Session 13 Lab Guide (Student) PDF

Lab 13 Lab Guide ================ ### Learning Goal: Safely and effectively utilize foundational intervention strategies when working with non-complex patients #### Course Goal 8: Transfer patients effectively Levels of Assistance for Transfers ---------------------------------- - **Independen...

Lab 13 Lab Guide ================ ### Learning Goal: Safely and effectively utilize foundational intervention strategies when working with non-complex patients #### Course Goal 8: Transfer patients effectively Levels of Assistance for Transfers ---------------------------------- - **Independent** (Safely, Timely, Consistently) -- **what modifications do they need (time, device)?** - **Supervision** (pt. performs 100%) - **what do they need supervision for?** - **Minimal Assistance** (pt. performs [\>]75% \]50%\]25%\1person you must indicate \# (e.g. max assist x2)** - **Total Assistance or not testable** (pt. performs \ - PIVOT TRANSFERS (with assistance or independent) ================================================ Skills: ------- - Stand Pivot - blocking 1 knee, blocking 2 knees - Squat Pivot - blocking 1 knee, blocking 2 knees - Step pivot -- blocking 1 knee -- -----------------------  -- ----------------------- - Naming the pivot transfer -- it is named based on the direction the patient's hips are moving - **Review Table 11.1 p 358 to differentiate between Stand-Pivot and Squat-Pivot** - Megaphone with solid fillCommunicating the Transfer: - Begin with the end in mind- communicate our goal to the patient and when necessary, your partner - Set up the environment for success- watch tubes and lines, ensure that the surface the patient is transferring to is ready for them (linens, brakes, etc.) - Ensure that you know what the long term function you are working on and this will help you choose the best transfer for the patient - Describe the plan before initiating any movement (instructions) while the pt is in a safe position where they can see and hear you - Use "teach-back": have the patient repeat the plan to you - This engages the patient in the task and helps ensure they understood the plan - Provide SHORT and CRISP Cues or verbal commands - Observe the verbal and non-verbal responses from your patient throughout - Guarding and Safety Considerations: **GAIT BELTS are a MUST** - **Shoes or Grippy Socks!** - Wheelchair locked - Once patient is sitting forward in the wheelchair or sitting on the EOB your hands must be on the gait belt - Stand Pivot Transfer ==================== - Indications for Stand Pivot Transfer: - Pt must have the leg strength and balance to be able to come to stand fully, must be able to follow directions and WB on at least 1 LE - This transfer is closer to a typical movement (ANAP) - Before the Transfer - Prepare the environment - Work to ensure that there are equal heights of the surfaces (unless it is a patient with a THA) - Remove the footrests but leave both armrests to allow pt to push off - Lock wheelchair - Prepare the patient - Explain the transfer fully, demonstrate what it will look like when they are in a safe position - 1^st^: Place the Gait Belt! Check for shoes! - 2^nd^: Scooting Forward - Can scoot forward by up and forward, weight shifts with assistance, or last result slide - Never hod a PT's neck to scoot forward - Feet underneath with the inner foot forward - The inside foot forward enables the pt to maintain a wide BOS and prevents the feet from becoming tangled during the pivot - Prepare the PT - PT in front with wide BOS - Inward foot back - During the Transfer - Pt should push straight down through the armrests to come to an upright standing position - Have the patient come all the way to standing, pause, turn then sit - Pt should reach back with both hands to lower themselves down on the new surface - Blocking Depends on the patient's needs - Blocking creates an extension moment to counteract the flexion moment at the pt's hips and knees through contact to the proximal tibia - Deciding what to block: - Both legs strong/reliable: no blocking needed - Both legs strong but first time you are getting a pt up: block 1:1 or 2:1 - Both legs weak/unreliable: block both legs 2:2 - 1 leg strong/reliable: block weaker leg 1:1 or 2:1 - UNLESS it is a pt with a THA, never block the operated leg - Both legs only partially reliable: block the stronger of the legs 1:1 or 2:1 - After the Transfer: Complete the Transfer - Construction worker female with solid fillGuarding and Safety Considerations: **Brakes, Gait Belt, Guarding, and Shoes!