Patient Transfer Techniques PDF

Lesson 10 of 10 Lesson 10- Patient Transfer Techniques After completing this lesson, the student will be able to identify patient transfer techniques in accordance with prescribed guidance and publications. Principles of Proper Body Mechanics Body mechanics is defined as the careful, coordinated, an...

Lesson 10 of 10 Lesson 10- Patient Transfer Techniques After completing this lesson, the student will be able to identify patient transfer techniques in accordance with prescribed guidance and publications. Principles of Proper Body Mechanics Body mechanics is defined as the careful, coordinated, and efficient use of the body to do work. We use our bodies every day when we sit, walk, lift, and perform numerous other activities. As medical service technicians, we use our bodies as “machines” when we lift, pull, push, and otherwise manipulate patients. Unfortunately, a lot of us injure ourselves because we don’t use our bodies properly. In this lesson, we are going to look at some basic principles of body mechanics. If you follow these principles, you should be able to perform nursing procedures without injuring yourself. It’s important for you to remember that the procedures we describe here are usually used on longterm, seriously ill patients whose chances for complete recovery range from slight to nonexistent. With patients like this, setbacks are common and advances are usually slow and painful. Under conditions like this, many nursing personnel become discouraged and demotivated. It sometimes helps if you go back to your basic goal, which is to restore your patients to the optimum possible health, considering their problems and conditions. In other words, you can’t cure them all, but you can treat all of them with dignity and make them feel cared for and as comfortable as possible. The techniques described throughout this lesson are not the absolute only way of doing any given procedure. We selected methods most commonly described in various nursing texts.  The final authority is and must be local policy as prescribed by senior medical technicians and nurses. Have no qualms about asking them for help if you become confused. C O NT I NU E Principals of Effective Body Mechanics Good body mechanics is a combination of good posture and the effective use of body muscles to perform various activities. Good body mechanics is a combination of good posture, balance, and using the strongest and largest muscles for work. Good body mechanics are as important for you as they are for your patients. As we mentioned in the last section, if patients do not use good body mechanics, they’ll develop backaches, contractures, and other problems. In fact, you can develop permanent problems from using poor body mechanics. One of the most common injuries for health care workers is lower back strain. In this section we’ll first discuss the different aspects of good posture. After that, we’ll talk about the best way to use your body muscles to perform different activities. Posture, or body alignment, is the proper relationship of body parts to one another. Correct body alignment reduces strain, helps maintain balance, and improves overall body functioning. Good posture requires energy to overcome the pull of gravity. Posture should be maintained in each of the body positions (standing, sitting, lying). We’ll briefly discuss proper body alignment in each of these positions. Posture Standing When you are standing, your body should be much like it is when you are in the parade-rest position. To stand correctly, keep your back straight without any of the exaggerated spinal curves you have when you are slouching. When you slouch or lean one way or the other, you stretch the muscles on one side and contract the muscles on the other. Over a period of time, a slouched or leaning position will cause the affected muscles to feel strained. Hold your shoulders up and back, and keep your chest up and slightly forward. This position will help maintain good spinal alignment and give your lungs more room to expand. Pull your buttocks in and hold your abdomen up and in. This will help keep your back straight by supporting the abdominal organs and reducing the pull on the lower back. Keep your head erect and in line with your back. Hold your chin in slightly but not so that it is uncomfortably close to your chest. Avoid any sort of exaggerated leaning position. Your back muscles are also involved in maintaining your head position. Any unusual position will cause back and neck strain. When you are standing, your feet are your base of support. You should stand so that your weight is centered over your feet. The point at which your body mass is centered is called the center of gravity. Your feet should be roughly parallel and approximately 4–12 inches apart. It isn’t necessary for your feet to be exactly parallel, so long as your toes are pointing in the same general direction. If one foot is pointing one way and one the other way, your entire body will be thrown out of balance and you’ll develop back, hip, and leg strain. Your feet should be at right angles to the lower legs (no high-heeled sneakers) and your body weight should be distributed equally between both feet. Bend your knees slightly so that they do not become locked. Locking your knees interferes with the circulation to your lower legs and reduces the effectiveness of your legs as shock absorbers. Do not twist your body, but instead, turn your whole body when changing directions – this will prevent injuries. When you stand as we have described, you’ll have a firm base of support and your body will be aligned so that your center of gravity is centered over the base of support. You’ll feel balanced and you should be able to maintain that position for long periods of time. Posture Sitting Since you don’t spend all your time on your feet, you should also be concerned about posture in other positions. When you sit, your base of support shifts from your feet to your seat. What we just said about upper body positioning for the standing position also applies to the sitting position (head erect, back straight, chest out, shoulders back, stomach and buttocks in). Your feet should be flat on the floor and your popliteal area (area behind your knees) should be free of the edge of the chair. Crossing your legs or sitting so that the edge of the chair is pressed against the back of your legs will interfere with your circulation and may eventually cause nerve damage. Posture Lying When you are lying down, your muscles are usually relaxed. When you are standing or sitting, your body alignment is maintained by various muscle groups; when you are lying down, you rely on your bed to provide that support. You can help if you make sure that your bed is firm enough to provide the necessary support and you are not lying in an abnormal position. Multiple Choice __________________is defined as the careful, coordinated, and efficient use of the body to do work. Body mechanics Body movements Body posture Body muscles SUBMIT Complete the content above before moving on. Effective Use of Body Muscles Your body is covered with muscles of varying sizes and strengths. Your goal should be to use the largest muscles and muscle groups to do the most work. When positioning or transferring patients, use the large muscles in the legs as much as possible. Unfortunately, in the name of convenience, many of us use smaller muscles to do most of the work, or we perform tasks with our bodies contorted into abnormal positions. In either case, we are not using good body mechanics. Experts have developed guidelines for making the most efficient use of our body muscles. These guidelines are as follows: Plan Your Movements – When you are standing with a patient half in and half out of bed, it is too late to figure out that you probably should have had help moving the patient. Consider how you’ll perform the task, what equipment you’ll need to perform the task, and how much help, if any, you’ll need. Be Realistic About Your Capabilities – Most of us are not built like Arnold Schwarzenegger, and we can’t lift patients single-handedly. If you do not accept your limitations and work with them, you may injure a patient, and you’ll almost certainly injure yourself. Assess The Amount of Assistance That The Individual Helping You Can Provide – For example, if you weigh 90 pounds dripping wet and the person assisting you is about the same size, you’ll probably have some difficulty lifting a 300-pound patient. Of course, you can’t always go by size. The best way to learn the capabilities of your fellow technicians is to work with and get to know them. Maintain a Broad Base of Support – Your base of support is determined by how far apart your feet are, and your base of support determines how well you are balanced. If your feet are close together, your base of support will be small and your balance a little shaky. To illustrate this, place your feet together and try to reach over and pick something up off the floor. If you try it again, with your feet about 15 to 20 inches apart, you should see the difference a broad base of support will make. When you are working with patients, plan your base of support according to the amount of stability you need. If you are trying to support a falling patient, for example, keep your feet relatively far apart for a firm base of support. Keep Your Center of Gravity Low – As we mentioned, your center of gravity is the point at which your body mass is centered. Your stability increases as your center of gravity moves closer to your base of support. Your stability is much greater when you squat to do something than it is when you stoop to perform the same task. Position yourself so that the line of gravity passes through your base of support. The line of gravity is an imaginary vertical line extending straight down through the center of gravity. It is just another way of saying the gravitational pull. If you lean or stoop so that your line of gravity is not over your base of support, your balance will be poor. This is why