EXERCISE,

TRANSFERS &
AMBULATION
BY:

MS. LOURADEL M. ULBATA, RN, MAN
MOBILITY
Mobility refers to a persons ability to move about freely.
Immobility refers to a persons inability to move about freely.

Mobility & immobility are the endpoints of a continuum with
many degrees of partial immobility in between.


mobility immobility

Some clients move back and forth, some clients remain
absolute.
ABILITY TO MOVE
The ability to move & function is a function most people take for granted.

The level of mobility has a significant impact on an ind.s physiological,
psychosocial, & developmental well-being (Hamilton & Lyon, 1995).

When there is an alteration in mobility, many body systems are at risk for
impairment.
Cardiovascular functioning orthostatic hypotension
Pulmonary complications pneumonia
Promote skin breakdown, muscle atrophy etc

Such changes can lead to altered self-concept & lowered self-
esteem.
An activity exercise pattern refers to a person's
routine of exercise, activity, leisure, and
recreation. It includes:
Activities of daily living (ADL) that require
energy expenditure such as hygiene, cooking ,
shopping, eating , working.
Type, quality, and quantity of exercises,
including sports.

PHYSIOLOGY OF MOVEMENT

Skeletal system; the bones and cartilage that protect
our organ and allow us to move are called skeletal
system. The function of this system include:
Maintain body posture by supporting the soft tissue
Protect the delicate structures of the body such as
brain, heart and spinal cord
Furnishes surface for attachments of muscles
tendons and ligaments
Storage areas of minerals salts and fats.
Produce blood cells


Ligaments; tough fibrous bands that bind joints together
& connect bones & cartilages.

Tendon; strong, flexible, inelastic fibrous band that attach
muscle to bone.

Cartilage; nonvascular connective tissue found in the joint
s as well as in the nose, ear, thorax, trachea and larynx

Muscular system; provide functions for the body through
contraction
Motion
Maintenance of posture
Heat production
The 3 types of muscles are 1) Skeletal 2) Cardiac 3)
Smooth or visceral muscles.
Muscles have two different points of attachments:
The attachment of a muscle to the more stationary bone is
called the Point of Origin.
The attachment to the more movable bone is the Point of
Insertion


Nervous System; the nerve impulses stimulate muscles to
contract.
Body Mechanics; is the efficient use of the body as a machine
and as a mean of locomotion, correct body mechanics lead to
health promotion and illness prevention so the responsibility of
the nurse to apply the body mechanics and to teach others .


MEDICAL CONDITIONS THAT CAN ALTER
MOBILITY
Fractures/sprains

Neurological conditions spinal cord injury, head
injury

Degenerative neurological conditions Myasthenia
gravis, Huntingtons chorea

NURSING MEASURES
Attempt to maintain and/or restore optimal mobility as well as to
decrease the hazards assoc. with immobility.


Muscle & joint exercises
Frequent repositioning q 2 hrs
fluid intake/fiber intake

Guidelines:
Check activity order
Know clients past medical history & limitations
Baseline vital signs are necessary
Become familiar with assistive devices




Major concern during transfer = Safety of both the
client and the nurse
Exercise
Is a type of physical activity defined as a
planned, structured, and repetitive bodily
movement performed to improve or maintain
one or more components of physical fitness.


Types of exercise:
Exercise can be classified according to the type of
muscle contraction to:-
I sotonic exercise; in which the muscle shortens to
produce muscle contraction and active movement.
Example; running, swimming, walking. This increase
muscle mass, tone and strength, increase cardiac and
respiratory and circulatory functions.
I sometric exercise; in which there is muscle contraction without moving
the joint shortening. An example includes squeezing a towel or pillow
between the knees. These exercises are useful for strengthening
abdominal, quadriceps and gluteal muscles so the nurse encourage both
isotonic and isometric exercises for the hospitalized clients.


I sokinetic exercises; involve muscle contraction with resistance example
include rehabilitation exercises for the knee and elbow injuries.


