The nurse observes clients ambulating on the rehabilitation unit. Which is the most important action for the nurse to take?

Question

1. Adjust height of crutches 5 inches below the axilla for client with crutches.
2. Prepare an incident report about client who advances walker 2 inches each time.
3. Instruct client who should not bear weight on left leg to use crutches as directed.
4. Follow client who ambulates by holding onto hallway handrails with wheelchair.

Answer 1

3
3. Instructing the client to use crutches as directed is the most important action for the nurse because it decreases the client's risk of injury and falling, and it facilitates client activity and mobilization. The crutches provide a stable method for ambulation to decrease the risk of injury and falling while allowing the client to be active. Phys-ical activity is vital to maintaining muscle bulk, endurance, and balance and to pre-vent complications of bed rest, including pressure ulcers, pneumonia, depression, and constipation.
1. The nurse should adjust the crutch pads for this client because the pads should be to 2 inches (4-5 cm) below the axilla to provide stability and to prevent pressure on the radial nerve running under the axilla.
2. Incident reports are reserved for untoward events that need to be reported so the system can benefit. This client needs a gentle reminder to extend the walker to 4 to 6 inches with each stride to more closely match the distance of one step.
4. The client who holds the handrails in the hallway may be strong and steady enough to need the wheelchair following behind. At a minimum, this client complies with safe behavior for ambulation and demonstrates the ability to follow directions.