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Chapter 011
- 1. Chapter 11 Safe Patient Handling,Safe Patient Handling, Transfer, and PositioningTransfer, and Positioning Copyright © 2018, Elsevier Inc. All rights reserved.
- 2. Lifting and Moving Patients • Apply principles of safe patient transferApply principles of safe patient transfer positioningpositioning • Safely and correctly position and moveSafely and correctly position and move patients to reduce risks related topatients to reduce risks related to immobilizationimmobilization • Always use safe patient-handling techniquesAlways use safe patient-handling techniques Copyright © 2018, Elsevier Inc. All rights reserved. 2
- 3. Quick Quiz! When lifting a patient, the nurse will:When lifting a patient, the nurse will: A.A.Bend deeply at the waist.Bend deeply at the waist. B.B.Twist her feet to the left.Twist her feet to the left. C.C.Keep her knees straight.Keep her knees straight. D.D.Tighten stomach muscles.Tighten stomach muscles. Copyright © 2018, Elsevier Inc. All rights reserved. 3
- 4. Principles for Practice • Use proper body mechanicsUse proper body mechanics • Safe patient-handling techniques increasesSafe patient-handling techniques increases level of independence for the patientlevel of independence for the patient • Teaching both proper body mechanics and theTeaching both proper body mechanics and the use of safe patient-handling equipment is moreuse of safe patient-handling equipment is more effect than using just oneeffect than using just one • Know patient’s movement abilityKnow patient’s movement ability Copyright © 2018, Elsevier Inc. All rights reserved. 4
- 5. Patient-Centered Care • Increasing mobility and activity level is theIncreasing mobility and activity level is the patient’s choicepatient’s choice • Develop a plan of care, assess:Develop a plan of care, assess: • Patient’s knowledgePatient’s knowledge • Cultural beliefsCultural beliefs • Attitude about loss of independenceAttitude about loss of independence • Willingness to participate in activityWillingness to participate in activity Copyright © 2018, Elsevier Inc. All rights reserved. 5
- 6. Evidence-Based Practice • Independent health care settings have highest rate of injury and illness • It is critical to train health care staff on devices, equipment, and handling policies • Most organizations have “no lift” policies, in which they require use of lift devices • Knowledge of positioning techniques and proper use of equipment reduces injuries to health care workers Copyright © 2018, Elsevier Inc. All rights reserved. 6
- 7. Safety Guidelines 1. Know how physiological influences on body alignment and mobility affect patients throughout the life span. 2. Control factors that can indirectly affect body mechanics by making the environment safe. 3. Determine a patient’s level of sensory perception (vision and hearing) as this affects a patient’s ability to cooperate during transfer and lifting procedures. Copyright © 2018, Elsevier Inc. All rights reserved. 7
- 8. Safety Guidelines (Cont.) 4. Loss of sensation increases vulnerability to the hazards of immobility because of the inability to sense pain or the need for repositioning. 5. Use assistive equipment and devices to transfer and position patients safely. Copyright © 2018, Elsevier Inc. All rights reserved. 8
- 9. Using Safe and Effective Transfer Techniques Skill 11-1 • Transferring is a nursing skill used to help the patientTransferring is a nursing skill used to help the patient attain positions to regain optimal independenceattain positions to regain optimal independence • Physical activity is beneficial for the patientPhysical activity is beneficial for the patient • Maintain safety of patient and nurseMaintain safety of patient and nurse • Be aware of patient circumstancesBe aware of patient circumstances • Obtain assistance, if neededObtain assistance, if needed Copyright © 2017, Elsevier Inc. All rights reserved. 9
- 10. Delegation and Collaboration • The task of effective transfer techniques canThe task of effective transfer techniques can be delegated to trained nursing assistivebe delegated to trained nursing assistive personnel (NAP). The nurse is responsible topersonnel (NAP). The nurse is responsible to initially assess patient’s readiness and abilityinitially assess patient’s readiness and ability to transferto transfer • The nurse directs NAP by:The nurse directs NAP by: • Assisting and supervising when moving patients whoAssisting and supervising when moving patients who are transferred for the first timeare transferred for the first time • Explaining any patient factors that may affect safeExplaining any patient factors that may affect safe transfertransfer • Explaining what to observe and report back to theExplaining what to observe and report back to the nursenurse Copyright © 2018, Elsevier Inc. All rights reserved. 10
- 11. Recording and Reporting • Record procedure, including pertinent observations • Report to next shift or other caregivers transfer ability and assistance needed; report progress or remission to rehabilitation staff Copyright © 2018, Elsevier Inc. All rights reserved. 11
- 12. Special Considerations • TeachingTeaching • Teach family and patient transfer skillsTeach family and patient transfer skills • PediatricPediatric • When possible, transport child outside of the roomWhen possible, transport child outside of the room by stretcher, stroller, or wheelchairby stretcher, stroller, or wheelchair • Children confined to bed need to have dependentChildren confined to bed need to have dependent skin surfaces assessed at least 3 times in a 24-hourskin surfaces assessed at least 3 times in a 24-hour periodperiod Copyright © 2018, Elsevier Inc. All rights reserved. 12
