Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.3 Superficial dissection, female pectoral region

  • On the specimen’s right side, the skin is removed; on the left side, the breast is sagittally sectioned.
  • The breast extends from the 2nd to the 6th ribs. The axillary process (tail) of the breast consists of glandular tissue projecting toward the axilla.
  • The region of loose connective tissue between the pectoral fascia and the deep surface of the breast, the retromammary bursa, permits the breast to move on the deep fascia.
  • Interference with the lymphatic drainage by cancer may cause lymphedema (edema, excess fluid in the subcutaneous tissue), which in turn may result in deviation of the nipple and a leathery, thickened appearance of the breast skin. Prominent (puffy) skin between dimpled pores may develop, which gives the skin an orange-peel appearance (peau d’orange sign). Larger dimples may form if pulled by cancerous invasion of the suspensory ligaments of the breast.

Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.1 Surface anatomy of male pectoral region

  • The subject is adducting the shoulders against resistance to demonstrate the pectoralis major muscle.
  • The pectoralis major muscle has two parts, the sternocostal and clavicular heads.
  • The anterior axillary fold is formed by the inferior border of the sternocostal head of the pectoralis major muscle.
  • The axillary fossa (“armpit”) is a surface feature overlying a fat-filled space, the axilla.


204 RLE Procedures



Crutches are artificial supports and assists patients who need aid in walking because of disease, injury, or a birth defect.


> To assist client who cannot bear  any weight on one leg.

> To assist client who have full weight bearing on both legs.

> Prevent injury to client who has difficulty in ambulation.


> Assess client’s physical limitations to determine safety and comfort.

> Take time to show patients how to walk with crutches for them to learn

> Maintain proper body mechanics.


> Gait belt                                         > Tape measure

> Crutches                                        > Sturdy footwear, properly fitted

Crutch Walking

1. Inform the client you will be teaching crutch ambulation.

Rationale:  Reduces anxiety. Helps increase comprehension and cooperation, promotes client independence.

2. Assess the client for strength, mobility, ROM, visual acuity, perceptual difficulties and balance. Note: nurse and therapist often collaborate on this assessment.

Rationale: Helps determine the clients capabilities and amount of assistance required.

3. Adjust crutches to fit the client. With the client supine, measure from the heel to the axilla. With the client standing, set the crutch position at a 4-5 inches lateral to the client and 4-6 inches in front of the client. The crutch pad should fit 1.5 – inches below the axilla (3 finger width). The hand grip should be adjusted to allow for  the client to have elbows bent at 30 degree flexion.

Rationale: Provide broad base of support for the client. Space between the crutch pad and axilla prevents pressure on radial nerves. The elbow flexion allows for space between the crutch pad and axilla.

4. Lower the height of the bed.

Rationale: Allows the client to sit with feet on the floor for stability.

5. Have the client dangle legs. Assess for vertigo.

Rationale: Allows for stabilization of blood pressure, thus preventing orthostatic hypotension.

6. Instruct the client to position crutches lateral to and forward to feet. Demonstrate correct positioning.

Rationale: Increases client comprehension and cooperation.

7. Apply the gait belt around the client’s waist if needed.

Rationale: Provides support, promotes client safety.

8. Assist the client to a standing position with crutches.

Rationale: Standing for a few minutes will assist in preventing orthostatic hypotension.

Four-Point Gait

9. a. Position crutches to the side and in front of each foot.

b. Move the right crutch forward 4 to 6 inches.

c. Move the left foot forward, even with the left crutch.

d. Move the left crutch forward 4 to 6 inches.

e. Move the right foot forward, even with the left crutch.

f. Repeat the four-point gait.

Rationale: The four point gait provides greater stability. Weight bearing is on three points at all times. The client must be able to bear weight with both legs.

Three-Point Gait

10. a. Advance both crutches and the weaker leg forward together.

b. Move the stronger leg forward, even with crutches.

c. Repeat three-point gait.

Rationale: The three point gait provides a strong base of support. This gait can be used if the client has a weak or non-weight-bearing leg.

Two-Point Gait

11. a. Move left crutch and right leg forward 4 – 6 inches.

b. Move right crutch and left leg forward 4 – 6 inches.

c. Repeat two-point gait.

Rationale: The two pint gait provides a strong base of support. The client must be able to bear on both legs. This gait is faster than four-point gait.

Walking UP stairs

12.a.  Instruct the client to position the crutches as if walking.

b. Place the strong leg on the first step.

c. Pull weak leg up and move the crutches up to the first step.

d. Repeat for all steps

Rationale: Prevents weight bearing on the weaker leg.

Walking DOWN stairs

13. a. Position the crutches as if walking.

b. Place weight on the strong leg.

c. Move crutches down the next lower step.

d. Place partial weight on hands and crutches.

e. Move the weak leg down to the step with crutches.

f. Put the total weight on arms and crutches.

g. Move strong leg same step as weak leg and crutches.

h. Repeat for all steps.

Rationale: Prevents weight bearing on weaker leg.

14. Set realistic goals.

Rationale: Crutch walking takes up to 10 times the energy required for unassisted ambulation.

15. Consult with a physical therapist.

Rationale: The physical therapist is the expert on the health care team for crutch-walking techniques.

16. Wash hands.

Rationale: Reduces the transmission of microorganisms.


Kozier, Barbare, Fundamentals of Nursing. Philippines: Pearson Education South Asia PTE LTD. pp. 1102-1104