Therapeutic Skills.
Examination Card 3.
Introduce yourself and your assistant to the patient, wash your hands properly before you begin.....
1. Explain what you are going to do with the patient and the benefits of using axillary crutches:
Help take the weight bearing strain/benefit away from the lower limbs and transfer it to the upper limbs – alleviate pain from joint, muscles and ligaments in right affected leg.
Increase body’s base area of support – body more stable and promotes overall balance.
Important to keep weight off leg to allow bones to heal.
2. Measuring crutches:
Explain what you are going to do and ask the patient to lie down on their back on the bed, keeping their shoes on.
There are 8different ways to measure the fit of crutches, though these are the most accurate:
5cm from axillary fold to the heel in supine.
Height minus 16inches.
Adjust handgrips so elbows are flexed to 15 degrees.
Ensure rubber ferules are fitted.
3. Inform patient of maintenance and safety issues:
Check ferrules aren’t worn down and if they are advise them where to go to change them, for example a Disabled Living Centre.
No splinters or cracks.
Check the measurements are suitable.
Keep a good posture – no weight bearing on affected right leg.
Axillary crutch should not press into axilla as this may damage the axillary artery and nerves. Instead it should be held in against the chest wall.
Support areas should be padded.
Check screws and clips aren’t broken.
Warn patient to be careful using crutches during adverse conditions.
4. Teaching the patient to use the axillary crutches:
Sitting to standing position:
· Demonstrate sitting on the edge of the bed, hold the crutches together in right hand (side of the affected leg) with the screws on the same side. Stand up on the left good leg and take the outside crutch and place it under your right arm. Remember the triangular base is very important!
· Tell the patient never to lean on the crutches inappropriately as this would damage the axilla. In a resting standing position the crutches should be out in front and to the side and the patient should not be leaning on them.
· So as the patient themselves attempts to move from a sitting to standing position you must ensure you are close to them and are stabilising them efficiently, make sure your assistant is doing this as well. Also remember to give some encouragement and support and at this point take a final check for height comfort and balance.
· Rest may be necessary at this point.
Walking:
· Position a chair an appropriate distance from the patient.
· Demonstrate using a 3point gait – used for non-weight bearing on one leg, hop too and hop through.
· Turning around or moving backwards – 1crutch forward, 1 crutch back and a little hop.
Practice a step then a gait cycle then progress forward and
again when patient is attempting this make sure to support them at all times.
· Sit down.
Ascending and descending the stairs:
· Always one stair at a time and helps to remember good leg to heaven bad leg to hell.
· Ask patient which side banister is on at home – have crutches opposite side.
(Assuming banister is on right hand side) Demonstrate.
Take crutches in left hand, one under arm normally and the other placed horizontally across the other crutch. Take hold of the banister with your right hand and hop up with your left leg, following with the crutch. Do not stand on right affected leg. Once you have reached the top of the stairs turn and move the crutches to your opposite side and take hold of the banister ready for descending.
· Descending the stairs stick your right affected leg out first and place the crutch on the stair below. Hop down on your good left leg keeping a firm grasp on the banister.
· As this patient then practices this you should be supporting from behind as they ascend the stairs ensuring that your assistant is also supporting from the side. Descending the stairs you should be in front of the patient with your assistant again beside them.
Functional Analysis of sit to stand – hip, knees and ankles.
· Phase 1 – Preparation phase – Model is sitting on chair with legs at right angle to trunk.
- Hips 90˚ flexion, knees 90˚flexion, ankle in neutral.
- Base of support is large, chair and legs with feet on floor.
- Centre of gravity is at the hips.
- Line of gravity is within your body – stable position.
- Forces, gravity is always present. Friction between and seat, and feet on floor.
· Phase 2 – Execution phase A – Begins as model initiates flexion of hips, bringing trunk forward and finishes when trunk flexion has finished and knee extension is initiated.
- Further flexion of hips as trunk moves forward, angle increases. Further flexion of knees, angle increases. Ankle moves into dorsiflexion, decreasing angle.
- Hip flexors – Sartorius, pectineus, rectus femoris, psoas major, iloiacus. Knee flexors – semitendinosis, semimembranosus, biceps femoris, gastrocnemius, gracilis, Sartorius, plantaris, popliteus. Ankle dorsiflexors – tibialis anterior, extensor digitorum longus, extensus hallucis longus, peroneus tertius.
- Body moving in sagittal plane in a frontal/coronal axis.
- Base of support remains large as bum still on seat at this point.
- Centre of gravity moves outside body as trunk moves forward.
- Line of gravity is now outside the body making it less stable.
- Forces, greater effect of gravity – assisting downward motion of trunk.
· Phase 3 – Execution phase B – begins as model initiates knee extension, hip extension bringing trunk forward. Finishes with the end of hip extension.
- Hip extension is initiated as trunk begins to straighten, angle decreases. Knee extension initiated and angle decreases. Ankles move back into neutral, angle decreases.
- Hip extensors – gluteus maximus, semitendinosis, semimembranosis, biceps femoris. Knee extensors – rectus femoris, vastus lateralis, vastus intermedius, vastus medialis, tensor fascia lata.
- Body moving in sagittal plane and frontal/coronal axis.
- Base of support decreases as bum is off seat.
- Centre of gravity still outside body.
- Line of gravity still outside body making body unstable.
- Forces, gravity resisting upward motion – reduced impact of friction with bum off seat.
· Phase 4 – End phase – movement has finished and model is stood up straight.
- Hips, knees and ankles in neutral. 180˚ between trunk and legs.
- Base of support smaller – only feet.
- Centre of gravity moves back within body.
- Line of gravity within body – anterior to body of second sacral vertebrae – body now stable.
- Forces, gravity and friction between feet and floor.