- 13. Special Considerations (Cont.) • GerontologicalGerontological • Fall preventionFall prevention • Home careHome care • Have caregiver practice transfer in hospital beforeHave caregiver practice transfer in hospital before taking the patient hometaking the patient home • Home should be hazard-free and accessible for theHome should be hazard-free and accessible for the patientpatient Copyright © 2018, Elsevier Inc. All rights reserved. 13
- 14. Quick Quiz! • A patient who recently suffered a nonhemorrhagicA patient who recently suffered a nonhemorrhagic stroke is having difficulty following the nurse’sstroke is having difficulty following the nurse’s instructions for transfer from bed to chair. Whichinstructions for transfer from bed to chair. Which of the following answers can explain why theof the following answers can explain why the patient is having difficulty with this instruction?patient is having difficulty with this instruction? A.A.The patient does not like the nurse directing her on whatThe patient does not like the nurse directing her on what to do.to do. B.B.It is not advisable for this patient to get out of bed after aIt is not advisable for this patient to get out of bed after a stroke.stroke. C.C.The patient has suffered short-term memory loss and isThe patient has suffered short-term memory loss and is confused.confused. D.D.Lunch is being delivered in an hour and the patient prefersLunch is being delivered in an hour and the patient prefers to eat in bed.to eat in bed. Copyright © 2018, Elsevier Inc. All rights reserved. 14
- 15. Wheelchair Transfer Techniques Procedural Guideline 11-1 • This procedure builds on the principles thatThis procedure builds on the principles that you learned in Skill 11-1: Using Safe andyou learned in Skill 11-1: Using Safe and Effective Transfer TechniquesEffective Transfer Techniques • Maintain patient safetyMaintain patient safety • Check wheelchair locks and footplates beforeCheck wheelchair locks and footplates before transferring the patienttransferring the patient Copyright © 2018, Elsevier Inc. All rights reserved. 15
- 16. Delegation and Collaboration • The task of transferring a patient to or from aThe task of transferring a patient to or from a wheelchair can be delegated to NAPwheelchair can be delegated to NAP • The nurse directs NAP by:The nurse directs NAP by: • Assessing and supervising when moving patients whoAssessing and supervising when moving patients who are transferring for the first timeare transferring for the first time • Explain any patient factors that may affect safeExplain any patient factors that may affect safe transfertransfer Copyright © 2018, Elsevier Inc. All rights reserved. 16
- 17. Quick Quiz! Can the skill of transferring a patient to or fromCan the skill of transferring a patient to or from a wheelchair be delegated to NAP?a wheelchair be delegated to NAP? A.A.Yes.Yes. B.B.No.No. Copyright © 2018, Elsevier Inc. All rights reserved. 17
- 18. Moving and Positioning Patients in Bed Skill 11-2 • Correctly position patientCorrectly position patient • Maintain body alignment, comfort, circulation, and balanceMaintain body alignment, comfort, circulation, and balance • Cause no restrictions to circulationCause no restrictions to circulation • Follow agency’s safe handling algorithmsFollow agency’s safe handling algorithms • Use appropriate repositioning devicesUse appropriate repositioning devices Copyright © 2018, Elsevier Inc. All rights reserved. 18
- 19. Delegation and Collaboration • This skill can be delegated to NAPThis skill can be delegated to NAP • The nurse directs NAP by:The nurse directs NAP by: • Explaining about any moving and positioningExplaining about any moving and positioning restrictionsrestrictions • Designating specific times during a shift that NAPDesignating specific times during a shift that NAP must reposition the patientmust reposition the patient • Providing information regarding the patient’s needsProviding information regarding the patient’s needs for body alignmentfor body alignment Copyright © 2018, Elsevier Inc. All rights reserved. 19
- 20. Recording and Reporting • Record procedure and observations (e.g., condition of skin, joint movement, patient’s ability to assist with positioning) • Report observations at change of shift and document in nurses’ notes • Record times and position changes of patient throughout the shift Copyright © 2018, Elsevier Inc. All rights reserved. 20
- 21. Special Considerations • TeachingTeaching • Instruct caregiver in patient positioning, signs andInstruct caregiver in patient positioning, signs and symptoms of complicationssymptoms of complications • Provide opportunity for return demonstrationProvide opportunity for return demonstration • GerontologicalGerontological • Reposition older-adult patients every 1 to 2 hours;Reposition older-adult patients every 1 to 2 hours; maintain range-of-motion (ROM) exercisesmaintain range-of-motion (ROM) exercises Copyright © 2018, Elsevier Inc. All rights reserved. 21
Editor's Notes
- This chapter reviews two skills and one procedure: using safe and effective transfer techniques, wheelchair transfer techniques, and moving and positioning patients in bed.
