Transfers, Ambulation Safety and Restraints

1. Transfers, Ambulation Safety and Restraints

2. 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

3. 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 devices • Explain the importance of knowing the diagnoses and capabilities of the client • Describe methods to support the client during ambulation • Discuss various gaits used for walking with a cane, walker or crutches • Create sample charting after ambulating a client, including the important data

4. Lesson Objectives (Restraints), By the end of this lesson the student vocational nurse will be able to: • Discuss rationale for using restraints • Define the terms immobilize, legal rights, limb holder, chemical restraints • Explain the patient’s Bill of Rights regarding consent of the client, family or guardian and written medical orders for use of restraints • Discuss the procedure for applying various physical restraints

5. Lesson Objectives (Safety), By the end of this lesson the student vocational nurse will be able to: • Define vocabulary related to hospital/client environment. • Discuss purposes of space and how a nurse can respect the client's space. • Describe how to maintain the client's right to privacy. • Describe specific environmental factors that contribute to the comfort and safety of the client. • Discuss the effects of sensory deprivation for the client. • Identify personnel and committees that are involved in maintaining a safe, comfortable and the therapeutic environment in the hospital. • Discuss rationale for using restraints. • List the common types of injury that may occur in the hospital setting

6. Lesson Objectives (Safety), By the end of this lesson the student vocational nurse will be able to: • Define the terms: a. Immobilized b. Legal rights c. Limb holder d. Chemical restraints • Explain the Bill of Rights regarding consent of the client, family, or guardian and written medical orders for use of restraints. • Discuss the procedure for applying various physical restraints.

7. Transfers, Ambulation, Restraints Safety !!!!

8. Transfers, Ambulation, Restraints(Safety Interventions): • Assess for Orthostatic Hypotension • Dangle • Client with special needs: (eg.) blind • Lock wheel chairs, stretchers and beds • Check floors for safety (wet or clutter) • Tub and shower surfaces • Non-skid slippers

9. Common Hazards Encountered: • Unable to assist or follow directions • Client fear • Client fatigue • Client weak • Problem with assistive devices • Inexperience of nurse • Size of client • Size of nurse

10. Supporting The Client: • Physically • Emotionally • Psychologically

11. 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

12. Basic Nursing Care: • Comfort • Safety • Change Position • Chair Cushions • ROM Exercises • Orientation of Client • Therapeutic Touch • Personal Items near Client • Client Daily Habits • ADL’S

13. Documentation: • Time • Distance • Use of Assistive Devices • Client’s Feelings • Weakness • Poor Balance Dizziness • Posture • Other Problems • Number of People to Assist

14. Procedure for Transfers: • Check the doctor’s orders • Check diagnosis of the patient • 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

15. Orthostatic Hypotension (Signs and Symptoms): • Dizziness • Weakness • Faint • Fatigue • Lightheadedness

16. Orthostatic Blood Pressures: • Lying • Sitting • Standing

17. Orthostatic Hypotension: • Systolic Blood Pressure drop < 25 mm Hg • Diastolic Blood Pressure drop < 10 mm Hg

18. Equipment (Transfers): • Wheel Chair with Replacement Arm • Geri Chair • Transfer Belt • Sliding Board • Mechanical Lifts (Hoyer) • Bed Scale • Pull Sheet

19. 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

20. Transfer (Two Person): • Very overweight client • Confused client • Uncooperative client

21. 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

22. Ambulation (common hazards with assistive devices): • Broken • Client not know how to use • Pathways are not clear

23. Equipment (ambulation) • Same with few exceptions • Gait Belts • Crutch • Walker

24. Ambulation: Prevent Falls !!! • Client Posture (head up, eyes open, looking forward) • Non-skid slippers • Walk at client’s side • Match client’s gate

25. 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)

26. Safety Define vocabulary related to hospital/client environment. • Air Pollution – the introduction of checmicals, particulate matter or biological materials that cause harm or discomfort to human or other living • Carbon Monoxide - (CO), also called carbonous oxide, is a colorless, odorless, and tasteless gas which is slightly lighter than air. It is highly toxic to humans and animals in higher quantities, although it is also produced in normal animal metabolism in low quantities, and is thought to have some normal biological functions. • Carcinogen - s any substance, radionuclide or radiation that is an agent directly involved in causing cancer.

