AUTHOR: CHAND RANI
Walking – Immobilization and Ambulation. Assistive Devices for Walking – Crutch Walking – Preparation of Client
Preparation of the Client for Crutch Walking
The psychological preparation of the client is exigent for the crutch walking. The nurses should win the confidence and co-operation of the client, for his successful crutch walking. If the client is afraid of fall during crutch walking he may not attempt for it.
Prior to crutch walking, the clients should do some exercises and that will strengthen the muscles of arms, hands, shoulder girdle and that of the lower limbs. These exercises also will help to prevent contractures and deformities in the hip and knee joint. The important exercises that are to be included are:
1. Exercise that Prevent Flexion Contracture of the Hip Joint
To prevent flexion contracture of the hip joint, the client after the amputation of the lower limb should be asked to lie on the abdomen for some time following the operation. The time should be increased day by day. If the client has an amputation below the knee, the client can begin to hyperextend his thigh and leg a he lies on his abdomen. If the client has an amputation above the knee, wait for specific orders from the doctor because this exercise will induce tension on the sutures and may cause haemorrhage.
2. Exercises that Prevent Flexion Contracture of the Knee Joint
In order to prevent flexion contracture of the knee joint, the client may be asked to sit at the edge of the bed and extend his lower limb. While the client is lifting the lower limb the nurse give resistance to the leg by pressing them down.
3. Exercises that Strengthen the Abdominal Muscles
The client should practice lifting the stump and the buttocks off the bed while he is lying flat on his back. This exercise will help to develop abdominal muscles and are necessary to stabilize the pelvis when the client stoops or bends.
4. Exercises for the Upper Limbs
In order to extend the elbow and to strengthen the triceps muscles, the client should lie on the abdomen and does push-up exercises several times a day. This can be done in another way also. The client may be asked to sit up on the edge of the bed with his feet on a chair. While pressing his pains against the mattress, he tries to lift his buttocks off the bed. This exercise strengthens the triceps muscles, extends the elbow and helps the client to become accustomed to rest his weight on his hands, because in crutch walking the client’s weight is borne out in the axilla but on the palms of the hands with the arms extended.
5. Exercises for Prevention of Deformities
The exercises carried out by the client should include exercises for the unaffected limb also. if the unaffected limb develops deformities, such as foot drop, it will affect the ambulation of the client.
1. It is important to have a crutch of proper length. Therefore, it should be measured carefully.
2. Frequent assessment of the height of the crutches should be made:
a. When the client’s posture improves.
b. When the child grow tall.
c. When the shoe height is changed.
If the re-adjustments are not made from time to time, they may develop postural deformities.
3. Make sure that the crutches are safe and properly fastened. All bolts should have wing nuts which must be tight.
4. The extension rod and the upright rods should have an adequate number of grooves to adjust the height of crutches as well as hand grips.
5. The crutches should have a rubber tip (castors) to prevent slipping.
6. Before the crutch walking is attempted, stress the importance of maintaining correct posture and balance of the body. The crutches and the feet are placed in a tripod position, thus producing a wide base of support. To provide stability, a greater height requires a broad base. Thus, a tall person requires a wider base than a short person.
7. To maintain a correct posture, the client should keep his knees and hips extended the back straight and the head held straight and high. There should be no hunch on the shoulders.
8. Before teaching the crutch walking, the nurse should make sure that the client has not altered level of consciousness or equilibrium that may interfere with the safe use of crutches.
9. There should be no injury or limitation of movement of the hands, arms, shoulders or back that may interfere with the client’s ability to bear weight on hands or mobilize.
10. The floor surface must be non-slippery and free of obstacles.
11. The practice area should be sufficiently large and free of obstacles.
12. The client should wear sturdy flat shoes to prevent slipping.
13. The client should not wear loose fitting garments that may be caught in crutches.
14. The nurse should practice crutch walking before she attempts to teach the client about crutch walking, so that she can learn the hazards associated with the crutch walking and warn the client about it. She should have a pair of crutches adjusted to her height in order to demonstrate crutch walking correctly.
15. The client should be made conscious of the hazards associated with the crutch walking (e.g., crutch paralysis, falls, back pain).
16. The nurses should have patience and tact when she deals with the clients who are crippled because they would make a very gradual process.
17. Client should have an adequate support and encouragement when they learn to use crutches. Disabled clients are afraid and anxious to use crutches for the fear of fall. Therefore, the nurse should stand close to the client to support him if a fall is anticipated.
18. In preparation for crutch walking, the clients should have exercises which strengthen the muscles of the upper and lower limbs, abdomen etc. these exercises will help the client to balance his body weight.
19. There should be rest periods between the crutches walking because crutch walking is tiresome. There must be chair or bench nearby on which the client can rest.
20. The client should be taught to bear his body weight on the hand grip rather than on the axillary bar. If the pressure is applied on the axillary bar, the client may develop crutch paralysis.
21. When a client get his crutches in the initial stage of his practice, the axillary bar should not be padded because it encourages him to lean on it while walking, thus increasing the danger of pressure upon the brachial nerve plexus.
22. Every client should learn at least 2 gaits – one for the rapid movement and another for walking in crowded situations.
23. Before a client is sent home on crutches, the nurse should make sure whether the client can act spontaneously, get in and out of chairs, on and off the toilet, in and out of doors, up and down the stairs and the ramps, can wear clothes etc.
