Skill 107 Moving a Patient Up in Bed PDF

580 SKILL 107 DOCUMENTATION Document the procedure, the patient’s response, and your assess- ment of the area before and after application of the Montgomery straps. Record a description of the wound, amount and character of the wound drainage, and an assessment of the surrounding skin. No...

580 SKILL 107 DOCUMENTATION Document the procedure, the patient’s response, and your assess- ment of the area before and after application of the Montgomery straps. Record a description of the wound, amount and character of the wound drainage, and an assessment of the surrounding skin. Note the type of dressing that was applied, including the application of skin protectant and a skin barrier. Document that Montgomery straps were applied to secure the dressings. Record the patient’s response to the dressing care and associated pain assessment. Include any pertinent patient and family education.  ͕͔͛               When a patient needs to be moved up in bed, it is important to avoid injuring yourself and the patient. The patient is at risk for injuries from shearing forces while being moved. Evaluate the patient’s condition, any activity restrictions, the patient’s ability to assist with positioning and to understand directions, and the patient’s body weight to decide how much additional assistance is needed. This is not a one-person task. Safe Patient Handling Algorithm 4 in Skill 173 can assist in making deci- sions about patient handling and movement. Using assistance, appropri- ate lifting and repositioning devices, good body mechanics, and correct technique are important to avoid injuries to yourself and the patient. During any patient-handling task, if any caregiver is required to lift more than 35 pounds of a patient’s weight, consider the patient to be fully dependent and use assistive devices (Waters, 2007). The procedure below describes moving a patient using a friction-reducing sheet. DELEGATION CONSIDERATIONS Moving a patient up in bed may be delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP), as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient’s needs and circumstances, as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. EQUIPMENT Friction-reducing sheet or Full-body sling lift and cover other friction-reducing device sheet, if necessary, based on Nonsterile gloves, if indicated; assessment other PPE, as indicated Additional caregivers to assist, based on assessment  ‘˜‹‰ƒƒ–‹‡–’‹‡†‹–Š••‹•–ƒ ‡ 581 ASSESSMENT Assess the situation to determine the need to move the patient up in the bed. Review the medical record and nursing plan of care for conditions that may influence the patient’s ability to move or to be positioned. Assess for tubes, IV lines, incisions, or equipment that may alter the positioning procedure. Assess the patient’s level of consciousness, ability to understand and follow directions, and ability to assist with moving. Assess the patient’s weight and your strength to determine the number of caregivers required to assist with the activity. Determine the need for bariatric equipment. Assess the patient’s skin for signs of irritation, redness, edema, or blanching. NURSING DIAGNOSIS Activity Intolerance Risk for Injury Impaired Bed Mobility OUTCOME IDENTIFICATION AND PLANNING Patient remains free from injury and maintains proper body align- ment. Patient reports improved comfort. Patient’s skin is clean, dry, and intact, and without any redness, irri- tation, or breakdown. IMPLEMENTATION ACTION RATIONALE 1. Review the medical record Reviewing the order and plan of and nursing plan of care for care validates the correct patient conditions that may influ- and correct procedure. Identifica- ence the patient’s ability to tion of limitations and ability move or to be positioned. and use of an algorithm helps Assess for tubes, IV lines, to prevent injury and aids in incisions, or equipment that determining best plan for patient may alter the positioning movement. procedure. Identify any movement limitations. Consult patient handling algorithm, if available, to plan appropriate approach to moving the patient. 582 SKILL 107 ACTION RATIONALE 2. Perform hand hygiene and Hand hygiene and PPE prevent put on PPE, if indi- the spread of microorganisms. cated. PPE is required based on transmission precautions. 3. Identify the patient. Explain Patient identification validates the procedure to the the correct patient and correct patient. procedure. Discussion and expla- nation help allay anxiety and prepare the patient for what to expect. 4. Close the curtains around the Closing the door or curtain bed and close the door to provides for privacy. Proper bed the room, if possible. Place height helps reduce back strain the bed at an appropriate and while you are performing the comfortable working height, procedure. Flat positioning helps usually elbow height of the to decrease the gravitational pull caregiver (VISN 8 Patient of the upper body. Placing the Safety Center, 2009). Adjust bed in slight Trendelenburg the head of the bed to a flat position aids movement. position or as low as the patient can tolerate. Place the bed in slight Trendelenburg position, if the patient is able to tolerate it. 5. Remove all pillows from Removing pillows from under under the patient. Leave one the patient facilitates movement; at the head of the bed, lean- placing a pillow at the head of ing upright against the head- the bed prevents accidental head board. injury against the top of the bed. 6. Position at least one nurse Proper positioning and lowering on either side of the bed, and the side rails facilitate moving lower both side rails. the patient and minimize strain on the nurses. 7. If a friction-reducing sheet (or A friction-reducing device sup- device) is not in place under ports the patient’s weight and the patient, place one under reduces friction during the the patient’s midsection. repositioning. 8. Ask the patient (if able) to Patient can use major muscle bend his or her legs and put groups to push. Even if the his or her feet flat on the bed patient is too weak to push on to assist with the movement. the bed, placing the legs in this fashion will assist with move- ment and prevent skin shearing on the heels.  ‘˜‹‰ƒƒ–‹‡–’‹‡†‹–Š••‹•–ƒ ǦǦǦ ‡ 583 ACTION RATIONALE 9. Have the patient fold the Positioning in this manner pro- arms across the chest. Have vides assistance, reduces friction, the patient (if able) lift the and prevents hyperextension of head with chin on chest. the neck. 10. One nurse should be posi- Doing so positions each nurse tioned on each side of the opposite the center of the body bed, at the patient’s mid- mass, lowers the center of section with feet spread gravity, and reduces the risk for shoulder width apart and injury. one foot slightly in front of the other. 11. If available on bed, engage Decreases friction and effort mechanism to make the bed needed to move the patient. surface firmer for reposition- ing. 12. Grasp the friction-reducing Having the sheet close to the sheet securely, close to the body brings the patient’s center patient’s body. of gravity closer to each nurse and provides for a secure hold. 13. Flex your knees and hips. Using the legs’ large muscle Tighten your abdominal and groups and tightening muscles gluteal muscles and keep during transfer prevent back your back straight. injury. 14. If possible, the patient can If the patient assists, the nurses assist with the move by exert less effort. pushing with the legs. Shift The rocking motion uses the your weight back and forth nurses’ weight to counteract the from your back leg to your patient’s weight. Rocking devel- front leg and count to three. ops momentum, which provides On the count of three, move a smooth lift with minimal exer- the patient up in bed. Repeat tion by the nurses. the process, if necessary, to get the patient to the right position. 15. Assist the patient to a Readjusting the bed and adjust- comfortable position and ing the bed height ensures patient readjust the pillows and safety and comfort. Having the supports, as needed. Take call bell and essential items bed out of Trendelenburg readily available helps promote position and return bed safety. surface to normal setting, if necessary. Raise the side rails. Place the bed in the lowest position. Make sure