Body Mechanics and ROM Exercises PDF

Body Mechanics Prepared by: Mylin C. Rendoque Objectives At the end of two hours session the students will be able to:  Describe four basic elements of normal movement.  Differentiate isotonic, isometric, isokinetic, aerobic and anaerobic exercise.  Compare the effects of exercise and immobility...

Body Mechanics Prepared by: Mylin C. Rendoque Objectives At the end of two hours session the students will be able to:  Describe four basic elements of normal movement.  Differentiate isotonic, isometric, isokinetic, aerobic and anaerobic exercise.  Compare the effects of exercise and immobility on body systems.  Identify factors influencing a client’s body alignment and activity  Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance and problems related to immobility.  Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.  Use safe practices when positioning, moving, transferring, and ambulating clients.  Compare and contrast active, passive and active –assistive range –of- motion(ROM) exercise. Objectives At the end of three hours session the students will be able to:  Describe client teaching for clients who use mechanical aids for walking.  Verbalize the steps used in: a. Moving a client up in bed. b. Turning a client to the lateral or prone position in bed. c. Logrolling a client d. Assisting a client to sit on the side of the bed e. Transferring between bed and chair. f. Transferring between bed and stretcher g. Assisting a client to ambulate.  Recognize when it is appropriate to assign aspects of moving , transferring, and ambulating a client to assistive personnel.  Demonstrate appropriate documentation and reporting of moving, transferring , and ambulating a client.  INTRODUCTION  Our ability to move is an essential aspect of well-being and our overall health is affected by our activities.  The nursing diagnosis of inactive lifestyle emphasizes the role of exercise and activity as an essential components of health.  Moderate exercise is identified as significant to enhancing physical fitness.  A strong, well-developed body of research evidence supports the role of exercise in improving the health status of individuals.  Activity-exercise pattern- refers to an individual’s routine of exercise, activity, leisure and recreation.  Mobility- the ability to move freely, easily, rhythmically and purposefully in the environment , is an essential part of living. It is vital to independence; a fully immobilized individual is as vulnerable and dependent infant.  Normal Movement and stability- are the result of an intact musculoskeletal system , an intact nervous system, and intact inner ear structures responsible for equilibrium.  Body Movement- involves four basic elements: body alignment (Posture), joint mobility, balance and coordinated movement. Alignment and Posture  Proper body alignment and posture promotes optimal balance and maximal body function whether client is standing, sitting or lying down.  Line of gravity- an imaginary vertical line drawn through the body’s center of gravity. In humans, the usual line of gravity begins at the top of the head and falls between the shoulders , through the trunk, slightly anterior to the sacrum, between the weight-bearing joints and base of support.  Center of Gravity- the point at which all of the body mass is centered.  Base of Support- The foundation on which the body rests. Joint Mobility  Joints are the functional units of the musculoskeletal system.  The bones of the skeleton articulate at the joints, and most of the skeletal muscles attach to the two bones at the joint.  Muscles produce on contraction: flexors, extensors, internal rotators, and the like.  Flexor muscles are stronger Types of Joint Movement Neck-Pivot Joint  Flexion- Move the head from the upright midline position forward , so that the chin rests on the chest(45 degree midline )  Extension- Move the head from the flexed position to the upright position.  Hyperextension – Move the head from the upright position back as far as possible  Lateral Flexion- Move the head laterally to the right and left shoulders  Rotation- turn the face as far as possible to the right and left shoulders. Types of Joint Movement Shoulder-Ball- and-Socket Joint  Flexion- Raised each arm from a position by the side forward and upward to a position beside the head. (180 degrees from the side).  Extension- Move each arm from a resting position at the side of the body.  Hyperextension – Move each arm from a resting side position to behind the body.  Abduction- Move each arm laterally from a resting position at the sides to side position above the head , palm of the hand either toward or away from the head.  Abduction( anterior)- Move each arm from a position at the sides across the front of the body.  Circumduction- Move each arm forward , up, back, and down in full circle.  External Rotation- With each arm held out to the side at the shoulder level and the elbow bent to a right angle , fingers pointing down, move the arm upward so that the fingers point up. Types of Joint Movement Shoulder-Ball- and-Socket Joint  Internal Rotation- With each arm held out to the side at the shoulder level and the elbow bent to a right angle, fingers pointing up, bring the arm forward and down so that the fingers point down. Types of Joint Movement Elbow –Hinge Joint  Flexion- Bring each lower arm forward and upward so that the hand is that the hand is at the shoulder.  Extension- bring each lower arm forward and downward straightening the arm.  Rotation for Supination- Turn each hand and forearm so that the palm is facing upward.  Rotation for pronation- Turn each hand and forearm so that the palm is facing down. Types of Joint Movement Wrist- Condyloid Joint  Flexion- Bring the fingers of each hand towards the inner aspect of the forearm.  Extension- Straighten each hand to the same plane as the arm.  Hyperextension- Bend the fingers of each hand toward the inner aspect of the forearm.  Radial Flexion(abduction)- Bend each wrist laterally toward the thumb sie with hand supinated.  Ulnar Flexion (Adduction)- Bend each wrist laterally toward the fifth finger with the hand supinated Types of Joint Movement Hand and Fingers: Metacarpophalangeal Joints- Condyloid; Interphalangeal Joints –Hinge  Flexion-Make a fist with each hand  Extension- Straighten the fingers of each hand.  Hyperextension- Bend the fingers of each hand back as far as possible.  Abduction-Spread the fingers of each hand apart.  Adduction- Bring the fingers of each hands together Types of Joint Movement Thumb –Saddle Joint  Flexion-Move each thumb across the palmar surface of the hand toward the fifth finger.  Extension- Move each thumb away from the hand.  Abduction-Extend each thumb laterally  Adduction- Move each thumb back to the hand.  Opposition- Touch the thumb to the top of each finger of the same hand. The thumb joint movements involved are abduction, rotation, and flexion. Types of Joint Movement Hip-ball-And –Socket Joint  Flexion-Move each leg forward and upward. The knee may be extended or flexed  Extension- Move each leg back beside the other.  Hyperextension- Move each leg back behind the body.  Abduction- Move each leg out to the side.  Adduction- Move each leg back to the other leg and beyond in front of it.  Circumduction- Move each leg backward , up, to the side , and down in a circle.  Internal Rotation- Flex knee and hip to 90 degree. Place the foot away from the midline. Move the thigh and knee toward the midline.  External Rotation- Flex knee and hip to 90 degree. Place the foot toward the midline. Move the thigh and knee away from the midline.  Types of Joint Movement Knee- Hinge Joint  Flexion- Bend each leg , bringing the heel toward the back of the thigh  Extension- Straighten each leg, returning the foot to its position beside the other foot Ankle –Hinge Joint  Extension (Plantar Flexion)- Point the toes of each foot downward.  Flexion( Dorsiflexion)- Point the toes of each foot upward  Types of Joint Movement Foot- Gliding  Eversion – Turn the sole of each foot laterally  Inversion- Turn the sole of each foot medially Toes: Interphalangeal Joints – Hinge ; Metatarsophalangeal Joints Hinge ; Intertarsal Joints – Gliding  Flexion- Curl the toe joints of each foot downward.  