you move objects within reach so that you can stand erect to work on them or squat to work on objects that are too low for you to reach without bending. An erect posture also helps to protect your back muscles. Use Smooth and Rhythmic Movements – You’ll understand this principle better if you first understand the principle of momentum. Once an object is moving, it gathers a certain force, or momentum, which helps to keep it moving. Each time the object stops moving, the momentum is lost and friction or gravity must be overcome to start it moving again. In other words, because you lose the force of momentum each time you hesitate, it is much easier to lift a patient with a smooth, steady motion than it is with a series of jerky motions. Smooth, rhythmical motions also make more efficient use of muscles by providing more time for muscle contraction and allowing the muscle to contract completely. Last but not least, smooth motions are more reassuring for patients because they feel less like a puppet on the end of a string. Use Leverage to Help Move or Lift Heavy Objects – Leverage increases the efficiency of your muscle power. You are using leverage when you brace your body against the side of the bed and use your body weight to help pull the patient towards you. In this example, the bed and your body weight provide leverage, increasing the force provided by your muscles. There are numerous other examples of leverage. The trick is to use your whole body rather than trying to work with muscle power alone. – Move In a Straight Direction This principle relates back to our earlier discussion of momentum. The force of momentum acts along a straight line. If you change directions when you are moving an object, you’ll lose your momentum. Also, face the direction of your motion. For example, if you are trying to slide a patient up in bed, face the head of the bed. This will prevent twisting motions that can cause painful back injuries. Use Large Muscle Groups – This is one of the most commonly violated principles of good body mechanics. Your largest muscles are located in your shoulders, upper arms, thighs, and hips. The muscles in your lower back are much smaller and less powerful. Yet, most people bend over to pick up objects rather than squatting and using the muscles of the legs and thighs. When you bend over, you place a tremendous amount of pressure on your vertebral column. When you pick something up from that position, you increase that pressure and risk injuring your back. Along the same line, you should use as many muscles as possible to avoid strain. If you are helping a patient move, for example, use both arms, rather than just one. Use The Internal Girdle of Support – When you simultaneously contract your abdominal muscles and your buttocks muscles, you create a muscular barrier around the intervertebral discs of your lower back. This barrier, or “girdle,” helps protect your lower back when you strain to lift or move objects. Use Pulling or Pushing Rather Than Lifting Movements Whenever Possible – The resistance of friction is less than the resistance of gravity. Thus, it is easier, and safer for your back, to slide a patient to the side of the bed than it is to lift the patient. Pulling motions are less strenuous compared to pushing or lifting. Additionally, this motion is easier because it brings the work load (patient) closer to your center of gravity. Perform pulling actions whenever possible. Keep Your Work Close to Your Center of Gravity – If you keep your work close, you’ll be able to use of your large muscle groups and avoid straining smaller arm and back muscles. Work at the same level or height as the object to be moved. For example, when making a patient’s bed, temporarily raise the bed to waist level. This ensures you are keeping the load near the center of gravity. The farther away the work load is from the center of gravity, the more likely an injury is to occur. There are other principles or guidelines you can apply to good body mechanics, but those we have covered are the most important. If you plan your work so that you make safe and effective use of your whole body, rather than just your muscles, you will be using good body mechanics. Multiple Choice Which body mechanic guideline is one of the most commonly violated principles? Move in a straight direction. Keep your center of gravity low. Use large muscle groups. Plan your movements. SUBMIT Complete the content above before moving on. Mechanical Aids for Lifting and Moving Procedures and Equipment Used to Move Bed Patients Now that you understand the possible consequences of immobility as well as principles of body mechanics, we’ll move on into the actual patient activities. We begin by talking about the different techniques and equipment we use to move helpless and near-helpless patients. Following that, we’ll talk about different exercises that we can help the patients do and that the patients can do themselves. Finally, we’ll talk about transfer techniques and equipment used to ambulate patients. Throughout the discussion, we’ll refer to the information we’ve covered on hazards of immobility and proper body mechanics to help illustrate the points we are trying to make. In this section, we discuss techniques used to move and adjust the patient’s position. As you know, if bedridden patients do not change their position frequently, they’ll develop complications like decubitus ulcers and contractures. Whenever possible, encourage patients to move themselves. There will be many times when a patient either cannot move at all or cannot move without help, and you’ll become involved in the movement. Follow the principles of body mechanics we discussed, and move each patient in a safe, careful manner. Patient Positions Before we get into moving the patient, let’s first discuss the various positions for bed patients. Supine Position Supine Position A patient in the supine position is lying on his or her back. The patient’s arms are at his or her sides with hands pronate. This position is also referred to as the dorsal recumbent position. To place the patient in this position, adjust the bed so that it is flat. Use pillows, sandbags, and similar devices to maintain the patient’s alignment and prevent contractures. Prone Position Prone Position A patient in the prone position is lying on his or her abdomen with head turned to the side. The patient’s elbows are normally flexed so that the hands are up near the head. The bed is flat and alignment is again maintained with pillows and sandbags. Also, place a pillow beneath the patient’s lower legs to prevent foot drop. If your patient is very tall, you can hang his or her feet over the end of the mattress. Semi-Fowler's Position Semi-Fowler's Position The semi-Fowler’s position is similar to the Fowler’s position except that the head is not usually elevated quite as high and the knees are bent at about a 15° angle. This knee elevation helps prevent the patient from sliding down in bed. Trendelenburg Position Trendelenburg Position In this position, the mattress is flat, but the bed itself is tilted so that the head is lower than the feet. This is a specialized position and can be used to help provide traction or to treat patients who are in shock. Sim's Position Sim's Position A patient in the Sim’s position is lying on his or her side with the head turned to the side. The patient’s lower arm is positioned down behind him or her, and the upper arm is flexed so that the hand is up near the patient’s head. The patient’s lower leg is bent very slightly and the upper leg is bent and extended so that it is not on top of the lower leg. Side-Lying or Lateral Position Side-Lying or Lateral Position The side-lying position is much like the Sim’s position except that the patient is on his or her side rather than partially towards the prone position. The mattress is flat as before. Both the upper and lower arms are flexed so that the patient’s hands are near the head. Both legs are also bent, with the upper leg bent slightly more than the lower leg. The pillows are positioned as before except that there is a pillow between the patient’s legs rather than just beneath the upper leg. Multiple Choice Which position has the patients head elevated to a 45–60° angle at the head of the bed which puts the patient in the semi-sitting position. Lateral Prone Fowler Semi-Fowler SUBMIT Complete the content above before moving on. The procedures we’ll now discuss include moving a patient up in bed; turning a patient to the side, back, and abdomen; moving a patient to the side of the bed; and turning a patient in a turning frame and circular bed. In each procedure, we specify what assistance, if any, the patient can provide. Moving a Patient up In Bed Many patients are placed in bed positions that elevate either the head or the foot of the bed. Over a period of time, gravity causes these patients to slide down in the direction that the bed is angled. Once they slide down, you will need to help them back to their original position to maintain proper body alignment and promote comfort. Using the person’s weight as a guide to plan a safe move, coordinate how much help and what equipment you will need prior to moving the patient. If the patient is fully able to assist, staff assistance is not needed – but will stand by for safety. The patient is partially able to assist: If weight is less than 200 lbs; 2-3 staff members and a friction-reducing device are needed. If weight is more than 200 lbs; at least 3 staff members and a friction-reducing device are needed. If the patient is unable to assist at all, at least 2 staff members and a mechanical lift are needed. You begin this procedure as you would any other: wash your hands, greet the patient, ask the patient his or her name and date of birth, check the patient’s ID band, and explain what you are going to do. There are three basic techniques, depending on the patient’s size and capabilities. One-person technique Two-person technique Two-person technique with a draw sheet O N E - PE R SO N T WO - PE R SO N T WO - PE