← Chapter 13
Medical-Surgical Nursing II · Chapter 13

Before the First Step: Transfers, Fitting and Gait

Most mobility disasters are failures of the thirty seconds before the patient stood up. Make six real decisions for one hemiparetic man and then run the transfer to see what your setup bought him — then fit a pair of crutches with the sliders until the brachial plexus is safe, and give five patients the gait pattern that actually belongs to them. Never lift a patient by the axillae.
Mr Sokolov, 68 · day 3 after a right MCA stroke Left hemiparesis: left arm flaccid, left leg 3 out of 5. Follows two-step directions reliably. Weighs about 205 pounds. He has been in bed for three days and takes lisinopril and furosemide. He is going bed to wheelchair for breakfast. Order: weight bearing as toleratedAlert, cooperativeNo spinal precaution
1 · Physiology — before you sit him up
2 · Where does the wheelchair go?
3 · Bed height and feet
4 · The gait belt
5 · Where do your hands go?
6 · People and equipment
Adjust the crutch on this 5′8″ patient
Two to three finger-widths is about 1.5 to 2 inches. Zero means the pad is jammed into the armpit.
Set the handgrip at the level of the wrist crease with the arms relaxed; that produces 20 to 30 degrees of elbow flexion. The same wrist-crease rule fits a cane and a walker — and for a cane the handgrip sits at the greater trochanter, which is roughly the same height.
Weight goes through the hands, never the armpit. Teach patients to check the tips for wear and to keep both hands free by using a backpack.
Pick the patient
Which device or gait pattern?
Now the stairs — four steps up, then four down

What happened

Six decisions, then run itSet every choice on the left and press Attempt the transfer. Each decision is graded on its own, because in a real transfer the one you get wrong is the one that hurts somebody — and it is usually not the one you were worrying about.

If he starts to go down

Do not fight the fallWiden your stance, pull him toward you, protect his head, and ease him down your leg to the floor. Then assess before you move him: responsiveness, airway, breathing and circulation, then head strike, neck or back pain, obvious deformity, and a leg that is shortened and externally rotated, which suggests hip fracture. Take vital signs and a neurological check on the floor. Only after you have ruled out spinal or fracture injury do you move him, with enough people and usually with a lift. Then notify the provider and the family, do neurological checks per protocol — more urgently if he is anticoagulated, because a delayed intracranial bleed is the classic killer — document objectively, and file the incident report separately from the chart.

The fit, drawn

A standing patient beside an axillary crutch, showing the gap between the axilla and the crutch pad, the handgrip height and the crutch tip position, all changing as the sliders move AXILLA gap elbow tip offset

Gait and stairs

Match the pattern to the legsPick a patient, then a device or gait. The question that decides it is always the same: how many legs can take weight, and how much?
GaitWho it is forSequence
CaneMild unilateral weakness, balanceHeld opposite the weak leg. Cane and weak leg advance together, then the strong leg
WalkerBilateral weakness, poor balance, partial weight bearingAll four points down, advance one step length, then weak leg, then strong leg. Never on stairs; never pull on it to stand
Four-pointWeight bearing on both legs; weak or unsteady. Slowest and most stableRight crutch, left foot, left crutch, right foot — three points on the ground at all times
Two-pointPartial weight bearing both legs; faster, mimics normal walkingRight crutch with left foot together, then left crutch with right foot together
Three-pointOne leg non-weight-bearing or partial; needs strong armsBoth crutches and the affected leg advance together, then the strong leg swings through
Swing-to / throughBilateral lower-limb paralysis with bracesBoth crutches forward, then both legs swing to the crutches, or past them