Safety; Basic Body Mechanics; Moving & Positioning Nursing 125

Patient Safety: “ Technically the biggest ‘safety system’ in healthcare is the minds and hearts of the workers who keep intercepting the flaws in the system and prevent patients from being hurt. They are the safety net, not the cause of injury”. Don Berwick

“ Technically the biggest ‘safety system’ in healthcare is the minds and hearts of the workers who keep intercepting the flaws in the system and prevent patients from being hurt. They are the safety net, not the cause of injury”.

Don Berwick

Patient Safety #1 A client’s health and wellness depend upon safety. Safety is the number 1 priority in all aspects of care. Nurses need to be aware of safety. The hospital setting is complex, potentially dangerous & unfamiliar to clients.

A client’s health and wellness depend upon safety. Safety is the number 1 priority in all aspects of care.

Nurses need to be aware of safety. The hospital setting is complex, potentially dangerous & unfamiliar to clients.

Ensuring Client safety: Reduces length of stay & cost of treatment Reduces frequency of treatment Reduces potential for law suits Reduces the number of work-related injuries to personnel

Reduces length of stay & cost of treatment

Reduces frequency of treatment

Reduces potential for law suits

Reduces the number of work-related injuries to personnel

Institute of Medicine Report, 1999 Estimated 48,000-98,000 deaths per year from medical errors. Adverse events ranked as the 8 th leading cause of death, ahead of MVA’s, breast cancer and AIDS Extrapolating from the U.S. data, adverse events would account for 4,000-10,000 deaths per year in Canada.

Estimated 48,000-98,000 deaths per year from medical errors.

Adverse events ranked as the 8 th leading cause of death, ahead of MVA’s, breast cancer and AIDS

Extrapolating from the U.S. data, adverse events would account for 4,000-10,000 deaths per year in Canada.

Impetus for action: Threefold 1. Health system has a moral imperative to ensure the safety of patients Adverse events have a tremendous cost to the system in extended hospital stays & additional medical procedures Adverse events expose health organizations to legal liability

1. Health system has a moral imperative to ensure the safety of patients

Adverse events have a tremendous cost to the system in extended hospital stays & additional medical procedures

Adverse events expose health organizations to legal liability

A safe environment is one in which basic needs are met, physical hazards are reduced or eliminated, transmission of organisms is reduced and sanitary measures are carried out.

Falls Fall risk, especially in the elderly, is growing. In hospitalized patients, 4-12 falls occur per 1,000 bed days, ranking them among the 10 most common claims presented to insurance agencies Nursing Management, September 2002 30% of people 65 yrs and older (in the community) fall at least once each year.

Fall risk, especially in the elderly, is growing. In hospitalized patients, 4-12 falls occur per 1,000 bed days, ranking them among the 10 most common claims presented to insurance agencies

Nursing Management, September 2002

30% of people 65 yrs and older (in the community) fall at least once each year.

Focus Assessment: To ensure patient safety – the nurse should conduct a focus assessment during every nurse-patient encounter which includes: A visual scan of the environment for potential hazards A quick appraisal of patient related factors

To ensure patient safety – the nurse should conduct a focus assessment during every nurse-patient encounter which includes:

A visual scan of the environment for potential hazards

A quick appraisal of patient related factors

Strategies to help reduce falls: Physical environment Appropriate furniture and lighting Call bell easily accessible/personal items within reach Traffic areas free from obstruction Secure/remove loose carpets or runners Eliminate clutter Grab bars in appropriate areas in washroom Handrails in the halls Keep bed in a low position – lock bed/wheelchairs/stretcher Identify clients at risk for falls. If a client experienced falls at home, they will likely continue to be at risk for falls in the hospital setting. Place them close to nsg station.