Extension- Straighten the toes of each foot Types of Joint Movement Trunk- Gliding Joint  Flexion- Bend the trunk toward the toes.  Extension- Straighten the trunk from a flexed position.  Hyperextension- Bend the trunk backward  Lateral flexion- Bend the trunk to the right and to the left  Rotation- Turn the upper part of the body from side to side Balance Mechanism of equilibrium response, frequently without our awareness , to various head movements. Depends on the informational inputs from the labyrinth( inner ear), vision (vestibulo-ocular input) and from stretch receptors of muscles and tendons( vestibulospinal input). Semicircular canals are concerned of equilibrium Is maintained when the line of gravity falls close to the base of support. Coordinated Movement Balanced, smooth ,purposeful movement is the result of proper functioning of the cerebral cortex, cerebellum and basal ganglia.  Body Mechanics  Used to describe the efficient coordinated and safe use of the body to move objects and carry out activities of daily living.  The application of mechanical principles and knowledge of human anatomy to the action of the body parts during an activity.  Refers to the coordinated efforts of the musculoskeletal and nervous system to maintain balance , posture and body alignment during lifting ,bending , moving and perform ADLS.  It entails adoptions of appropriate ways of moving the body in order to accomplish tasks without stress or injury.  Purposes  Client’s Benefits:  It reduces the risk of injury to the musculoskeletal system.  It facilitate ease of body movement and allows for more efficient use of energy. Nurses' Benefits:  work-related musculoskeletal injuries. Body mechanics helps protect joints and muscles from being pulled or stretched beyond their capacities while allowing them to be used for maximum effectiveness.  nurse fatigue  Purposes Nurses' Benefits:  Teaching patients how to move safely especially those with musculoskeletal disorders will contribute to the healing process.  The nurse can further promote good body mechanics by such simple measures as placing articles within easy reach of patients so that they do not twist or over-stretch in reaching out to them.  Also demonstrating correct techniques for getting in and out of bed can prevent musculoskeletal injuries  Principles of Body Mechanics 1. Keep weight balanced above base of support. 2. Enlarge base of support as necessary to increase body’s stability. 3. Lower center of gravity toward base of support as necessary to increase body’s stability. 4. Enlarge base of support in the direction in which force is to be applied. 5. Tighten abdominal and gluteal muscles in preparation for all activities. 6. Face the direction of task and turn body in one plane. 7. Bend hips and knees (rather than back) when lifting. 8. Move objects on level surface whenever possible. 9. Slide (rather then lift) objects on smooth surface whenever possible. 10. Hold objects close to the body, and stand close to object to be moved. 11. Use body’s weight to assist in lifting or moving whenever possible. 12. Use smooth motions and reasonable speed when carrying out tasks. 13. When moving patients, use pulling motion whenever possible. 14. Raise the working surface to your waist level when possible.  Some principles of body mechanics are: Use major muscles Avoid twisting bending at the knee or because it can lead to squatting when lifting or torsion of the spine reaching out to items lower lessening its ability to than your center of gravity. function effectively. This is because the broad flat muscles of the back are weakest when stretched and flattened and so are very susceptible to injury Maintain the center of when heavy objects are gravity over a broad lifted. base of support  Pulling and Pushing  Slide (push/pull) instead of lifting. Lifting should be the last option to be considered.  Keep the weight to be lifted as close to the body as possible- this positions the weight of the lifted item/person and the lifter in the same plane and closer to the center of gravity for proper balance.  Maintains balance with least effort when the base of support is enlarged in the direction in which the movement is to be produced or opposed.  It is easier and safer to pull an object toward one‟s own center of gravity than to push it away.  Lifting  When a person lifts or carries an object, the weight of the object becomes part of the person‟s body weight which affects the location of the person‟s center of gravity.  1. Stand close to the load and flex the back and the knees, lowering the body to grasp the load.  2. Begin lifting with the back flexed , and gradually straighten the knees so that the leg muscles bear most of the burden.  3. To hold or walk with the object maintain a less flexed but not a completely straight position. NB: Do not lift more than 51 lbs without assistance from equipment or persons.  When moving heavy objects, face the direction of the movement.  Work on a level that avoids strain on your body; e.g. raise the bed to a level that you can comfortably bath a patient without bending over.  Put on the internal abdominal girdle by tightening the stomach and tucking in the pelvis. Without this, the abdominal muscles can be weakened or torn causing its contents to herniate.  Pivoting  Is a technique in which the body is turned in a way that avoids twisting of the spine.  Turn 90 degrees in the desire direction to avoid twisting of the spine.  Twisting of the back can be avoided by squarely facing the direction of movement whether pushing , pulling or sliding and moving the object directly toward or away from the one‟s center of gravity. Positioning Clients  Positioning a client in good body alignment and changing the position regularly (every 2 hours) are essential aspects of nursing practice  When the client is not able to move independently or assist with moving , the preferred method is for two or more nurses to move or turn the client and use assistive equipment.  Make sure the mattress is firm and level yet has enough give to fill in and support natural body curvatures.  Ensure that the bed is clean and dry.  Place support devices in specified areas according to client‟s position.  Avoid placing one body part, particularly one with bony prominences , directly on top of another body part  Avoid friction and shearing.  Plan a systemic 24-hour schedule for position changes.  Always obtain information from the client to determine which position is most comfortable and appropriate.  Range of Motion (ROM) The maximum movement that is possible for that joint.Joint range of motion varies from individual to individual and is determined by genetic makeup, developmental patterns, the presence or absence of disease, and the amount of physical activity in which the individual normally engages. Factors Affecting Body Alignment Growth and Development Nutrition Personal Values and Attitude External Factors Prescribed Limitations Exercise  Types of Exercise  Isotonic (dynamic) exercises – those in which muscles shorten to produced muscle contractions and active movement.  Isometric (static or setting ) exercises- those in which muscle contraction occurs without moving the joint (muscle length does not change).  Isokinetic (resistive) exercises- involve muscle contraction or tension against resistance.  Aerobic Exercise- is activity during which the amount of oxygen taken into the body is greater than that used to perform the activity.  Anaerobic Exercise –involves activity in which the muscles cannot draw out enough oxygen from the blood stream ,and anaerobic pathways are used to provide additional energy for a short time.  