Transfers, Ambulation and Restraints

1. Transfers, Ambulation and Restraints M. Freeman-McGuire, R.N., MSN Revised by: Jean D. Lansang, RN, MSN, HHRN

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. Transfers, Ambulation, Restraints Safety !!!!

6. 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

7. 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

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

9. 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

10. 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

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

12. 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

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

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

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

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

17. 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

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

19. 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

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

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

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

23. 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)

24. 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 (!!!)

25. 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

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

27. 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)

28. 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

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

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

31. 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

32. 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?

33. 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

34. 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

35. 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

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

37. 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

38. Rights of the Elderly