R SO N WI T H DR AW SH E E T The one-person technique is actually a coordinated effort involving both the patient and technician. As a technician lifts and slides the patient up in bed, the patient uses his or her arms and legs to pull and push him or her toward the head of the bed. The one-person technique only works if the patient is not extremely large and is capable of assisting with the move. If either or both of those do not apply, use a different technique. Some patients may be able to use only their arms or their legs. You can still use the one-person technique if the amount of assistance is enough to move the patient. Ensure the patient is in the supine position. Prepare the bed for the move by raising it to a waist- height working level, and lock the wheels to prevent it from moving as you shift the patient. Lower the head of the bed, if permissible by the patient’s condition, to reduce resistance to the move. Lower the side rail on your side of the bed so that you can reach the patient comfortably, but MAKE SURE that the other side rail is up so that the patient can’t accidentally fall out. Remove the pillow from beneath the patient’s head and place it against the headboard to protect the patient’s head. Instruct the patient to reach back and grasp the headboard with legs bent and feet flat on the mattress. Instruct the patient to pull with his or her arms and push his or her legs when you give the signal, such as at the count of three. Position yourself so that you are facing the head of the bed at about a 40° angle, place one arm beneath the patient’s hips, and the other arm beneath the patient’s shoulders. Spread your feet to provide a wide base of support, and bend your knees slightly so you can use your leg muscles to lift. Stand so that most of your body weight is on the leg nearest the foot of the bed. When you are ready, give the signal. Lift the patient slightly and slide the patient toward the head of the bed. With luck, the patient will pull and push at the same time, and the move will be relatively easy. As you move the patient, shift your weight from your back foot to the foot closest to the head of the bed. This will allow you to use your body weight as leverage. When you complete the move, realign the patient’s body, and make sure the sheet is as smooth as possible. Place the pillow back beneath the patient’s head, and raise the side rail. Raise the head of the bed, and return the bed back to its original position. O N E - PE R SO N T WO - PE R SO N T WO - PE R SO N WI T H DR AW SH E E T The two-person technique is similar to the one-person technique except that there are at least two technicians involved and the patient may or may not assist. This technique is for patients who are not capable of assisting or are too heavy for one person to handle safely. The initial steps of this technique are the same as for the one-person move. The bed is raised to a working level, the wheels are locked, and the head is lowered. The side rails are lowered so that both technicians can reach the patient, and the patient’s arms are usually crossed over his or her chest rather than extended over his or her head. There are several different ways you can move a patient, depending on the capabilities of the patient and your preference. One common technique is simply a modified approach to the one-person technique. The technicians stand on either side of the patient and position themselves so they are facing the head of the bed at about a 40° angle. They then link arms under the patient’s shoulders and buttocks, and on signal, lift and slide the patient up in bed. Although it is not essential, the patient should be allowed to assist by pushing with his or her feet, if the patient is capable of doing so. After the move, realign and make the patient comfortable, and return the bed to its original position. The shoulder-lift is a modified version of the two-person technique. It is used to move patients who are capable of sitting up and using their hands and arms. The technicians stand beside and slightly behind the patient. They each place the arm closest to the foot of the bed beneath the patient’s thighs and grasp each other’s wrists. The patient drapes an arm over the back of each technician, and the technicians place their free hand on the bed or headboard for support. When the technicians are ready to move, they simply shift their weight and slide the patient along his or her buttocks. The shoulder- lift technique cannot be used for patients who have back, shoulder, or chest injuries. It can be used for other patients and is especially useful for moving patients when the bed cannot be raised to the proper working level. Because patients are sitting up, they are higher than they would be if they were in the lying position. Another variation of the two-person technique is the modified shoulder-drag, which is simply a modification of the way the technicians grasp the patient. Instead of sliding their hands underneath the patient and grasping each other’s wrists, they each slide a forearm under one of the patient’s upper arms near the axilla. The other hand is placed beneath the shoulder for support and lift. When they are ready to move, the technicians slide the patient toward the head of the bed. Although fast and relatively simple to perform, this technique has certain disadvantages—the technicians’ hand position does not provide much lift, the patient is dragged up in bed rather than lifted and slid, it places a lot of pressure on the upper arms and axillary areas of the patient and can be extremely painful to the patient if the technicians are not careful. Obviously, this technique should not be used for very heavy patients or patients who have back, shoulder, and chest injuries. It is useful for moving patients who are small and not seriously disabled. It also adds an element of speed which the other techniques lack. O N E - PE R SO N T WO - PE R SO N T WO - PE R SO N WI T H DR AW SH E E T A drawsheet is one of the most useful mechanical aids you’ll find. It is really nothing more than a specially constructed, short, heavy sheet or a regular sheet that has been folded in half lengthwise. The draw sheet is placed beneath the patient so that it supports the patient from the head level to below the buttocks. When the technicians are ready to move the patient, they prepare the bed as in previous examples. After they lower the side rails, they untuck the drawsheet and roll up the sides so they are as close as possible to the patient. The rolled sheet then becomes a handle that the technicians grasp to lift and slide the patient. If two technicians are working together to move the patient, they position themselves on either side and grasp the rolled sheet at the hip and neck level. They then use their body weight and shoulder muscles to lift and slide the patient up in bed. On completion of the move, the technicians simply tuck the sides of the draw sheet under the mattress and ensure that the patient is properly aligned in the bed. Draw sheets offer numerous advantages over other manual procedures. Because they provide full back support, they can be used to move patients with back injuries. They are also useful for moving very obese patients because more technicians can get involved. Draw sheets eliminate awkward bending positions. Technicians are able to work in an erect position and run less risk of injuring their backs. Draw sheets also eliminate painful holds and friction (shearing forces) between the patient’s body and the bed. Turning the Patient One of the most effective ways to prevent decubitus ulcers and other complications is to turn immobilized patients from one position to another. Doctors will usually specify how often they want patients to be turned, but the normal routine is at least once every two hours for completely immobilized patients. If you are managing such a patient’s care, use a schedule to ensure the patient is turned regularly and spends an equal amount of time in each position. C O NT I NU E General Guidelines There are a number of general guidelines and precautions that apply to all of the turning procedures. We mentioned most of these guidelines earlier, but we’ll review them again. Always introduce yourself, check the patient’s ID, explain In either case, you do not want the patient jumping down from a bed that has what you are going to do, and what the patient can do to help. been raised. Lock the wheels before beginning a procedure. Technicians and Patients respond to treatment better if they understand how patients have been injured because the bed moved at a crucial moment. Lower the treatment is going to help them. Provide privacy during the the head of the bed before moving a patient. It is much easier to move a patient procedure. Most patients do not want other patients watching if the bed is in a flat position. them as they are being dragged around. Also, patients are sometimes inadvertently exposed during a moving procedure. In any case, always respect the patient’s right to privacy. Ensure that any tubes, wires, or other devices attached to the patient are placed so they’ll not be pulled loose when you begin the move. Use the side rails to keep the patient from falling out of bed during a procedure. Patients Plan your work before beginning. Make sure you know what frequently move further and faster than you expect. Protect them by keeping you are going to do and have the right equipment and enough the side rail up on the far side of the bed and putting it back up on your side help. Raise the bed to a working level before beginning the before you move away. Always use good body mechanics. Use a wide base of procedure. This precaution will keep your work closer to your support, large muscle groups, and so forth. Before you leave a patient, make center of gravity and help prevent back strain. About the only sure the patient’s body is aligned properly and that the patient is comfortable. time you would not follow this rule is when you are positioning a patient to sit on the side of the bed or get out