Benefits of Exercise Respiratory System Musculoskeletal Cardiovascular Improving gas exchange,more System System toxins are eliminated,prevents Increases heart rate ,the strength of pooling of secretions in the Increases joint the heart muscle contraction and bronchial and flexibility,stability and the blood supply to the heart and bronchioles.Decreases breathing range of motion. muscles through increased cardiac effort and risk of infection output Endorine and Metabolism Gastrointestinal System Improves the appetite Elevates metabolic rate ,Increase and increases body production of body heat gastrointestinal tract and ease products and calorie tone, facilitating use peristalsis  Benefits of Exercise Psychoneurologic System Elevating the mood and relieving Urinary System Immune System stress,and anxiety across lifespan.Relieves symptoms of depression. metabolites for Improved circulation of lymph neurotransmitters , levels of Promotes efficient blood nodes where destruction of endorphins , levels of oxygen in the flow, the body excretes pathogens and removal of foreign brain and other system,releases wastes more antigens can occur. endogenous opiods,improves sleep. effectively.Prevent urine stagnation, decreases Cognitive Function the risk of UTI. Spiritual Health Improves the mind-body-spirit Positive effects on cognitive connect, relationship with God, functioning ,decision- making, and physical well being by problem-solving processes, establishing balance planning, and paying attention.  Effects of Immobility  Musculoskeletal System 1. Disuse Osteoporosis- bones demineralize. 2. Disuse atrophy- muscles decrease in size. 3. Contractures-permanently shortening of muscles 4. Joint deformity- foot drop, wrist drop and external hip rotation. 5. Stiffness and pain in the joints – ankylosed (permanently immobile)  Cardiovascular System 1. Diminished cardiac reserve 2. Increase use of Valsalva Manuever 3. Orthostatic ( postural )hypotension 4. Venous vasodilation and stasis 5. Dependent Edema 6. Thrombus Formation Effects of Immobility  Respiratory System 1. Decreased respiratory movement 2. Pooling of respiratory secretions 3. Atelectasis 4. Hypostatic Pneumonia  Metabolism 1. Decreased metabolic rate- BMR 2. Negative Nitrogen Balance 3. Anorexia 4. Negative Calcium Balance  Urinary System 1. Urinary Stasis 2. Renal Calculi 3. Urinary retention 4. Bladder gradually distended  Effects of Immobility  Integumentary System 1. Reduce Skin Turgor 2. Skin Breakdown  Psych neurologic System 1. Decline of mood elevating substances 2. Unable to carry out the usual activities 3. Frustration and decrease in self-esteem 4. Narrower and the variety of stimuli decreases 5. Client’s perception of time intervals deteriorates 6. Causes anxiety Nursing Management Assessment Client’s activity should be routinely addressed and includes nursing history and physical examination of the body alignment ,gait, appearance, and movement of joints,capabilities and limitations of movement ,muscle mass and strength, activity tolerance, problems related to immobility , and physical fitness.  Body Alignment  Slumped posture  Neck is flexed forward  Lordosis – an exaggerated anterior or inward curvature of the lumbar spine  Knees are hyperextend  Low back pain  Fatigue  Gait (Walk)  To determine client’s mobility and risk for injury due to falling.  Two Phases: Swing and Stance  Stance Phase: (a) The heel one foot strikes the ground (b) Body weight is spread over the ball of that foot while the other heel pushes off and leaves the ground.  The nurse assess as the client’s walks into the room or walk a distance of 10 feet down a hallway.  Nurse also assess pace ( no. of steps taken per minute).Normal walking pace ( 70 to 100 steps per minute)Adult ( slow about 40 steps per minute.)  The nurse should note the client’s need for a prosthesis or assistive device , such as cane or walker.  Appearance and Movement of Joints  Physical examination involves inspection, palpation, assessment of range of active motion , and if active motion is not possible, assessment of range of passive motion: Swelling, redness, deformity, symmetry, palpable tenderness, crepitation (palpable or crackling or grating sensation),increased temperature, Degree of movement.  Assessment of ROM  Capabilities and Limitations for Movements  The nurse needs to obtain data that may indicate hindrances or restrictions to the client’s movement and the need for assistance. Client’s illness influences the ability Limitations to movement Mental alertness and ability to follow directions Balance and coordination Presence of orthostatic hypotension Degree of comfort Vision  Nurse also assess the amount of assistance the client Moving in bed Rising from lying position to a sitting position Rising from a chair to a standing position. Coordination and balance Muscle Mass and Strength  Assess clients strength and ability to move  Providing appropriate assistance decreases the risk of muscle strain and body injury  Assessment of upper extremities strength for client’s who will use the ambulation aids Physical Energies for Activities  Determining an appropriate activity level for client  Assessment is useful in encouraging increasing independence in clients who a. Have a cardiovascular or respiratory disability b. Have been completely immobilized for prolonged period. c. Have decreased muscle mass or musculoskeletal disorder d. Have experienced inadequate sleep e. have experienced pain f. Depressed, anxious or unmotivated  Physical Energies for Activities  The most useful measures in predicting activity tolerance are heart rate, strength, and rhythm; respiratory rate, depth, and rhythm, and blood pressure.  The activity should be stopped immediately in the event of any physiologic change indicating the activity  Client tolerates the activity well , and if client’s heart rate returns to baseline levels within 5 minutes after the activity ceases, the activity is considered safe. Problems Related to Immobility  The nurse uses the assessment methods of inspection, palpation, and auscultation; checks result of laboratory tests.  Check results of laboratory test  Take measurements  Including body weight  Fluid intake  Fluid output  Obtain and record baseline assessment data soon after the client first immobile.  Support Devices Hand roll Pillows Mattresses To keep hand in a functional position and Used for support or Should be evenly prevent finger contractures elevation of n arm or supported leg. Footboard Suspension or heel It keeps the feet in guard boot dorsiflexion to prevent Prevent foot drop and plantar flexion relieve pressure on heels. Abduction Pillow Prevent hip dislocation following total hip replacement Types of Client’s Position  Fowler’s Position (Semisitting Position)  Bed position in which the head and trunk are raised 45 degree to 60 degree relative to the bed( visualize a 90 degree right angle to orient your thinking) and the knees may or may not be flexed.  The position of choice for people who have difficulty breathing and for some people with heart problems. Semi-Fowler’s Position  When the head and trunk are raised 15 degree to 45 degree. Sometimes called low Fowler‟s and typically means 30 degree of elevation. High-Fowler’s Position  The head and trunk are raised 60 to 90 degree, and most often the client is sitting upright at a right angle to the bed.  Orthopneic Position  The client sits either in bed or on the side of the bed with an over bed table across the lap  Position facilitates respiration by allowing maximum chest expansion. Dorsal Recumbent (Back-lying) Position  The client‟s head and shoulder are slightly elevated on small pillow.  The client‟s forearms may be elevated on pillows or placed at the client‟s side.  Used to provide comfort and to facilitate healing following certain surgeries or anaesthetics. Prone Position  The client lies on the abdomen with the head turned to one side. The hips are not flexed  Helps to prevent flexion contractures of the hips and knees.  Should be used only when the client‟s back is correctly aligned only for short periods, and only for client‟s with no evidence of spinal abnormalities.  Lateral Position  The client lies on one side of the body. Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and achieves greater stability.  Reduces lordosis and promotes good back alignment. Relieves pressure on the sacrum and heels in clients who sit for much of the day. Sim’s (Semiprone) Position  The client assumes a posture halfway between lateral and the prone positions  Used for unconscious clients because it facilitates drainage from the mouth and prevents aspiration of fluids.  