Due to illness or trauma when activity tolerance is decreased, it may be necessary to assist in walking. Besides, any damage to the musculo-skeletal system or nervous system may cause temporary or permanent damage which may necessitate the use of mechanical devices for moving about.
Assisting a Client to Walk
The amount of assistance required is determined on the following basis:
1. Clients activity tolerance
3. Presence of pain
4. Coordination and balance
Detailed explanation is given to the client regarding why it is important to walk, when to start walking, who will help in walking, how much effort client must put on and how much independence client can have. Make sure there is no obstacle in the client’s pathway. Before starting walking, rest points for the client also must be determined.
Care must be taken to prevent orthostatic hypotension. Allow the client to sit at the side of the bed for few minutes before begin to walk, than stay in the standing position for few minutes before starting to walk. Make sure the stability of client’s balance is obtained before starting to walk. If the client feels dizzy, immediately make the client sit or lie down.
While walking provide support at the waist to balance the centre of gravity. For this, client can use walking belt also. While walking the client should not lean to one side because this alters the centre of gravity, disturbs the balance and increases the chances of falling.
While the nurse is assisting the client to walk, nurse must stand on the affected side of the client by holding the arm around the client’s waist and the other arm under the client’s axilla. Holding the client’s arm giving support is wrong, because in case the client faints or begin to fall, the nurse will not able to support the client. If the client is heavy or the nurse is weak, two nurses, one on either side of the client can assist in walking.
Use Assistive Devices in Walking
1. Walkers are very light movable devices, made of metal tubing with height upto the waist. Walkers have four widely placed legs and handgrips. The client hold the handgrips on the upper bars, takes a step, moves the walker forward and take another step.
2. Canes are light, easily movable devices made of metal or wood with a height up to the waist. These are two types (1) single straight-legged cane. (2) Quad lane. The quad lane is used when there is partial or complete leg paralysis, because it provides greater support.
Crutches are made of wooden or metal stuff and are often used to increase mobility. Its use may be temporary or permanent. Crutches are commonly used after operation of the hip, following amputations and injuries of the leg when mobility is desirable but weight bearing capacity on the affected limb is only partial or not allowed. The nurse has a responsibility to prepare the patient to use crutches if a physiotherapist is not available. Therefore, every nurse should know the essentials about using crutches.
Variety of crutches is available in the market. The essential part of a crutch is:
1. Arm rest (axillary bar)
2. Adjustable hand grip
3. Upright rods
4. Adjustable extension rod
5. Rubber crutch tip
It is essential that the length of the crutches should be adjusted to the height of the patient. The crutches that are too long cause pressure in the armpit and elevation of the shoulder girdle. The pressure in the armpit causes a crutch paralysis. If the crutches are too short, the client has to stoop over the crutches and it will not support the body weight. These are different methods used to measure the length of the crutches for a client:
a. With the client lying in bed, measure from the anterior fold of axilla to the heel of the foot on the same side (with the shoes on) and add 5 cm. (2 inches).
b. While the client is in a standing position, measure from 5 cm from the anterior fold of the axilla to a point 14 cm (6 inches) lateral to the heel (with the shoes on).
c. Subtract 40.5 cm or 16 inches from the client’s total height.
When the client starts to walk with crutches, one has to make sure whether the height of the crutches is adjusted to the client’s height. When the client stands upright with the shoes on and the shoulders relaxed, the top of the crutch should reach 5 cm below the axilla (one should be able to insert two fingers between the axillary fold and the top of the crutch) and the crutch tip should extend 14 cm (6 inches) in front of and lateral to the toes. The hand grip need to be placed in a position so that the client’s elbow are slightly flexed (15 to 25 degree angle) when the hands are holding them.
GAITS (MANNER OF WALKING WITH CRUTCHES)
There are five gaits commonly used in crutch walking. The gait used, depends on the limitations of the client relative to the weight bearing. All these gaits begin with the tripod position (three legged support) i.e., the triangle made by the two crutches and the feet.
1. Four Point Alternate Crutch Gait
This gait is used by the clients who can bear partial weight on both of their feet (e.g., cerebral palsy). It is safer than other gaits, because there are three points of support on the floor at one time. The movement of the crutches and the feet are as follows:
a. Tripod position: a position in which both feet are placed together and two crutches are in foot and lateral to the feet.
b. Right crutch forward.
c. Left foot forward
d. Left crutch forward
e. Right foot forward
2. Three Point Gait (orthopaedic Gait)
This gait is used when complete weight bearing is allowed on one foot and partial or no weight bearing is allowed on the other foot. It is faster than the four point gait. The sequence of movements of the crutches and the feet are as follows:
a. Tripod position
b. Both crutches and the non-weight bearing foot are placed forward
c. Weight bearing foot is place forward.
3. Two Point Gait
This is a gait similar to walking. In this gait, weight bearing is permitted equally on both feet. The sequence of movements is as follows:
a. Tripod position
b. Left crutch and right foot are placed forward
c. Right crutch and the left foot are placed forward
4. Swing-to-crutch Gait
In this gait both crutches are placed ahead of the client and the client then swings forward to the crutches. Since the muscles of lower extremity are not used in walking, prolonged use of these gaits results in atrophy of the unused muscles.
5. Swing-through-crutch Gait
In this gait both crutches are placed ahead of the client and the client then swings through the crutches and advances to a position in front of the crutches. This gait allows the client to a movement faster than any other gaits or even normal walking.