the client needs a possible rest place.
• Make sure the client wears nonskid footwear.
• Use a gait or transfer belt when required by the facility or agency.
• Encourage the client to use wall handrails for extra support when available.

Supporting a Client With One-Sided Weakness

For a client with weakness or paralysis on one side after a cerebrovascular accident, or stroke, the correct side for the support worker depends on:

• the care plan
• employer policy
• the walking environment

When the client uses a cane or handrail, the unaffected side provides support while the support worker protects the affected side.

When no handrail or walking aid is available, the support worker should walk slightly behind the client’s affected side to provide assistance.

The client might need periodic rest while walking.

Respecting Walking Preferences

Support personal choices when walking when they are safe, possible, and approved by the supervisor.

A client might prefer:

• walking outside
• walking at a particular time
• waiting until a visitor arrives
• waiting until a visitor leaves

What to Report and Record After Ambulation

After helping a client walk, report and record:

• how well the client tolerated the activity
• any pain or discomfort
• the distance walked

Follow employer policy for reporting and recording actions and observations.

Obesity, Lifestyle, and Ambulation

Excess body weight places greater stress on weight-bearing joints such as the knees and hips. Increased joint wear contributes to cartilage breakdown and osteoarthritis.

Osteoarthritis (OA) is the most common type of arthritis described here. It involves wearing away of cartilage in joints, resulting in joint pain and disfigurement.

Obesity and a sedentary lifestyle ⓘ are main contributors to OA. Weight loss is encouraged for people who are overweight to reduce the load placed on their joints.

Walking Aids

Walking aids support the body. A physician, nurse, or physiotherapist orders them.

The type selected depends on:

• the client’s physical condition
• how much support the client needs
• the type of disability

The walking aids and supportive devices covered here include crutches, canes, walkers, and braces.

Crutches

Crutches provide support when a client cannot use one leg or when one or both legs need to gain strength.

Some clients with permanent leg weakness use Lofstrand crutches. These metal crutches include a band around the forearm.

Axillary crutches extend from the underarm to the ground and consist of wood or metal.

A regulated health care provider teaches the client how to use crutches safely. A client using crutches needs instruction for:

• walking
• going upstairs
• going downstairs
• sitting
• standing

Crutch safety is important because clients using crutches face a risk of falling.

Crutch Safety Checks

• Check the crutch tips. Report worn or torn tips to the supervisor and replace them according to policy.
• Dry wet crutch tips with a towel or paper towels.
• Check wooden crutches for cracks.
• Check metal crutches for bends.
• Make sure all bolts remain tight.
• Make sure the client wears well-fitted, flat, nonskid street shoes.
• Make sure clothing fits properly. Loose clothing might catch between the crutches and underarms or block the client’s view of the feet and crutch tips.
• Follow fall-prevention safety measures.
• Keep crutches within the client’s reach when they are not in use.

Canes

A cane helps support a weak or unsteady side and provides balance.

Two types described here are:

• single-tip canes
• four-point, or quad, canes

A four-point cane gives more support than a single-tip cane, but it is harder to move.

The client holds the cane on the strong, unaffected side. For example, a client with a weak left leg holds the cane in the right hand.

Cane Position

The cane tip should sit:

• about 15 to 25 cm (6 to 10 in.) to the side of the foot
• about 15 to 25 cm (6 to 10 in.) in front of the foot
• on the unaffected side

The cane grip should sit level with the hip.

Walking With a Cane

Use this order:

1. Move the cane forward 15 to 25 cm (6 to 10 in.).
2. Move the affected leg forward until it is even with the cane.
3. Bring the unaffected leg forward and ahead of both the cane and affected leg.

Walkers

A walker is a four-point walking aid. It provides more support than a cane.

Different types of walkers work differently.

Standard Walker

With a standard walker:

1. Pick up the walker.
2. Move it about 15 to 20 cm (6 to 8 in.) in front of the client.
3. Move the affected leg and foot forward.
4. Move the unaffected leg and foot forward to the walker.

Wheeled Walker

A wheeled walker, also called a rollator, has wheels on the front legs and rubber tips on the back legs.

The client:

1. Pushes the walker ahead about 15 to 20 cm (6 to 8 in.).
2. Walks up to the walker.

The rubber tips on the back legs help prevent movement while the client stands or walks.

Some wheeled walkers include a padded seat so the client has a place to rest.

Baskets, pouches, and trays also attach to walkers. These attachments hold needed items, support independence, and keep the client’s hands free to grip the walker.

