Transfers, Ambulation and Restraints

M. Freeman-McGuire, R.N., MSN

Revised by: Jean D. Lansang, RN, MSN, HHRN

Lesson Objectives (Transfers), By the end of this lesson the student vocational nurse will be able to:

Describe the procedure for transferring the client: moving up in bed, bed to chair, bed to stretcher, chair to bed,

Explain at least three safety factors practiced while performing a transfer

List common hazards encountered during a transfer

Explain the importance of knowing the diagnoses and capabilities of the client

Lesson Objectives (Ambulation), By the end of this lesson the student vocational nurse will be able to:

List common hazards of ambulation and of using assistive devicesExplain the importance of knowing the diagnoses and capabilities of the clientDescribe methods to support the client during ambulationDiscuss various gaits used for walking with a cane, walker or crutchesCreate sample charting after ambulating a client, including the important data

Lesson Objectives (Restraints), By the end of this lesson the student vocational nurse will be able to:

Discuss rationale for using restraintsDefine the terms immobilize, legal rights, limb holder, chemical restraintsExplain the patient’s Bill of Rights regarding consent of the client, family or guardian and written medical orders for use of restraintsDiscuss the procedure for applying various physical restraints

Transfers, Ambulation, Restraints

Safety !!!!

Transfers, Ambulation, Restraints(Safety Interventions):

Assess for Orthostatic HypotensionDangleClient with special needs: (eg.) blind Lock wheel chairs, stretchers and bedsCheck floors for safety (wet or clutter)Tub and shower surfacesNon-skid slippers

Common Hazards Encountered:

Unable to assist or follow directionsClient fear Client fatigueClient weakProblem with assistive devicesInexperience of nurseSize of client Size of nurse

Supporting The Client:

Physically

Emotionally

Psychologically

Tips:

Moving from bed to chair:

Chair on strong side

Pivoting (client’s hand on arm of chair)

Ambulating A Client:

Support weak side

Match client’s gate

Basic Nursing Care:

ComfortSafety Change PositionChair CushionsROM ExercisesOrientation of ClientTherapeutic TouchPersonal Items near Client Client Daily HabitsADL’S

Documentation:

TimeDistanceUse of Assistive DevicesClient’s FeelingsWeaknessPoor Balance Dizziness PostureOther ProblemsNumber of People to Assist

Procedure for Transfers:

Check the doctor’s orders

Dangle (usually necessary-after BR)

Assist client to a sitting position, legs at side of bed, not touching the floor

Allow client to dangle for several minutes

May be necessary to return client to bed

Orthostatic Hypotension (Signs and Symptoms):

Dizziness

Weakness

Faint

Fatigue

Lightheadedness

Orthostatic Blood Pressures:

Lying

Sitting

Standing

Orthostatic Hypotension:

Systolic Blood Pressure

drop < 25 mm Hg

Diastolic Blood Pressure

drop < 10 mm Hg

Equipment (Transfers):

Wheel Chair with Replacement Arm

Geri Chair

Transfer Belt

Sliding Board

Mechanical Lifts (Hoyer)

Bed Scale

Pull Sheet

Moving Client Up In Bed:

Position on back

Ask client to bend knees and push with feet on the count of three

Nurse assist client to the top of the bed (usually two person assist)

Use good body mechanics

Transfer (Two Person):

Very overweight client

Confused client

Uncooperative client

Transfer To Chair from Bed:

Dangle Position (may be first step)

Stand

Pivoting (client’s arm on the arm of chair)

Place chair on the client’s strong side

Ambulation (common hazards with assistive devises):

Broken

Client not know how to use

Pathways are not clear

Equipment (ambulation)

Same with few exceptions

Gait Belts

Crutch

Walker

Ambulation: Prevent Falls !!!

Client Posture (head up, eyes open, looking forward)

Non-skid slippers

Walk at client’s side

Match client’s gate

Ambulation (Procedure):

Walk on client’s weak side/match gate Stabilization (allow client to hold your elbow or hand)Minimal Support (hold client’s arm with your hand)Moderate Support (encircle client’s waist with your hand)Maximum Support (two persons, one on each side of client)

Preventing Falls:

Floors Clean and Dry

Floor Free from Clutter

Anticipate Client Needs (toileting etc.)

Know Client’ Diagnosis (eg.) CVA Blind Client’s, Alzheimer's

Keep Belongings and Call Light in Reach, Bed in Low Position and Locked, Side Rails (!!!)

Breaking Client’s Fall:

Stand with your feet apart slightly behind the clientGrasp the client firmly at waist/axillaYour near leg against the client’s legSlowly lower the client to the floorExamine for injuryCall for helpDocument as per agency policyDoctor notified

Restraints:Purpose

Applied for safety

Prevent injury

Prevent dislodgement of tubes

Psychiatric Setting

RestraintsLegal Consideration:

Must be ordered by a physician in writing

Emergency (can be applied by a nurse, orders within 24-48 hours)

Documentation (all that was done to remedy situation before applying)

Restraints:Must !!!

Must help client or be needed for medical therapyMust be ordered by a physicianMust not be used as a means of pushing or disciplining the clientMust be applied snugly/not tightlyMust be removed/Reposition Q2 Must notify doctor when no longer neededMust intervene to promote safetyMust be documented

RestraintsTypes:

Safety Belts

Wrist Extremity Immobilizer

Vest (Posey)

Hand Mittens

Leather

Chemical

RestraintsBasic Principals:

Know agency policyCheck client Q 15 minutesRemove and reposition Q 2 hoursAssist with ROMCall light in reachComfort measure (eg) water, food, rest roomFamilyDiversional ActivitiesPsycho/Social (tough, isolation, confusion)Client’s daily habits (eg) news paperNeuro/Vascular AssessmentRapid Release of Restraints

RestraintsLong Term Use (problems):

Muscle weakness, atrophyLoss of bone mass, joint contracturesConstipation/incontinencePressure UlcersCognitive ImpairmentDecrease confidence in ambulationWithdrawn, detachedDepressionLoss of independence

ConclusionAsk Yourself:

Is my client safe from harm?Does my client need anything?Is the bed locked?Is the bed in the low position?Is the call light in reach?Does my client have anything to do?How is my client’s neuro/vascular assessment?

Physical Restraints

Restrict or control movement or behavior. They may be attached to a person's body or create physical barriers.

wrist vest side rails wheelchair safety hand mittens

Chemical Restraints - are any medication used for the purpose of restraining patients involuntarily to prevent them from harming themselves or staff.

Advantages of chemical restraints

Control violent behavior and patient agitation

May reduce need for physical restraints

Allow examination and performance of radiographic imaging

Disadvantages of chemical restraints

•May result in complications, such as respiratory depression and loss of gag reflex

•Occasional paradoxical reaction results in increased agitation

•Limit mental status assessment and neurologic examination during sedation

Environmental restraints

change or modify a person's surroundings to restrict or control movement. For example, a locked door.

Title XXII and Legal Rights of the Elderly

Policies and procedures which contain competency standards for staff performance in the delivery of patient care shall be established, implemented, and updated as needed for each nursing unit, including standards for the application of restraints. Standards shall include the elements of competency validation for patient care personnel other that registered nurses as set forth in Section 70016

Rights of the Elderly