For paralyzed clients it reduces pressure over the sacrum and greater trochanter of the hip. Moving and Turning Client’s in Bed  Assessment  Assess the height of the bed and the client‟s leg‟s length.  Inspect the mattress for support.  Assess the caregiver‟s knowledge and application of body mechanics to prevent injury.  Demonstrate how to turn and position the client in bed.  Teach care givers the basic principles of body alignment  Warn care givers of the dangers of lifting and repositioning and encourage the use of assistive devices and “no solo lift” policy.  Teach caregiver to check the client‟s skin for redness and integrity after repositioning the client.  Moving up a Client Up in Bed Purpose: to assist client who have slid down in bed from the Fowler‟s position to move up in bed. Assessment:  Client‟s ability to lie flat or contraindications to lie flat.  Client‟s abilities to assist with the move.  Client‟s ability to understand instructions and willingness to participate  Client‟s degree of comfort or discomfort when moving  Client‟s weight  The availability of equipment or personnel to assist you.  Moving up a Client Up in Bed Planning:  Review the client‟s record to determine if previous nurses have recorded information about the client‟s ability to move.  Use proper assistive equipment and additional personnel whenever needed.  Ensure that the client understands instructions  Provide and interpret as needed.  Determine the number of personnel and type of equipment needed to safely perform the positional change.  Moving up a Client Up in Bed Equipment Needed:  Assistive devices such as an overhead trapeze, friction reducing device or mechanical lift.  Moving up a Client Up in Bed Implementation Preparation Determine:  Assistive devices that will be required  Limitations to movement  Medications the client is receiving  Assistance required from other health care personnel  Moving up a Client Up in Bed Performance: 1. Introduce self and verify client‟s identity using agency protocol 2. Explain the procedure to client. 3. Perform hand hygiene and observe appropriate infection prevention procedures. 4. Provide client‟s privacy 5. Adjust bed and client‟s position. 6. Adjust the head of the bed to a flat position. 7. Raise the bed to a height appropriate 8. Lock the wheels of the bed and raise the rail on the side of the bed opposite you 9. Remove all pillows, then place one against the head of the bed.  Moving up a Client Up in Bed Performance: 10. For client who is able to reposition without assistance:  Place the bed flat or reverse Trendelenburg‟s position  Encourage the client to reach up and grasp the upper side rails with both hands, bend knees, and push off with the feet and pull up with arms simultaneously.  Ask if positioning device is needed. For client who is partially able to assist:  For client who weighs less than 200 pounds: Use friction reducing device and two assistants  For client who weigh between 201- 300 lbs: Use a friction reducing slide sheet and four assistants OR an air transfer system and two assistants.  Moving up a Client Up in Bed Performance: For client who weighs more than 300 lbs: Use an air transfer system and two assistants OR a total transfer lift. Ask the client to flex the hips and knees and position the feet so that they can be used effectively for pushing. Place the client‟s arms across the chest. Use the friction –reducing device and assistants to move the client up in bed. 12. Position yourself appropriately , and move the client. 13. For the client who is unable to assist: Use the ceiling lift with supine sling or mobile floor-based lift and two or more caregivers. Follow manufacturer‟s guidelines for using the lift.  Moving up a Client Up in Bed Performance: 14. Ensure client comfort. 15. Document all relevant information. Record: Time and change of position moved from and position moved to Any signs of pressure areas Use of support devices Ability of client to assist in moving and turning Response of client to moving and turning Turning a Client to the Lateral or Prone Position in Bed Purpose:  Movement to the lateral (side-lying) position may be necessary when placing a bedpan beneath the client , when changing the client „s bed linen, or when repositioning the client. Implementation:  Assistive devices required  Limitations to movement e.g. IV  Medications receiving  Assistance from Health Care Practitioner Performance:  Introduce self and verify client‟s identity  Perform hand hygiene and observed infection prevention procedures  Provide Privacy Turning a Client to the Lateral or Prone Position in Bed Purpose: Performance:  Position yourself and the client appropriately before performing the move;  Adjust the head of the bed to a flat position or as low as client can tolerate.  Raise the bed to height appropriate for personnel safety  Lock the wheels of the bed  Move the client closer to the side of the bed opposite the side the client will face when turn.  While standing on the side of the bed nearest the client, place the client‟s near arm across the chest.  Place the client‟s near ankle and foot across the far ankle and foot  Roll the client to lateral position. Turning a Client to the Lateral or Prone Position in Bed Purpose: Performance:  Place one hand on the client‟s far hip and the other hand on the client‟s far shoulder  Position the client on his side with arms and legs positioned ans supported properly.  Turning on Prone Position: 1. Instead of abducting the far arm , keep the client‟s arm alongside the body for the client to roll over. 2. Roll the client completely onto the abdomen. 3. Document relevant information. Logrolling a Client - A technique used to turn clients whose body must at all times be kept alignment(like a log). - Log roll or logrolling is a maneuver used to move a patient without flexing the spinal column. Patient's legs are stretched, the head is held, to immobilize the neck. - Client with back or spinal injury. Preparation:  Assistive device  Limitations to Movement  Medications client is receiving  Assistance required from other health care personnel.  At least 2-3 additional people. Logrolling a Client Performance:  Prior to performing the procedure, introduce self and verify the client‟s identity using agency protocol.  Perform hand hygiene and observe other appropriate infection prevention procedures.  Provide for client privacy.  Position yourselves and the client appropriately before the move.  Place the client‟s arm across the chest( avoid injury)  Pull the client to the side of the bed  Use friction- reducing device to facilitate logrolling  One nurse counts.” One, two, three, go” at the same time all member s must pull the client to the side of the bed by shifting the weight to the back foot.  One nurse moves to the other side of the bed, and places supportive devices for the client when turned. Logrolling a Client Performance:  Place a pillow where it will support the clients head after the turn.(Prevents lateral flexion of the neck and ensures alignment of the cervical spine)  Place one or two pillows between the client‟s legs to support the upper leg when the client is turned ( Prevents adduction of the upper leg and keeps the legs parallel and aligned.)  Roll and position the client in proper alignment.  Go to the other side of the bed ( farthest from the client , and assume a stable stance.  Reaching over the client, grasp the friction-reducing device and roll the client toward you.  One nurse count.  The second nurse (behind the client) helps turn the client and provides pillow supports to ensure good alignment in the lateral position  Support the client‟s head ,back,and upper and lower extremities with pillows. Logrolling a Client Performance:  Raise the side rails and place the call bell within the client‟s reach  Document all relevant information. Record:  Time and change of position moved from and position moved to  Any signs of pressure areas  Use of support devices  Ability of client to assist in moving and turning  Response of client to moving and turning Lifespan Considerations Infant:  Position Infants on their back for sleep, even after feeding.  