Helping a Client With a Walker Sit on a Chair, Wheelchair, or Toilet

When helping the client sit:

1. Lock wheelchair wheels when a wheelchair is used.
2. Ask the client to stand with their back toward the chair, wheelchair, or toilet.
3. Have the client back up with the walker until the knees touch the seat.
4. Ask the client to remove one hand from the walker and grasp an armrest or grab bar.
5. Help the client sit slowly, with the buttocks toward the back of the seat.
6. If no armrest or grab bar is available, support the client while sitting. Use a transfer belt when the client is weak or unsteady.
7. Move the walker away from the client.

The procedure also lists these additional support steps:

1. Support the client while standing.
2. Place your hands under the client’s arms and over the shoulder blades.
3. Block the client’s feet and knees using your feet and knees.
4. Lower the client slowly onto the seat.

Helping a Client With a Walker Sit on a Bed

1. Use a transfer belt when the client is weak or unsteady.
2. Raise the head of the bed to a sitting position.
3. Ask the client to stand with their back to the bed near the middle of the bed.
4. Have the client back up with the walker until the knees touch the bed.
5. Ask the client to reach for the bed with one hand. Assist when needed.
6. Help the client sit slowly.
7. Provide for comfort.

Helping a Client Move From Sitting to Standing With a Walker

1. Put the walker where the client easily reaches it.
2. Let the client position the walker.
3. Ask the client to move to the edge of the seat or bed.
4. Help the client rise to standing as needed.
5. Do not let the client pull up on the walker. The client should push on the mattress or chair armrests first, then transfer their hands to the walker.

Braces and Orthotics

A brace, also called an orthotic, is an apparatus worn to support or align affected body parts or to prevent or correct musculoskeletal problems.

Braces described here fit over the:

• ankle
• knee
• back

An ankle-foot orthosis, or AFO, sits inside the shoe. The foot goes into the device, and a Velcro strap secures it.

Keep skin and bony areas under braces clean and dry to prevent skin breakdown.

Report:

• redness
• signs of skin breakdown
• pain
• discomfort

In facilities, the nurse assesses the skin under braces during every shift.

Follow the care plan for when to apply and remove a brace.

Range-of-Motion Exercises

Range of motion (ROM) means moving a joint as far as possible without causing pain.

ROM exercises help reduce the risk of joint stiffness and loss of mobility.

The care plan controls how many repetitions the client receives. The procedure commonly states five repetitions or the number listed in the care plan.

Preparing for ROM Exercises

Before beginning:

1. Warm up your own muscles by performing ROM exercises on your joints daily and before providing the procedure.
2. Use good posture and body mechanics throughout the procedure.
3. Ask whether the client wants background music during the exercises.
4. Identify the client according to employer policy.
5. Explain the procedure.
6. Perform hand hygiene.
7. Cover the client with a bath blanket or top sheet. Expose only the body part being exercised.
8. Provide privacy.
9. Raise the bed to a comfortable working height.
10. Follow the care plan for bed rail use.

Raising the bed to a comfortable working height reduces the worker’s risk of back strain.

Performing ROM Exercises

After preparation:

1. Lower the bed rail closest to you.
2. Place the client in the supine position.
3. Cover the client with a sheet and fan-fold the top linens to the foot of the bed.
4. Exercise the neck only when the employer allows it and the supervisor instructs you to do so. Follow the care plan.
5. Exercise the shoulder.
6. Exercise the elbow.
7. Exercise the forearm.
8. Exercise the wrist.
9. Exercise the thumb.
10. Exercise the fingers.
11. Exercise the hip.
12. Exercise the knee.
13. Exercise the ankle.
14. Exercise the foot.
15. Exercise the toes.
16. Cover the leg.
17. Raise the bed rail when used, move to the other side, and lower the rail near you when it is raised.
18. Repeat the shoulder-through-toes exercises on the other side.

Some ROM exercises, especially neck movements, risk serious injury when performed without the required permission and direction.

Neck ROM

Safety: Exercise the neck only when the employer permits it and the supervisor directs you to do so.

Support the head by placing your hands over the client’s ears and supporting the jaws with your fingers.

Then perform:

• Rotation: Turn the head from side to side.
• Lateral flexion: Move the head toward the right and left. Stop if the client reports discomfort.

Repeat these movements five times or the number stated in the care plan.

Shoulder ROM

Support the arm by holding the wrist with one hand and the elbow with the other.

