PERFORMANCE CHECKLIST

CRUTCHWALKING UP AND DOWN THE STAIRS WITH OR WITHOUR RAILING

NOT
PROCEDURE DONE SCORE
DONE
1. Identify patient capabilities, activity ordered, previous level of
3
activity, assistive devices, take vital signs.
2. Plan for pain relief, set goal, support needed, technique, wash 3
hands.
3. Identify patient, explain procedure, obtain robe and shoes. 3

4. Have patient take crutch stance, with crutch tips 3

approximately 2 in to side and 6 inches ahead.
5. Hold both crutches under one arm as if to walk. 3

6. Place other hand on railing in front of the body. 3

7. Raise unaffected leg to first step, and pull up with hand rail. 3

8. Pull up affected leg, and advance crutches to next step. 3

9. Again, raise unaffected leg, and pull up affected leg, 3

advancing crutches.
10. Position crutches under arms as if walking 3

11. Put weight on hands. 3

12. Raise unaffected leg to first step on which patient is standing. 3

13. Advance crutches to step on which patience is standing. 3

14. Again, raise unaffected leg to next higher step. 3

15. Downstairs: position crutches under arm as if walking. 3

16. Place weight on unaffected leg. 3

17. Place crutches on next lower step. 2

18. Put partial weight on hands and crutches. 3

19. Move affected leg to lower step. 3

20. Put total weight on crutches and affected leg. 3

21. Move unaffected leg to the same step as crutches and 2

affected leg.
22. If railing is present, hold crutches with one arm, and use other 3
to grasp railing.
TOTAL 50
Name: ____________________ Score: _______________
Section: ___________________ Date: _______________
Instructor:__________________