- Health care providers are required to provide employees with safety information and training to be used when transferring, positioning, and lifting patients. Relying on proper body mechanics and manual lifting techniques alone is not effective for reducing health care workers musculoskeletal injuries. Refer to the policies and procedures in the institution where you work. [Describe examples of local policies and procedures related to lifting and moving patients.] Workers might need to move, roll, steady, and position patients while using lifting equipment. However, because most musculoskeletal injuries in hospital settings are cumulative, any steps taken to minimize the potential for musculoskeletal injuries during patient-handling tasks benefit hospital caregivers. Many patients have conditions resulting in immobility or require limitations in activity imposed by their treatment plan. It is an important nursing role to safely and correctly position and move patients effectively to reduce the risks related to immobilization, such as skin breakdown, pneumonia, and deep vein thrombosis.
- Correct answer: D Rationale: The nurse will bend at the knees, keeping her back, neck, pelvis, and feet aligned, and will avoid twisting. Tightening the stomach muscles and tucking the pelvis provides balance and protects the back.
- Body mechanics is the coordinated effort of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living (ADLs). The use of safe patient transfer and positioning techniques help patients achieve an optimal level of independence without resultant injury to health care providers. Teaching the use of safe patient-handling equipment in combination with proper body mechanics is more effective than either one in isolation. Key principles in determining the proper handling techniques to use for patients is knowing if a patient is weight bearing, the patient’s weight and height, strength and ability to cooperate and provide assistance. Patients who are at high risk for complications from improper positioning and injury during transfer include those with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility, and impaired muscle development.
- Ultimately it is a patient’s choice to increase his or her mobility and activity level. When developing a care plan, consider a patient’s knowledge, cultural beliefs, and circumstances surrounding the loss of independent activity and the willingness to participate in activity when developing a plan of care. Use simple language when you provide patients information about the complications of immobility and their unique risks. Consider the circumstances surrounding a patient’s loss of independent activity and mobility to ensure a plan of care is realistic and attainable. Understand to what extent the patient chooses to have a family caregiver involved to learn transfer and positioning techniques for home care.
- Inpatient health care settings have some of the highest rates of injury and illness among all industries. In 2013, U.S. hospitals recorded 57,680 work-related injuries and illnesses, a total case rate of 6.4 work-related injuries and illnesses for every 100 full-time employees, almost twice as high as the rate for private industry as a whole (3.3 per 100 full-time employees). OSHA has provided guidelines on how to complete an ergonomics hazard assessment based on patient population, patient-handling tasks, and physical environment. Most organizations have developed “no lift” policies that discourage manual lifting and requires the use of safe handling equipment and devices as needed. Knowledge about safe, efficient transfer and positioning techniques and proper use of assistive equipment and devices promotes safe patient transfer without injury to a patient or health care worker. [Review Box 11-1: Principles of Safe Body Mechanics When Transferring and Positioning Patients, with the students.]
- 1. Inactive older adults are at risk for muscle atrophy, loss of bony mass, contractures of joints, and pressure ulcers. 2. Cluttered hallways and bedside areas increase a patient’s risk of falling. Assess a patient’s range of motion. Contractures or spasticity limit joint and muscle mobility; take care not to position a patient’s limb in an unnatural position. This could result in injury or dysfunction of the affected limb.