Appropriate furniture and lighting

Call bell easily accessible/personal items within reach

Traffic areas free from obstruction

Secure/remove loose carpets or runners

Eliminate clutter

Grab bars in appropriate areas in washroom

Handrails in the halls

Keep bed in a low position – lock bed/wheelchairs/stretcher

Identify clients at risk for falls.

If a client experienced falls at home, they will likely continue to be at risk for falls in the hospital setting. Place them close to nsg station.

Strategies to help reduce falls: (Communication/Assessment) Orient client to physical surroundings Explain use of call bell Assess client’s risk for falling Alert all personnel to the client’s risk for falling Instruct client and family to seek assistance when getting up Maintain client’s toileting schedule Observe/assess client frequently Encourage family participation in client’s care

Orient client to physical surroundings

Explain use of call bell

Assess client’s risk for falling

Alert all personnel to the client’s risk for falling

Instruct client and family to seek assistance when getting up

Maintain client’s toileting schedule

Observe/assess client frequently

Encourage family participation in client’s care

Body Mechanics The coordinated efforts of the musculoskeletal & nervous system to maintain balance, posture & body alignment during lifting, bending, moving & performing ADL’s. Knowledge & practice of proper body mechanics protect the client and nurse from injury to their musculoskeletal systems. Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, & contributes to balance.

The coordinated efforts of the musculoskeletal & nervous system to maintain balance, posture & body alignment during lifting, bending, moving & performing ADL’s.

Knowledge & practice of proper body mechanics protect the client and nurse from injury to their musculoskeletal systems.

Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, & contributes to balance.

Body Mechanics (cont.) Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support & a vertical line can be drawn from the center of gravity through the base of support. When lifting an object, come close to the object, enlarge the base of support & lower the center of gravity.

Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support & a vertical line can be drawn from the center of gravity through the base of support.

When lifting an object, come close to the object, enlarge the base of support & lower the center of gravity.

Body Mechanics (cont.) Proper body mechanics facilitates movement without muscle strain & excessive use of muscle energy. Improper body mechanics can lead to injury for both the nurse & the patient, especially back injury when lifting.

Proper body mechanics facilitates movement without muscle strain & excessive use of muscle energy.

Improper body mechanics can lead to injury for both the nurse & the patient, especially back injury when lifting.

“ In 1990, Canadian hospitals reported 30,487 time loss injuries. Fifty-three percent were sustained by nurses. Almost half (of the injuries) were back injuries. Back injury is now recognized as one of the major reasons for ill-health retirement from nursing. Not only is it the most frequent injury sustained by nurses, it is the most debilitating”

Action Rationale A broad base of support increases stability. The force is minimized. 10 lbs at waist height close to the body is equal to 100 lbs at arms’ length. Flex knees; keep feet wide apart. Position self close to client (or object being lifted). Reduces risk of injury to lumbar vertebrae & muscle groups. Twisting increases risk of injury. Keep back, neck, pelvis and feet aligned. Avoid twisting. This promotes the client’s abilities & strength while minimizing workload. Encourage client to assist as much as possible. Two workers lifting together divide the workload by 50%. When planning to move a client, arrange for adequate help. Use mechanical aids if help is unavailable.

Action Rationale Simultaneous lifting minimizes the load by any one lifter. Person with the heaviest load coordinates efforts of team involved by counting to three. Preparing muscles for the load minimizes strain. Set (tighten) abdominal & gluteal muscles in preparation for move. Sliding requires less effort than lifting. Pull sheet minimizes shearing forces, which can damage client’s skin. Slide client toward yourself using a pull sheet. The leg muscles are stronger, larger muscles capable of greater work without injury. Use arms and legs (not back)

Moving & Positioning Mobility – persons ability to move about freely. Immobility – person unable to move about freely, all body systems at risk for impairment. Frequent movement improves muscle tone, respiration, circulation & digestion. Proper positioning at rest also prevents strain on muscles, prevents pressure sores (decubitus ulcers within 24 hours) & joint contractures (abnormal condition of a joint, characterized by flexion & fixation & caused by atrophy & shortening of muscle fibers or by loss of normal elasticity of the skin).

