NCLEX-RN · Basic Care and Comfort · 7 min read · Open lesson
Mobility Aids: Canes, Walkers, Crutches and Prostheses
- Determine proper measurement, fitting parameters, and safe ambulation mechanics for canes and walkers.
- Select appropriate crutch-walking gaits based on weight-bearing status and identify key complications of improper crutch use.
- Formulate nursing interventions for stair navigation, chair transfers, residual limb shaping, and orthotic maintenance.
Canes and Walkers: Fitting and Ambulation Techniques
Canes provide balance and support for clients who have unilateral weakness or mild instability. Proper fitting is essential to promote safe mobility and avoid musculoskeletal strain. When fitting a cane, the top of the handle should align with the client's greater trochanter or the crease of the wrist when the arm hangs at the side. When grasping the handle, the client's elbow should be flexed at an angle of 15 to 30 degrees. When a cane supports a weak or painful leg, the client holds it on the opposite, stronger side; a client using a cane solely for balance should follow individualized fitting instructions. If the client uses a quad cane, the device must be placed so that the wider, flat side faces toward the body to prevent tripping.
During ambulation, the client advances the cane forward first, followed by the affected leg, and then the unaffected leg. Alternatively, the client can advance the cane and the affected leg simultaneously to simulate a normal, rhythmic gait pattern. Consider how a person naturally walks: the arm on one side swings forward alongside the opposite leg. Placing the cane on the stronger side allows the device and the weaker limb to move together, distributing support evenly across the base.
A walker provides a wide base of support for clients needing greater balance assistance. As with a cane, the top handgrips of the walker must be adjusted to the level of the client's wrist crease when the arms hang loosely, ensuring that the elbows are flexed between 15 and 30 degrees when gripping the frame. A two-wheeled walker has wheels on its front legs, and clients should always use the specific type of walker prescribed and fitted for their unique needs.
To walk safely with a walker, the client should advance the device approximately 6 to 8 inches before stepping forward. After advancing the walker, the client steps forward first with the weaker or affected leg, followed by the unaffected leg. The client must step directly into the walker frame rather than remaining behind it, which keeps the center of gravity stable. Walkers must never be used on escalators, and navigating stairs with a walker requires an alternative method taught by a physical therapist.
Axillary Crutches: Fitting, Safety, and Gait Selection
Axillary crutches require precise measurement to ensure stability and protect underlying neurovascular structures. When measuring a client, the distance between the axillary crutch pad and the axilla must be 2 to 3 finger breadths. The handgrips should be positioned so that the client's elbows are flexed at 15 to 30 degrees. In the basic crutch tripod stance, the crutch tips rest approximately 6 inches in front of and 6 inches to the side of each foot, creating a broad, stable triangle.
Weight-bearing mechanics are critical for preventing injury. During crutch walking, the client must support all upper-body weight through the hands on the handgrips, never through the axillary pads. Bearing body weight directly on the axillary crutch pads compresses the radial nerve and the brachial plexus. This compression leads to crutch palsy, a condition characterized by altered sensation in the hand and weakness of wrist or finger extension, including wrist drop.
The choice of crutch gait depends directly on the client's prescribed weight-bearing ability. A two-point crutch gait requires partial weight-bearing capability on both lower extremities and involves the simultaneous movement of one crutch and the opposite lower extremity. A three-point crutch gait is indicated when one lower extremity is non-weight-bearing or partial-weight-bearing; the client advances both crutches and the affected leg together, keeping the affected foot off the ground if completely non-weight-bearing, and then advances the unaffected leg.
A four-point crutch gait is the most stable of the standard crutch gaits; it advances each crutch and each foot separately and requires weight-bearing capability on both lower extremities. For clients needing rapid movement or those with specific movement patterns, swing gaits may be used: in a swing-to gait, both crutches are advanced forward together and both legs swing forward to the level of the crutches, whereas in a swing-through gait, both crutches are advanced forward together and both legs swing forward past the crutches.
| Gait Pattern | Weight-Bearing Requirement | Movement Sequence | Key Clinical Feature |
|---|---|---|---|
| Two-Point Gait | Partial weight-bearing on both lower extremities | One crutch and opposite lower extremity advance simultaneously | Simulates normal reciprocal walking pattern |
| Three-Point Gait | Non-weight-bearing or partial-weight-bearing on one leg | Both crutches and affected leg move forward together, then unaffected leg advances | Affected foot stays off ground if non-weight-bearing |
| Four-Point Gait | Weight-bearing capability on both lower extremities | Each crutch and each foot advance separately in a four-step cycle | Provides the greatest stability among standard crutch gaits |
| Swing-To Gait | Varies by client status | Both crutches advance together, then both legs swing forward to crutch level | Legs stop at the line of the crutches |
| Swing-Through Gait | Varies by client status | Both crutches advance together, then both legs swing forward past crutches | Legs swing beyond the line of the crutches |
Safe Stair Navigation and Chair Transfers
Navigating stairs and executing chair transfers present high fall risks and require precise sequences. The core memory rule 'up with the good, down with the bad' guides safe stair navigation when using canes and crutches. This means the unaffected ('good') extremity always leads when climbing upward toward safety, while the affected ('bad') extremity and assistive device lead when stepping downward. Note that stair navigation with a walker requires a separately taught method by a physical therapist.
