Teaching Crutch Walking

When only one leg can bear weight:
1. Swing-to-gait: crutches forward; swing body to crutches.
  1. Move both crutches forward.
  2. Move both legs to meet the crutches.
  3. Continue pattern.
2. Swing-through gait: crutches forward; swing body through crutches.
  1. Move both crutches forward.
  2. Move both legs farther ahead than crutches.
  3. Continue pattern.
3. Three-point gait: crutches and affected extremity forward; swing forward, placing nonaffected foot ahead of or between crutches.
  1. Both crutches and affected limb move at same time.
  2. Move both crutches and affected leg (e.g., left) ahead 6 inches.
  3. Move unaffected leg (e.g., right) to same place as left and crutches.
  4. Continue pattern.
When both legs can move separately and bear some weight:
1. Four-point gait: right crutch forward, left foot forward; swing weight to right side while bringing left crutch forward, then right foot forward; gait simulates normal walking.
  1. Move right crutch forward 4-6 inches.
  2. Move left foot forward same distance as right crutch.
  3. Move left crutch forward ahead of left foot.
  4. Move right foot forward to meet right crutch.
  5. Continue pattern.
2. Two-point gait: same as four-point gait but faster; one crutch and opposite leg moving forward at same time.
  1. Opposite crutch and limb move together.
  2. Move right crutch and left leg ahead 6 inches.
  3. Move left crutch and right leg ahead.
  4. Continue pattern.
When patient is unable to walk: tripod gait: crutches forward at a wide distance; drag legs to point just behind crutches, balance, and repeat.

Measuring Crutches Correctly

Have patient lie on a flat surface. Measure from anterior fold of axilla to 4 inches lateral to heel.
Have patient stand. Measure from 1-2 inches below axilla to 2 inches in front of and 6 inches to the side of the foot.
Hand placement on bar of crutch: have patient stand upright, support body weight with hand on bar (not putting weight on axilla). Elbow flexion should be 30 degrees.
Slightly pad the shoulder rests of the crutches for general comfort.
Make sure there are nonskid rubber tips on the crutches.

Assessing Injured Limb: CSM
C	Circulation Is it warm to touch? Are both limbs equal in size? Are peripheral pulses present? Is there adequate capillary refill?
S	Sensation Does the patient feel pain? Can the patient distinguish different sensations, e.g., painful stimuli vs. soft touch? Is the patient aware of the position of the limb?
M	Motion Can the patient move extremities that are not immobilized? Can the patient do this independently? Can the patient do this on command?

Evaluation/outcome criteria:
1. No injury or complications related to apparatus or immobilization (, infection, tissue injury, altered circulation/sensation, dislocation).
2. Bone remains in correct alignment and begins to heal.
3. Demonstrates elevated limb position to relieve edema with casted extremity.
4. Lists complications related to circulation or neurological impairment and infection.
5. Begins to use affected part.
6. Demonstrates correct technique for ambulation with crutches-no pressure on axilla, uses strength of arms and wrists.
7. No falls while using crutches.

