Lecture 4 – Assistive Devices and Psychiatric Care Essentials

Importance: Proper instruction on the use of crutches, canes, and walkers is crucial for patients with impaired mobility to maintain safe ambulation and reduce the risk of injury.
Who Needs Them: Individuals with unstable gaits, muscle weakness, or those needing to reduce the load on weight-bearing joints often benefit from these assistive devices.

Goal: Proper crutch measurement is essential to prevent nerve damage during walking.
Steps:
1. Hold the crutch vertically, with the tip resting on the ground.
2. Ensure there is a space of 2-3 finger widths between the crutch pad and the patient’s underarm (anterior axillary fold).
3. The crutch tip should be placed approximately 6 inches to the side and 6 inches in front of the foot.
Important Tip: Never rely solely on foot or underarm landmarks for measuring!

The patient’s elbows should be flexed at a 30-degree angle when holding the crutches.
The handgrips should align with the patient’s wrist level.

2-Point Gait

How to Perform: Move one crutch and the opposite foot together, then repeat with the other crutch and foot.
- Example: Right crutch + left foot → Left crutch + right foot.
Indications: Used for patients with mild bilateral leg weakness.

3-Point Gait

How to Perform: Move both crutches and the affected (injured) leg together, followed by the unaffected leg.
- Example: Crutches + injured leg → Good leg (repeat).
Indications: For patients who cannot bear weight on one leg.

4-Point Gait

How to Perform: Move each limb and crutch separately.
- Example: Right crutch → Left foot → Left crutch → Right foot.
Indications: Suitable for patients with severe bilateral leg weakness, providing maximum stability.

Swing-Through Gait

How to Perform: Move both crutches forward, then swing the unaffected leg past the crutch tips.
Indications: Commonly used by amputees or patients who cannot bear weight on one leg. Allows for faster movement when non-weight-bearing.

Mnemonic: “Up with the GOOD, down with the BAD.”
- Going Up Stairs: Step up with the unaffected (good) leg first, then bring up the crutches and the affected (bad) leg.
- Going Down Stairs: Lead with the affected (bad) leg and crutches, followed by the unaffected (good) leg.
- Always: Both crutches move with the bad leg.

NCLEX Tips:

“Even-Point” Gait for Bilateral Weakness:
- Use an even-numbered gait (2-point or 4-point) when both legs are affected to some degree.
- 2-Point Gait: Best for mild bilateral weakness.
- 4-Point Gait: Suitable for severe bilateral weakness, offering greater stability.
“Odd-Point” Gait for Unilateral Weakness:
- Use the 3-Point Gait when only one leg is affected (injured or weak).
- The patient moves both crutches and the affected leg together, followed by the unaffected leg.
Swing-Through Gait for Non-Weight Bearing or Amputation:
- Used when the patient cannot bear weight on one leg (e.g., amputation or severe injury).
- The patient swings the unaffected leg past the crutches after moving them forward.

Holding the Cane: Always hold the cane on the unaffected (good) side.
How to Walk: Advance the cane at the same time as the opposite leg to create a wide base of support.
Handgrip: The handgrip should align with the level of the patient’s wrist.

Positioning: The walker should always be positioned in front of the patient.
How to Use: The patient should “pick it up, set it down, then walk to it.”
Standing Up: Instruct the patient to hold onto the chair while standing, then grab the walker for support.
Carrying Belongings: Avoid tying belongings to the front of the walker, as this may cause it to tip. Instead, attach items to the sides for balance.

First Question: Determine if the patient is psychotic or non-psychotic.
- Non-Psychotic: The patient has insight and is reality-based.
  - Approach: Use therapeutic communication techniques, similar to med/surg patients.
  - Example responses: “That must be very overwhelming for you,” or “How are you feeling?”
  - Techniques: Reflection, clarification, amplification, and restatement.
- Psychotic: The patient lacks insight and is not based in reality.
  - They often believe others have the problem, not them.
  - Symptoms:
    - Delusions: False, fixed beliefs with no sensory component.
      - Types: Paranoid (“People are out to get me”), Grandiose (“I’m the smartest person in the world”), Somatic (“There are worms in my arm”).
    - Hallucinations: False sensory experiences (e.g., hearing, seeing, or feeling things that aren’t there).
      - Types: Auditory (hearing voices), Visual (seeing things), Tactile (feeling), Gustatory (taste), Olfactory (smell).
    - Illusions: Misinterpretations of real sensory input (e.g., thinking nurses’ voices are demon voices).

Identify the Type of Psychosis:
- Functional Psychosis: The patient can still function in everyday life (e.g., schizophrenia, schizoaffective disorder, major depression with psychosis, acute mania).
  - These patients can be taught reality since they have no brain damage.
  - Nursing Approach:
    1. Acknowledge feelings.
    2. Present reality.
    3. Set limits.
    4. Enforce limits.
- Psychosis of Dementia: Caused by actual brain damage (e.g., Alzheimer’s, stroke, organic brain syndrome).
  - These patients cannot learn reality, so avoid trying to reorient them.
  - Nursing Approach:
    1. Acknowledge feelings.
    2. Redirect them to something they can do.
    - Note: Don’t confuse reality orientation (person, place, time) with presenting reality.
- Psychosis of Delirium: Temporary and sudden loss of reality, often due to an underlying condition (e.g., UTI, drug reaction, thyroid imbalance).
  - Nursing Approach:
    1. Acknowledge feelings.
    2. Reassure the patient about their safety and the temporary nature of their condition.

Flight of Ideas: Rapid, disconnected flow of thoughts.
Word Salad: A jumble of incoherent words.
Neologisms: Creation of new, nonsensical words.
Narrow Self-Concept: The patient refuses to change clothes or leave their room.
- For functional psychosis, don’t force the patient to do something they don’t want to do.
Idea of Reference: The patient believes everyone is talking about them.

Memory Loss: Inability to learn or retain new information.
Nursing Approach:
1. Acknowledge their feelings.
2. Reassure and redirect their focus.

Is the patient psychotic or non-psychotic?
Non-psychotic patients: Use therapeutic communication as with med/surg patients.
Psychotic patients: Determine the type of psychosis.
- Functional:
  1. Acknowledge feelings.
  2. Present reality.
  3. Set limits.
  4. Enforce limits.
- Dementia:
  1. Acknowledge feelings.
  2. Redirect to something they can do.
- Delirium:
  1. Acknowledge feelings.
  2. Reassure them about safety and the temporary nature of their condition.