The skin of newborns can be fragile and may be abraded or torn(sheared) if the infant is pulled across a bed. Lifespan Considerations Children:  Carefully inspect the dependent skin surfaces of all infants and children confined to bed at least three times in each 24 hour period. Older Adults:  In clients who have had strokes , there is risk of shoulder displacement on the paralyzed side from improper moving or repositioning techniques. Lifespan Considerations Older Adults:  Decreased subcutaneous fat and thinning of the skin place older adults at risks for skin breakdown.  Repositioning approximately every 2 hours.  Transferring Between Bed and Chair Purpose: A client may need to be transferred between the bed and a wheelchair or chair , the bed and the commode, or wheelchair and toilet. There are numerous variations in the technique. Assessment:  Client‟s body size and weight  Ability to follow instructions  Ability to bear weight (full, partial, none)  Ability to position and reposition feet on the floor  Ability to push down with arms and lean forward  Ability to grasp  Ability to achieve independent balance  Ability to tolerance  Transferring Between Bed and Chair Assessment:  Muscle strength  Joint mobility  Presence of Paralysis  Level of comfort  Presence of orthostatic hypotension  The technique with which the client is familiar  The space in which the transfer will need to be maneuvered  The number of assistants( one or two) needed to accomplish the transfer safely.  Transferring Between Bed and Chair Planning:  Review the client record to determine if previous nurses have recorded information about the client‟s ability to transfer.  Implement pain relief measures  The decision must be made at this time regarding the client‟s ability to participate.  If the client can safely participate in the transfer , a gait or transfer belt or sliding board can be used; if not, a powered standing assist lift or full-body lift would be safer for the client and nurse.  Transferring Between Bed and Chair Planning:  Review the client record to determine if previous nurses have recorded information about the client‟s ability to transfer.  Implement pain relief measures  The decision must be made at this time regarding the client‟s ability to participate.  If the client can safely participate in the transfer , a gait or transfer belt or sliding board can be used; if not, a powered standing assist lift or full-body lift would be safer for the client and nurse.  Transferring Between Bed and Chair Equipment:  Robe or appropriate clothing  Slippers or shoes with nonskid soles  Gait or transfer belt  Chair ,commode, wheelchair as appropriate to client need  Slide board if appropriate  Lift, if appropriate  Transferring Between Bed and Chair Preparation:  Plan what to do and how to do it.  Obtain essential equipment before starting and check that all equipment is functioning correctly.  Remove obstacles from the area so clients do not trip.  Note any devices attached to the client  Transferring Between Bed and Chair Performance:  Prior to performing the procedures, introduce self and verify the client‟s identity using agency protocol.  Perform hand hygiene and observe other appropriate infection prevention procedures.  Provide the client privacy.  Position the equipment appropriately.  Prepare and assess the client.  Give explicit instructions to the client.  Position yourself correctly.  Transferring Between Bed and Chair Performance:  Assist the client to stand ,and then move together toward the wheelchair or sitting area to which you wish to transfer the client.  Assist the client to sit.  Ensure client safety.  Wheelchair Safety  Always lock the brakes on both wheels of the wheelchair when the client transfers in or out of it.  Raise the footplates and move the leg rests out of the way before transferring the client into the wheelchair.  Lower the footplates after the transfer, and place the client's feet on them.  Wheelchair Safety  Ensure the client is positioned well back in the seat of the wheelchair.  Use seat belts that fasten behind the wheelchair to protect confused clients from falls. Note: Seat belts are a form of restraint and must be used in accordance with policies and procedures that apply to the use of restraints.  Clinical Alert!  Air, foam, and gel cushions that distribute weight evenly (not dough- nut-type cushions) are essential for clients confined to a wheelchair and must be checked frequently to ensure they are intact.  Strict continence management is also important for preventing skin breakdown.  Maintaining tire pressure' will prevent added resistance and energy expenditure.  Periodically monitor the client's upper extremities for pain and overuse syndromes.  Transferring with a Belt and Two Nurses  Even if a client is able to partially bear weight and is cooperative , it still may be safer to transfer a client with the assistance of two nurses.  You should position yourselves on both sides of the client , facing the direction as the client.  Flex your hips, knees and ankles.  Grasp the client‟s transfer belt with the hand closest to the client , and with the other hand support the client‟s elbows.  Coordinating your efforts, all three of you stand simultaneously, pivot and move to the wheelchair.  Transferring a client with an injured lower extremity  When the client has an injured lower extremity, movement should always occur toward the client‟s unaffected (strong) side.  E.g. If the client‟s right leg is injured and the client is sitting on the edge of the bed preparing to transfer to a wheelchair, position the wheelchair on the client‟s left side. Rationale: Promotes client‟s client sense of independence but also preserves your energy.  Transferring a client with an injured lower extremity  „  When the client has an injured lower extremity, movement should always occur toward the client‟s unaffected (strong) side.  E.g. If the client‟s right leg is injured and the client is sitting on the edge of the bed preparing to transfer to a wheelchair, position the wheelchair on the client‟s left side. Rationale: Promotes client’s client sense of independence but also preserves your energy. Transferring a client with an injured lower extremity Document:  Client‟s ability to bear weight and pivot  Number of staff needed for transfer and safety measures and precautions used.  Length of time up in chair  Client response to transfer and being up in chair or wheelchair Note: The skill describes the process to use for a client who is able to perform the task independently and only needs standby assistance for steadying. For clients who is require moderate or maximum assistance, a lateral chair or a mobile or ceiling mounted transfer system is required. Transferring Between Bed and Stretcher (Gurney) PURPOSE Used to transfer supine clients from one location to another. Whenever the client is capable of accomplishing the transfer from bed to stretcher independently, either by lifting onto it or by rolling onto it, the client should be encouraged to do so, if the client cannot move onto the stretcher independently and weighs less than 200 pounds, a friction- reducing device (i.e., slide sheet) or a lateral transfer board or an air transfer system should be used, and at least two caregivers are needed to assist with the transfer. Transferring Between Bed and Stretcher (Gurney)  Some friction-reducing devices have handles or long straps to avoid awkward stretching by the caregivers when pulling the client during the lateral transfer. For clients between 201 and 300 pounds, a slide sheet or transfer board and four caregivers or an air transfer system and two caregivers should be used.  For clients who weigh more than 300 pounds, two caregivers and either an air transfer system or a celling lift with supine sling should be used. Transferring Between Bed and Stretcher (Gurney)  Depending on the client's condition (e.g., neck immobilizer, IVs, drains, chest tube), additional assistants may be needed. ASSESSMENT Before transferring a client, assess the following:  The client's body size and weight  Ability to follow instructions  Activity tolerance  Level of comfort  The space in which the transfer is maneuvered  The no. of assistants (one to four ) needed to accomplish the transfer safely. Transferring Between Bed and Stretcher (Gurney) PLANNING Review the client record to determine if previous nurses have recorded information about how the client tolerated similar transfers. Indicated, implement pain relief measures so that they are effective when the transfer begins. Equipment  Stretcher  Transfer assistive devices (e.g., slide sheet, transfer board, air transfer system lift) Transferring Between Bed and Stretcher (Gurney) Performance 1. Prior to performing the procedure, introduce self and verify the client's identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. Explain the transfer to the nursing personnel who are helping and specify who will give directions (one staff member needs to be in charge). 