Overview
Instructor Ellen Ruble demonstrates safe acute-care gait training with a walker, guarding, bailout chair placement, altered weight-bearing cues, and vital sign monitoring for a patient named Nelson.
Preparation and Safety
- Lock wheelchair and equipment; organize lines and devices before mobilizing.
- Maintain slack and control of IV line without compromising guarding position.
- Identify stronger (green) and weaker (yellow) limbs; stand on the involved (weaker) side when walking.
- Use gait belt, non-slip socks/slippers; confirm wheelchair is locked before stands.
Walker Gait Sequence
- Standard sequence: walker, involved leg, strong leg; repeat until possible step-over-step.
- Cue pacing: small steps; avoid two people moving simultaneously.
- Clinician advances back leg only when patient is most stable after each step.
Bailout Chair Strategy
- Anticipate fatigue or pain; pre-position a “bailout chair” along the route.
- Place chair on the stronger limb side to allow pivot over the strong leg and sit.
- Chair on weaker side may require backward steps; acceptable but riskier when fatigued.
- Consider out-and-back needs; patients may only need the chair on return.
Turning and Pivoting
- Turn over the stronger leg as the inside pivot whenever possible.
- Manage IV pole clearance during turns; do not let lines force lateral guarding.
- Control speed during approach to chair; align with seat before sit-down.
Guarding Position and Technique
- Maintain posterior-lateral guarding “slice of pie” behind patient.
- Avoid being too lateral; patient must be able to fall into clinician support.
- Do not compromise guarding for line management; bring lines to your side with slack.
- Increase vigilance during novel tasks: first steps, direction changes, turning to sit.
Sit-to-Stand and Stand-to-Sit
- Assess natural strategy; cue only as needed; assist to fill gaps.
- For weakness: cue scooting forward to chair edge; lean forward; push from armrests.
- To limit hip flexion: scoot forward, kick out strong leg, power up through strong side.
- With weight-bearing limits: keep restricted leg lifted during stand; set onto floor only per status.
Altered Weight-Bearing Status
- Weight bearing as tolerated (WBAT): load as tolerated; use arms to offload as needed.
- Toe-touch weight bearing (TTWB): toes skim surface; no pressure through foot.
- Foot-flat weight bearing (FFWB): entire foot may skim; no pressure; reduces hip co-contraction.
- Use analogies to teach “no pressure”: paper slides freely; saltines not crushed; putty not flattened.
- Verification method: clinician’s foot under patient’s restricted foot briefly to gauge pressure.
Teaching Cues for Altered Weight Bearing
- Sequence for TTWB/FFWB: walker, skim, push with arms, step through with weight-bearing leg.
- Reinforce “just the toes/foot skimming”; frequent reminders during turns and sit-to-stand.
- Recheck adherence during new phases: backward steps, turning, and initial sitting.
Wheelchair and Footrest Management
- Remove foot pedal on restricted side to prevent inadvertent weight through foot.
- Leave the other foot on leg rest if needed; use equipment to assist early on.
- Restore leg rests and equipment at session end; ensure call bell within reach.
Vital Sign Monitoring
- Capture resting sitting vitals on entry; consider vitals at stand if orthostasis risk.
- Recheck vitals when patient stops unexpectedly; identify cause (pain, BP, HR).
- Take end-of-activity vitals; consider recovery vitals after rest.
- Use a leg-taped “cheat sheet” to record values without breaking guarding.
- Ask symptom-focused questions: reason for stopping, pain levels, relief with rest or arm loading.
Key Terms & Definitions
- Bailout chair: pre-positioned chair for timely rest during gait training.
- Posterior-lateral guarding: clinician stands behind and slightly to the side of patient for support.
- Toe-touch weight bearing (TTWB): toes may contact floor lightly for balance; no weight through limb.
- Foot-flat weight bearing (FFWB): whole foot may contact floor lightly; no weight through limb.
- Weight bearing as tolerated (WBAT): weight through limb to tolerance; use arms to offload.
Structured Protocol Summary
| Phase | Clinician Role | Patient Cues | Key Safety Points |
|---|
| Preparation | Lock, organize lines, don belt | Report pain/fatigue | Do not compromise guarding for lines |
| Sit to stand | Guard posterior-lateral; assist as needed | Scoot forward; push from chair | Keep restricted leg lifted if limited WB |
| Gait start | Test WB (foot-under-foot briefly) | Walker, involved, strong | Small steps; steady pace |
| Mid-gait | Advance back foot when patient stable | Push through arms | Avoid two people moving simultaneously |
| Turning | Manage IV clearance; stay posterior-lateral | Turn over strong leg | Recheck WB adherence |
| Approach chair | Align with seat; slow | Reach back to chair | No weight through restricted leg |
| Stand to sit | Guard; control descent | Lift restricted leg; reach back | Confirm chair contact before sit |
| Post-activity | Restore equipment; record vitals | Report symptoms | Call bell within reach |
Action Items / Next Steps
- Pre-plan route and bailout chair location relative to stronger limb.
- Review and teach patient-specific weight-bearing status with clear analogies.
- Maintain posterior-lateral guarding; manage lines without drifting lateral.
- Monitor vitals at rest, during activity changes, at stop, end, and recovery.
- Document measures on a wearable note and debrief causes for stops with patient.