of bed. Multiple Response Before moving a patient, what should you do? Mark all that apply. Plan out how you are going to move the patient before moving them. Ensure that any tubes, wires, or other devices attached to the patient are placed so they’ll not be pulled loose when you begin the move. Introduce yourself, check the patient’s ID, explain what you are going to do, and what the patient can do to help. Always use good body mechanics. Use a wide base of support, large muscle groups, and so forth. SUBMIT Complete the content above before moving on. Turning Movements You’ll be turning patients onto their side, back, and abdomen. The procedures are fairly simple, but we’ll review them and explain any extra precautions you should take. Before you turn a patient from a supine position to a side-lying position, cross the patient’s arms on his or her chest so the patient won’t roll on them. Bend the patient’s legs or cross the far leg over the near leg. Either technique will partially shift the patient’s weight so the patient is easier to move and will prevent the patient from rolling back into the original position. Assume a wide base of support with one leg braced against the bedframe and the other slightly back and 12–15 inches to the side. This position will allow you to use your body weight as leverage to move the patient. Place your hands on the patient’s far hip and shoulder and roll the patient towards you. As you move the patient, bend your knees slightly and shift your weight back to help pull the patient toward you. Position the patient as we discussed under side-lying position, bending the upper leg and using pillows to maintain the patient’s position and support the legs, arms, and head. Turning a patient from a supine to a prone position is simply a continuation of the supine to side-lying move. However, instead of the patient’s arms being crossed on the chest, the technicians are positioned so their near arm is extended over the patient’s head and their far arm is kept alongside the patient’s body. That will keep the patient from rolling over and possibly injuring his or her arm. When the move is completed, you simply adjust the patient’s arms to a position that is comfortable for him or her. The patient may request a pillow be placed under his or her head. Make sure the patient’s lower ear is not crimped before you leave, and place a pillow under the ankles to prevent hyperextension of the feet. Moving the Patient to The Side of the Bed Your patient will need to be moved to the side of the bed to be repositioned for various procedures or in preparation for getting out of bed. The patient can be moved from either the supine (the preferred position) or prone position by one, two, or three technicians. You can also use the draw sheet procedure, which can involve four or more technicians. That procedure is covered when we discuss patient transfers. The initial procedure is the same as with the previous patient moves—greet your patient, check the patient’s ID, and explain what you are going to do. Raise the bed to a working level, lock the wheels, and lower the head so the bed is flat. Line yourself and your assistants on the side of the bed to which you’ll move the patient. Designate one person, usually the most experienced technician, to control the move. That technician should have a clear view of the patient’s face and see what the other technicians are doing. The best position for this is usually at the head of the patient. For this procedure, we’ll assume that you are the most experienced technician. Begin by crossing the patient’s arms over the chest. Then, you and the other technicians slide your arms as far as possible under the patient. As the senior person, you’ll be at the head and place your arms under the patient’s shoulders and upper back; the next technician will slide his or her arms under the patient’s lower back and hips; and the technician closest to the patient’s feet will place his or her arms under the patient’s thighs and calves. All of you should have a good base of support with one leg braced against the bedframe for leverage. At a prearranged signal, the three of you will step back, pulling the patient to your side of the bed. Obviously, you’ll not need or have three technicians to move all patients. If the patient is small and you have one assistant, position yourself and your assistant so that the weight is equally divided and follow the same procedure. If you are working alone, move the patient in stages; move the head and shoulders first, then the hips, and finally the legs and feet. Do not use this technique if your patient has any sort of back problem or is very large. GET HELP! If your patient is in the prone position, place your arms in the same relative positions. Take care not to trap the patient’s near arm beneath his or her body when you make the move. In either case, make sure that the patient is properly aligned before you leave. C O NT I NU E Procedures and Mechanical Aids Used to Transfer Patients The procedures used to move patients from one place to another are called transfer techniques. These techniques are actually just extensions of the lifting and moving techniques discussed earlier. Transfer techniques are used to move patients back and forth from their beds to stretchers, wheelchairs, and bedside chairs. These techniques are also used to transfer patients from bedside chairs to wheelchairs, or from wheelchairs to commodes, and so forth. All of the safety precautions and principles of body mechanics discussed earlier also apply to transfer techniques. In fact, they are more applicable because there is more lifting and movement involved and a much greater chance of injury for both the technician and the patient. Transfer Techniques The procedure you will use for each type of transfer depends on the size and condition of the patient and the number of technicians and equipment involved in the transfer. The procedure used to transfer a young, healthy preoperative patient from a bed to a stretcher, for example, is totally different from the procedure used to transfer an obese back-injury patient. You should already be somewhat familiar with transfer techniques from technical school, so we won’t repeat all the step-by-step procedures. We’ll limit our discussion to the specific mechanical principles, safety precautions, and patient comfort measures for each type of transfer. Transfer Techniques Bed-to-Stretcher Transfers Stretchers (gurneys, litters) are frequently used to transport patients to various locations throughout the hospital. Patients transported in this manner include helpless and nearly helpless patients, such as patients with spinal injuries, stroke victims, pre- and postoperative patients, and other patients who must remain in a lying position. These patients are either physically lifted or slid by physical or mechanical means from the bed to the stretcher. Bed-to-stretcher transfers are particularly risky for patients because both the bed and stretcher are at waist height and on wheels. Either the bed or the stretcher could be shoved out of place allowing the patient to fall to the floor. At that height, if a patient falls or is dropped, his or her chance for injury are fairly high. Bed-to-stretcher transfers are also hard on technicians because they require more lifting and reaching than other types of moves. If the technicians are careful to lock the bed and stretcher wheels and position both to minimize chances of their bed being accidentally moved, much of the risk can be eliminated from these transfers. Technicians can reduce the chances of injury to themselves if they use good teamwork and follow the principles of body mechanics discussed earlier. The most senior technician should be in charge of the move and should be positioned at the head of the bed on the stretcher side. This will enable that technician to see both the patient’s face and what the other technicians are doing. This senior technician should control the move with prearranged verbal signals. For example, one person controls a move by saying, “One, two, three, GO!” or “Ready, MOVE!” It doesn’t really matter what words are used, as long as everybody knows what they mean. The first step in the bed-to-stretcher transfer is to prepare the stretcher. Cover it with a clean, dry sheet and tuck it in around the edges to remove the wrinkles. Have another sheet and a blanket available to cover the patient on the stretcher. Also, have a pillow available for the patient that is permitted to raise his or her head. Make provisions to support any IV tubing, catheters, or oxygen tubing the patient may have. Finally, include safety straps to prevent the patient from falling off the stretcher. If the patient is to be lifted to the stretcher, position the stretcher at a 90° angle to the foot of the bed. At least three technicians should position themselves along the same side of the bed as they did to move the patient to the edge of the bed. In fact, begin the move by moving the patient as close as possible to the edge of the bed. The technicians should maintain the same arm positions and on command, lift and curl the patient into their bodies. Holding the patient in this manner keeps the patient close to the technicians’ center of gravity and reduces strain. If the patient is very heavy, has a spinal injury, or an extremity in a cast, it may be necessary to have a fourth technician to provide additional support. If the patient has a spinal injury, the fourth technician should be positioned at the patient’s head and ensure that the head maintains proper alignment with the rest of the body. Once the technicians lift the patient, they move together to the side of the stretcher, and on signal, lower the patient to the stretcher. You can see that there might be a slight problem if the stretcher moved before the technicians could finish lowering the patient. Don’t forget to lock the wheels! When the technicians are ready to put the patient on the stretcher, they assume a wide base of support with one foot slightly forward. They