Perform:

• Flexion: Raise the straight arm forward and over the head.
• Extension: Bring the arm down to the side.
• Hyperextension: Move the arm behind the body. Perform this when the client sits in a straight-backed chair or stands.
• Abduction: Move the straight arm away from the side of the body.
• Adduction: Return the straight arm toward the side of the body.
• Internal rotation: Bend the elbow, place the arm level with the shoulder, and move the forearm downward toward the body.
• External rotation: Move the forearm toward the head.

Repeat the movements five times or according to the care plan.

Elbow ROM

Support the wrist with one hand and the elbow with the other.

• Flexion: Bend the arm until the hand touches the shoulder on the same side.
• Extension: Straighten the arm.

Repeat five times or according to the care plan.

Forearm ROM

• Pronation: Turn the hand so the palm faces down.
• Supination: Turn the hand so the palm faces up.

Repeat five times or according to the care plan.

Wrist ROM

Hold the wrist with both hands.

• Flexion: Bend the hand downward.
• Extension: Straighten the hand.
• Hyperextension: Bend the hand backward.
• Radial flexion: Move the hand toward the thumb.
• Ulnar flexion: Move the hand toward the little finger.

Repeat five times or according to the care plan.

Thumb ROM

Support the client’s hand with one hand and hold the thumb with the other.

• Abduction: Move the thumb away from the inner side of the index finger.
• Adduction: Return the thumb beside the index finger.
• Opposition: Touch each fingertip with the thumb.
• Flexion: Bend the thumb into the hand.
• Extension: Move the thumb outward beside the fingers.

Repeat five times or according to the care plan.

Finger ROM

• Abduction: Spread the fingers and thumbs apart.
• Adduction: Bring the fingers and thumbs together.
• Extension: Straighten the fingers so the fingers, hand, and arm form a straight position.
• Flexion: Make a fist.

Repeat five times or according to the care plan.

Hip ROM

Support the leg with one hand under the knee and the other under the ankle.

• Flexion: Raise the leg.
• Extension: Straighten the leg.
• Abduction: Move the leg away from the body.
• Adduction: Move the leg toward the other leg.
• Internal rotation: Turn the leg inward.
• External rotation: Turn the leg outward.

Repeat five times or according to the care plan.

Knee ROM

Support the knee with one hand under the knee and the other under the ankle.

• Flexion: Bend the leg.
• Extension: Straighten the leg.

Repeat five times or according to the care plan.

Ankle ROM

Support the foot and ankle with one hand under the foot and the other under the ankle.

• Dorsiflexion: Pull the foot forward while pressing down on the heel.
• Plantar flexion: Turn the foot downward or point the toes.

Repeat five times or according to the care plan.

Foot ROM

Continue supporting the foot and ankle.

• Pronation: Turn the outside of the foot upward and the inside downward.
• Supination: Turn the inside of the foot upward and the outside downward.

Repeat five times or according to the care plan.

Toe ROM

• Flexion: Curl the toes.
• Extension: Straighten the toes.
• Abduction: Spread the toes apart.
• Adduction: Bring the toes together.

Repeat five times or according to the care plan.

Finishing ROM Exercises

After exercising both sides:

1. Make sure the client is covered with bed linens.
2. Provide for safety and comfort.
3. Place the call bell within reach when this step applies in the setting.
4. Return the bed to its lowest position.
5. Follow the care plan for bed rail use.
6. Remove privacy measures.
7. Perform hand hygiene.
8. Report and record actions and observations according to employer policy.

Recording and reporting actions, observations, and basic assessments keeps the health care team informed and meets the stated legal reason for this documentation.

Some call bell and bed rail steps do not always apply in community settings.

Helping a Client Walk

Before Walking

1. Warm up your own muscles with ROM exercises on your joints daily and before beginning. Use good posture and body mechanics.
2. Identify the client according to employer policy.
3. Explain what you are going to do.
4. Perform hand hygiene.
5. Gather the required supplies, including a robe, nonskid shoes, paper or a sheet to protect the bed linens, and a gait belt when used by the agency.
6. Provide privacy.

The robe covers the client’s body. Nonskid shoes reduce slipping. A gait belt gives the worker a secure place to hold the client.

Getting the Client Ready to Walk

7. Lower the bed to its lowest position, lock the wheels, and lower the bed rail when used.
8. Fan-fold the top linens to the foot of the bed.
9. Put paper or a sheet on the bed to protect the linens, then put shoes on the client.
10. Help the client dangle the legs.
11. Help the client put on a robe when the client is not dressed.
12. Apply a gait belt when required by employer policy.
13. Help the client stand. When a gait belt is used, grasp it on both sides. Another supported method is placing your arms under the client’s arms and around toward the shoulder blades. If the client is too weak to stand, safely return the client to sitting on the bed.
14. Stay at the client’s side while balance is gained. Hold the gait belt at the side and back, or support the client with one arm around the back.
15. Encourage the client to stand upright with the head up and back straight.