Complications of Fractures

Complication	Assessment	Analysis/Nursing Diagnosis	Nursing CarePlan/Implementation	Evaluation/Outcome Criteria
Fat emboli: serious, potentially life-threatening complication in which pressure changes in interior of fracture force molecules of fat from marrow into systemic circulation; may cause problems in respiratory or nervous system; seen most frequently on third day after multiple fractures, fractures of long bones, or comminuted fracture	Subjective data: dyspnea, severe chest pain; confusion, agitation; decrease in level of consciousness; numbness; feeling faint; history of diabetes, obesity Objective data: cyanosis; pupillary changes; muscle twitching; petechiae-chest, buccal cavity, axilla, conjunctiva, soft palate; extremities-pallor, cold; shock; vomiting	Risk for injury related to fat emboli Altered tissue perfusion related to fat emboli	Position: high Fowler’s to relieve respiratory symptoms Administer oxygen stat, to relieve anoxia and reduce surface tension of fat globules Institute respiratory support measures, as ordered - IPPB, respiratory assistive devices: be prepared for CPR in event of respiratory failure Monitor vital signs, cardiac monitor, ql5 mins. during acute episode and prn (shock/cardiac failure possible) Obtain baseline data and monitor level of consciousness, neurological signs ql5 mins. during acute episode and pm (neurological involvement possible) Administer parenteral fluids, as ordered: IV alcohol, blood and fluid replacements Administer medications as ordered: corticosteroids; digitalis; aminophylline; heparin sodium DO NOT RUB ANY LEG CRAMPS, BUT REPORT IMMEDIATELY	Patient alert Pain relieved Respiratory, cardiac, and neurological systems have no permanent damage
Nerve compression: pressure on nerve in affected area from edema, dislocation of bone, or immobilization apparatus; if pressure not relieved, permanent paralysis can result	Subjective data: discomfort, pain, referred pain; burning, tingling, “stinging sensation”; numbness, altered sensation, inability to distinguish touch Objective data: limited movement; muscle weakness; paralysis; reflexes - diminished, irritable, or absent; color changes related to impaired circulation	Pain related to pressure on nerve Potential for physical injury related to pressure on nerve Impaired tissue perfusion related to impaired circulation Impaired physical mobility related to joint contracture, numbness	Monitor for potential signs qlh for first 48 hours; neurovascular assessment ql2h and prn as condition indicates (circulation, sensation, and motion [CSM]) B Elevate affected limb; flex hand or foot of affected extremity; passive and active ROM exercises Be prepared to cut cast or remove constrictions if signs of impairment exist Begin active ROM exercises to unaffected extremities Use footboard to prevent footdrop 6. Encourage use of trapeze if applicable Isometric exercises, as ordered Ambulation, weight bearing as ordered, support casts	Sensation, motor function are normal No complications noted
Avascular necrosis/circulatory impairment: interference with normal circulation to affected area due to interruption of blood vessel, pressure on the vessel from dislocation, edema, or immobilization devices; re- sults of impaired circulation lead to discomfort and, if not corrected, necrosis of tissue and bone due to lack of oxygen supply	Subjective data: tenderness; pain, especially on passive motion Objective data: edema, swelling in affected area; decreased color, temperature, mobility; bleeding from wound	Risk for altered peripheral tissue perfusion related to vessel damage	Monitor for potential signs qih for first 48 hours; blanching, coolness, edema; palpate pulse above and below injury, report absent pulse or major discrepancies stat B Elevate affected limb to decrease edema Report to physician if signs persist Be prepared to assist with bivalving of casts, or cut cast to relieve pressure Monitor size of drainage stains on casts; measure accurately and report if size increases	Circulation adequate to limb, to present tissue damage
Infection	Risk for injury related to tissue destruction Altered peripheral tissue perfusion related to swelling	Risk for injury related to tissue destruction Altered peripheral tissue perfusion related to swelling	Monitor vital signs, drainage Ensure patient has had prophylactic tetanus toxoid May have prophylactic antibiotics ordered if wound was contaminated at time of injury Instruct patient not to touch open wound or pin sites or put anything inside cast (could interrupt skin integrity and become potential source of infection)	No infection or heals with no serious complications
Delayed union/nonunion: failure of bone to heal within normal time related to lack of use, inadequate circulation, other complicating medical conditions such as diabetes or poor nutrition	Subjective data: pain Objective data: lack of callus formation on x-ray: poor alignment	Risk for injury related to poor healing of bone fracture Impaired physical mobility related to lower-limb fractures Dressing/grooming, bathing/hygiene, self-care deficit related to upper- limb fracture Impaired skin integrity related to cast trauma	Maintain immobilization and alignment of affected limb Maintain adequate nutrition Avoid trauma to affected limb Monitor for circulatory or infection complication Dietary instructions regarding foods containing calcium and protein necessary for bone healing	Bone heals No complications noted Pain decreased Ambulation and self-care return to pre-injury status
Skin breakdown (related to cast)	Subjective data: pain Objective data: temperature and pulse elevated; erythema; edema - cast edges, exposed distal portion of limb, limb area within cast; drainage and foul odor from break in skin (may be under cast and stain through or exit at ends of cast); crepitus (crackling sound could indicate gas gangrene); hyperactive reflexes		If open wound: verify tetanus administra- tion; monitor site through cast window, change dressing daily and pm Apply lotion or cornstarch to exposed skin (no powder) Petal upc edges of cast to reduce irritation Inspect skin for irritation, edema, odor, drainage - q2h initially, then q3h Instruct patient not to place any object under cast because skin abrasions may lead to decubitus ulcers Promote drying of cast by leaving it uncovered and exposed to air for 48 hours. use no plastic Present indenting casts with fingertips or hard surface: place on pillows; use palms of hands when positioning affected limb Avoid excessive padding of Thomas splint in groin area padding traps moisture, may lead to skin breakdown	No skin breakdown
Duodenal distress (with spica cast): spica cast incorporates the trunk and affected limb and can cause respiratory or abdominal distress when edema is present under the cast or cast is too tight to allow for normal body functions	Subjective data: anorexia, nausea, abdominal pain Objective data: duodenal distress, vomiting, distention, cast too tight	Ineffective breathing related to pressure from cast Pain related to abdominal distress from pressure Fear related to cast constriction	Place on firm mattress; use bed boards if necessary to reduce muscle spasm Maintain warmth by covering uncasted areas Avoid turning for first 8 hours.; when turning: use enough personnel to logroll; do not use bar between legs as turning device; support chest with pillows Monitor for signs of respiratory distress: increased respirations, apprehension Monitor for signs of duodenal distress: vomiting, distention; if these signs occur: place in prone position; have cast bivalved; may need NG tube; monitor for fluid imbalance Protect cast with nonabsorbent material during elimination	Complications avoided or detected early enough to prevent serious damage