2. Perform hand hygiene and observe other appropriate infection prevention procedures. Transferring Between Bed and Stretcher (Gurney) Performance 3. Provide for client privacy. 4. Adjust the client's bed in preparation for the transfer. Lower the head of the bed until it is flat or as low as the client can tolerate, Place the friction-reducing device under the client. Transferring Between Bed and Stretcher (Gurney)  Raise the bed so that it is slightly higher (i.e., 1/2 in.) than  the surface of the stretcher. Rationale: It is easier for the client to move down a slant.  Ensure that the wheels on the bed are locked.  Place the stretcher parallel to the bed next to the client and lock the stretcher wheels.  Fill the gap that exists between the bed and the stretcher loosely with the bath blankets (optional). Transferring Between Bed and Stretcher (Gurney)  5. Transfer the client securely to the stretcher. If the client can transfer independently, encourage him to do so and stand by for safety.  If the client is partially able or not able to transfer: One caregiver needs to be at the side of the client's bed between the client's shoulder and hip.  The second and third caregivers should be at the side of the stretcher: positioned between the client's shoulder and hip and other in between the client‟s hip and lower legs.  All caregivers should position their feet in a walking stance.  Transferring Between Bed and Stretcher (Gurney)  Ask the client to flex the neck during the move, if possible, and place the arms across the chest Rationale: This prevents injury to those body parts.  On a planned command, the caregivers at the stretcher's side pull (shifting weight to the rear foot), and the caregiver at the bedside pushes the client toward the stretcher (shifting weight to the front foot) 6. Ensure client comfort and safety  Make the client comfortable, unlock the stretcher wheels, and move the stretcher away from the bed.  Immediately raise the stretcher side rails or fasten the safety straps across the client. Rationale: Because the stretcher is high and narrow, the client is in danger of falling unless these safety precautions are taken. Variation: Using a Transfer Board  The transfer board is a lacquered or smooth polyethylene board measuring 45 to 55 cm (18 to 22 in.) by 182 cm (72 in.) with hand- holds along its edges. Transfer mattresses are also available, as are mechanical assistive devices.  It is imperative to have enough staff assisting with the transfer to prevent injury to staff as well as clients. Turn the client to a lateral position away from you, position the board close to the client's back, and roll the client onto the board. Pull the client and board across the bed to the stretcher. Safety belts may be placed over the chest, abdomen, and legs. Variation: Using a Transfer Board  The transfer board is a lacquered or smooth polyethylene board measuring 45 to 55 cm (18 to 22 in.) by 182 cm (72 in.) with hand- holds along its edges. Transfer mattresses are also available, as are mechanical assistive devices.  It is imperative to have enough staff assisting with the transfer to prevent injury to staff as well as clients. Turn the client to a lateral position away from you, position the board close to the client's back, and roll the client onto the board. Pull the client and board across the bed to the stretcher. Safety belts may be placed over the chest, abdomen, and legs. Transferring Between Bed and Stretcher (Gurney) 7. Document relevant information: Equipment used Number of personnel needed for transfer and safety measures and precautions used Destination if reason for transfer is to transport from one location to another. Transferring Between Bed and Stretcher (Gurney) EVALUATION  Compare client capabilities such as weight bearing, pivoting activity, and strength and control during previous transfers.  Report any significant deviations from normal to the primary care practitioner.  Note use of safety measures. Lifespan Considerations in Transferring Clients Infant: The infant who is lying down, on the side or supine, can be placed in ether a bassinet or crib for transport. If the bassinet has a bottom shelf, it can be used for carrying the IV pump or monitor Lifespan Considerations Children: The toddler should be transported in a high-top crib with the side rails up and the protective top in place. Stretchers should not be used because the mobile toddler may roll or fall off. Lifespan Considerations Older Adults:  Because conditions of older adults can change from day to day always assess the situation to ensure that you have the right equipment and enough people to assist when transferring a client.  Use special caution with older clients to prevent skin tears or bruising during a transfer or when using a hydraulic lift. Lifespan Considerations Older Adults:  Write the method used to transfer each client-equipment used, best position, and number of personnel needed to assist in transfer. This can be part of the care plan and also be avail- able in the client's room as a guide to all personnel caring for the client.  Avoid sudden position changes. They can cause orthostatic hypotension and increase the risk of fainting and falls. Providing ROM Exercises Active ROM- are isotonic exercises in which the client moves each joint in the body through its complete range of movement, maximally stretching all muscle groups within each plane over the joint. Providing ROM Exercises Passive ROM Exercises Individual moves each clients joints through its complete range of movement maximally stretching all muscle groups each plane over each joint.  Ambulation  The act of walking  Routine mobilization of critically ill clients is safe, improves muscle strength and functional independence , reduces incident of delirium and decrease hospital length of stay.  1 to 2 days of bed rest can make an individual feel weak , unsteady and shaky when getting out of bed.  Preambulatory Exercise  Clients who have been in bed for long periods often need to perform muscle tone exercises to strengthen the muscles used for walking before attempting to walk.  One of the most important muscle groups is the quadriceps femoris, which extends the knee and flexes the thigh. This group is also important for elevating the legs, for example, for walking upstairs. These exercises are frequently called quadriceps drills or sets.  To strengthen these muscles, the client consciously tenses them, drawing the kneecap upward and inward. The client pushes the popliteal space of the knee against the bed surface, relaxing the heels on the bed surface.  Preambulatory Exercise  On the count of 1, the muscles are tensed; they are held during the counts of 2, 3, 4; and they are relaxed at the count of 5. The exercise should be done within the client's tolerance, that is, with- out fatiguing the muscles.  Carried out several times an hour during waking hour. This simple exercise significantly strengthens the muscles used for walking. Safety: Assisting the Client to Ambulate When the nurse is assisting a client to ambulate in the home setting, the following should be considered:  When making a home visit, assess carefully for safety issues concerning ambulation. Counsel the client and family about inadequate lighting, unfastened rugs, slippery floors, and loose objects on the floors.  Check the surroundings for adequate supports such as railings and grab bars.  Recommend that nonskid strips be placed on outside steps and inside stairs that are not carpeted.  