** - Cues: **"Scoot, Stand, Turn, Sit"** - **Special Case Considerations:** - **THA** - Must do a modified stand pivot- STEP PIVOT - Prepare the Environment: - Ensure the height of the surfaces is high enough that the pt is not at risk of breaking the 90 degree limitation, if transferring to a w/c ensure a pillow or cushion is in the chair to prevent breaking 90 degrees - Externally rotate the operated leg - During the Transfer: - Pt scoot to the EOB maintaining backward lean, come to stand with leg in ER - Instead of Pivoting, the pt will STEP to ensure that they do not move into IR. - With returning to sitting ensure that the pt keeps the chest lifted up and leans back to prevent forward flexion past 90 degrees - DO NOT BLOCK the OPERATED LEG - Megaphone with solid fillCues: **"Stand, Step, Step, Sit- Lean back"** - **CVA** - Transfer toward the stronger side whenever possible - Support and DO NOT PULL on the involved UE, the pt may need more assistance coming to the EOB chair - **Unilateral NWB** - Hold the NWB limb slightly off the ground during the pivot, it becomes a PIVOT-HOP - Squat Pivot Transfer ==================== - Indications for Squat Pivot Transfer: - Pt does not have the strength to come to standing - Pt lacks the balance or the ability to follow the commands safely - Before the Transfer - Prepare the environment - Work to ensure that there are equal heights of the surfaces - Lock wheelchair - Remove the footrests and the armrests on the side the pt will transfer toward - Prepare the patient - Explain the transfer fully, demonstrate what it will look like when they are in a safe position - 1^st^: Place the Gait Belt! Check for shoes! - 2^nd^: Scooting Forward - Can scoot forward by up and forward, weight shifts with assistance, or last result slide - Never hod a PT's neck to scoot forward - Feet underneath with the inner foot forward - The inside foot forward enables the pt to maintain a wide BOS and prevents the feet from becoming tangled during the pivot - Prepare the PT - PT in front with wide BOS - Inward foot back - During the Transfer - This transfer is one continuous motion- Up, Lateral, Down - Patient only comes to a partially standing position - Pt should reach back with both hands to lower themselves down on the new surface - May use rocking or momentum to generate the smooth motion, so it would be **"rock 1-2-3, up, turn, down"** - Blocking Depends on the patient's needs - Blocking creates an extension moment to counteract the flexion moment at the pt's hips and knees through contact to the proximal tibia - Deciding what to block: - Both legs strong/reliable: no blocking needed - Both legs strong but first time you are getting a pt up: block 1:1 or 2:1 - Both legs weak/unreliable: block both legs 2:2 - 1 leg strong/reliable: block weaker leg 1:1 or 2:1 - Pt with a THA: never block the operated leg - Both legs only partially reliable: block the stronger of the legs 1:1 or 2:1 - After the Transfer: Complete the Transfer - Guarding and Safety Considerations: **Brakes, Gait Belt, Guarding, and Shoes!** - Megaphone with solid fillCues: **"Scoot, Up, Turn, Down"** - **Special Case Considerations:** - **CVA** - Transfer toward the stronger side whenever possible - Support and DO NOT PULL on the involved UE, the pt may need more assistance coming to the EOB chair Decision Making: Consider the direction to pivot & whether to block 1 or 2 legs ------------------------------------------------------------------------------- 1. Basketball player NWB R ankle 2. Pt s/p R THA 3. Pt s/p RCVA/L hemiplegia - HORIZONTAL TRANSFERS ==================== - Skills: - Lateral Transfers **with a sliding board** from bed to wheelchair and wheelchair to bed - Lateral Transfers **without a sliding board** from bed to wheelchair and wheelchair to bed - Anterior Posterior Transfers are highly functional but risky - Indications for Lateral or Horizontal Transfers - Pt cannot WB through B LEs ex. SCI or B TTA/TFA - Can be risky for the pt so ensure good balance, strength, and proper guarding by the PT - Before the Transfer - Prepare the Environment: - Ensure that the heights of the surfaces are equal - Remove armrest on the side you are transferring toward - Prepare the Patient: - Explain and demonstrate what it will look like with pt in a safe position - Have pt scoot to the edge of the surface - AMAP - During the Transfer - Hands on the gait belt, knees close but not touching (hovering) - Insruct pt to place the board on a diagonal toward the surface, remove hands from the around the edge of the board so not to pinch fingers - Instruct pt to lift and shift - Guarding and Safety Considerations: **Brakes & Gait Belt** - **Do not make contact with knees!** Need to be in a position to stop any forward movement but do not want to be pushing against the knees during a lateral transfer with a transfer board - **Don't be too wide!