OR exercise can be classified according to the source of energy
to:-
Aerobic exercise is activity during which the amount of oxygen
taken in the body is greater than that used to perform the
activity. An example walking, running.


Anaerobic exercise involves activity in which the muscles cannot
draw out enough oxygen from the bloodstream, and anaerobic
pathways are used to provide additional energy for a short time.
An example weight lifting.

TYPES OF JOINT MOVEMENT

Flexion: decreases the angle of the joint" bending the
elbow"
Extension: Increasing the angle of the joint "
straightening the arm at the elbow"
Hyperextension: further extension or straightening of a
joint " bending the head backward"
Abduction: movement of the bone away from the
midline of the body
Adduction: movement of the bone toward the midline of
the body
Rotation: movement of the bone around its central axis

Circumduction: movement of the distal part of the bone
in a circle while the proximal end remains fixed.
Eversion: Turning the sole of the foot outward by
moving the ankle joint
Inversion: Turning the sole of the foot inward by
moving the ankle joint.
Pronation: moving the bones of the forearm so that the
palm of the hand faces downward when held in front
of the body.
Supination: moving the bones of the forearm so that the
palm of the hand faces upward when held in front of
the body.

RANGE OF MOTION EXERCISE (ROM)
- ROM exercises, in which a body part is
moved through a range of motion, are
carried out to promote circulation, maintain
muscle tone & promote flexibility.
- In doing this, joint stiffness & debilitating
contractures are prevented.
ROM(CONT.)
- ROM exercises are planned as a regular part of
nursing activities. During a bath, for example, the
nurse has an excellent opportunity to move the
patients limbs through their full range of motion.
- The patient is encouraged to exercise actively
those muscles that can be used. However, in
certain cases, the nurse may need to assist the
patient in performing ROM (active assisted ROM),
or to perform passive ROM.
ROM (CONT.)
The maximum movement that is possible for a joint is its range of
motion.

If a joint is not moved sufficiently it begins to stiffen within 24 hrs &
eventually becomes inflexible, flexor muscles contract & pull tight
causing contractures or fixed joint flexion.

To prevent joint contractures & muscle atrophy (wasting or
decrease in size of a normally developed organ or tissue), exercise
must be performed ROM exercise.

Contracture abnormal flexion & fixation of joints caused by the
disuse, shortening & atrophy of muscle fibers.

Correcting contractures requires intensive therapy over a prolonged
period of time, and may be impossible. Prevention is the key.
CONTRAINDICATIONS TO ROM
ROM requires energy & increased circulation, any
illness/disorder where increased use of energy or
increased circulation is hazardous is
contraindicated; puts strain/stress in soft tissues of
the joint & bony structures, therefore not done with
swollen, inflamed joints.
TWO PURPOSES OF ROM
1. Maintain joint function

2. Restore joint function

Do not exercise joints beyond the point of
resistance or to the point of fatigue or pain
PERFORM EXERCISES IN HEAD TO TOE
FORMAT
Start with the head and move down, always do bilaterally

Do not grasp the joint directly

Cup the joint gently (prevents pressure)

Do not grasp fingernail or toenail

Important joints thumb, hip, knee, ankle

Return to correct anatomic position

Move joint through movement 5 times/session




START AT THE NECK
Neck Flexion look @ the toes
Extension look straight ahead
Hyperextension look up @ ceiling
Lateral flexion look straight ahead, tilt head to shoulder
Shoulder Flexion raise arm forward & overhead
Extension return arm to side of body
Abduction raise arm to side to position above head with palm
away from head.
Adduction return arm & bring across chest
Internal rotation elbow flexed, rotate the shoulder by moving
arm til thumb is turned inward & toward the back (fingers to the
floor)
External rotation elbow flexed, move arm until thumb is upward
& lateral to head. (fingers point up)
Circumduction move arm in full circle (arm straight out, move
hand as if to draw a circle.
ELBOW
Elbow Flexion bend elbow
Extension straighten elbow
Hyperextension bend lower arm back as far as possible
Forearm Supination turn lower hand so palm is up
Pronation - turn lower hand so palm is down