Ask to see the shoes the client intends to wear while ambulating. They should be in good repair and should support the foot. Controlling Orthostatic Hypotension  Rest with the head of the bed elevated 8 to 12 inches. This position makes the position change on rising less severe.  Avoid sudden changes in position. Arise from bed in three stages:  a. Sit up in bed for 1 minute.  b. Sit on the side of the bed with legs dangling for 1 minute.  c. Stand with care, holding onto the edge of the bed or another nonmovable object for 1 minute. Controlling Orthostatic Hypotension  Never bend down all the way to the floor or stand up too quickly after stooping.  Postpone activities such as shaving and hair grooming for at east 1 hour after rising.  Wear elastic stockings at night to inhibit venous pooling in the legs.  Be aware that the symptoms of hypotension are most severe al the following times: a. 30 to 60 minutes after a heavy meal Controlling Orthostatic Hypotension b. 1 to 2 hours after taking an antihypertension medication Get out of a hot bath very slowly, because high temperatures can lead to venous pooling  Use a rocking chair to improve circulation in the lower extremities. Even mild leg conditioning can strengthen muscle tone and enhance circulation,  Refrain from any strenuous activity that results in holding the breath and bearing down. This Valsalva maneuver slows the heart rate, leading to subsequent lowering of blood pressure. Assisting a client to ambulate Purpose: - To provide a safe condition for the client to walk with whatever support is needed. Assessment:  Length of time in bed and the amount and type of activity the client was last able to tolerate.  Baseline vital signs  Range of motion of joints needed for ambulating (e.g. hips)  Muscle strength of lower extremities  Need for ambulation aids (e.g. cane, walker, crutches)  Client’s intake of medications  Presence of joint inflammation,fractures,muscle weakness or ability and other conditions that impair physical mobility. Assisting a client to ambulate Assessment:  Presence of joint inflammation , fractures, muscle weakness , or other conditions that impair physical mobility.  Ability to understand directions.  Level of comfort  Weight-bearing status Planning: Implement pain relief measures so that they are effective. The amount of assistance needed while ambulating will depend on the client’s condition(e.g. age, health status) Assisting a client to ambulate Equipment: Assistive devices required for safe ambulation of client or transfer belt, walker, cane , sit-to-stand assist device, lift with ambulation sling Wheelchair for following client, or chairs along the route if the client needs o rest. Portable oxygen tank if the client needs it Preparation Be certain that others are available to assist you needed. Also, plan the route of ambulation that has the fewest hazards and a clear path for ambulation. Assisting a client to ambulate Performance: 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. 2. Perform hand hygiene and observe appropriate infection prevention procedures. 3. Ensure that the client is appropriately dressed to walk and has shoes or slippers with nonskid soles. 4. Prepare client for ambulation. 5. Ensure client safety while assisting the client to ambulate. 6. Protect the client who begins to fall while ambulating. 7. Document distance and duration of ambulation and assistive devices Assisting a client to ambulate Variation: Two Nurses Place a gait or transfer belt around the client’s waist. Each nurse grasps the side handle with the near hand and the lower aspect of the client’s upper arm with the other hand. Walk in unison with the client, using smooth , even, gait , at the same speed and with steps the same size as the client’s. Evaluation: Establish a plan for continued ambulation based on expected or normal ability for the client. Assisting a client to ambulate Lifespan Considerations Children Children and adolescents who have suffered a sports injury may want to be more active than they should be A cast, splint or boot may be put in place to limit activity and assist in healing. Teach the child the importance of appropriate activity , and the use of assistive device (e.g. crutches )if necessary. Help children focus on what they can do rather than what they cannot do. Assisting a client to ambulate Lifespan Considerations Older Adults Inquire how the client has ambulated previously and check any available chart notes regarding client’s abilities and modify assistance accordingly. Take into account a decrease in speed , strength, resistance to fatigue, reaction time, and coordination due to a decrease in nerve conduction Be cautious when using a gait belt with a client with osteoporosis. If assistive device such as walker or cane are used, make sure clients are supervised in using them. Assisting a client to ambulate Lifespan Considerations Older Adults Be alert to signs of activity intolerance Set small goals and increase slowly to build endurance and increase slowly to build endurance. Be aware of any fall risks the old adult may have , such as the following: 1. Effects of medication 2. Neurologic disorders 3. Orthopedic problems 4. Presence of equipment 5. Environment hazards 6. Orthostatic Hypotension Assisting a client to ambulate Lifespan Considerations Older Adults : In older adults, the body’s responses return to normal more slowly. For instance , an increase in heart rate from exercise may stay elevated for hours before returning to normal. Mechanical Aids in Walking Using mechanical aids in walking 1. Canes 3 types of Canes: 1. The standard straight-legged cane-91 cm(36 in) long, aluminum canes 56 to 97 cm (22 to 38 in). 2. The tripod cane-3 feet 3. The quad cane -4 feet , most support Should have rubber caps The length should permit the elbow to be slightly flexed Clients may use either one or two canes\ Using mechanical aids in walking Using mechanical aids in walking 2. Walkers -Mechanical devices for ambulatory clients who need more support than a cane provides and lack the strength and balance required for crutches. -comes in different sizes and shapes. -Standard type is made of polished aluminum. -Has four legs with rubber tips and plastic handgrips. -Have adjustable legs -Standard Walker needs to be picked up to be used. -requires partial strength in both hands and wrists, strong elbow extensors and strong shoulder depressors. -Clients needs the ability to bear at least partial weight on both legs. Using mechanical aids in walking 2. Walkers four-wheeled and two-wheeled models of walkers (roller walkers) do not need to be picked up to be moved, they are less stable than the standard walker Clients who are too weak or unstable to pick up and move the walker with each step use the roller walkers Some roller walkers have a seat at the back so the client can sit down to rest when desired. An adaptation of the standard and four- wheeled walker is one that has two tips and two wheels. This type provides more stability than the four-wheeled model yet still permits the client to keep the walker in contact with the ground all the time. The legs with wheels allow the client to easily push the walker forward, and the legs without wheels prevent the walker from rolling Using Walkers WHEN MAXIMUM SUPPORT IS REQUIRED Move the walker ahead about 15 cm (6 in.) while your body weight is borne by both legs. Then move the right foot up to the walker while your body weight is borne by the left leg and both arms. Next, move the left foot up to the right foot while your body weight is borne by the right leg and both arms. Using Walkers IF ONE LEG IS WEAKER THAN THE OTHER Move the walker and the weak leg ahead together about 15 cm (6 in.) while your weight is borne by the stronger leg. Then move the stronger leg ahead while your weight is borne by the affected leg and both arms. Crutches -enable the clients to ambulate independently ,therefore it is important to learn use them properly. Kinds of crutches: Underarm crutches Axillary crutch with hand bars Loft strand crutch –extends only to the forearms. The metal bar stabilize the wrists and thus make walking easier, especially on stairs. Platform or elbow extensor crutch also has a cuff for upper arm to permit forearm weight bearing.  