lower the patient by uncurling their arms and bending slightly at the knees. They should not lower the patient by bending forward while keeping their legs straight. Once on the stretcher, check the patient’s body alignment and correct it as needed. Cover the patient and secure in place with safety straps at the chest and thigh levels. If the stretcher has side rails, raise them for additional safety. This technique will also work to transfer the patient from the stretcher to an operating table, x-ray table, or back to the bed. When the patient is returned to bed, the technicians should go to the far side, use the three-person technique to move the patient to the center of the bed, and reposition him or her. Always raise the side rail, before moving to the other side of the bed! In most cases, it is easier to just slide the patient from the bed to the stretcher. If you are doing so without mechanical aids, such as a draw sheet or roller board, begin by lowering the side rail and positioning the patient as close as possible to the edge of the bed. One technician goes to the far side and holds the patient so the patient doesn’t fall out of bed. Keep the side rail on the near side down while the stretcher is being positioned. The other two technicians place the stretcher alongside the bed and then position themselves on the far side of the stretcher. Once they are positioned, the third technician on the far side raises the side rail and joins them. Patients capable of sliding will slide over to the stretcher. You’ll help by making sure that the patient is covered during the move and providing physical assistance as needed. If a patient can’t move, you and the other technicians will reach across the stretcher and pull the patient the same way you repositioned the patient. If you have enough help, you can also have technicians stand at the patient’s head and feet to help lift and slide him or her. As you can see, neither of these procedures is entirely satisfactory. The first involves too much lifting and the second involves too much reaching. The preferred method of transferring helpless patients is to use a draw sheet, also called a turning sheet, to pull them over. We’ll talk more about this when we discuss the mechanical aids for lifting and moving. However, here are a few safety practices regarding stretchers: Never leave a patient alone on a stretcher. Such a patient is entirely helpless and can easily be knocked off or pushed into something. Always use safety straps. Even if the stretcher does have siderails, they won’t help much if you have to stop suddenly. In a sudden stop, the patient will just slide out the end of the stretcher. Transport patients feet first with one technician at the head and one alongside. Back patients on stretchers head-first into elevators so they can be taken off feet-first. Transfer Techniques Bed-to-Wheelchair/Bedside-Chair Transfers Since the bed plays such an important role in the patient’s recovery, it may seem like a contradiction to say that one of your first goals should be to get that patient up and moving as soon as possible. The bed is an important place for the patient to rest and begin the healing process. However, once that process begins, the patient must also begin to move around to restore muscle strength and function. As soon as the patient’s condition permits, and the doctor’s orders allow you to do so, work toward getting the patient out of bed. Moving the patient from the bed to a wheelchair or bedside chair is the first step in this direction. Moving a patient from the bed to a chair is a lengthy process. First, allow the patient to sit up in bed. When the patient can tolerate sitting in bed, allow the patient to sit on the side of the bed and “dangle.” Finally, transfer the patient from the bed to the chair. Of course, you don’t go through all this every time you want to put a patient in a chair; but, since we are describing rehabilitative measures, we should include the steps that lead up to the transfer. Transfer Techniques Sitting a Patient up in Bed With our adjustable hospital beds, sitting the patient up is a very simple task. Begin by placing the patient in the center of the bed in the supine position. Place a footboard at the base of the mattress to keep the patient’s feet at a 90° angle to the rest of his or her body. Raise the head of the bed to the Fowler’s position. Make sure the patient is far enough up in bed so that the bend of the bed is at the base of the patient’s buttocks. Support the patient with pillows under the head and arms. Transfer Techniques Dangling the Patient “Dangling” means positioning the patient on the side of the bed with the patient’s feet resting on a footstool or the floor. In spite of the name, do not allow the patient’s legs to dangle unsupported from the edge of the bed. Doing so would put pressure on the back of the legs and interfere with circulation. Begin the dangling procedure by moving the patient to the edge of the bed as we described earlier. Raise the side rail, and raise the head of the bed to a high Fowler’s position. It will be much easier for you to dangle the patient from that position than it will be for you to first sit the patient up and then turn the patient to a dangling position. Before you sit the patient on the edge of the bed, make sure the bed is in the low position so that the patient’s feet will be able to reach the floor. This and actually helping the patient out of bed are two of the few times you’ll work with a patient while the bed is in the low position. When deciding which side of the bed to move the patient, consider the patient’s condition. If your patient has had a stroke or another problem that has left him or her weaker on one side, move the patient in the direction of the stronger side so the patient will be able to help with the move. Place the patient’s arms across his or her chest so they won’t get in the way while you are turning the patient. Also make the patient comfortable for dangling by helping him or her put on a robe and slippers. Turn the patient to the dangling position by positioning yourself beside the patient, placing one hand and arm under the patient’s thighs and one arm behind the patient’s shoulders. Lift the patient’s legs slightly and pivot the patient outward on the buttocks. Use your body weight as leverage by shifting yourself around as you turn the patient. Once the patient is turned, place the patient’s feet on the floor, or footstool if the patient’s legs are too short to reach the floor. Patients frequently feel faint the first few times they dangle. Do not leave the patient’s side until you are sure the patient is not going to collapse! If the patient is going to dangle for awhile, position the overbed table so the patient can rest on it. Remain in the area until the patient is back in the bed. The dangling position is relatively unstable, and the patient can easily fall if you are not around to support him or her. When the patient has dangled for as long as the patient’s condition or the doctor’s orders will allow, help the patient back to bed. Move the overbed table and footstool out of the way, and pivot the patient back to the sitting position in the bed. Help the patient remove his or her robe and slippers, and raise the side rails. Lower the head of the bed, raise the bed to a working level, and place the patient in the center of the bed in a comfortable position. Sitting up and dangling are preliminary steps to ambulating the patient. Transfer Techniques Moving a Patient to a Chair Moving a patient from the bed to a bedside chair or wheelchair is simply a continuation of the dangling procedure. Place the chair parallel to the bed and on the patient’s strong side, if the patient has one. If you are using a wheelchair, make sure that the wheels are locked and the footrests are out of the way before moving the patient. Because patients frequently knock the chair backwards as they begin to sit, be sure the chair or wheelchair is placed against some solid object before you begin the move. Sit the patient on the side of the bed as we just described. Help the patient put on a pair of hard-soled, well- fitting shoes. Shoes will prevent the patient from slipping while being moved; patient slippers do not work well for this purpose. You can also help the patient put on a robe so he or she will be comfortable while he or she is sitting. You may want to put a transfer belt on a patient who is very unsteady. Such a device will give you something stable to hold on to as you are trying to move the patient. There are several ways to move the patient from the sitting position on the edge of the bed to the standing position. Select the technique you are most comfortable with; the technique that allows you to maintain the most control over the patient’s movements and still permits you to use good body mechanics. With this first technique, assume a wide base of support with one foot between the patient’s feet and your knee braced up against the bedframe. This position allows you to use the bed and your body for leverage while controlling the patient’s movements. Place the patient’s hands on your shoulders and place your hands under the patient’s axilla or on the transfer belt, if you are using one. Instruct the patient to stand as you lift. Flex your knees and keep your back straight so that you will use your large muscle groups to do the lifting. Use your body weight to counter the patient’s weight and pull the patient toward you as you stand. Allow the patient to stand for a few moments before you move the patient to the chair. As with dangling, the patient may be unsteady for the first few times. Once the patient is stable, pivot yourself and the patient until the patient’s legs are touching the edge of the seat of the chair. Have the patient glance back at the chair for reassurance that the chair is actually there. Position yourself again so that you have one foot between the patient’s feet and your knee braced against the edge of the seat. Flex your knees and use your weight to counteract