UNIVERSITY OF ILOILO COLLEGE OF NURSING NAME:________________________________________________ YEAR AND SECTION:___________________________________ RETURN DEMONSTRATION ON CRUTCHWALKING: GENERAL PROCEDURE ASSESSMENT 1.

IDENTIFY PATIENTS CAPABILITIES 2.IDENTIFY ACTIVITY ORDERED 3. CHECK PREVIOUS LEVEL OF ACTIVITY 4. DETERMINE WHETHER ASSISTIVE DEVICES WERE USED PREVIOUSLY 5.TAKE PULSE, RESPIRATIONS AND BLOOD PRESSURE PLANNING 6. PLAN FOR PAIN RELIEF, IF INDICATED BEFORE AMBULATION 7.SET TENTATIVE GOAL 8.DECIDE ON SUPPORT NEEDED 9.PLAN SPECIFIC TECHNIQUE IF NEEDED 10.WASH YOUR HANDS IMPLEMENTATION 11.IDENTIFY PATIENT 12.EXPLAIN PROCEDURE TO THE PATIENT 13.OBTAIN ROBE AND SHOES, AND CLEAR FLOOR OF LITTER OR SPILLS 14.ASSIST PATIENT TO AMBULATE USING CRUTCHES A. STANDING 1.STABILIZE BODY BY STANDING ON THE AFFECTED LEG 2.PLACE CRUTCHES UNDER BOTH ARMS B.HAVE PATIENT TAKE CRUTCH STANCE, WITH CRUTCH TIPS APPROXIMATELY 2 INCHES TO THE SIDE AND 6 INCHES AHEAD OF THE FEET C.GAIT PATTERN 1.THREE POINT GAIT a.SUPPORT WEIGHT ON AFFECTED LEG b.LIFT CRUTCHES AND AFFECTED LEG FORWARD 4-6 INCHES SIMULTANEOUSLY c.SHIFT WEIGHT TO CRUTCHES d.STEP FORWARDWITH UNAFFECTED LEG e.SHIFT WEIGHT TO UNAFFECTED LEG f.REPEAT PATTERN 2. THREE POINT GAIT PARTIAL WEIGHT BEARING a.TAKE CRUTCH STANCE, WITH FULL WEIGHT ON UN AFFECTED LEG AND PARTIAL WEIGHT ON AFFECTED LEG b.SHIFT WEIGHT TO UNAFFECTED LEG c.MOVE CRUTCHES AND AFFECTED LEG FORWARD 6-12 INCHES d.SHIFT WEIGHT TO HANDS ON CRUTCHES, WITH PARTIAL WEIGHT ON AFFECTED LEG e.STEP UNAFFECTED LEG AHEAD f.SHIFT WEIGHT TO UNAFFECTED LEG g.REPEAT PATTERN DONE NOT DONE COMMENTS GRADE:_________________

3. FOUR POINT GAIT a.TAKE CRUTCH STANCE WITH WEIGHT ON BOTH LEGS AND BOTH CRUTCHES b.MOVE LEFT CRUTCH FORWARD c.MOVE RIGHT LEG FORWARD d.MOVE RIGHT CRUTCH FORWARD e.MOVE LEFT LEG FORWARD f.REPEAT PATTERN 15.PROVIDE SAFETY 16.RETURN PATIENT TO BED, AND POSITION FOR COMFORT 17.RECHECK PULSE, RESPIRATIONS, AND BLLOD PRESSURE 18.WASH YOUR HANDS EVALUATION 19.COPMARE PRE AMBULATION AND POST AMBULATION VITAL SIGNS 20.CHECK FATIGUE OR PAIN LEVEL 21.ASK HOW PATIENT FEELS 22.EVELUATE OVERALL STRENGTH, BALANCE AND ABILITY TO AMBULATE DOCUMENTATION 23.DOCUMENT ACCORDING TO FACILITY POLICY

NAME AND SIGNATURE OF STUDENT: _____________________________________________ CLINICAL INSTRUCTOR: __________________________________________________________

UNIVERSITY OF ILOILO COLLEGE OF NURSING NAME:________________________________________________ YEAR AND SECTION:___________________________________ GRADE:_________________

