The Walking Program He Won't Do
Mr. Pike, 70, is 10 days out from surgery to repair a hip fracture. His restorative plan reads: ambulate 30 feet with a front-wheeled walker twice a day with standby assist and a gait belt. Yesterday he walked both times. Today at 9:00 a.m. he is sitting on the edge of the bed in his pajamas and says, 'I'm not walking. My hip hurts and I'll fall - I fell at home, you know.' He has a PRN pain pill ordered that he has not asked for. He is alert and oriented. The nurse is passing medications on another hall and is 20 minutes away.
1. What do you do in the next few minutes? What do you offer him?
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Find out what is actually in the way before deciding anything.
- Ask about the pain: where, how bad, and whether it is worse than yesterday. Pain and fear are legitimate barriers, not excuses.
- Ask what he means by "I'll fall." A prior fall at home is a real fear and naming it often lowers it.
Then act on both barriers:
- Tell the nurse (call light or go get her) that he wants to walk but is hurting and ask whether the PRN can be given now. A PRN takes time to work, so the timing matters - waiting until after the walk defeats the purpose. Do not give it yourself and do not promise it.
- Shrink the goal without abandoning it: sit on the edge of the bed and dangle, march in place, or walk to the doorway instead of 30 feet. Put the gait belt on for any standing and stay at his side.
Do not: pull him up by the arm, threaten him ("you'll never walk again"), or say "okay" and leave without telling anyone or documenting. A missed session that no one knows about looks like progress the next day.
2. He agrees to dangle at the bedside but refuses to stand. What do you chart and report?
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Reasonable effort plus honest documentation is a complete answer.
Chart, for example: "9:10 a.m. Resident declined ambulation; states hip pain and fear of falling. Agreed to dangle at bedside for 5 minutes with assist, gait belt in place. Nurse notified at 9:05 a.m. re: pain before walking; PRN requested through nurse. Restorative walk not completed this a.m. Will offer again this afternoon."
Report to the nurse, and see that the therapist learns of the change in participation through the nurse or the facility's usual channel - a drop-off in participation changes the therapy plan, and only the therapist can change it.
Do not chart "uncooperative," "noncompliant," "lazy," or "refused all care." They are inaccurate (he accepted part of the plan), they are opinions, and they follow him in the record. Do not chart that he received a pain pill - the nurse documents medications.
3. Two days later he walks the full 30 feet with one rest. How do you document and what must you not do on your own?
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Document specific facts: the distance actually covered, the device, the level of assistance, the rest taken and where, any symptoms, and how he responded. "Walked 30 ft with FWW and gait belt, standby assist, one rest at 15 ft. No dizziness or shortness of breath. Pleased, said it was easier than last time."
Tell him exactly what he did, not just "good job": "You walked the whole 30 feet and you only needed one rest. Last week that wasn't happening."
Do not on your own:
- Increase the distance, add a third walk, or drop the gait belt because he had a good day. That is the therapist's plan; a good day is reported and the therapist adjusts it.
- Chart vague praise like "tolerated well" with no numbers - it erases the evidence of progress that the care team uses.
- Chart that he will "probably need less help from now on" or make any prediction about discharge. Report what happened; let the team draw conclusions.