Wrist Flexion bend wrist forward
Extension straighten wrist (fingers, wrist & arm in same
plane)
Hyperextension bring dorsal surface of hand as far back
as possible
Abduction (radial flexion) bring wrist medially towards
the thumb
Adduction (ulnar flexion) bend wrist laterally towards 5
th

finger
FINGERS & THUMB
Fingers & thumb Flexion bend fingers & thumb into palm make a fist
Extension straighten fingers & thumb
Hyperextension bend fingers as far back as possible
Abduction spread fingers apart / extend thumb
laterally
Adduction bring fingers together/ thumb back to hand
Circumduction move finger/thumb in circular motion
Opposition touch thumb to each finger of same hand
HIP
Hip
Flexion move leg forward (ROM 90-120 deg)
Extension move leg back beside other leg
Hyperextension move leg backwards (ROM 30-50
deg)
Abduction move leg laterally away from body (ROM
30-50 deg)
Adduction move leg back to medial position &
beyond if possible (ROM 30-50 deg)

Knee
Flexion bring heel toward back of thigh (120-130
deg)
Extension return leg to floor
ANKLE
Ankle
Dorsiflexion move foot so toes are pointed upward
Plantarflexion move foot so toes are pointed downward

Foot
Inversion turn sole of foot medially (ROM 10 deg)
Eversion turn sole of foot laterally (ROM 10 deg)
Flexion curl toes downward (ROM 30-60 deg)
Extension straighten toes (ROM 30-60 deg)
Abduction spread toes apart
Adduction bring toes together

SPINE
Spine
Flexion when standing bend forward from the
waist
Extension straighten up
Hyperextension bend backward
Lateral flexion bend to the side
Rotation twist from the waist
TYPES OF ROM EXERCISES
Active exercises the client is able to perform
independently. It is a form of isotonic exercise & as
such, it maintains strength, tone & flexibility.

Passive exercises performed for the client by
someone else. Passive exercise helps to maintain joint
flexibility & prevent stiffness & contractures. Because
this type of exercise involves no active movement on the
part of the muscles, it does not contribute to muscle
tone or strength.


Active assisted performed by a client with some
assistance client can move a limb partially through its
ROM, but needs help completing the ROM.
FACTORS AFFECTING BODY ALIGNMENT
AND ACTIVITY

Growth and development; according to person age the nurse
should be familiar with the differences of the neuromuscular
development of the client in order to facilitate coping.
Physical health; because any problems in the musculoskeletal
or nervous system can have negative influence on the body
alignments and movement.
Mental health; bodily processes tend to slow down in
depression
Lifestyle variables; such as exercise, food, smoking,
occupation, culture.
Attitude and values; such as swim, fitness, many individual
values also influence the exercise options people make.


Fatigue and stress; chronic stress may deplete body energy to
the point that fatigue makes even the thought of exercise
overwhelming
External factors; environment which influence, humidity,
support people, lack of free time, unsafe environment.
Nutrition; both undernutritioin and overnutrition can influence
body alignment and mobility.

Effects of exercise on major body system
Musculoskeletal system
Increased muscle efficiency' strength and
flexibility
Increased coordination, stability, gait and
posture
Increased efficiency of nerve impulses
transmission
Improve range of motion
Maintained bone density and strength

Cardiovascular system;
Meet the demands for oxygen
Increase blood flow
Increase efficiency of the heart
Decreased blood pressure
Increased blood flow to all body parts
Improved heart rate, improved circulation,
and self reported stress reduction
Decreased cholesterol level

Respiratory system; work together with
the cardiovascular system
Increase oxygen available to the muscle
Increase depth, rate of gas exchange,
rate of CO2 excretion
Improved pulmonary functioning
Decreasing breathing effort and risk of
infection.