Examination Card 3.
Introduce yourself and your assistant to the patient, wash your hands properly before you begin.....
1. Explain what you are going to do with the patient and the benefits of using axillary crutches:
Help take the weight bearing strain/benefit away from the lower limbs and transfer it to the upper limbs – alleviate pain from joint, muscles and ligaments in right affected leg.
Increase body’s base area of support – body more stable and promotes overall balance.
Important to keep weight off leg to allow bones to heal.
2. Measuring crutches:
Explain what you are going to do and ask the patient to lie down on their back on the bed, keeping their shoes on.
There are 8different ways to measure the fit of crutches, though these are the most accurate:
5cm from axillary fold to the heel in supine.
Height minus 16inches.
Adjust handgrips so elbows are flexed to 15 degrees.
Ensure rubber ferules are fitted.
3. Inform patient of maintenance and safety issues:
Check ferrules aren’t worn down and if they are advise them where to go to change them, for example a Disabled Living Centre.
No splinters or cracks.
Check the measurements are suitable.
Keep a good posture – no weight bearing on affected right leg.
Axillary crutch should not press into axilla as this may damage the axillary artery and nerves. Instead it should be held in against the chest wall.
Support areas should be padded.
Check screws and clips aren’t broken.
Warn patient to be careful using crutches during adverse conditions.
4. Teaching the patient to use the axillary crutches:
Sitting to standing position:
· Demonstrate sitting on the edge of the bed, hold the crutches together in right hand (side of the affected leg) with the screws on the same side. Stand up on the left good leg and take the outside crutch and place it under your right arm. Remember the triangular base is very important!
· Tell the patient never to lean on the crutches inappropriately as this would damage the axilla. In a resting standing position the crutches should be out in front and to the side and the patient should not be leaning on them.
· So as the patient themselves attempts to move from a sitting to standing position you must ensure you are close to them and are stabilising them efficiently, make sure your assistant is doing this as well. Also remember to give some encouragement and support and at this point take a final check for height comfort and balance.
· Rest may be necessary at this point.
Walking:
· Position a chair an appropriate distance from the patient.
· Demonstrate using a 3point gait – used for non-weight bearing on one leg, hop too and hop through.
· Turning around or moving backwards – 1crutch forward, 1 crutch back and a little hop.
Practice a step then a gait cycle then progress forward and
again when patient is attempting this make sure to support them at all times.
· Sit down.
Ascending and descending the stairs:
· Always one stair at a time and helps to remember good leg to heaven bad leg to hell.
· Ask patient which side banister is on at home – have crutches opposite side.
(Assuming banister is on right hand side) Demonstrate.
Take crutches in left hand, one under arm normally and the other placed horizontally across the other crutch. Take hold of the banister with your right hand and hop up with your left leg, following with the crutch. Do not stand on right affected leg. Once you have reached the top of the stairs turn and move the crutches to your opposite side and take hold of the banister ready for descending.
· Descending the stairs stick your right affected leg out first and place the crutch on the stair below. Hop down on your good left leg keeping a firm grasp on the banister.
· As this patient then practices this you should be supporting from behind as they ascend the stairs ensuring that your assistant is also supporting from the side. Descending the stairs you should be in front of the patient with your assistant again beside them.
Functional Analysis of sit to stand – hip, knees and ankles.
· Phase 1 – Preparation phase – Model is sitting on chair with legs at right angle to trunk.
- Hips 90˚ flexion, knees 90˚flexion, ankle in neutral.
- Base of support is large, chair and legs with feet on floor.
- Centre of gravity is at the hips.
- Line of gravity is within your body – stable position.
- Forces, gravity is always present. Friction between and seat, and feet on floor.
· Phase 2 – Execution phase A – Begins as model initiates flexion of hips, bringing trunk forward and finishes when trunk flexion has finished and knee extension is initiated.
- Further flexion of hips as trunk moves forward, angle increases. Further flexion of knees, angle increases. Ankle moves into dorsiflexion, decreasing angle.
- Hip flexors – Sartorius, pectineus, rectus femoris, psoas major, iloiacus. Knee flexors – semitendinosis, semimembranosus, biceps femoris, gastrocnemius, gracilis, Sartorius, plantaris, popliteus. Ankle dorsiflexors – tibialis anterior, extensor digitorum longus, extensus hallucis longus, peroneus tertius.
- Body moving in sagittal plane in a frontal/coronal axis.
- Base of support remains large as bum still on seat at this point.
- Centre of gravity moves outside body as trunk moves forward.
- Line of gravity is now outside the body making it less stable.
- Forces, greater effect of gravity – assisting downward motion of trunk.
· Phase 3 – Execution phase B – begins as model initiates knee extension, hip extension bringing trunk forward. Finishes with the end of hip extension.
- Hip extension is initiated as trunk begins to straighten, angle decreases. Knee extension initiated and angle decreases. Ankles move back into neutral, angle decreases.
- Hip extensors – gluteus maximus, semitendinosis, semimembranosis, biceps femoris. Knee extensors – rectus femoris, vastus lateralis, vastus intermedius, vastus medialis, tensor fascia lata.
- Body moving in sagittal plane and frontal/coronal axis.
- Base of support decreases as bum is off seat.
- Centre of gravity still outside body.
- Line of gravity still outside body making body unstable.
- Forces, gravity resisting upward motion – reduced impact of friction with bum off seat.
· Phase 4 – End phase – movement has finished and model is stood up straight.
- Hips, knees and ankles in neutral. 180˚ between trunk and legs.
- Base of support smaller – only feet.
- Centre of gravity moves back within body.
- Line of gravity within body – anterior to body of second sacral vertebrae – body now stable.
- Forces, gravity and friction between feet and floor.
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