Question

A client will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this client?

A Clients who are fearful of walking should be told to look at their feet when walking to ensure correct positioning.

B If an ambulating client whom a nurse is assisting begins to fall, the nurse should slide the client down his own body to the floor, carefully protecting the client's head.

C Nurses should never assist clients with ambulation without a physical therapist present.

D Clients who can lift their legs only 1 to 2 inches off the bed do not have sufficient muscle power to permit walking.

Answer 1

A nurse should assess the client's balance, coordination, and muscle strength before assisting with ambulation. If the client begins to fall, the nurse must protect their head and control the descent. Assistive devices can increase stability, and professional, encouraging communication is important for client confidence.

Step-by-step explanation:

When a nurse is assisting a client with ambulation for the first time post-cardiac surgery, several considerations are important to ensure the client's safety and to facilitate successful ambulation. Primarily, the nurse should assess the client's muscle power and stability. Clients who can lift their legs only 1 to 2 inches off the bed likely do not have sufficient muscle power to support walking. In such cases, further strength building is required before attempting to walk.

Please, disregard the option D because it is not always accurate to assume that clients who can lift their legs only 1 to 2 inches off the bed cannot walk. Each client's strength and readiness for ambulation should be individually assessed. A more accurate approach is to assess balance, strength, and coordination using subtests such as normal walking, tandem gait (where the patient places the heel of one foot against the toe of the other foot), and walking on heels or toes. These tests help in identifying any issues related to balance and coordination, which are crucial to consider when assisting with ambulation.

If the client begins to fall while ambulating, it is essential for the nurse to protect the client's head and control the descent to the floor, as stated in option B. This ensures the client's safety. Assistive devices such as a cane, crutch, or walker can increase stability for the client, as they widen the base of support.

It is not always necessary for a physical therapist to be present during ambulation assistance as suggested in option C; however, nurses should be adequately trained and should refer to the care plan and collaborate with physiotherapists as needed.

Lastly, the nurse should engage in professional communication and utilize a supportive attitude to help alleviate any fears the client may have about ambulation post-surgery. Encouraging eye contact with the surroundings rather than looking at the feet may help in maintaining proper posture and stability.