Transfers, Ambulation and Restraints
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Transcript Transfers, Ambulation and Restraints
Transfers, Ambulation
Safety and Restraints
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 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
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
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 the effects of sensory
deprivation for the client.
Discuss purposes of space and how Identify personnel and
committees that are involved in
a nurse can respect the client's
maintaining a safe, comfortable
space.
and the therapeutic environment
in the hospital.
Describe how to maintain the
client's right to privacy.
Discuss rationale for using
restraints.
Describe specific environmental
factors that contribute to the
List the common types of injury
comfort and safety of the client.
that may occur in the hospital
setting
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.
Transfers, Ambulation,
Restraints
Safety !!!!
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
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
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:
Comfort
Safety
Change Position
Chair Cushions
ROM Exercises
Orientation of Client
Therapeutic Touch
Personal Items near Client
Client Daily Habits
ADL’S
Documentation:
Time
Distance
Use of Assistive Devices
Client’s Feelings
Weakness
Poor Balance Dizziness
Posture
Other Problems
Number of People to Assist
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
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 devices):
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)
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.
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.
Space and Privacy
Purpose of Space
1.
Importance of space
2.
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
Environmental factors related to
comfort & safety
Temperature of room
Relative humidity
Physical hazards
Carcinogens
Pathogens
Pollution
Developmental factors
Effects of Sensory Deprivation
Cognitive
Decreased learning
Bizarre thinking
Affective
Boredom
Restlessness
Increased anxiety
Perceptual
Decreased attention span
Confusion
Personnel Maintaining Client
Environment
Medical and Nursing staff
Housekeeping
Engineering /Maintenance
Common Hospital Injuries/Safety
Common Hospital
Injury
Safety
Falls
Fire Safety
Client-Incurred Accidents
Earthquake Safety
Procedure-Related
Accidents
Disaster Preparedness
Equipment-Related
Accidents
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
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 (!!!)
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
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
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
Restraints:
Purpose
Applied for safety
Prevent injury
Prevent dislodgement of
tubes
Psychiatric Setting
Restraints
Legal 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 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
Restraints
Types:
Safety Belts
Wrist Extremity Immobilizer
Vest (Posey)
Hand Mittens
Leather
Chemical
Restraints
Basic 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
Restraints
Basic Principals:
Family
Diversional Activities
Psycho/Social (tough, isolation, confusion)
Client’s daily habits (eg) news paper
Neuro/Vascular Assessment
Rapid Release of Restraints
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
Restraints
Long 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
Conclusion
Ask 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
Securing Restraint to Bed Frame
Restraint Secured Behind Chair
Using a Hand Mitt
Child With Elbow Restraint in Place
Chemical Restraints
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.