the patient’s weight as you lower the patient into the chair. Use pillows and other devices to make the patient comfortable and to make sure the patient is properly aligned. If your patient is at all unstable, use a safety belt to secure the patient to the chair. Make sure the call bell is within easy reach of the patient before you leave. The second technique is just a modification of your body position when you raise patients to the standing position. Instead of placing one foot between the patient’s feet, stand so that your feet are braced against the patient’s feet. In this position, you will be able to keep the patient’s feet from sliding out from under him or her. As before, balance your weight against the patient’s weight as you pull the patient to his or her feet. Pivot the patient, and brace your feet against the patient’s feet as you lower the patient to the sitting position. To return the patient to the bed, simply reverse the procedure you used to put the patient into the chair. If you want to move the patient from a bedside chair to a wheelchair or from a wheelchair to a commode, position the equipment so that the patient can be pivoted from one position to the other. If wheelchairs are involved, make sure that the wheels are locked and the footrests are out of the way before you begin the transfer. Use the same techniques as before to actually move the patient. The techniques we just covered assume that your patient has some degree of body control and can help you with the move. You may also want to put the patient who cannot participate in the move in a chair or wheelchair. A chair offers a welcome change for a patient who has been on prolonged bed rest, and wheelchairs are much more maneuverable than stretchers if you need to transport a patient who can tolerate the sitting position. Depending on the patient’s size and your own strength, you can make such a transfer by yourself or with the assistance of one or two other technicians. If you are working by yourself, position the chair or wheelchair by the bed as before. If you are moving to a wheelchair, remove the armrest closest to the bed. Assist the patient to the side of the bed nearest the wheelchair. Raise the patient to a sitting position by placing one of your arms under the patient’s near arm and shoulder and the other behind the patient’s neck and far shoulder. Use your body weight and shoulder muscles to pull the patient to a sitting position. Once the patient is sitting, shift your position so that you are behind him or her. Slide your arms beneath the patient’s arms and grasp his or her forearms. Lift the patient’s upper body slightly and slide it back onto the wheelchair or chair seat. Placing one arm behind the patient’s back and one under the thighs, swing the patient’s legs off the bed so that his or her feet are resting on the floor. Replace the armrest on the wheelchair, put the patient’s shoes on his or her feet, use pillows, as needed, to ensure good body alignment, and use a safety strap to secure the patient in the wheelchair. Do not use this technique if the patient is large or if the patient can be injured by compressing the upper body. If you have an assistant, your assistant can help with this procedure by lifting and moving the patient’s legs as you lift the upper body. Even with two people, this technique is not the preferred method for patient movement because it places a great deal of pressure on the back of the person lifting the patient’s upper body. Also, it can be painful for the patient because you are supporting the patient’s weight on his or her axillary areas, and most technicians tend to increase pressure on the patient’s forearms as they lift. If your hands are moderately strong, you can possibly damage the patient’s arms. A third alternative is to use three technicians to move the patient to a chair. Two of the technicians will support the patient’s upper body while the third supports the patient’s legs. The two technicians will assist the patient to a sitting position and position themselves so that they are behind the patient. They may need to turn the patient so the patient’s back is angled toward the edge of the bed. From that position, they each place one arm behind the patient’s shoulders and one arm under the patient’s thighs. The third technician slides his or her arms under the patient’s legs. All three flex their legs and, on signal, lift the patient slightly and move the patient onto the chair. It is very important that the technicians remember to keep their backs as straight as possible and use their legs and shoulders to lift. The patient can be returned to the bed by reversing these techniques. If you are working alone, place the patient’s feet on the bed first, then lift or slide the patient’s upper body onto the bed. Once the patient is in bed, reposition the patient’s body and make him or her comfortable. None of these techniques are very effective with very large or very helpless patients or very large and helpless patients. As we’ll discuss shortly, a mechanical hoist is the best way to move such patients. If a hoist is not available, we strongly suggest that you use a stretcher and multiple assistants to transport the patient. The transfer techniques discussed here will suffice for most situations you’ll encounter in a patient- care environment. We’ll discuss loading patients onto field stretchers and into ambulances when we talk about emergency medicine. Other situations you might encounter include assisting a patient into an automobile or transferring a patient from a wheelchair, examining table, or bathtub. If you are helping a patient into a tub, use no-slip devices and rails to help steady the patient. In any case, if you use common sense and good body mechanics, you shouldn’t have any trouble. Safety Factors Last and not least, safety factors related to the transfer techniques we discussed are essential! Wheelchair and stretcher/gurney safety are very similar: Never leave a patient unattended in a wheelchair. Use a safety strap to prevent the patient from falling out of the stretcher. Always transport the patient feet first unless you are entering an elevator or going through a doorway; then you should back in. C O NT I NU E Mechanical Aids In the previous section, we mentioned a number of mechanical aids that can be used to help transfer a patient from one position to another. Such devices are designed to provide a smooth transfer and reduce the possibility of injury for either you or the patient. Using such devices does not mean that you are not “macho,” but it does mean that you are a lot smarter than someone who tries to show off by not using these aids. There are a wide variety of mechanical aids. We’ll talk about the following four examples: DR AW SH E E T T R A PE Z E R OLLE R B OAR D H Y DR A UL I C L I F T As we mentioned earlier, a draw sheet or turning sheet, is a specially constructed sheet that is placed on top of the bottom sheet so that it supports the patient from the neck to the calves. If a regular draw sheet is not available, you can make a reasonably good copy by folding a regular sheet in half from top to bottom and placing that beneath the patient. If you do that, be sure the single fold is toward the head of the patient’s bed. A draw sheet can be used to protect the bed or help move the patient around on the bed or from the bed to a stretcher. When you are using the drawsheet to move the patient, untuck the edges and roll them up as close as possible to the patient. Then, use the rolled portion of the sheet as a handle. DR AW SH E E T T R A PE Z E R OLLE R B OAR D H Y DR A UL I C L I F T The trapeze is simply a bar hanging from an overhead brace. Its primary function is to allow the patient to change position in the bed. It can also be used for pull-ups by the patient. The trapeze is also useful for patient transfers. Patients can use it to pull themselves into a sitting position and to swing themselves back into bed from a wheelchair or stretcher. DR AW SH E E T T R A PE Z E R OLLE R B OAR D H Y DR A UL I C L I F T The roller board is made up of a row of round poles mounted in a rigid frame and covered by vinyl or canvas. Although the frame is rigid, the poles can roll or turn in place. The board acts as sort of a conveyor belt. The board is placed across the gap between the stretcher and the bed. The rollers turn as the patient is pulled over the board, so less effort is required to move the patient. Since the roller board bridges the gap, it also keeps the patient from falling down between the stretcher and bed. DR AW SH E E T T R A PE Z E R OLLE R B OAR D H Y DR A UL I C L I F T A hydraulic hoist or lift consists of a canvas sling supported by a metal frame on wheels. The lift has several pivot points, which can be adjusted by a hydraulic cylinder. Without attempting to teach you principles of hydraulics, suffice it to say that hydraulic pressure provides the leverage required to lift the patient. This pressure can then be adjusted to lower the patient to another position. The lift is usually on wheels, allowing you to pick up and move a patient to another location before lowering. Hydraulic hoists can be used to transfer patients safely, and with very little effort, from their beds to stretchers, wheelchairs, toilets, tubs, or other locations. When using these lifts, explain the procedure to the patient and follow the manufacturer’s instructions carefully. Do not exceed the hoist’s weight limitations. Test the hoist by raising and lowering the patient over the bed before attempting to move the patient to another location. This will also help to reassure the patient. Finally, be sure that the condition of the patient is not such that the patient will be harmed by the lift. As you can see from the illustration, the sling does not immobilize the patient’s back and neck. Therefore, it should not be used for patients with spine and neck injuries. As with everything else, make sure you have a doctor’s order before moving the patient. Multiple Choice The_________ is made up of a row of round