Types of Crutches and Canes Measuring Clients for Crutches Two methods of measuring crutch length: 1. The client lies in a supine position and the nurse measures from the anterior fold of the axilla to the heel of the foot and adds 2.5 cm(1 in). 2. The client stands erect and positions the crutch. The nurse makes sure the shoulder rest of the crutch is at least 3 finger widths that is 2.5 to 5 cm (1 to 2 inches)below the axilla. To determine the correct placement of the hand bar: 1. The client stands upright and supports the body weight by the handgrips of the crutches. 2. The nurse measures the angle of the elbow Crutch Gait -is the gait a client assumes on crutches by alternating body weight on one both legs and the crutches. Five Standard Crutch Gait: 1. Four-point gait 2. Three-point gait 3. Two-point gait 4. Swing-to gait 5. Swing -through gait Individual Factors: 1. Ability to take steps 2. Ability to bear weight and keep balance in a standing position on both legs or one 3. Ability to hold the body erect Crutch Gait -is the gait a client assumes on crutches by alternating body weight on one both legs and the crutches. Five Standard Crutch Gait: 1. Four-point gait 2. Three-point gait 3. Two-point gait 4. Swing-to gait 5. Swing -through gait Individual Factors: 1. Ability to take steps 2. Ability to bear weight and keep balance in a standing position on both legs or one 3. Ability to hold the body erect Crutch Stance Clients needs to learn the facts about posture and balance. Tripod Position- proper standing position with crutches. Crutches are placed about 15cm (6 in)in front of the feet and out laterally about 15 cm (6 in)/creating a wide base of support. Tall client requires wider base than does a short client. Hip and knees are extended Back is straight Head is held straight and high No hunch to the shoulder and no weight borne by the axillae Using Crutches Follow the plan of exercises developed for you to strengthen your arm muscles before beginning crutch walking. Have a healthcare professional establish the correct length for your crutches and the correct placement of the handpieces Crutches that are too long force your shoulders upward and make it difficult for you to push your body off the ground. Crutches that are too short will make you hunch over and develop an improper body stance. Using Crutches The weight of your body should be borne by the arms rather than the axillae (armpits). Continual pressure on the axillae can injure the radial nerve and eventually cause crutch palsy, a weakness of the muscles of the forearm, wrist, and hand. Maintain an erect posture as much as possible to prevent strain on muscles and joints and to maintain balance. Each step taken with crutches should be a comfortable distance for you. It is wise to start with a small rather than large step Using Crutches Inspect the crutch tips regularly, and replace them if worn Keep the crutch tips dry and clean to maintain their surface friction. If the tips become wet, dry them well before use. Wear a shoe with a low heel that grips the floor. Rubber soles decrease the chances of slipping. Adjust shoelaces so they cannot come untied or reach the floor where they might catch on the crutches. Consider shoes with alternative forms of closure (e.g., Velcro), especially if you cannot easily bend to tie laces. Slip-on shoes are acceptable only if they are snug and the heel does not come loose when the foot is bent. Crutch Stance or Tripod Position Four Point Gait Most elementary and safest gait Providing at least three points of support at all times, but requires coordination. Clients can use when walking in crowds ,does not require too much space Client needs to be able to bear weight on both legs. Four Point Gait  Move the right crutch ahead a suitable distance, such as 10 to 15 cm (4 to 6 in.). 2. Move the left front foot forward, preferably to the level of the left crutch.  3. Move the left crutch forward.  4. Move the right foot forward. Three-Point Gait To use this gait, the client must be able to bear the entire body weight on the unaffected leg. The two crutches and the unaffected leg bear weight alternately (Figure 44.65, reading from bottom to top). The nurse asks the client to: 1. Move both crutches and the weaker leg forward. 2. Move the stronger leg forward. Two-Point Alternate Gait This gait is faster than the four-point gait. It requires more balance because only two points support the body at one time; it also requires at least partial weight bearing on each foot. In this gait, arm movements with the crutches are similar to the arm movements during normal walking, reading from bottom to top). The nurse asks the client to: 1. Move the left crutch and the right foot forward together. 2. Move the right crutch and the left foot ahead together. Swing –to Gait Used by client with paralysis of the legs and hips. Prolonged use of these gaits results in atrophy of the unused muscles. It is the easier of these two gait Nurse asks the client to: 1. Move both crutches ahead together. 2. Lift Body weight by the arms and swing to the crutches. Swing-Through Gait 1. This gait requires considerable skill, strength, and coordination. The nurse asks the client to: 1. Move both crutches forward together. 2. Lift body weight by the arms and swing through and beyond the crutch. Getting into a Chair Chairs that have armrests and are secure or braced against a wall are essential for clients using crutches. For this procedure, the nurse instructs the client to: 1. Stand with the back of the unaffected leg centered against the chair. The chair helps support the client during the next steps. 2. Transfer the crutches to the hand on the affected side and hold the crutches by the hand bars. The client grasps the arm of the chair with the hand on the unaffected side. This allows the client to support the body weight on the arms and the unaffected leg. 3. Lean forward, flex the knees and hips, and lower into the chair. Getting Out of a Chair For this procedure, the nurse instructs the client to: 1. Move forward to the edge of the chair and place the unaffected leg slightly under or at the edge of the chair. This position helps the client stand up from the chair and achieve balance, because the unaffected leg is supported against the edge of the chair. 2. Grasp the crutches by the hand bars in the hand on the affected side, and grasp the arm of the chair by the hand on the unaffected side. The body weight is placed on the crutches and the hand on the armrest to support the unaffected leg when the client rises to stand. 3. Push down on the crutches and the chair armrest while elevating the body out of the chair. 4. Assume the tripod position before moving. Going Down Stairs For this procedure, the nurse stands one step below the client on the affected side if needed. The nurse instructs the client to: 1. Assume the tripod position at the top of the stairs. 2. Shift the body weight to the unaffected leg, and move the crutches and affected leg down onto the next step You sent 3. Transfer the body weight to the crutches, and move the unaffected leg to that step. The affected leg is always supported by the crutches. 4. Repeat steps 2 and 3 until the client reaches the bottom of the stairs. Evaluating The goals established during the planning phase are evaluated according to specific desired outcomes, also established in that phase. Examples of these are shown in the accompanying Nursing Care Plan. If outcomes are not achieved, the nurse, client, and support person if appropriate need to explore the reasons before modifying the care plan. For example, the following questions may be considered if an immobilized client fails to maintain muscle mass and tone and joint mobility: Has the client's physical or mental condition changed motivation to perform required exercise? Evaluating Were appropriate range-of-motion exercises implemented? Was the client encouraged to participate in self-care activities as much as possible? Was the client encouraged to make as many decisions as possible when developing a daily activity plan and to express concerns? Did the nurse provide appropriate supervision and monitoring? Was the client's diet adequate to provide appropriate nourishment for energy requirements? Thank you!Take Care.