transfers, ambulation and restraints m. freeman-mcguire, r.n., msn revised by: jean d. lansang, rn,...
TRANSCRIPT
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