Assisting a Patient with Ambulation Using Crutches

Skill 9-8

Assisting a Patient With Ambulation Using Crutches

Crutches enable a patient to walk and remove weight from one or both legs. The patient uses their arms to support the body weight. Crutches can be used for the short or the long term. This section will discuss short-term use of axillary crutches. Crutches must be fitted to each person. When standing up straight, the top of the crutches should be about 1 to 2 inches below the armpits (AAOS, 2015). When using crutches, the patient's weight should rest on the hands, not on the underarm supports (AAOS, 2015). Pressure placed on the axillae can cause damage to nerves and circulation. When using crutches, the elbow should be slightly bent at about 30 degrees and kept close to the sides. Fitting of and the procedure for crutch walking is usually the responsibility of a physical therapist, 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.

Early mobility plays an important role in the patient's physical and psychological well-being (Arnold et al., 2018). Use a screening or assessment tool to assess the patient's ability to walk and the need for SPHM devices and assistance to guide decision making (VA Mobile Health, n.d.; VHACDOSH, 2016). One example of a decision-making tool and associated SPHM equipment are outlined in Fundamentals Review 9-4. Figure 1 in Skill 9-6 provides an example of a decision-making tool related to ambulation.

Delegation Considerations

Patient teaching regarding use of crutches cannot be delegated to assistive personnel (AP). Reinforcement or implementation of the use of crutches may be delegated to AP. 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.

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

Assessment

Review the patient's health record and plan of care 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.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired walking
Knowledge deficiency
Fall risk

Outcome Identification and Planning

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

Implementation

Action	Rationale
1. Review the health record and plan of care for conditions that may influence the patient's ability to move and ambulate. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for ambulation. Assess the patient's knowledge and previous experience regarding the use of crutches. Determine that the appropriate size crutch has been obtained.	Reviewing the health record and plan of care validates the correct patient and correct procedure. Assessment helps identify problem areas to minimize the risk for injury.
2. Perform hand hygiene. Put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain the procedure to the patient. Tell the patient to report any feelings of dizziness, weakness, or shortness of breath while walking. Decide how far to walk.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. Place the bed in a position that allows the patient's feet to reach the floor, if the patient is in bed.	Proper bed height ensures safety when getting the patient out of bed.
5. Encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed.	Use of assistive devices encourages independence, reduces strain for staff, and decreases risk for patient injury.
6. Assist the patient to the side of the bed, if necessary. Have the patient sit on the side of the bed. Assess for dizziness or lightheadedness. Have the patient stay seated until they feel secure.	Having the patient sit on the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change. Assessing patient complaints helps prevent injury.
7. Assist the patient to put on skid-proof footwear and a robe, if desired.	Doing so ensures safety and warmth. Skid-proof footwear decreases the risk of falls.
8. Wrap the gait belt around the patient's waist, based on assessed need and facility policy.	Gait belts improve the caregiver's grasp, reducing the risk of musculoskeletal injuries to staff and the patient and provide for a firmer grasp if patient should lose their balance. A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
9. Assist the patient to stand erect, face forward in the tripod position (Figure 1). This means the patient holds the crutches 12 inches in front of, and 12 inches to the side of, each foot.	Positioning the crutches in this manner provides a wide base of support to increase stability and balance.
10. For the four-point gait:	This movement ensures stability and safety.
a. Have the patient move the right crutch forward 12 inches and then move the left foot forward to the level of the right crutch.
b. Then have the patient move the left crutch forward 12 inches and then move the right foot forward to the level of the left crutch.
11. For the three-point gait:	The patient bears weight on the stronger leg.
a. Have the patient move the affected leg and both crutches forward about 12 inches.
b. Have the patient move the stronger leg forward to the level of the crutches.
12. For the two-point gait:	The patient bears partial weight on both feet.
a. Have the patient move the left crutch and the right foot forward about 12 inches at the same time.
b. Have the patient move the right crutch and left leg forward to the level of the left crutch at the same time.
13. For the swing-to gait:	The swing-to gait provides mobility for patients with weakness or paralysis of the hips or legs.
a. Have the patient move both crutches forward about 12 inches.
b. Have the patient lift the legs and swing them to the crutches, supporting their body weight on the crutches.
14. Continue with ambulation for the planned distance and time. Return the patient to the bed or chair based on the patient's tolerance and condition. Remove the gait belt if used.	Continued ambulation promotes activity, and adhering to the planned distance and time prevents the patient from becoming fatigued.
15. Ensure the patient is comfortable, with the side rails up and the bed in the lowest position, as necessary. Place the call bell and other essential items within reach.	Proper positioning with raised side rails and proper bed height provide for patient comfort and safety. Having the call bell and other essential items within reach promotes safety.
16. Clean transfer aids per facility policy, if not indicated for single-patient use. Remove gloves and any other PPE, if used. Perform hand hygiene.	Proper cleaning of equipment between patient use prevents the spread of microorganisms. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has ambulated safely without experiencing falls or injury, and the patient has demonstrated proper crutch-walking technique.

Documentation

Guidelines

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.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

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.

Special Considerations

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. The patient transfers their weight to the crutches and holds the railing. The patient places the unaffected leg on the first stair tread past the crutches. The patient then transfers their weight to the unaffected leg, moving up onto the stair tread. The patient moves the affected leg then crutches up to the step. Continue with this sequence until top of stairs is reached. Using this process, the crutches always support the affected leg.
Patients should not lean on the crutches. Prolonged pressure on the axillae can damage the brachial nerves, causing nerve palsy (Warees et al., 2020), 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.

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Skill 9-8