- [Ask students: how is physical activity beneficial for the patient? Discuss: it maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on skin, and improves urinary and respiratory functions. Physical activity benefits a patient psychologically by increasing social activity and mental stimulation and providing a change in environment.] Consider individual patient problems during transfer: For example, a patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred. If you have any doubt about safe transfer, use a transfer belt and obtain assistance when transferring patients.
- The nurse directs nursing assistive personnel (NAP) by: Assisting and supervising when moving patients who are transferred for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. Explaining the patient’s mobility restrictions, changes in blood pressure to look for, or sensory alterations that may affect safe transfer. Explaining what to observe and report back to the nurse, such as dizziness or the patient’s ability to assist.
- Examples of pertinent observations include weakness, ability to follow directions, weight-bearing ability, balance, ability to pivot, number of personnel needed to assist, and amount of assistance (muscle strength) required. Rehabilitation staff includes the physical therapist and the occupational therapist.
- Teaching Teach family and patient transfer skills, including principles of body mechanics and hazards of immobility. Incorporate return demonstration in discharge planning. Pediatric [Ask students: what is the benefit of transporting a child out of his or her room? Discuss: it increases environmental stimuli and provides social contact with others.] An example of children confined to bed for any length of time is children in traction. [Ask students why these patients need to have dependent skin surfaces assessed at least 3 times in a 24-hour period.]
- Gerontological A major health concern that threatens the function of an older adult is the risk for falls. Concern increases when an older adult enters a hospital. Assess the patient for the risk for falls on admission and implement a protocol to prevent falls. Home care Have family or caregiver practice transfer in the hospital to achieve success before taking the patient home. Alternatively, have the patient (if living alone) practice transfer skills in bed that will be used at home. Teach the patient to transfer to a chair with arms for ease of rising and sitting. Home should be free of hazards. [Ask students: what kinds of hazards would you want to eliminate in homes that belong to patients with mobility problems? Discuss: throw rugs, electric cords, slippery floors.] If a wheelchair is used, access must be possible through all doors, and space for transfer must be available in the bedroom and the bathroom. Aids that enhance transfer ability are shower stools, commode elevators, handrails on the tub, and a nonskid shower surface.
- Correct answer: C Rationale: Patients may experience short-term memory loss, which will influence transfer, initial learning, or consistent performance.
- Several additional steps must be taken to maintain safety of the patient and the nurse and to prevent injury when transferring from or to a wheelchair.
- The nurse directs NAP to: Assist and supervise when moving patients who are transferring for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. Explain the patient’s mobility restrictions, changes in blood pressure, or sensory alterations that may affect safe transfer.
- Correct answer: A Rationale: The nurse will assist and supervise the NAP when moving patients who are transferring for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. The nurse will explain to the NAP the patient’s mobility restrictions, changes in blood pressure, or sensory alterations that may affect transfer.
- Correctly positioning patients in bed is crucial for maintaining their body alignment and comfort; preventing injury to their musculoskeletal and integumentary systems; and providing sensory, motor, and cognitive stimulation. A patient with impaired mobility, decreased sensation, impaired circulation, or lack of voluntary muscle control can suffer damage to the musculoskeletal and integumentary systems while lying down. You minimize this risk so that positioning will cause no restrictions to the patient’s circulation and the patient achieves correct body alignment. The term body alignment refers to the condition of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures. Caregivers are at risk for injury during positioning of patients in bed. It is important to follow an agency’s safe handling algorithms and use appropriate repositioning devices.
- The nurse directs the NAP by: Explaining about any moving and positioning restrictions (e.g., avoid prone position, patient has one-sided weakness) and type of safe patient-handling devices needed. Designating specific times throughout the shift that NAP must reposition the patient. Providing information regarding patient’s individual needs for body alignment (i.e., patient with spinal cord injury), ability to assist, and number of other caregivers needed to assist.
- [Ask students: why is it important to record the time and position change? Discuss.]
- Teaching Teach family members how to position the patient, especially when caring for an infant, a young child, or a confused or unconscious patient. Teach the patient ways to help with positioning, and provide the opportunity for return demonstration. Teach the patient and family signs and symptoms of pressure ulcers and contractures. Gerontological Reposition older-adult patients at least every 1 to 2 hours, and maintain a regular program of range-of-motion (ROM) exercises.