Mobility – persons ability to move about freely.

Immobility – person unable to move about freely, all body systems at risk for impairment.

Frequent movement improves muscle tone, respiration, circulation & digestion.

Proper positioning at rest also prevents strain on muscles, prevents pressure sores (decubitus ulcers within 24 hours) & joint contractures (abnormal condition of a joint, characterized by flexion & fixation & caused by atrophy & shortening of muscle fibers or by loss of normal elasticity of the skin).

Moving & Positioning (cont.) Pressure Sores – tissues are compressed, decreased bld supply to area, therefore, decreased oxygen to tissue & cells die.

Pressure Sores – tissues are compressed, decreased bld supply to area, therefore, decreased oxygen to tissue & cells die.

Correct Positioning Is crucial for maintaining body alignment and comfort, preventing injury to the musculoskeletal system, and providing sensory, motor, and cognitive stimulation. It is important to maintain proper body alignment for the patient at all times, this includes when turning or positioning the patient. Aim – least possible stress on patient’s joints & skin. Maintain body parts in correct alignment so they remain functional and unstressed. Patients who are immobile need to be repositioned q 2 hrs.

Is crucial for maintaining body alignment and comfort, preventing injury to the musculoskeletal system, and providing sensory, motor, and cognitive stimulation.

It is important to maintain proper body alignment for the patient at all times, this includes when turning or positioning the patient.

Aim – least possible stress on patient’s joints & skin. Maintain body parts in correct alignment so they remain functional and unstressed.

Patients who are immobile need to be repositioned q 2 hrs.

Application of proper body mechanics “ By applying the nursing process and using the critical thinking approach, the nurse can develop individualized care plans for clients with mobility impairments or risk for immobility. A care plan is designed to improve the client’s functional status, promote self care, maintain psychological well being, and reduce the hazards of immobility.” (Potter and Perry, 2006)

“ By applying the nursing process and using the critical thinking approach, the nurse can develop individualized care plans for clients with mobility impairments or risk for immobility. A care plan is designed to improve the client’s functional status, promote self care, maintain psychological well being, and reduce the hazards of immobility.” (Potter and Perry, 2006)

Moving & Positioning: Nursing Process Assessment Comfort level & alignment while lying down Risk factors - Ability to move, paralysis Level of consciousness Physical ability/motivation Presence of tubes, incisions, equipment Nursing Diagnosis Defining characteristics from the assessment Activity intolerance Impaired physical mobility Impaired skin integrity refer to Perry and Potter

Assessment

Comfort level & alignment while lying down

Risk factors - Ability to move, paralysis

Level of consciousness

Physical ability/motivation

Presence of tubes, incisions, equipment

Nursing Diagnosis

Defining characteristics from the assessment

Activity intolerance

Impaired physical mobility

Impaired skin integrity

refer to Perry and Potter

Nursing Process (cont.) Planning Know expected outcomes – good alignment, increased comfort Raise bed to comfortable working height Remove pillows & devices Obtain extra help if needed Explain procedure to client Implementation Wash hands Close door/curtain Put bed in flat position Move immobile patient up in bed Realign patient in correct body alignment (pillows etc.)

Planning

Know expected outcomes – good alignment, increased comfort

Raise bed to comfortable working height

Remove pillows & devices

Obtain extra help if needed

Explain procedure to client

Implementation

Wash hands

Close door/curtain

Put bed in flat position

Move immobile patient up in bed

Realign patient in correct body alignment (pillows etc.)

Nursing Process (cont.) Evaluation Assess body alignment, comfort Ongoing assessment of skin condition Use of proper body mechanics (nurse)

Evaluation

Assess body alignment, comfort

Ongoing assessment of skin condition

Use of proper body mechanics (nurse)

Restraints Device used to immobilize a client or an extremity A temporary means to control behavior Restraints are used to: Prevent falls & wandering Protect from self-injury (pulling out tubes) Prevent violence toward others Restraints deprive a fundamental right to control your own body.