** If your legs are too far apart then the pt can slide right through - Megaphone with solid fillCues: **"Lift and Shift"** - Special Considerations: - If pt has pain transfer toward that side Decision Making: Consider direction, strength, and other constraints. --------------------------------------------------------------------- - You are working with a 23 y.o. pt with bilateral transfemoral amputations. Prior to the injury they were a body builder. You want to teach the pt to transfer from wc to bed. What type of transfer would you teach? - You are working with a 15 y.o. s/p L2 SCI with paraplegia, RUE has 5/5 strength and LUE 4-/5 with pain in L shoulder. Which direction should you teach the pt to transfer towards? - VERTICAL TRANSFERS ================== - Skills: Chair to Plinth Transfer ------------------------ - Indication: When a pt may need to get onto a table in a doctor's office - Key Concepts: AMAP/ANAP, CCDD, guard - May use a step stool to have pt come to standing, step onto step stool then turn and sit down if the height difference is too great - Transfer toward the stronger side Wheelchair to and From the Floor Transfers ------------------------------------------ - The type of transfer depends on the pt's use of UEs and Les - Long sitting requires a lot of shoulder ROM  Table Description automatically generated Decision Making: Consider UE and LE ROM and Strength ---------------------------------------------------- 1. Pt with L2 SCI with paraplegia has been in bed as a result of a medical issue for the past 2 weeks and is showing generalized weakness. The pt has good UE and LE ROM and UE strength is in the 4-/5 range. 2. Pt. is a w/c user for many years with a recent shoulder injury resulting in limited UE ROM. You want to teach the pt to get up into the w/c from the floor 3. Pt has an L2 SCI with paraplegia with 5/5 strength in BUEs, flaccid paralysis in BLEs, and full ROM in BLEs and BUEs Goal Writing ------------ **The ABCDEs of Goal Writing** **A** = Actor - Who will accomplish the goal? Patient? Caregiver? **B** = Behavior - What **action/FUNCTION** do you expect him/her to perform? Walk? Dress? Transfer? **C** = Condition - Under what circumstances do you expect him/her to perform? With an assistive device? In the hospital? At home? At work? Indoors? Outdoors? **D** = Degree - How will you measure the outcome? Degrees? Time? Distance? HR? Level of Assistance? \# repetitions? **E** = Expected Time - When do you expect the goal to be achieved? 2 weeks? 1 month? 4 visits? ***F= Function***. If your behavior is not explicitly linked to function be explicit and link to a functional task that is meaningful to the pt. Be sure that the link is understandable and appropriate In writing goals consider: - **Consistency =** ability to perform a skill repeatedly over multiple trials or days - **Flexibility** = ability to perform a skill under a variety of environmental conditions - **Efficiency** = ability to perform a skill within a certain level of energy expenditure **CAUTION!!** **Do Not Use Impairment Level Goals Alone!** Goals must be linked to **FUNCTION** ### Goal Writing Activity: **Diagram these goals** (label the ABCDEF): [Pt will amb 150' with rollator walker in 45 seconds to the toilet in 3 months.] [Pt will crawl up 12 stairs using a reciprocal pattern to reach her playroom in 6 months.] [Pt will come to sitting EOB via R sidelying with min A at the shoulder to sit up for meals in 2 days. ] **In pairs, using the packet of words make 3 goals** - Write one goal on the wall in the correct format- it can be a goal for anything or any imaginary patient but must be in the ABCDEF format. Summary ------- - When WB through the LEs is not advised, patients can perform lateral/horizontal transfers in a seated position. - When WB through the LEs is possible, patients can perform squat- or standing-pivot transfers. - Blocking of the knees may be needed in pivot transfers. - Modifications to transfer techniques may be required for patients with unilateral WB limitations, with hemiplegia, or following THA or SCI. - Vertical transfers include the additional challenge of gravity and require good upper extremity range of motion and strength. - As patients' skill levels increase, their transfers may be able to be accomplished in one smooth movement rather than broken down into components. - There are multiple vertical transfer methods, and patients sometimes develop their own to accommodate their own particular needs. Summary Questions Transfer Part II ---------------------------------- 1. How do you name a pivot transfer? 2. Describe the foot and hand placement in doing a stand pivot transfer? 3. When should you use a gait belt? 4. How can you help a patient move forward in the chair? 5. When do you block both knees in doing a stand pivot transfer? 6. If both legs are partially reliable and one is stronger than the other, which leg would you block? 7. If you were doing a pivot transfer with your patient who has a THA which leg would you block and what modification might you make? 8. When would you use a squat pivot over a stand pivot and what is the difference? 9. If you were transferring a patient with a CVA using a squat pivot transfer, which direction would be optimal for this transfer? 10. When should you use a gait belt? 11. What modifications would you make to a stand-pivot transfer if your patient was NWB? 12. In having a patient use a transfer board what would you caution your patient about his hand placement? 