GI system; exercises lead to
Increased intestinal tone, facilitating
peristalsis
Improve digestion and elimination
Improve the appetite

Metabolic system; exercise elevates the
metabolic rate, thus increasing the
production of body heat and waste
products and calorie use.
Increased efficiency of metabolic
system
Increased efficiency of body
temperature regulation
Reduce level of serum triglycerides and
cholesterol.

Urinary system; regular exercise
increase blood circulation including
improved blood flow to the kidneys
which allows the kidneys to
maintain the body's fluid balance and
acid-base balance more efficiently
and to excrete body waste.


Skin; regular exercise increase circulation
which lead to promote good health

Psychosocial outlook; regular exercise
have psychological effects such as
increase energy, improve sleep, body
image, improve self-concepts and
increase positive health behaviors,
improve general well being.


EFFECTS OF IMMOBILITY ON MAJOR BODY
SYSTEM


Musculoskeletal system
Disuse osteoporosis; demineralization process, known as
osteoporosis, the bones become spongy and may gradually
deform and fracture easily.
Disuse atrophy; atrophy in muscles losing most
of their strength and normal function.
Contractures; when the muscle fibers are not
able to shorten and lengthen (permanent
shortening of the muscle) forms limiting joint
mobility. This process eventually involves the
tendons, ligaments, and joint capsules.


Cardiovascular system
Diminished cardiac reserve
Orthostatic hypotension; is a common result of
immobilization. The blood pools in the lower extremities,
and central blood pressure drops. Cerebral perfusion is
seriously compromised, and the person feels dizzy or
light headed and may even faint.
Venous vasodilation and stasis; the skeletal muscles do not
contract sufficiently, and the muscles atrophy, so the skeletal
muscles can no longer assist in pumping blood back to the
heart against gravity. Blood pools in the leg veins, causing
vasodilation and engorgement.


Dependent edema; when the venous
pressure is sufficiently great, some of
serous part of the blood is forced out of
the blood vessel into the interstitial spaces
surrounding the blood vessel, causing
edema.
Thrombus formation

3. Respiratory system
Decreased respiratory movement; in immobile client,
ventilation of the lungs is passively altered. The body
presses against the rigid bed and curtails chest
movement. The abdominal organs push against the
diaphragm, restricting lung movement and making it
difficult to expand the lungs fully.

Pooling of respiratory secretions; secretions of the respiratory
tract are normally expelled by changing positions or posture
and by coughing. Inactivity allows secretions to pool by
gravity, interfering with the normal diffusion of oxygen and
carbon dioxide in the alveoli.


Atelectasis; is the collapse of a lobe or of an entire lung, when
ventilation is decreased, pooled secretions may accumulate in a
dependent area of a bronchiole and effectively block it.
Immobile elderly, postoperative clients are at greatest risk of
Atelectasis.

Pneumonia; pooled secretions provide excellent media for
bacterial growth. Under these conditions, a minor upper
respiratory infection can evolve rapidly into severe infection of
the lower respiratory tract.



Metabolic system
Decreased metabolic rate; in immobile clients, the basal
metabolic rate and gastrointestinal motility and secretions of
various digestive glands decrease as the energy requirements of
the body decrease.
Negative nitrogen balance
Anorexia; loss of appetite occurs because of the decreased
metabolic rate and the increased catabolism that accompany
immobility.
Negative calcium balance

5. Urinary system
Urinary stasis; in a mobile person, gravity plays an
important role in the emptying of the kidneys and the
bladder. When the person remains in abed, gravity
impedes the emptying of urine from the kidneys and
the urinary bladder, so emptying is not as complete
and urinary stasis occurs after few days of bed rest.

Urinary retention, which is accumulation of
urine in the bladder, bladder distention, and
occasionally urinary incontinence (involuntary
urination). The decreased muscle tone of the
urinary bladder inhibits its ability to empty
completely.
Urinary infection, static urine provides an
excellent medium for bacterial growth


6.Gastrointestinal system
Constipation is a frequent problem for
immobilized people because of decreased
peristalsis and colon motility.