27. Vocabulary related to hospital/client environment: • Decibels - logarithmic unit that indicates the ratio of a physical quantity relative to a specified or implied reference level ( noise ratio). • Relative humidity - is a term used to describe the amount of water vapor in a mixture of air and water vapor • Sensory overload • Parasites - Parasites are organisms that obtain food and shelter by living on or within another organism. • Pathogens – microorganism that cause disease.

28. Space and Privacy • Purpose of Space • Importance of space • Nurse's role in protecting client space • Maintaining the client's right to privacy 1. Screening 2. Requesting family/ friends to leave the room 3. Draping 4. Client consent to view procedures

29. Environmental factors related to comfort & safety • Temperature of room • Relative humidity • Physical hazards • Carcinogens • Pathogens • Pollution • Developmental factors

30. Effects of Sensory Deprivation Cognitive • Decreased learning • Bizarre thinking Affective • Boredom • Restlessness • Increased anxiety Perceptual • Decreased attention span • Confusion

31. Personnel Maintaining Client Environment • Medical and Nursing staff • Housekeeping • Engineering /Maintenance

32. Common Hospital Injuries/Safety Common Hospital Injury Safety Fire Safety Earthquake Safety Disaster Preparedness • Falls • Client-Incurred Accidents • Procedure-Related Accidents • Equipment-Related Accidents

33. Preventing Fall • Identifying at-risk patients • Assess for a history of falls • Assess for additional risk factors • Combining an assessment tool with a care plan • Accurate assessment and use of appropriate fall intervention

34. Preventing Falls: • Determine the client's diagnoses and capabilities • 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 (!!!)

35. Breaking Client’s Fall: • Stand with your feet apart slightly behind the client • Grasp the client firmly at waist/axilla • Your near leg against the client’s leg • Slowly lower the client to the floor • Examine for injury • Call for help • Document as per agency policy • Doctor notified

36. Interventions for a Patient Who Experiences a Fall • Immediately assess the patient’s condition • Provide care and interventions appropriate for status/injuries • Notify patient’s physician or primary caregiver of incident and your assessment of the patient • Ensure prompt follow-through for any test orders • Evaluate circumstances of the fall and the environment; institute preventive measures • Document the fall and complete an event report

37. Alternatives to Restraints • Determine whether a behavior pattern exists • Assess for pain and treat appropriately • Rule out physical causes for agitation • Involve family members • Reduce stimulation, noise, and light • Check environment for hazards and modify, if necessary • Use therapeutic touch • Investigate discontinuing bothersome treatment devices

38. Restraints:Purpose • Applied for safety • Prevent injury • Prevent dislodgement of tubes • Psychiatric Setting

39. 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)

40. Restraints:Must !!! • Must help client or be needed for medical therapy • Must be ordered by a physician • Must not be used as a means of pushing or disciplining the client • Must be applied snugly/not tightly • Must be removed/Reposition Q2 • Must notify doctor when no longer needed • Must intervene to promote safety • Must be documented

41. RestraintsTypes: • Safety Belts • Wrist Extremity Immobilizer • Vest (Posey) • Hand Mittens • Leather • Chemical

42. RestraintsBasic Principals: • Know agency policy • Document use of restraints and patient monitoring • Check client Q 15 minutes • Remove and reposition Q 2 hours • Assist with ROM • Call light in reach • Comfort measure (eg) water, food, rest room

43. RestraintsBasic Principals: • Family • Diversional Activities • Psycho/Social (tough, isolation, confusion) • Client’s daily habits (eg) news paper • Neuro/Vascular Assessment • Rapid Release of Restraints

44. R-E-S-T-R-A-I-N-T Acronym • R: Respond to the present, not the past • E: Evaluate the potential for injury • S: Speak with family members or caregivers • T: Try alternative measures first • R: Reassess the patient to determine success of restraint • A: Alert the physician and family of need for restraint • I: Individualize restraint use • N: Note important information on chart • T: Time limit the use of restraints

45. RestraintsLong Term Use (problems): • Muscle weakness, atrophy • Loss of bone mass, joint contractures • Constipation/incontinence • Pressure Ulcers • Cognitive Impairment • Decrease confidence in ambulation • Withdrawn, detached • Depression • Loss of independence

46. 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?

47. 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

48. Securing Restraint to Bed Frame

49. Restraint Secured Behind Chair

50. Using a Hand Mitt