RETURN DEMONSTRATION ON CRUTCHWALKING UP STAIRS WITH RAILING: GENERAL PROCEDURE ASSESSMENT 1.IDENTIFY PATIENTS CAPABILITIES 2.IDENTIFY ACTIVITY ORDERED 3. CHECK PREVIOUS LEVEL OF ACTIVITY 4. DETERMINE WHETHER ASSISTIVE DEVICES WERE USED PREVIOUSLY 5.TAKE PULSE, RESPIRATIONS AND BLOOD PRESSURE PLANNING 6. PLAN FOR PAIN RELIEF, IF INDICATED BEFORE AMBULATION 7.SET TENTATIVE GOAL 8.DECIDE ON SUPPORT NEEDED 9.PLAN SPECIFIC TECHNIQUE IF NEEDED 10.WASH YOUR HANDS IMPLEMENTATION 11.IDENTIFY PATIENT 12.EXPLAIN PROCEDURE TO THE PATIENT 13.OBTAIN ROBE AND SHOES, AND CLEAR FLOOR OF LITTER OR SPILLS 14.TEACH THE PATIENT TO DO THE FOLLOWING: a.HOLD BOTH CRUTCHES UNDER ONE ARM AS IF TO WALK b.PLACE OTHER HAND ON THE RAILING IN FRON OF THE BODY c.RAISE UNAFFECTED LEG TO THE FIRST STEP, AND PULL UP WITH HAND RAIL d.PULL AUP AFFECTED LEG, AND ADVANCE CRUTCHES TO THE NEXT STEP e.AGAIN, RAISE UNAFFECTED LEG, AND PULL UP AFFECTED LEG, ADVANCING CRUTCHES 15.PROVIDE SAFETY 16.RETURN PATIENT TO BED, AND POSITION FOR COMFORT 17.RECHECK PULSE, RESPIRATIONS, AND BLOOD PRESSURE 18.WASH YOUR HANDS EVALUATION 19.COPMARE PRE AMBULATION AND POST AMBULATION VITAL SIGNS 20.CHECK FATIGUE OR PAIN LEVEL 21.ASK HOW PATIENT FEELS 22.EVELUATE OVERALL STRENGTH, BALANCE AND ABILITY TO AMBULATE DOCUMENTATION 23.DOCUMENT ACCORDING TO FACILITY POLICY NAME AND SIGNATURE OF STUDENT: _____________________________________________ CLINICAL INSTRUCTOR: __________________________________________________________ DONE NOT DONE COMMENTS

UNIVERSITY OF ILOILO COLLEGE OF NURSING NAME:________________________________________________ YEAR AND SECTION:___________________________________ GRADE:_________________

RETURN DEMONSTRATION ON CRUTCHWALKING UP STAIRS WITHOUT RAILING: GENERAL PROCEDURE ASSESSMENT 1.IDENTIFY PATIENTS CAPABILITIES 2.IDENTIFY ACTIVITY ORDERED 3. CHECK PREVIOUS LEVEL OF ACTIVITY 4. DETERMINE WHETHER ASSISTIVE DEVICES WERE USED PREVIOUSLY 5.TAKE PULSE, RESPIRATIONS AND BLOOD PRESSURE PLANNING 6. PLAN FOR PAIN RELIEF, IF INDICATED BEFORE AMBULATION 7.SET TENTATIVE GOAL 8.DECIDE ON SUPPORT NEEDED 9.PLAN SPECIFIC TECHNIQUE IF NEEDED 10.WASH YOUR HANDS IMPLEMENTATION 11.IDENTIFY PATIENT 12.EXPLAIN PROCEDURE TO THE PATIENT 13.OBTAIN ROBE AND SHOES, AND CLEAR FLOOR OF LITTER OR SPILLS 14.TEACH THE PATIENT TO DO THE FOLLOWING: a.POSITION CRUTCHES UNDER ARMS AS IF WALKING b.PUT WEIGHT ON HANDS c.RAISE UNAFFECTED LEG TO FIRST STEP, AND PULL UP AFFECTED LEG d.ADVANCE CRUTCHES TO THE STEP ON WHICH PATIENT IS STANDING e.AGAIN, RAISE UNAFFECTED LEG TO THE NEXT HIGHER STEP 15.PROVIDE SAFETY 16.RETURN PATIENT TO BED, AND POSITION FOR COMFORT 17.RECHECK PULSE, RESPIRATIONS, AND BLLOD PRESSURE 18.WASH YOUR HANDS EVALUATION 19.COPMARE PRE AMBULATION AND POST AMBULATION VITAL SIGNS 20.CHECK FATIGUE OR PAIN LEVEL 21.ASK HOW PATIENT FEELS 22.EVELUATE OVERALL STRENGTH, BALANCE AND ABILITY TO AMBULATE DOCUMENTATION 23.DOCUMENT ACCORDING TO FACILITY POLICY DONE NOT DONE COMMENTS

NAME AND SIGNATURE OF STUDENT: _____________________________________________ CLINICAL INSTRUCTOR: __________________________________________________________

UNIVERSITY OF ILOILO COLLEGE OF NURSING NAME:________________________________________________ YEAR AND SECTION:___________________________________ GRADE:_________________