poles mounted in a rigid frame and covered by vinyl or canvas. rollerboard trapeze drawsheet harness SUBMIT Complete the content above before moving on. Techniques and Equipment Used to Ambulate Patients Ambulation, or walking, is the last type of patient movement we’ll discuss in this lesson. The goal of all the rehabilitative techniques we have discussed is to improve the condition of patients to the point where they can function independently. Ambulation is a major step in that direction. A patient who is able to ambulate alone is well along the road to recovery. Some patients have disabilities, such as fractures and degenerative disorders, which interfere with ambulation. These patients can still achieve some measure of mobility and independence through the use of ambulation aids. In this section, we discuss techniques for helping the patient to walk and for protecting a patient against a fall. We’ll also describe selection and use of the different ambulation aids. Patients who have been bedridden for any length of time will not be able to just spring out of bed and run around the room. During the time that they have been lying in bed, their muscles have atrophied and weakened. They are often very unsteady when they first try to stand. You can prevent much of that unsteadiness by helping patients exercise, allowing them to remain as active as possible during the time they are bedridden, and moving them out of bed gradually. As we discussed in the last section, patients should first sit up in bed. When they are able to tolerate that well, patients should be allowed to dangle. Finally, patients should be encouraged to sit in a bedside chair for increasing lengths of time. If you do all that, your patients shouldn’t have any problems when the time comes to actually ambulate. You should always take precautions to prevent injury or to prevent the patient from falling the first couple of times you help your patient walk. These precautions include using a transfer belt, positioning yourself to support the patient, and encouraging the patient to use hand rails and other stationary objects for support. In the last section, we talked about using the transfer belt to help move a patient to a chair. These belts can also be used to help the patient walk or just stand up. A transfer belt gives you something firm to hang onto when you are trying to move or support the patient. Without such a device, you’ll find yourself trying to support a patient by holding on to the patient’s pajamas or various anatomical parts. As I am sure you have already discovered, hospital pajamas are not the most durable garments in the world. If you try to support a falling patient by grabbing the patient’s pajamas, you may find yourself with an irate, injured, and naked patient on your hands! Grabbing the patient’s body is not much of an improvement. You may be able to support the patient, but you will probably also bruise the patient and possibly even fracture some of the patient’s bones. If you don’t have a transfer belt, you can improvise with a stretcher strap or even the patient’s own belt. All you need is a sturdy belt that will fit around the patient’s waist and give you something to hold onto. Positioning is also very important when you are helping a patient ambulate. Some textbooks recommend that you walk arm-in-arm beside the patient. If the patient does become faint, you assume a wide base of support and slide your arm up into the patient’s axillary region. You then rest the patient against your hip until the patient recovers or help arrives. The arm-in-arm position may provide enough support to hold up a patient who becomes a little unsteady, but it is ineffective for a patient who becomes unconscious or just falls. In either case, the patient will probably pull you down, too. Stand beside and a little behind the patient. If you have a transfer belt, either place both of your hands on the belt or place one hand on the patient’s waist and one hand under the patient’s near arm. If the patient begins to fall, you simply step back and assume a wide base of support with one leg between the patient’s legs and one leg to the rear for support. You then slide both hands up into the patient’s axillary area and pull the patient back towards you. The patient’s buttocks should be resting on your extended leg to allow the patient to slide down your leg to the floor. When the patient is on the floor, ease him or her into a lying position, protecting the head and other vital parts as you do so. When you have completed the move, the patient will be in a safe position and you’ll have your hands free to examine the patient for injuries. Instruct and encourage your patients to use any solid object for additional support. Most medical facilities have handrails in bathrooms and similar areas. Some also have rails in hallways and common areas. If handrails are not available, patients can use the wall, sofas, desks, or other large solid objects. Caution your patients not to try to hold themselves up with light, unstable objects like ordinary chairs or overbed tables. These items provide support when properly used but can easily be pulled over. Objects with wheels are also dangerous because they will roll out from underneath falling patients. C O NT I NU E Ambulation Aids Ambulation aids include devices such as crutches, canes, braces, and walkers. Such devices provide additional support for patients whose legs are injured or otherwise too disabled to support them. Without ambulation aids, many of these patients would be forced to remain in bed or to depend on others for their personal needs. Ambulation aids allow patients to function independently. The specific type of ambulation aid used for each patient depends on that individual’s physical condition, support needed, type of disability, and doctor’s orders. Although a physical therapist or physical therapy technician will normally be responsible for fitting and instructing the patient on the proper use of ambulation aids, you may have to perform these functions when they are not available. C R UT C H E S C AN E S WA L K E R S Crutches are wooden or metal devices designed to provide support and balance during ambulation for patients with both long- and shortterm disabilities. There are three basic types of crutches—each designed to meet different patient requirements for support and strength. Regardless of the type that is used, the crutch must be adjusted to fit the patient, and the patient must be taught how to use the crutch properly. Axillary crutches, are designed to fit under the arm into the axillary area and provide axillary and hand support for the patient. They are the type most commonly used for short-term disabilities (e.g., fractures) and the type you will most likely help the patient use. When axillary crutches are properly fitted, the top piece does not dig into the patient’s axilla during use. The crutches can be measured with the patient in either the lying or the standing position. With the patient in the lying position, the crutch length is estimated by measuring the distance from the patient’s axillary fold and adding two inches or by measuring the distance from the axillary fold to a point 6–8 inches out to the side of the patient’s heel. The patient should be wearing sturdy, well-fitting shoes during these measurements. Standing measurements are simpler and more accurate. Have the patient stand up straight and place the crutch tip 6–8 inches out from the side of the patient’s heel. Adjust the crutch so the top piece is two to three fingerbreadths from the axillary fold. You can do the same thing with a tape measure, but who has one when you need it? Adjust the handgrips so that the patient’s elbows are bent at about a 30° angle and the patient’s wrists are slightly hyperextended when holding the grips. Make sure that the wood is not split or cracked, all fasteners are properly secured, and the crutch tips are flexible and not worn, split, or loose. Using crutches requires a certain amount of upper body and hand strength. Encourage the patient to do some of the strengthening exercises to prepare for crutch walking. Also, prepare for teaching the patient by becoming thoroughly familiar with the crutches. You’ll find your teaching more effective if you demonstrate how to use the crutches than if you just try to tell the patient how it is done. Demonstration will also increase your appreciation of the patient’s difficulties. Begin the instruction by teaching the patient how to balance and handle the crutches. When standing, the patient should have a wide base of support with the crutch tips positioned 6–8 inches to the side and in front of the patient. Emphasize that the patient should support his or her weight on the hands, not the axilla. The blood vessels and nerves that supply the hands and arms run through the axillary area. When a patient leans on the crutches, it interferes with this blood supply. The patient may be a little unsteady at first, so start out gradually. You might also want to use a transfer belt to help support the patient until the patient becomes comfortable. Patients who have learned to balance are ready to learn how to ambulate with the crutches. There are a number of different strides or gaits that patients can use, depending on their physical limitations, preferences, and physician recommendations. The four-point gait is used by patients who can bear some weight on both legs. It is a comparatively slow, safe, stable gait. The patient moves only one support at a time so that three points are in contact with the ground at all times. The patient alternates movement of crutch and foot. First the right crutch is moved forward; then the left foot; then the left crutch; and finally the right foot. Illustrates gait movements. The three-point gait is used by patients who can bear full body weight on one foot and partial or no weight on the other. This gait is faster than the four-point gait. The patient moves both crutches and the affected foot forward at the same time, then the patient brings up the