A secure grasp helps prevent a fall. Upright posture supports balance.

Walking With the Client

16. Walk at the client’s side and slightly behind. Provide support using the gait belt or one arm around the client’s back. Check the care plan for the required support.
17. Encourage normal walking. The heel should contact the floor first. Discourage shuffling, sliding, and walking on tiptoes.
18. Walk the required distance when the client tolerates the activity. Do not rush the client. Encourage the client’s effort.

Helping the Client Return to Bed

19. Help the client return to bed in this order:
    1. Have the client stand beside the bed.
    2. Have the client pivot one-quarter turn until the backs of the knees touch the bed.
    3. With one-sided weakness, have the client lead or pivot from the unaffected side.
    4. Grasp both sides of the gait belt.
    5. Lower the client onto the bed while bending your knees.
    6. Remove the gait belt and robe.
    7. Help the client lie down.
20. Help the client move to the centre of the bed.
21. Remove the shoes when they were not removed while the client sat at the bedside. Remove the protective paper or sheet when used.

Slowly supporting the client while sitting helps prevent a fall.

After Helping the Client Walk

22. Provide for safety and comfort.
23. Put the call bell within reach when this step applies in the setting.
24. Follow the care plan for bed rail use.
25. Remove privacy measures.
26. Return the robe and shoes to the proper place.
27. Perform hand hygiene.
28. Report and record actions and observations according to employer policy.

Some call bell and bed rail steps do not always apply in community settings.

Falls During Standing or Walking

A client might begin to fall because of weakness, light-headedness, dizziness, or fainting. Slips and falls also occur with spills, waxed floors, throw rugs, or improper shoes.

Trying to stop a falling client creates a risk of greater injury. The support worker might twist, strain, lose balance, or fall with the client.

Safety: If a client starts to fall, ease the client to the floor. This helps control the direction of the fall and protects the client’s head.

Helping a Falling Client to the Floor

Use this sequence:

1. Stand with your feet apart and keep your back straight.
2. Bring the client close to your body quickly. Use the gait belt when the client wears one. If there is no belt, wrap your arms around the client’s waist or hold under the arms.
3. Move your leg so the client’s buttocks rest against it.
4. Lower the client to the floor while the client slides down your leg. Bend at your hips and knees. Do not bend from the waist.
5. Follow the correct after-fall response for your care setting.

A broad base of support helps you maintain balance. Correct lowering technique helps reduce injury to both the client and worker.

After a Fall in a Facility

If a client falls in a facility:

1. Stay with the client.
2. Do not move the client.
3. Do not allow the client to get up.
4. Remain calm and reassure the client.
5. Call for the charge nurse or nurse to assess the client for injuries.
6. Later, complete the required incident report according to facility policy.

After a Fall in Home Care

A private home does not have a nurse present to respond immediately. Follow employer procedures for falls.

After the fall, check for:

• pain or tenderness
• swelling or bruising
• inability or difficulty moving a limb
• bleeding
• the client’s report of feeling or hearing a bone snap or pop

Also consider whether a head, neck, or back injury is suspected.

If any listed sign is present or a head, neck, or back injury is suspected:

1. Do not move the client.
2. Call 9-1-1.
3. Call the supervisor.
4. Keep the client warm and calm.
5. Stay with the client until help arrives.

Helping an Unhurt Client Up in Home Care

When the client is unhurt and able to assist:

1. Place a chair beside the client.
2. Have the client use the armrests for support.
3. Support the client’s hips and help the client into a kneeling position facing the chair.
4. Have the client rest their forearms on the chair.
5. Ask the client to raise one knee and place that foot on the floor. Assist as required.
6. On a count of three, help the client push up, stand, and pivot into the chair while the client holds the armrests.
7. Let the client rest in the chair before helping them up again.

Many community agencies have policies that prevent individual caregivers from helping clients off the floor unless the client has enough mobility to do so independently. Follow employer policy.

Report the fall to the supervisor and complete an incident report according to employer policy.

What to Report and Record After a Fall

Report and record actions and observations according to employer policy.

Include:

• how the fall happened
• how far the client walked
• how the client tolerated activity before the fall
• any complaints before the fall
• how much assistance the client needed while walking

Complete an incident report and record the actions taken.