7. Integumentary system
Reduced skin turgor. Skin turgor is an abnormality in the
skin's ability to change shape and return to normal (elasticity).
The skin can atrophy as a result of prolonged immobility.
Skin breakdown. Normal blood circulation relies on muscle
activity. Immobility impedes circulation and diminishes the
supply of nutrients to specific areas. As a result skin
breakdown and formation of pressure ulcers can occur.

PRESSURE ULCERS
8. Psychoneurologic system
Lower the persons self esteem
Increased risk of depression
Decreased social interaction

Nursing management
Assessing
Nursing History
Physical examination
Body Alignment
Appearance and movement of joints
Capabilities and limitation for movement
Muscle mass and strength
Activity tolerance
Problems related to immobility

Nursing Diagnosis
Nursing diagnoses related to mobility focus primarily on activity
and mobility levels, and the psychosocial impact that
alterations in mobility can have on a client and the
clients family. Common NANDA nursing diagnoses related to
the physical adaptations or risks resulting from altered mobility
include:

Activity Intolerance related to bed rest and immobility,
generalized weakness, sedentary lifestyle, and imbalance
between oxygen supply and demand.
Impaired Physical Mobility related to intolerance to activity or
decreased strength and endurance, pain, perceptual or cognitive
impairment, neuromuscular impairment, musculoskeletal
impairment, and depression or severe anxiety.

Self-Care Deficits related to inability to wash body or body
parts, inability to obtain or get to water source, activity
intolerance, decreased strength and endurance, pain, and
impaired transfer ability
Ineffective Health Maintenance related to lack of or significant
alteration in communication skills (written, nonverbal)

Risk for Falls related to impaired mobility. Alterations in family
and social processes may also result from immobility and
inactivity. Disruption in activity and mobility leads to
impairment of the ability to perform ones usual social,
vocational, educational, and family roles.

There are often changes in the clients perception of role.
Disturbed Body Image and Situational Low Self-Esteem can
result from:
1. Changes in physical abilities
2. Changes in family responsibilities
3. Lack of knowledge regarding rehabilitation
Fear (of falling)
Ineffective coping
Low self esteem
Powerlessness


Planning
Implementing
Nursing strategies to maintain or promote body alignment and
mobility involve positioning clients appropriately, moving and
turning clients in bed, transferring clients, providing ROM
exercises, ambulating clients with or without mechanical aids.


Techniques to prevent back stress:
Develop a habit of erect posture correct alignment
Use the longest and strongest muscle of the arms and the legs
to help provide the power needed in strenuous activities
Use the internal girdle and a long midriff to stabilize the pelvis
and to protect the abdominal viscera when stopping, reaching ,
lifting or pulling

Use the weight of the body as a force for pulling or pushing by
rocking on the feet or leaning forward or backward
Work as closely as possible to an object that is to be lifted or
moved.
Flex the knees, put on the internal girdle and come down to an
object that is to be lifted.
Spread the feet apart to provide a wider base of support when
increased stability of body

BENEFITS OF PROPER POSITIONING
Maintains body alignment & comfort

Prevents injury to musculoskeletal system, prevents
strain

Provides sensory, motor & cognitive stimulation

Prevents pressure sore (decubitus ulcer) & joint
contractures
TRANSFERS
Transferring is a nursing skill that helps the client with
restricted mobility attain/maintain mobility & independence.

Benefits of transfers
Maintains & improves joint motion
Increases strength
Promotes circulation
Relieves pressure on the skin
Improves urinary/respiratory function
Increases social activity
Increased mental stimulation

TRANSFERS - SAFETY
Safety is a major concern when transferring. Falls are a
common hazard. If a patient starts to fall do not try to stop
the fall, instead assist the patient to the floor while protecting
the head from injury. This will reduce the risk of patient as
well as staff injury.

Complete a thorough nursing assessment before you move
the patient to determine if she/he has suffered any injuries.

Prevention of injury is the key, be aware of the clients motor
deficit, ability to support their body weight and use effective
body mechanics & lifting techniques.