Device used to immobilize a client or an extremity

A temporary means to control behavior

Restraints are used to:

Prevent falls & wandering

Protect from self-injury (pulling out tubes)

Prevent violence toward others

Restraints deprive a fundamental right to control your own body.

CRNNS Position Statement on Use of Physical Restraints “ The Registered Nurses’Assoc. of N.S. recognizes the right of all persons to be treated in a respectful and dignified manner. Additionally, the CRNNS believes that all individuals have an inherent right to autonomously and independently make decisions regarding their health care. (RNANS, 1997) Use of physical restraints may violate these inherent rights. The CRNNS does not endorse the use of physical restraints.

“ The Registered Nurses’Assoc. of N.S. recognizes the right of all persons to be treated in a respectful and dignified manner. Additionally, the CRNNS believes that all individuals have an inherent right to autonomously and independently make decisions regarding their health care. (RNANS, 1997)

Use of physical restraints may violate these inherent rights.

The CRNNS does not endorse the use of physical restraints.

Cautious Use of Restraints While restraint-free care is ideal, there are times that restraints become necessary to protect the patient & others from harm. Highly agitated, violent individual – Physical/Chemical restraints Intubated patient – pulling out endotracheal tube Suicide patient - ? Chemical restraints

While restraint-free care is ideal, there are times that restraints become necessary to protect the patient & others from harm.

Highly agitated, violent individual – Physical/Chemical restraints

Intubated patient – pulling out endotracheal tube

Suicide patient - ? Chemical restraints

Use of Restraints: Use only when absolutely necessary. Attending physician is responsible for the assessment, ordering & continuation of restraint. Can be instituted on your nsg judgment – must have a doctors order ASAP. Continued use of restraints must be reviewed daily by the RN & documented on the health record. Always explain what you do & why, to reduce anxiety & promote cooperation.

Use only when absolutely necessary.

Attending physician is responsible for the assessment, ordering & continuation of restraint.

Can be instituted on your nsg judgment – must have a doctors order ASAP.

Continued use of restraints must be reviewed daily by the RN & documented on the health record.

Always explain what you do & why, to reduce anxiety & promote cooperation.

Goals of Restraint Use To avoid the use of restraints whenever possible. Encourage alternatives Family member to sit with patient Geri chair vs. bed Non restraint measures – safety belt, wedge pillows, lap tray Consider restraints as a temporary measure – decrease likelihood of injury from restraint use. Remove restraints as soon as the patient is no longer at risk for injury.

To avoid the use of restraints whenever possible.

Encourage alternatives

Family member to sit with patient

Geri chair vs. bed

Non restraint measures – safety belt, wedge pillows, lap tray

Consider restraints as a temporary measure – decrease likelihood of injury from restraint use.

Remove restraints as soon as the patient is no longer at risk for injury.

Complications assoc. with restraints Hazards of immobility Death Pressure sores, pneumonia, constipation, incontinence, contractures, decreased mobility, decreased muscle strength, increased dependence Altered thought processes Humiliation, fear, anger & decreased self-esteem Strangulation Compromised circulation Lacerations, bruising, impaired skin integrity Must release restraint every 2 hours for assessment & ROM

Hazards of immobility

Death

Pressure sores, pneumonia, constipation, incontinence, contractures, decreased mobility, decreased muscle strength, increased dependence

Altered thought processes

Humiliation, fear, anger & decreased self-esteem

Strangulation

Compromised circulation

Lacerations, bruising, impaired skin integrity

Must release restraint every 2 hours for assessment & ROM

Physical Restraints – device that limits a clients ability to move Side rails – stop patient from rolling out, but does not stop them from climbing out – side rail down when working on that side. Jackets & Belts – patient who is confused & climbing over rails may need a jacket or belt to restrain them to bed. Sleeveless with cross over ties, allows relative freedom in bed. Arm & Leg – Undesirable, limits patients movement, injury to wrist/ankle from friction rubbing against skin – use extra padding. Restrain in a slightly flexed position, if too tight could impair circulation. Never tie to a bed rail.