13. If you were using a transfer board with a patient with R shoulder pain or weakness, which side would your transfer towards and why? 14. When using a transfer board to transfer from wc to bed, how would you position the chair and why? 15. How would you assist your patient with SCI to transfer using a transfer board if you were concerned that she might slip forward off the board? 16. What is the biggest challenge with an A-P transfer from wc to bed? 17. What 4 options do you have in teaching your patient with SCI to transfer from wc to floor? 18. Which option is best for someone with limited ROM or pain in one shoulder? 19. What modification would you consider if a patient does not have the strength to do a straight backward lift from floor to chair? 20. When should you use a gait belt? Here are answers for various patient transfer techniques: 1\. \*\*Naming a Pivot Transfer\*\*: \- Pivot transfers are named according to the \*\*direction of the pivot\*\*, like \"left pivot transfer\" if moving leftward. 2\. \*\*Foot and Hand Placement in a Stand Pivot Transfer\*\*: \- \*\*Foot placement\*\*: Patient\'s feet should be firmly on the ground with the stronger foot slightly forward. \- \*\*Hand placement\*\*: Patient places one hand on the chair's armrest (if available) while the therapist holds a gait belt for support. 3\. \*\*When to Use a Gait Belt\*\*: \- Use a gait belt \*\*whenever assisting in transfers or mobility tasks\*\* where extra support may prevent falls, especially if the patient has poor balance or strength. 4\. \*\*Helping a Patient Move Forward in the Chair\*\*: \- Use \*\*weight shifting\*\* or have the patient rock side to side while scooting forward. You can assist by gently lifting from behind. 5\. \*\*When to Block Both Knees in a Stand Pivot Transfer\*\*: \- Block both knees if \*\*both legs are weak or unreliable\*\* to prevent buckling. 6\. \*\*Which Leg to Block if One Leg is Stronger\*\*: \- Block the \*\*weaker leg\*\* to prevent it from giving way. 7\. \*\*Pivot Transfer with a Patient with THA (Total Hip Arthroplasty)\*\*: \- Block the \*\*non-operative leg\*\* to avoid violating the THA precautions (such as avoiding hip flexion over 90 degrees on the operative side). Consider \*\*avoiding twisting\*\* and ensure minimal flexion at the hip. 8\. \*\*Using a Squat Pivot Over a Stand Pivot and Key Differences\*\*: \- Use a squat pivot when the patient \*\*cannot fully stand but has partial weight-bearing ability\*\*. Unlike a stand pivot, a squat pivot keeps the patient in a partial seated position during the pivot. 9\. \*\*Optimal Direction for Squat Pivot Transfer with a CVA Patient\*\*: \- Transfer \*\*toward the stronger, unaffected side\*\* to reduce strain and enhance stability. 10\. \*\*When to Use a Gait Belt\*\*: \- Use a gait belt in any \*\*standing, pivoting, or ambulatory transfer activity\*\* to increase safety for both the patient and therapist. 11\. \*\*Modifications for a Stand-Pivot Transfer if the Patient is NWB\*\*: \- Keep the \*\*NWB leg elevated\*\* and ensure it doesn't bear weight. The patient should pivot on the stronger leg only, and the therapist may need to assist more fully with the pivot. 12\. \*\*Cautions About Hand Placement with a Transfer Board\*\*: \- Advise the patient to \*\*keep hands away from the edges of the board\*\* to avoid pinching or crushing fingers during transfer. 13\. \*\*Transfer Board Use with Right Shoulder Pain or Weakness\*\*: \- Transfer towards the \*\*left side\*\* to reduce the load on the weakened or painful right shoulder. 14\. \*\*Positioning Chair for Transfer Board from WC to Bed\*\*: \- Position the wheelchair \*\*angled toward the bed with minimal gap\*\*. This allows easier access to the bed and maintains stability. 15\. \*\*Assisting SCI Patient with Transfer Board if Slipping Forward\*\*: \- Use a \*\*gait belt to support their torso\*\* or place a towel roll under the thighs to prevent forward sliding. 16\. \*\*Biggest Challenge with an A-P (Anterior-Posterior) Transfer from WC to Bed\*\*: \- Maintaining \*\*balance and alignment\*\* while moving backward, especially if the patient lacks core stability or arm strength. 17\. \*\*Options for Teaching SCI Patient WC to Floor Transfers\*\*: \- Techniques include \*\*sideways transfer, forward transfer, backward transfer, or using a transfer board\*\*. 18\. \*\*Best Option for Someone with Limited ROM or Shoulder Pain\*\*: \- A \*\*sideways transfer\*\* minimizes shoulder stress and is more adaptable for those with limited ROM. 19\. \*\*Modification if Patient Lacks Strength for Backward Lift from Floor to Chair\*\*: \- Use \*\*incremental height surfaces\*\* to step up or use a sliding method to reduce the lift demand. 20\. \*\*When to Use a Gait Belt\*\*: \- Use a gait belt \*\*whenever assisting with transfers, balance, and standing tasks\*\* for additional stability and control.