RETURN DEMONSTRATION ON CRUTCHWALKING DOWN THE STAIRS: GENERAL PROCEDURE ASSESSMENT 1.IDENTIFY PATIENTS CAPABILITIES 2.IDENTIFY ACTIVITY ORDERED 3. CHECK PREVIOUS LEVEL OF ACTIVITY 4. DETERMINE WHETHER ASSISTIVE DEVICES WERE USED PREVIOUSLY 5.TAKE PULSE, RESPIRATIONS AND BLOOD PRESSURE PLANNING 6. PLAN FOR PAIN RELIEF, IF INDICATED BEFORE AMBULATION 7.SET TENTATIVE GOAL 8.DECIDE ON SUPPORT NEEDED 9.PLAN SPECIFIC TECHNIQUE IF NEEDED 10.WASH YOUR HANDS IMPLEMENTATION 11.IDENTIFY PATIENT 12.EXPLAIN PROCEDURE TO THE PATIENT 13.OBTAIN ROBE AND SHOES, AND CLEAR FLOOR OF LITTER OR SPILLS 14.TEACH THE PATIENT TO DO THE FOLLOWING: a.POSITION CRUTCHES UNDER ARM AS IF WALKING b.PLACE WEIGHT ON UNAFFECTED LEG c.PLACE CRUTCHES ON NEXT LOWER STEP d.PUT PARTIAL WEIGHT ON HANDS AND CRUTCHES e.MOVE AFFECTED LEG TO LOWER STEP f.PUT TOTAL WEIGHT ON CRUTCHES AND AFFECTED LEG g.MOVE UNAFFECTED LEG TO THE SAME STEP OF THE CRUTCHES AND AFFECTED LEG h.IF RAILING IS PRESENT, HOLD CRUTCHES WITH ONE ARM, AND USE THE OTHER TO GRASP THE RAILING 15.PROVIDE SAFETY 16.RETURN PATIENT TO BED, AND POSITION FOR COMFORT 17.RECHECK PULSE, RESPIRATIONS, AND BLLOD PRESSURE 18.WASH YOUR HANDS EVALUATION 19.COPMARE PRE AMBULATION AND POST AMBULATION VITAL SIGNS 20.CHECK FATIGUE OR PAIN LEVEL 21.ASK HOW PATIENT FEELS 22.EVELUATE OVERALL STRENGTH, BALANCE AND ABILITY TO AMBULATE DOCUMENTATION 23.DOCUMENT ACCORDING TO FACILITY POLICY NAME AND SIGNATURE OF STUDENT: _____________________________________________ CLINICAL INSTRUCTOR: __________________________________________________________ DONE NOT DONE COMMENTS

UNIVERSITY OF ILOILO COLLEGE OF NURSING NAME:________________________________________________ YEAR AND SECTION:___________________________________ RETURN DEMONSTRATION ON USING A CANE: GENERAL PROCEDURE ASSESSMENT 1.IDENTIFY PATIENTS CAPABILITIES 2.IDENTIFY ACTIVITY ORDERED 3. CHECK PREVIOUS LEVEL OF ACTIVITY 4. DETERMINE WHETHER ASSISTIVE DEVICES WERE USED PREVIOUSLY 5.TAKE PULSE, RESPIRATIONS AND BLOOD PRESSURE PLANNING 6. PLAN FOR PAIN RELIEF, IF INDICATED BEFORE AMBULATION 7.SET TENTATIVE GOAL 8.DECIDE ON SUPPORT NEEDED 9.PLAN SPECIFIC TECHNIQUE IF NEEDED 10.WASH YOUR HANDS IMPLEMENTATION 11.IDENTIFY PATIENT 12.EXPLAIN PROCEDURE TO THE PATIENT 13.OBTAIN ROBE AND SHOES, AND CLEAR FLOOR OF LITTER OR SPILLS 14.GAIT PATTERN: TEACH THE PATIENT TO DO THE FOLLOWING: a.HOLD CANE AHEAD 4-6 INCHES b.MOVE AFFECTED LEG AHEAD, OPPOSITE CANE c.PUT WEIGHT ON AFFECTED LEG AND CANE d.MOVE AFFECTED LEG AHEAD e.REPEAT SEQUENCE 15.PROVIDE SAFETY 16.RETURN PATIENT TO BED, AND POSITION FOR COMFORT 17.RECHECK PULSE, RESPIRATIONS, AND BLLOD PRESSURE 18.WASH YOUR HANDS EVALUATION 19.COPMARE PRE AMBULATION AND POST AMBULATION VITAL SIGNS 20.CHECK FATIGUE OR PAIN LEVEL 21.ASK HOW PATIENT FEELS 22.EVELUATE OVERALL STRENGTH, BALANCE AND ABILITY TO AMBULATE DOCUMENTATION 23.DOCUMENT ACCORDING TO FACILITY POLICY NAME AND SIGNATURE OF STUDENT: _____________________________________________ CLINICAL INSTRUCTOR: __________________________________________________________ DONE NOT DONE COMMENTS GRADE:_________________