When in doubt regarding the patients ability-GET
ASSISTANCE

TRANSFER & AMBULATION:
CLIENT BENEFITS
maintains / improves joint motion
increases balance, strength, endurance
promotes circulation & relieves pressure
improves respiratory function; appetite; bowel & urinary
function
increases social activity & mental stimulation
TRANSFER: BED TO CHAIR
(ONE PERSON)
chair 45-90 degree angle to head of bed
lock bed & wheelchair / chair with armrests (make
sure footrest of chair is out of way!)
raise HOB 30
o
& pause to assess. Turn client in
side lying position facing you. Slowly swing to
sitting position by reaching under shoulders and
over clients thighs.

Calf pumps, move legs, deep breaths- assess for
hypotension

put on shoes or nonskid slippers (may be done
previously!)

widen stance, bend knees & supporting clients knees,
grasp belt or put arms behind their scapulae- Not
under axilla!

straighten your knees as they push off the bed, assist
to stand, client pivots, places hands on armrest and
sits down

TRANSFERRING FROM BED TO CHAIR
TRANSFERRING FROM CHAIR TO BED
MECHANICAL LIFTS
when a client is heavy
and has little ability to
weight bear or assist, use
the mechanical lift
at least 2 nurses must
assist with the use of all
mechanical lifts to ensure
safety
(Portable or ceiling lifts)

AMBULATION
Clients who have been immobile even for a short time may
require assistance

A client may require the use of an assistive device to aid in
ambulation.

Assistive devices
Increase stability
Support a weak extremity
Reduce the load on weight bearing structures; hip,
knees
ASSISTING THE PATIENT
Simple assist / One person assisted
1. Place arm near patient under the arm & at the elbow &
grasp pts hand, synchronize walking with the pt
(move inside foot forward at same time as pts inside
foot)
2. Grasp pts left hand in nurses left hand & encircle pts
waist with the rt hand & synchronize walking
3. Using a transfer belt (held at the waist from the rear by
the belt helps maintain balance)

Nurse to stand on the pts weak side. The nurse provides
support with his/her leg to the pts weakened one if
necessary. Do not allow the pt. to place their arm around
your shoulder.

Walk slowly, even gait, synchronize your steps.
WALKERS AND CANES
Walkers and canes are generally used as mobilizati
on aids for patients who
can bear weight on the affected leg, but require so
me support

CANE
Helps maintain balance by widening the base of support increases a pts
security.

Should be held on stronger side
Should have rubber tip prevent slipping
Height (from greater trochanter to the floor allowing 15-30 deg of
elbow flexion.

The patient should hold a cane on the unaffected side with his el
bow slightlyflexed and the cane tip about 6 inches in front of and
6 inches to the side of his foot. (Acane is used for balance, rather
than physical support. It is held on the unaffected side
to prevent the patient from "leaning" on it for support.)

Stand from sitting
Cane in hand opposite affected leg, grasp arm of chair & cane in
other, push to stand, gain balance



CANES
STANDARD CROOK;
TRIPOD; QUAD CANE
cane moves ahead approx. 15 to 25cm (6-10
in)
weak leg moves forward in line with cane
strong leg moves ahead past cane & other leg
sequence repeated
Cane weak leg strong leg
Sit-Down
client reaches back with free hand and grasps
arm of chair
lowers self while most wt bearing done on
stronger leg (chair must be heavy, solid chair or
client must use both hands on armrests at same time)
Stand-Up
both hands push down on armrests OR
hand with cane on strong side and opposite
hand pushing down on armrest
WALKER
Wide base of support, provides great
stability & security. Used for clients who are
weak or who has problems with balance.

Patient should have at least one weight bearing leg and
arm
Pick up walker is more stable, walker with wheels easier
for pts who have difficulty with lifting or balance,
however can roll forward when weight is applied.
Height upper bar of walker should be slightly below the
clients waist with arms flexed 15-30 deg
WALKERS
WALKER (CONT.)
To stand walker in front of seat, push up off arms
of chair (walker is less stable, chair is lower pt. can
push with more force. Hands move to walker one
at a time.