Side rails – stop patient from rolling out, but does not stop them from climbing out – side rail down when working on that side.

Jackets & Belts – patient who is confused & climbing over rails may need a jacket or belt to restrain them to bed. Sleeveless with cross over ties, allows relative freedom in bed.

Arm & Leg – Undesirable, limits patients movement, injury to wrist/ankle from friction rubbing against skin – use extra padding. Restrain in a slightly flexed position, if too tight could impair circulation. Never tie to a bed rail.

Physical Restraints (cont.) Mitts are used for those confused & pulling at@ edges of dsgs, tubes, iv’s, wounds. Doesn’t limit arm movement, soft boxing glove that pads the hand, remove, wash & exercise. Ensure not too tight Use quick release tie for all restraints

Mitts are used for those confused & pulling at@ edges of dsgs, tubes, iv’s, wounds. Doesn’t limit arm movement, soft boxing glove that pads the hand, remove, wash & exercise.

Ensure not too tight

Use quick release tie for all restraints

Chemical Restraints Medication Patient must be closely observed and assessed frequently post medication. Remains a high risk for injury.

Medication

Patient must be closely observed and assessed frequently post medication.

Remains a high risk for injury.

Supporting Documentation Rationale for the use of restraints, including a statement describing the behavior of the patient. Previous unsuccessful measures or the reason alternatives are not feasible. Decision to restrain with the type of restraint selected and date & time of application. Observations regarding the placement of the restraint, its condition and the patient’s condition, including the frequency of observation (not just at the end of your shift)

Rationale for the use of restraints, including a statement describing the behavior of the patient.

Previous unsuccessful measures or the reason alternatives are not feasible.

Decision to restrain with the type of restraint selected and date & time of application.

Observations regarding the placement of the restraint, its condition and the patient’s condition, including the frequency of observation (not just at the end of your shift)

Supporting Documentation (cont.) Assessment of the need for ongoing application of restraint. Care of the patient which may include re-positioning, toileting, mobilization and/or skin care

Assessment of the need for ongoing application of restraint.

Care of the patient which may include re-positioning, toileting, mobilization and/or skin care

Civil Actions Most civil cases are based on allegations of negligence. Important to support your judgment/actions with quality documentation

Most civil cases are based on allegations of negligence.

Important to support your judgment/actions with quality documentation

Promoting Safety Measures designed to promote client safety are the result of individualized assessment findings. Often it is the conclusion of the nurse that a client’s safety is at risk, and subsequent nursing interventions are implemented. Assessment of a client’s safety should occur in the home, healthcare facility, and community environment. (Perry and Potter, 2002)

Measures designed to promote client safety are the result of individualized assessment findings. Often it is the conclusion of the nurse that a client’s safety is at risk, and subsequent nursing interventions are implemented. Assessment of a client’s safety should occur in the home, healthcare facility, and community environment.

(Perry and Potter, 2002)

Canadian Nurses Association’s (CNA) online Patient Safety Resource Guide www.cna-aiic.ca

Canadian Nurses Association’s (CNA) online Patient Safety Resource Guide

www.cna-aiic.ca

Nursing 125 LAB Safety; Basic Body Mechanics; Moving & Positioning

Moving the patient: up in bed Patient bends knees, feet firmly on bed, 1 st nurse at HOB arms under head & shoulders, face foot of bed, 2 nd nurse under hips facing foot of bed, on same side – count to 3. Up in bed (2 nurses) (heavy patient or one who cannot help) Encourage independence & foster self-esteem. Patient bends knees, feet firmly on the bed – grasps side rail @ shoulder level. Nurse positions hand & arms under patients hips, back straight, bend knees, feet apart, count to 3. Nurse pulls patient up in bed & pt pulls arms & pushes feet up into bed. Up in bed (1 nurse) (Patient alert & cooperative) Back straight, knees bent, one foot forward (broad base of support) Move close to the side of the bed