When ascending stairs with a cane, the client steps up first with the unaffected leg, followed by the cane and the affected leg. When descending stairs with a cane, the sequence reverses: the client steps down first with the cane and the affected leg, followed by the unaffected leg. When ascending stairs with crutches, the unaffected leg steps up first; when descending, the crutches move to the lower step before the unaffected leg, while an affected leg that is non-weight-bearing remains off the step.
Safe chair transfers also demand strict adherence to body mechanics. When preparing to sit down in a chair using crutches, the client backs up until the back of the unaffected leg touches the edge of the chair seat. The client then transfers both crutches to the hand on the affected side. With the crutches secured on the affected side, the client reaches back with the free hand to grasp the chair armrest for support before lowering into the seat.
Sitting and standing with a walker follow similar protective principles. To stand up safely from a chair with a walker, the client must push off from the chair armrests rather than pulling up on the walker frame. Pulling on the walker frame can cause the device to tip backward onto the client, resulting in a fall.
Residual Limb Management, Prosthetics, and Orthotics
Postoperative care of a residual limb focuses on skin integrity, contracture prevention, and shaping for future prosthetic use. The residual limb must be inspected daily for erythema, excoriation, blister formation, and edema. Hygiene requires washing the residual limb daily with warm water and mild soap, followed by drying it completely. To protect the fragile skin, lotions, powders, and mineral oils should not be applied to the residual limb before donning a prosthesis unless specifically prescribed. Residual limb socks must also be changed daily and washed with mild soap.
Edema control and limb shaping allow for proper prosthetic socket fitting. Compression wrapping reduces edema and shapes the residual limb into a conical form. A compression bandage must be wrapped in a figure-eight pattern, applying greater tension distally than proximally to avoid trapping fluid in the end of the limb. If a shrinker sock is used instead, it is applied directly as a fitted garment and is not wrapped.
Contracture prevention after a lower limb amputation includes preventing hip flexion contractures, particularly after transfemoral amputation, and knee flexion contractures after transtibial amputation. To avoid contractures, the client should lie prone for 20 to 30 minutes several times daily. Additionally, elevation of a residual lower limb on pillows should be avoided after the first 24 to 48 hours postoperatively, and the client must avoid prolonged sitting in a chair. Nurses must also distinguish sensory phenomena: phantom limb sensation is common and does not necessarily require treatment, whereas phantom limb pain is real and should be actively assessed and treated.
Orthotic devices, such as an ankle-foot orthosis, require diligent skin surveillance and device maintenance. Wear the sock or liner recommended for the specific ankle-foot orthosis and inspect the skin regularly; cotton is not required for every device. After removing an orthosis, the nurse or client must evaluate the skin; redness beneath the device that persists longer than 20 to 30 minutes indicates improper fit. Orthotic devices should be inspected regularly for loose screws, cracked plastic, and worn straps, and their plastic components should be cleaned with mild soap and water and air-dried completely.
Common mistakes
- Holding a cane on the affected side rather than the unaffected (stronger) side.
- Supporting body weight on axillary crutch pads instead of using the handgrips, risking radial nerve compression and crutch palsy.
- Prolonged elevation of a residual lower limb on pillows can promote hip or knee flexion contractures, depending on the amputation level.
- Pulling up on a walker frame to stand from a chair instead of pushing off from the chair armrests.
Summary
- Canes are held on the unaffected side, aligned with the wrist crease or greater trochanter, with elbows flexed at 15 to 30 degrees.
- Walker handgrips align with the wrist crease; clients advance the device 6 to 8 inches, step forward first with the affected leg, and step into the frame.
- Crutch pads must rest 2 to 3 finger breadths below the axilla, with all body weight borne on handgrips to prevent radial nerve compression and wrist drop.
- Four-point gaits offer maximum stability; stair navigation follows 'up with the good, down with the bad' for canes and crutches.
- To sit with crutches, transfer both crutches to the affected side, back up until the unaffected leg touches the seat, and reach back for the armrest.
- Residual limb shaping requires a figure-eight wrap with greater distal tension, daily washing with soap and water, and avoiding unprescribed lotions.
- Positioning measures such as prescribed prone lying, avoiding prolonged sitting, and avoiding prolonged pillow support help prevent hip flexion contractures after transfemoral amputation and knee flexion contractures after transtibial amputation.
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