Exam 3 Ambulation using crutches

4The nurse has instructed the client with a knee injury on how to perform crutch walking with a four-point gait. Which statement clarifies client understanding?

"The four-point gait uses one crutch, then one leg, followed by the other crutch, and then the other leg."

Nursing use of crutches sample documentation

5/10/20 1830 Patient instructed in crutch walking using four-point gait. Patient return demonstrated gait, ambulating for approximately 15 ft in hallway, without difficulty. —H. Pointer, RN

use of crutches - equipment

Crutches with axillary pads, handgrips, and rubber suction tips Nonskid shoes or slippers PPE, as indicated Stand-assist device, as necessary, if available Gait belt, based on assessment

The nurse is demonstrating proper ambulation technique with crutches to a child with a fractured ankle. What is priority assessment should the nurse perform?

weight bearing status

The nurse is providing step-by-step instructions to a client who is learning how to climb stairs while using crutches. Place the following instructions in the correct order. Use all options.

Correct Response: 1)"Place both crutches under your left arm."2)"Grasp the stair railing with your right arm."3)"Place your unaffected leg on the first stair tread."4)"Transfer your weight to the unaffected leg."5)"Move up onto the stair tread."6)"Move your crutches and the affected leg up onto the stair tread."

Nursing use of crutches

Crutches can be used when climbing stairs. The patient grasps both crutches as one, on one side of the body and uses the stair railing. Have the patient stand in the tripod position facing the stairs. The patient transfers his or her weight to the crutches and holds the railing. The patient places the unaffected leg on the first stair tread. The patient then transfers his or her weight to the unaffected leg, moving up onto the stair tread. The patient moves the crutches and affected leg up to the stair tread and continues to the top of the stairs. Using this process, the crutches always support the affected leg. Long-term use of the swing-to gait can lead to atrophy of the hips and legs. Include appropriate exercises in the patient's care plan to avoid this complication. Patients should not lean on the crutches. Prolonged pressure on the axillae can damage the brachial nerves, causing brachial nerve palsy, with resulting loss of sensation and inability to move the upper extremities. Patients using crutches should perform arm- and shoulder-strengthening exercises to aid with crutch walking.

Nursing use of crutches documentation

Document the activity, any other pertinent observations, the patient's ability to use the crutches, the patient's tolerance of the procedure, and the distance walked. Document the use of transfer aids and number of staff required for transfer.

Nursing use of crutches diagnosis

Impaired walking Deficient knowledge Risk for falls

Nursing use of crutches Assessment

Review the patient's record and nursing care plan to determine the reason for using crutches and instructions for weight bearing. Check for specific instructions from physical therapy. Perform a pain assessment before the time for the activity. If the patient reports pain, administer the prescribed medication in sufficient time to allow for the full effect of the analgesic. Determine the patient's knowledge regarding the use of crutches and assess the patient's ability to balance on the crutches. Assess for muscle strength in the legs and arms. Determine the appropriate gait for the patient to use.

Nursing use of crutches

The expected outcome to achieve when assisting a patient with ambulation using crutches is that the patient ambulates safely without experiencing falls or injury and the patient demonstrates proper crutch-walking technique.

Nursing use of crutches unexpected situations

You are assisting a patient ambulating in the hallway using crutches when the patient reports fatigue. You notice that the patient is bearing weight on the axillary area: Call for assistance and have a coworker obtain a wheelchair to transport the patient back to the room. Once the patient is back in bed, reinforce instructions about avoiding pressure on the axillary area. In the future, plan to ambulate for a shorter distance to prevent the patient from becoming fatigued. Talk with the multidisciplinary health care team about possible exercises for upper-extremity strengthening.

encourage patient to do

as many exercises my themselves as possible

Patient teaching regarding use of crutches

cannot be delegated to nursing assistive personnel (NAP) or unlicensed assistive personnel (UAP). Reinforcement or implementation of the use of crutches may be delegated to NAP or UAP. Assisting a patient with ambulation using crutches may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances, as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A in your Supplemental Resources.

The nurse is talking to a client who has been using crutches for ambulation. The client reports intermittent numbness of the upper arms. What should the nurse instruct the client to avoid?

leaning for prolonged periods by the axilla on the crutches

When using crutches, the elbow should be

slightly bent at about 30 degrees and the hands, not the armpits, should support the patient's weight. Weight on the armpits can cause nerve damage. A physical therapist usually teaches the procedure for crutch walking, but it is important for the nurse to be knowledgeable about the patient's progress and the gait being taught. Be prepared to guide the patient at home or in the hospital after the initial teaching is completed. Remind the patient that the support of body weight should be primarily on the hands and arms while using the crutches. There are a number of different ways to walk using crutches, based on how much weight the patient is allowed to bear on one or both legs.

The nurse is caring for a client in the postanesthetic care unit (PACU) who has just undergone a third foot surgery. Which gate is best for the nurse to teach this client?

swing-to gait

Crutches enable a patient to

walk and remove weight from one or both legs. The patient uses the arms to support the body weight. Crutches can be used for the short or the long term. This section will discuss short-term crutch use. Crutches must be fitted to each person. Have the patient stand up straight with the palm of the hand pressed against the body under the arm. The hand should fit between the top of the crutches and the armpit. When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the patient's weight. Weight on the armpits can cause nerve damage. A physical therapist usually teaches the procedure for crutch walking, but it is important for the nurse to be knowledgeable about the patient's progress and the gait being taught. Be prepared to guide the patient at home or in the hospital after the initial teaching is completed. Remind the patient that the support of body weight should be primarily on the hands and arms while using the crutches. There are a number of different ways to walk using crutches, based on how much weight the patient is allowed to bear on one or both legs.