#nursing-notes

Assistive Devices for Ambulation

Definition: used to provide an extension of the upper extremities to help transmit body weight and provide support for the clients (canes, crutches, walkers)

A. Collaborative Care

Nursing Interventions

Determine client's mobility status and ability to bear weight per provider's order

Monitor the client for the need of a safety belt

Instruct the client to wear shoes with non-slip soles

Monitor the client for risk orthostatic hypotension

Provide safe environment free of clutter

B. Client Education and Refferal

Avoid rapid position changes to prevent orthostatic hypotension

Inspect rubber tips on the device for wear and replace as needed

Physical Therapy consult

C. Crutches

Monitor client for correct fit of crutches: 2 - 3 finger widths between the axilla and top of the crutch

Position hands on crutch pads with elbows flexed ( do not bear weight on axilla)

D. Non-weight bearing

Begin in the tripod position, maintain weight on the "unaffected" (weight-bearing) extremity

Advance both crutches and the affected extremity

Move the "unaffected" weight-bearing foot/leg forward (beyond the crutches)

Advance both crutches, and then the affected extremity

Continue sequence making steps of equal length

E. Weight bearing

Move crutches forward about one step's length

Move "affected" leg forward; level with the crutch tips

Move the "unaffected" leg forward

Continue sequence making steps of equal length

F. Walking up stairs

Hold to rail with one hand and crutches with the other hand.

Push down on the stair rail and the crutches and step up with the "unaffected" leg.

If not allowed to place weight in the affected leg, hold up with the unaffected leg.

Bring the affected leg and the crutches up beside the unaffected leg.

Remember the unaffected leg goes up first and the crutches move with the affected leg.

G. Walking down stairs

Place the affected leg and the crutches down on the step below; support weight by leaning on the crutches and the stair rail.

Bring the unaffected leg down.

Remember the affected leg goes down first and the crutches move with the affected leg.

H. Cane

For correct size have the client wear shoes. The correct length is measured from the wrist to the floor.

Cane is used on the unaffected side to provide support to the opposite affected lower limb.

Advance the cane simultaneously with the opposite affected lower limb.

The unaffected limb should assume the first full weight-bearing step on level surfaces.

I. Walker

For correct size have the client wear shoes. The client's wrists are even with the handgrips on the walker when arms are dangling downward

Advance the walker approximately 12 inches

Advance with the affected lower limb

Semi-Fowler’s

Head of bed elevated to 30°

Gastric feedings, head injury, postoperative cranial surgery, respiratory illness with dyspnea, postoperative cataract removal, increased intracranial pressure

Fowler’s

Head of bed elevated to 45°

Head injury, postoperative cranial surgery, postoperative abdominal surgery, respiratory illness with dyspnea, cardiac problems with dyspnea, bleeding esophageal varices, postoperative thyroidectomy, postoperative cataract removal, increased intracranial pressure

High Fowler’s

Head of bed elevated to 90°

Respiratory illness with dyspnea: emphysema, status asthmaticus, pneumothorax, cardiac problems with dyspnea, feeding, meal times, hiatal hernia, during and after meals

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Supine (dorsal recumbent)

Lying on back, head, and shoulders; slightly elevated with a small pillow

Spinal cord injury (no pillow), urinary catheterization

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Prone

Lying on abdomen, legs extended, and head turned to the side

Client who is immobilized or unconscious, post lumbar puncture 6 to 12 hr, post myelogram 12 to 24 hr (oil based dye), postoperative tonsillectomy and adenoidectomy

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Lateral (side laying)

Lying on side with most of the body weight borne by the lateral aspect of the lower ilium

Post abdominal surgery, client who is unconscious, seizures (head to side), postoperative tonsillectomy and adenoidectomy, postoperative pyloric stenosis of the lower scapula and the lateral (right side), post liver biopsy (right side), rectal irrigations

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Sims’ (semi-prone)

Lying on the left side with most of the body weight borne by the anterior aspect of the ilium, humerus, and clavicle

Client who is unconscious, enemas

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Lithotomy

Lying on the back with hips and knees flexed at right angles and feet in stirrups

Perineal procedures, rectal procedures, vaginal procedures

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Trendelenburg

Head and body lowered while feet are elevated

Shock

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Modified Trendelenburg

Supine with legs elevated

Prevent shock

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Reverse Trendelenburg

Head elevated while feet are lowered

Cervical traction; also used to feed clients restricted to supine position, such as postcardiac catheterization

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Elevate one or more extremities

Elevate legs/feet or arms/hands by adjusting or supporting with pillows

Client Transfer and Positioning

Maintain safe practices with patient transfer and ensure proper positioning of clients to maintain good body alignment.

A. NURSING INTERVENTIONS

Transferring clients from bed to chair or chair to bed:

Instruct the client how to assist when possible.

Lower the bed to the lowest setting.

Position the bed or chair so that the client is moving toward the strong side.

Assist the client to stand, then pivot.

Repositioning clients in bed:

Raise the bed to waist level.

Lower side rails.

Use slide board or draw sheets.

Have the client fold his arms across his chest while lifting the head.

Proceed in one slow movement.

Lifting and Transfer of Clients

Implement safe care using proper body mechanics when lifting, positioning, transporting, or assisting a client to reduce the risk of injury.

A. NURSING INTERVENTIONS

Assess client's mobility and strength.

Instruct client to assist when possible.

Use mechanical lift and assistive devices.

Avoid twisting the thoracic spine or bending at the waist.

Chemical Agents and Radiation

Nurses must review institutional guidelines and follow all safety guidelines.

A. NURSING INTERVENTIONS

Determine type and amount of radiation used.

Place a sign on door: "Caution Radioactive Material."

Wear monitoring badge to record amount of exposure.

Wear appropriate protective equipment.

Dispose of items removed from the room in appropriate containers.