Moving the patient: lifter Do not lift, always slide One nurse on each side of the bed, firmly grasp the lifter in both hands, ask the patient to lift their head. Slide the patient up in bed on the count of 3. Benefit: 1. movement b/w 2 layers of cloth has less friction than skin on cloth. 2. Much easier to grasp sheet firmly than it is to hold a patient’s body. 3. Lifter supports the entire body (except the head) making it easier to keep the patient straight. Up in bed using the pull sheet/lifter (2 nurses)

Moving the patient: lateral Move the patient to the side of the bed, so the patient will be in the center when complete. Raise rail, move to other side of bed, roll patient toward you far ankle over near ankle, far knee over near knee . Place one hand on client’s hip and one hand on his/her shoulder and roll pt. onto side toward you. Place pillow under head & neck, bring shoulder blade forward, position both arms in slightly flexed positions (protects joints). Upper arm supported by pillow. Place pillow behind patient’s back & pillow under semi flexed upper leg Assess need to support feet (footboard, high top sneakers). From the back to the side (lateral) position

Moving the patient: prone Move to the extreme edge of the bed, raise rail on that side, move to other side. Pillow for support under abdomen, near arm over head, turn face away, roll as above, check arm & face, continue rolling. Prone - infrequently used because respirations can be compromised Good position for pressure sores on hips/buttocks. Important to turn head to the side, no pillow b/c it hyper extends the neck – can use small towel, small folded towel under each shoulder to prevent slumping, flat pillow at abdomen (esp. women with large breasts) Arms at either sides or flexed by head, hand rolls, feet in dorsiflexion – sandbags under ankles. From the back to the abdomen (prone)

Tips for positioning the patient After turning – use aids i.e. pillows, towels, washcloths, blankets, sandbags, footboards etc. Joints should be slightly flexed b/c prolonged extension creates undue muscle tension & strain Supine Low or flat pillow (prevents neck flexion) Trochanter role (supports hip joint prevents external rotation) Hand roll – used if hands are paralyzed (thumb & fingers flexed around it) High top sneakers, foot board, sandbags (support feet with toes pointing upward. Prolonged plantar flexion leads to foot drop (permanent plantar flexion & inability to dorsiflex)

After turning – use aids i.e. pillows, towels, washcloths, blankets, sandbags, footboards etc.

Joints should be slightly flexed b/c prolonged extension creates undue muscle tension & strain

Supine

Low or flat pillow (prevents neck flexion)

Trochanter role (supports hip joint prevents external rotation)

Hand roll – used if hands are paralyzed (thumb & fingers flexed around it)

High top sneakers, foot board, sandbags (support feet with toes pointing upward. Prolonged plantar flexion leads to foot drop (permanent plantar flexion & inability to dorsiflex)

Tips (cont.) Side lying Even if paralyzed on one side a patient can be placed on that side. Take care not to pull on the affected extremity. Head on low pillow, pillow along back – supports back & holds body in position, underlying arm comes forward & flexed onto pillow used for head, top arm flexed forward & resting on pillow in front of body, hand rolls if necessary, flex top leg forward & place on pillow, feet at right angles with sandbag.

Side lying

Even if paralyzed on one side a patient can be placed on that side. Take care not to pull on the affected extremity.

Head on low pillow, pillow along back – supports back & holds body in position, underlying arm comes forward & flexed onto pillow used for head, top arm flexed forward & resting on pillow in front of body, hand rolls if necessary, flex top leg forward & place on pillow, feet at right angles with sandbag.