To sit back up to chair, reach back with one arm to
arm of chair, then with the other arm and lower to
chair.

Gait walker ahead 6-8 inches, weight on arms.
Partial weight on affected leg first.

Walker weak leg strong leg

WALKER
When utilizing a walker, the patient should use the
muscles of the arms andupper body to help support
his weight. After placing the walker in front of the p
atient,
instruct the patient to ambulate with a walker using t
he following sequence of moves.
(1)Firmly grasp the hand grips.
(2)Move the walker and the affected leg forward ab
out 6 inches.
(3)Move the unaffected leg forward, parallel to the a
ffected leg.
(4)Repeat the sequence for each step.

Lofstrand or forearm
crutches




Axillary wooden/
metal crutches
CRUTCHES

Size
Top of crutches leaves 11/2 2
inches below the axilla. (5cm;
3 finger widths)
crutch rests 4-6 inches in front & 4-6
inches to side of foot., while
handgrips - elbow flexion of 30
degrees
support body with hands & arms NOT
under the axilla.


be cautious regarding crutch
palsy
damage to the radial nerve in axilla area -
numbness, tingling, muscle weakness and
paralysis
PLACE THE CRUTCH TIPS ABOUT 6 TO THE SIDE
AND IN FRONT OF EACH FOOT. STAND ON YOUR
"GOOD" FOOT
CRUTCHES
Gait depends on persons ability to support their
weight and balance
Types of gait with use of crutches:
2 point
3 point
4 point
Swing to
Swing through
To Stand
Hold both crutches on strong side (hands on
handgrips)
Lean ahead with stronger leg close to chair, and
weak leg extended out front
Push hand down on armrest and raise body to
standing position
If chair is tipsy, use both arm rests to push to
standing position rather than holding crutches
To Sit
Same technique used, in reverse direction
2 POINT GAIT
Requires at least partial weight bearing of both legs:
Lt foot & Rt crutch move together ahead 10-15 cm
(4-6 inches)
Rt. foot & Lt crutch move together ahead
2 POINT GAIT
The 2-point gait (see figure 1-10) is used when the
patient can bear some weight on both lower extremities.
Place the patient in the tripod position and instruct him
to do the following.

(1) Move the right leg and left crutch forward together.

(2) Move the left leg and the right crutch forward
together.

(3) Repeat this sequence for desired ambulation.


2 POINT GAIT
3 POINT GAIT
able to wt. bear on one foot, full wt. on unaffected
leg then on both crutches


begin in tripod position -> move crutches &
affected leg ahead -> move stronger leg forward
and repeat.
3 POINT GAIT
The 3-point gait (see figure 1-9) is used when the
patient should not bear any weight on the affected leg.
Place the patient in the tripod position and instruct him
to do the following.

(1) Move the affected (non-weight bearing) leg and both
crutches forward together.

(2) Move the unaffected (weight bearing) leg forward.

(3) Repeat this sequence for desired ambulation.


THREE POINT GAIT
4 POINT GAIT
Provides best balance & stability for person but
must be able to weight bear on both legs
Rt. crutch forward
Lt. foot forward
Lt. crutch forward
Rt. foot forward
4 POINT GAIT
The 4-point gait (see figure 1-8) is used when the patient can
bear some weight on both lower extremities. Place the patient
in the tripod position and instruct him to do the following.

(1) Move the right crutch forward.

(2) Move the left foot forward.

(3) Move the left crutch forward.

(4) Move the right foot forward.

(5) Repeat this sequence of crutch-foot-crutch-foot for desired
ambulation.


4 POINT GAIT
SWING TO POINT
both crutches are advanced forward together;
weight is shifted onto hands for support and both
legs are then swung forward to meet the crutches;
requires the use of two crutches or a walker;
indicated for individuals with limited use of both
lower extremities and trunk instability.
SWING-THROUGH GAIT
is used for patients with lower extremities
that are paralyzed and/or in braces. Place the patie
nt in the tripod position and instruct him to
do the following:
(1)Move both crutches forward together about 6 inc
hes.
(2)Move both legs forward together about 6 inches.
(3)Repeat the sequence in rhythm for desired ambu
lation.

