When ambulating a client using an assistive device, the nurse should evaluate the client’s strength and stamina.

This client’s
symptoms tell us that the demands of walking with the walker exceed the physical reserve of the client.
Because of pooling of the blood in the lower extremities and decreased circulating volume, immobilized clients can experience
orthostatic hypotension. Immobility is also the greatest risk factor for formation of a deep vein thrombosis.

Constipation: Constipation can be treated and prevented by increasing fluids and fiber in the diet. Medication therapy may be
required, including stool softeners, bulk forming or osmotic laxatives, or stimulants.
Pressure injuries: Frequent repositioning (at least every 2 hours) and devices to reduce pressure and shearing forces on the client
are primary interventions to prevent pressure injuries. Good skin care and nutrition also should be provided to clients at risk for
pressure injuries.

Wheelchairs are used both long term and short term for clients that are unable to ambulate on their own. Wheelchairs may be
indicated for clients with leg paralysis, musculoskeletal disorders, neurological disorders, or gait and balance issues. Typically,
battery-powered wheelchairs are used for clients requiring long-term mobility support to promote independence. Manual
wheelchairs are better for short-term use, being pushed by a caretaker, or for clients who have upper body strength to propel the
wheelchair on their own. When fitting a client for a wheelchair, the nurse should measure the widest part of a client’s hips and
add 2 inches (5.08 cm). The wheelchair should be about this wide to promote maximum comfort and safety.

When caring for a client in a wheelchair, the nurse should be sure the brakes are locked whenever transferring the client into or
out of the wheelchair or whenever the wheelchair is not being used to transport. Feet should be placed on footrests during
ambulation and sitting in a wheelchair. In-home accommodations for a client that requires a wheelchair for long-term use include
installation of ramps, widening of doorways and lowering of counters. For clients that spend significant time in a wheelchair, the
nurse will need to teach methods to prevent pressure injuries. Adjust at least every 2 hours. These methods include the push-up
method (where the client pushes on both armrests to raise the buttocks from the chair), one-half push-up method (where the client
pushes on one armrest to raise one side of the buttocks and then repeats on the other side), and also simply moving from side to
side in the chair. Periodic inspection of the wheelchair to ensure proper maintenance can prevent client injury.
The walker should be about waist height. If the walker is the correct height, the client’s arms should be flexed at about 30 degrees
when holding the handgrips on the side of the walker.

When walking with a pick up walker, the client holds on to the handgrips of the walker, lifts it up, moves it forward 8 to 10
inches, and then takes a step forward. When ambulating with a rolling walker, the client holds on to the handgrips of the walker,
rolls the walker forward 8 to 10 inches, and then takes a step forward. The client should be careful not to lean forward on the
walker.
Axillary crutches should be adjusted to a client’s height so there is a 2-inch gap (2 to 3 finger widths, or about 5 cm) between the
armpit and the rest pad of the crutch. Appropriate fit prevents nerve damage to the brachial plexus.

Four-point gait: part weight bearing, safest but slowest

Four-point gait: Requires partial weight-bearing on both legs. This is the safest but slowest of all the gaits. The right crutch is
advanced, followed by the left leg, left crutch, and finally the right leg.
Two-point gait: Requires partial weight-bearing on both legs but requires less support than a four-point gait. The sequence of this
gait is right crutch with left leg, followed by left crutch with the right leg.
Three-point gait: This is the most commonly used gate. It only requires weight-bearing on one leg. Both crutches and the injured
leg advance simultaneously, while the strong leg supports the body weight. Then, the uninjured leg is advanced while the
crutches bear the client’s weight.
Swing to or through gait: This is the fastest crutch gate, but it also requires the most strength and balance. Lifting the injured leg,
the client advances both crutches, and then swings the legs forward to meet the churches (swing to). If the client is strong enough,
the client may swing both legs in front of the crutches (swing through).
Canes provide the least amount of support to clients of the assistive devices discussed today, but they also
provide for the most independence. They can be helpful for clients who are able to bear weight on both legs
but need the extra balance support provided by a cane. They also can be helpful for clients with unilateral
weakness to provide extra support for the weak leg. The cane acts as an additional leg, allowing for three
points of support while the client is ambulating.

*TA Catherine, RN:Two types of canes commonly used include the straight-leg cane and the quad cane. As
the names imply, the straight-leg cane has just a single leg, while the quad cane has a four-leg base. The four-
leg base makes the quad cane more stable, but is also heavier than the straight-leg cane.

he purpose of a cane is to allow the client to keep two locations of support on the ground at all times (instead of just one, as is the
case with normal walking). Teach clients to keep the cane on the strong side of the body when ambulating (Remember
“COAL”—Cane Opposite Affected Leg). To use, the client should move the cane forward first, keeping weight distributed on
both legs. Then the client moves the weak leg forward, followed by the strong leg.

Climbing stairs with a cane: For climbing stairs with a cane, think up with the good leg and down with the bad. Teach clients to
place the cane in the hand opposite the weaker side. If possible, encourage the client to grasp the handrail with the free hand. The
client should lead with the strong leg up the stairs. Then the client should move the weaker leg, along with the cane, to the same
step. To come down stairs, the cane is in the same position, opposite the weaker side, and the free hand is on the handrail. The
client should place the cane on the first step down, followed by the weak leg. Then the client should move the stronger leg to the
same step.
When measuring a cane for proper fit, the top of the cane should be about the level of the greater trochanter, and the client should
be able to hold the cane comfortably with the elbow bent to 30 degrees. Be sure a nonskid rubber tip is on the end of the cane to
prevent slipping. Change the tip if it is worn.