uninjured foot. The two-point gait is used by patients who can bear weight on both feet. A crutch and opposite foot are moved forward at the same time, for example, right crutch, left foot. The crutches are used more for balance than for support purposes. This gait is very much like normal walking movements. The swing-through gait is used by patients who can bear weight on one foot but some or none on the other. It is a gait you will see frequently because it is simple and fast. Patients move both crutches up together, and then swing their bodies up to or past the crutches. The gait requires considerable balance and upper body strength. It is frequently used by patients who have permanent disabilities, such as amputations. In addition to one or more gaits, also teach the patient how to go up and down stairs and move from sitting to standing positions. If there is a railing or banister, instruct the patient to use it for support on one side. The rule for going up stairs is “body first, then crutches,” and “crutches first, then body” for going down stairs. Provide plenty of support and practice until the patient becomes comfortable with stairs. The patient can move from sitting to standing position by using the crutches as leverage on the affected side. Canadian crutches are also fairly common. They do not have any axillary support. Instead, they have metal bands that fit around the patient’s forearms. Patients support themselves on their hands like the axillary crutches. Canadian crutches offer less support and balance for the uninitiated than the axillary crutches and are usually used by long-term patients. Platform crutches are the third type. They also have no axillary support and are designed so that the patient’s forearms rest on the weight-bearing surface. Platform crutches are used by long-term patients who have little hand and wrist strength. C R UT C H E S C AN E S WA L K E R S Canes are wood or metal devices used for additional support by people who are unable to bear full body weight on one side. Some canes are single-tipped, others may have three or four tips. Metal canes are usually adjustable, but wood canes are not. A cane is properly fitted when the patient’s elbow is slightly bent when supported by the cane. As with the crutches, the tip(s) should be flexible and in good shape. When using a single-tipped cane, the patient should hold the cane on the unaffected side. To ambulate, the patient should move the cane first, then move the affected foot up to the cane, and finally, the good foot should be moved 10 inches or so past the cane. Three and fourtipped canes are usually held on the affected side. They are heavier and more awkward than the single-tip cane but also offer more support. C R UT C H E S C AN E S WA L K E R S A walker is a metal device used as a four-point walking aid. Walkers are used by patients who are unsteady and/or unable to bear their full weight on their feet. Walker height is adjusted to about the same height as the cane and handgrip for the crutch. Some walkers have been adapted with wheels; others have attachments to carry things. When using a walker, the patient should use a gait similar to the threepoint gait discussed earlier. The patient lifts or slides the walker forward and then shuffles along behind it. Each of the ambulation aids we discussed has numerous advantages and disadvantages. You should be familiar with each type of aid so that you can provide the necessary help to your patient. Watch the video below to learn more about crutches, canes, and walkers. Crutches, Canes, and Walkers Video Transcript.pdf 174.9 KB Multiple Choice What type of ambulation aid is shown in the photo below? Walker Crutches Cane Wheelchair SUBMIT Complete the content above before moving on. Different Types of Patient Exercises Exercise is one of the most basic and essential rehabilitative measures that we can provide. It is necessary for proper body function and muscle tone, and will prevent or improve most of the conditions we discussed earlier. Exercise is not limited to weight lifting, jogging, and other activities. Any type of activity involves a certain amount of exercise. The two types we are most concerned with are passive and active exercise. Before we begin our discussion of these exercises, we should mention a word of caution. As helpful as exercises are, they can also be painful and even dangerous for patients who have heart problems and conditions, such as arthritis, fractures, sprains, strains, torn ligaments, and joint dislocations. The doctor will specify the type and amount of exercise the patient is to have, and if you are uncertain, ask the doctor. Of course, a doctor’s order for treatment is no guarantee that the patient will not have problems. Stop the exercise and notify the doctor or nurse if the patient begins to show signs of pain, resistance, or fatigue. PA SSI V E E X E R C I SE A C T I V E E X E R C I SE I SO ME T R I C E X E R C I SE Patients who are either unable or not allowed to exercise actively are provided passive exercise by a technician. A good example of such a patient would be one who has been paralyzed from the neck down. Although such patients are incapable of doing exercises, they will have the same complications, such as decubitus ulcers and contractures that any other inactive person will have. Passive exercise help to maintain muscle tone and joint flexibility. PA SSI V E E X E R C I SE A C T I V E E X E R C I SE I SO ME T R I C E X E R C I SE Active exercises are activities done by the patient. Such activities include active ROM exercises, isometric exercises, bed exercises, such as push-ups and pull-ups, dangling, and ambulation. Active ROM exercises are simply ROM exercises that are done without assistance. If patients are capable, encourage them to do such exercises at least two or three times a day. Most patients will be eager to do so if they know the exercise will speed their recovery. PA SSI V E E X E R C I SE A C T I V E E X E R C I SE I SO ME T R I C E X E R C I SE These are activities that involve muscle contraction without any body movement. If you place your palms together in front of your chest, for example, and push as hard as you can, you are doing an isometric exercise. Isometric exercises are useful because they do not require any equipment and can be done from any position. A bed patient can do isometric exercises by contracting the various muscle groups. Isometric exercises help to increase the patient’s strength and endurance for other activities. Isometric exercises are potentially dangerous if done incorrectly. Instruct patients not to hold their breath. Such straining will affect the heartbeat and may cause a heart attack. Also instruct patients not to contract a muscle for a prolonged period. Isometric exercises are most beneficial, if muscles are contracted several times for a few seconds each time. C O NT I NU E ROM Exercises ROM exercises should be performed several times each day, and each joint should be exercised five or six times during each session. Ideally, a physical therapy technician will help the patient with these exercises, but if one is not available, you’ll assist the patient. ROM exercises serve a number of useful functions and they are the following: Help to maintain joint mobility, prevent shortening of muscles, tendons, ligaments, and joint capsules, which leads to joint stiffness and fixation (ankylosis), and contractures. Prevent adaptive stretching or lengthening of connective tissue around joints; prevent deformities that limit function; stimulate circulation and sensory nerve endings. Restore loss of joint function. Maintain or increase muscle strength. Increase endurance. There are a number of basic guidelines for you to follow when assisting patients with ROM exercises. These guidelines will help ensure the patient receives full benefit from the exercises, and neither you nor the patient is injured. The basic guidelines for assisting patients are as follows: Steps 1 2 Guidelines Be familiar with the doctor’s orders and the patient’s diagnosis and capabilities. This information will help you decide what exercises are needed and how much the patient can participate. Explain to the patient what you are doing. This is a must for any procedure. Patients will be much more likely to relax and participate in activities if they understand what is going on. 3 Use good body mechanics, such as a wide base of support and large muscle groups, when performing these activities. This will conserve your energy and prevent injury and strain. Steps Guidelines 4 Avoid overexerting the patient or performing exercises to the point of pain. Fatigue and pain will not help the patient and may cause the patient to stop participating. Begin gradually and work slowly. All movements should be 5 smooth and rhythmic. Irregular, jerky movements are uncomfortable for the patient. Move each joint through its normal ROM until you begin to meet resistance. Stop immediately if the patient experiences pain or muscle spasms. Report such reactions to the nurse or 6 doctor, and delay further exercises until the patient can be examined. Excessive stretching of joints can cause injuries and even bleeding into joints. If the patient can’t talk, observe the patient’s face for signs of pain as you do the exercise. Support the body part you are moving above and below the 7 8 joint you are exercising. Cradle or cup the body part and avoid grasping at muscles or tendons. Begin each exercise with the joint in its normal anatomical position and return it to that position at the end of the exercise. 10 Move each joint through its complete ROM, five or six times, slowly, rhythmically, and with control. Repetition is important for joint flexibility, and slow, controlled movements prevent injury. Unless contraindicated, encourage the patient to participate in the exercises. Begin with passive exercises and gradually 11 increase patient participation until the patients can do the exercises without help. Recovery will accelerate as the patient becomes more and more independent.