GOING UP & GOING DOWN THE STAIRS
SUMMARY : USE OF ASSISTIVE DEVICE
MOVING AND POSITIONING THE
PATIENT
MOVING THE PATIENT: UP IN BED
Move close to the side of the
bed
Back straight, knees bent, one foot forward (broad
base of support)
Up in bed (1 nurse)
(Patient alert & cooperative)
Encourage independence & foster self-esteem.
Patient bends knees, feet firmly on the bed
grasps side rail @ shoulder level. Nurse positions
hand & arms under patients hips, back straight,
bend knees, feet apart, count to 3. Nurse pulls
patient up in bed & pt pulls arms & pushes feet up
into bed.

Up in bed (2 nurses)
(heavy patient or one who
cannot help)
Patient bends knees, feet firmly on bed, 1
st
nurse
at HOB arms under head & shoulders, face foot of
bed, 2
nd
nurse under hips facing foot of bed, on
same side count to 3.
MOVING THE PATIENT: LIFTER
Up in bed using the pull sheet/lifter
(2 nurses)
Do not lift, always slide
One nurse on each side of the bed, firmly
grasp the lifter in both hands, ask the patient
to lift their head. Slide the patient up in bed
on the count of 3.

Benefit: 1. movement b/w 2 layers of cloth
has less friction than skin on cloth.
2. Much easier to grasp sheet firmly than it is
to hold a patients body.
3. Lifter supports the entire body (except the
head) making it easier to keep the patient
straight.

MOVING THE PATIENT: LATERAL
From the back to the side
(lateral) position
Move the patient to the side of the bed, so
the patient will be in the center when
complete.
Raise rail, move to other side of bed, roll
patient toward you far ankle over near ankle,
far knee over near knee. Place one hand on
clients hip and one hand on his/her shoulder
and roll pt. onto side toward you. Place
pillow under head & neck, bring shoulder
blade forward, position both arms in slightly
flexed positions (protects joints).
Upper arm supported by pillow.
Place pillow behind patients back & pillow
under semi flexed upper leg
Assess need to support feet (footboard, high
top sneakers).
MOVING THE PATIENT: PRONE
From the back to the
abdomen (prone)
Move to the extreme edge of the bed, raise rail on that
side, move to other side.
Pillow for support under abdomen, near arm over head,
turn face away, roll as above, check arm & face, continue
rolling.

Prone - infrequently used because respirations can be
compromised
Good position for pressure sores on hips/buttocks.

Important to turn head to the side, no pillow b/c it hyper
extends the neck can use small towel, small folded towel
under each shoulder to prevent slumping, flat pillow at
abdomen (esp. women with large breasts)
Arms at either sides or flexed by head, hand rolls, feet in
dorsiflexion sandbags under ankles.
TIPS FOR POSITIONING THE PATIENT
After turning use aids i.e. pillows, towels, washcloths,
blankets, sandbags, footboards etc.

Joints should be slightly flexed b/c prolonged extension
creates undue muscle tension & strain

Supine
Low or flat pillow (prevents neck flexion)
Trochanter role (supports hip joint prevents external rotation)
Hand roll used if hands are paralyzed (thumb & fingers flexed around
it)
High top sneakers, foot board, sandbags (support feet with toes
pointing upward. Prolonged plantar flexion leads to foot drop
(permanent plantar flexion & inability to dorsiflex)
TIPS (CONT.)
Side lying
Even if paralyzed on one side a patient can be placed
on that side. Take care not to pull on the affected
extremity.

Head on low pillow, pillow along back supports back &
holds body in position, underlying arm comes forward &
flexed onto pillow used for head, top arm flexed forward
& resting on pillow in front of body, hand rolls if
necessary, flex top leg forward & place on pillow, feet at
right angles with sandbag.