The nurse instructs the client, who has right-sided weakness, to use the cane during ambulation and assesses the client's use of the cane. Which assessment should the nurse address before the client ambulates with the cane?
1. The cane clicks each time the client touches it to the floor.
2. The client uses the cane on the unaffected side for support.
3. The client holds the cane 4 to 6 inches to the side of the left foot.
4. The client ambulated four times with the cane in physical therapy.
1
1. The cane should have a rubber tip on the end and should be silent when the rubber tip contacts the floor, indicating the rubber is intact; if the cane clicks each time it hits the floor, the rubber cannot effectively maintain the client's stability.
2 and 3. Using the cane on the unaffected side and holding it 4 to 6 inches to the side of the unaffected foot are good technique for ambulating with a cane.
4. The client's history of cane use is valuable information for subsequent instruction and gives the nurse a basis for comparison.
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