TRANSFER AND AMBULATION Objectives: 1. Definition of Terms: 1.

1 Alignment- Body alignment typically refers to a practice in chiropractics — a field within health care that focuses on the musculoskeletal system. The practice utilizes a practitioner who stretches, pulls, massages, and applies pressure to the patient's body to improve skeletalalignment. Chiropractors argue that body alignment improves the functioning of the nervous system which in turn improves physical and mental health. 1.2 Ambulation- the ability to walk from place to place independently with or without assistive device. 1.3 Ambulatory - promotion and assistance with walking to maintain or restore autonomic and voluntary body functions during treatment and recovery from illness or injury. 1.4 Braces - An orthopedic appliance used to support, align, or hold a bodily part in the correct position. 1.5 Canes- Canes or walking canes are just one of several devices available to assist in ambulation, or walking. Using a walking cane improves balance by increasing a person’s base of support. When used correctly, canes unload the leg opposite to the hand the cane is in by up to twenty five percent. There are many types of cane - example: C cane, Functional grip cane, Quad cane and Hemiwalker. 1.6 Carry – To hold or support while moving 1.7 Crutches - is a wooden or metal staff used to aid a patient’s mobility impairment or an injury that limits walking ability. 1.8 Gait – the manner or style of walking. Depends on the person’s ability to support their weight and balance. 1.9 Hydraulic Lift – it can help transfer an immobile or obese patient safely from the bed to a chair. 1.10 Lift Sheet - is a sheet used in the medical industry to lift immobile patients from their bed. It can be made of plastic, rubber, or cotton, and is about half the size of a regular sheet. It supports the body from the upper back to mid thigh during lifting. 1.11 mobility – the state or quality of being mobile. 1.12 Movement- The act or process of moving. 1.13 Non-ambulatory- not able to walk around. 1.14 Orthostatic Hypotension- blood pressure that falls when a client sits or stands abruptly. It is usually the result of peripheral vasodilatation in which blood leaves the central body organs, especially the brain, and moves to periphery, often causes the person to feel faint. 1.15 Stretcher- a device for carrying a sick, injured, or dead person. 1.16 transfer- to move a person from one place to another 1.17 transfer belt - is used primarily t help a patient to transfer between bed and wheelchair or wheelchair and toilet or car.

1.18 walker - an enclosing framework of lightweight metal tubing, sometimes with wheels, for patients who need more support in walking. 1.19 weight - A measure of the heaviness of an object. 1.20 wheelchair - is a device used for mobility by people for whom walking is difficult or impossible, due to illness or disability.

2. 2.1 Importance of Transfer and Ambulation Ambulation: - it helps strengthen the muscles, especially those of the abdomen and legs - it helps joint flexibility, Especially that of the hips, knees and ankles. - it stimulates circulation, it help prevents Phlebitis (inflammation of the veins) and the development of stroke-causing clots. - it helps prevent constipation because the movement of the abdominal muscles stimulates the intestinal track. - it helps prevent osteoporosis due to mineral loss from bones when they do not bear weight. - it stimulates the appetite - it helps prevent urinary incontinence and infection-when residents are able to go to the bathroom on their own, incontinence is reduced. - it relieves pressure on the body and skin, helping to prevent pressure ulcers. - it improves self-esteem and the resident's feelings of independence. - it improves the resident's ability to socialize. Transfer: - allows minimum strength of the nurse when using proper body mechanics. - uses patrients independence and aids in rehabilitation. - mobilizes the patient without causing injury. - changes the patient's surroundings. - prevents systematic hazards of immobilization. 2.2 Indications of Transfer and Ambulation Ambulation: - the patient needs help in moving - for elderly person - for pregnant woman - patient undergone surgery - continued bed exercise to regain muscle strength. Transfer: - needs to transfer to another room/unit - patient has treatment/diagnostic test - permitted out of the bed (client)

2.3 Contraindications and Indications of Transfer and Ambulation

Indications of Transfer and Ambulation: Ambulation: - the patient needs help in moving - for elderly person - for pregnant woman - patient undergone surgery - continued bed exercise to regain muscle strength. Transfer: - needs to transfer to another room/unit - patient has treatment/diagnostic test - permitted out of the bed (client) Contraindications of Transfer and Ambulation: Ambulation: - spinal injury - both legs are paralyzed - contraindicated by the doctor Transfer: - spinal injury - recent operation (spinal cord) - burns/severe wounds 2.4 Basic Guidelines in Transferring and Ambulating Patients Follow the rules for good body mechanics. Check walking aids frequently to make sure they are in good condition. Always explain the procedure to the patient ahead of time. Make sure all devices are fitted properly to the patient. Make sure all tips of canes, walkers and crutches are flat on the floor. Make sure the patient is not placing the walker too far from him or her. 7. Do not allow the patient on crutches to support his or her weight on the axillary pad. Only on the handle bar. 8. Make sure the patient’s nonskid shoes or slipers fit well and in good repair. 9. Watch signsfor patient discomfort or fatigue.

3. 3.1 Mechanical devices used in: 3.1.1 Transferring patients using: 3.1.1.1 stretcher 3.1.1.2 wheelchair 3.1.1.3 transfer belt 3.1.1.4 hydraulic lift 3.1.2 ambulating patients using: 3.1.2.1 canes  Instruct the patient to use a cane with a small base as possible and eventually progress to a singleended cane if possible.  Teach patients to stand erect when walking with a cane and not to lean out over the cane  Patients should be taught to position their canes within easy reach when they sit down so they can rise easily. 3.1.2.2 walkers • The nurse should determine the following for patient’s using walkers: 1. Amount of weight bearing allowed on lower limb. 2. Appropriateness for client’s height. 3. Type of Walker ( pick-up or rolling ). 4. With pick-up walker: client’s ability to grip, lift and propel the walker forward. 5. With using rolling walkers: patient’s ability to grip and propel the walker forward. • Educate the client about the use of walkers; inform them that when transferring from chair or commode, they should back the walker to the toilet seat and use arms of chair or commode to assist standing. Teach clients to always use both hands when using a walker to transfer from standing to sitting.

3.1.2.3 crutches  Follow the plan of exercises developed to strengthen the arm muscles before beginning crutch walking.  To prevent slipping, crutches should have dry rubber tips.  If rubber tops are worn or lose, they must be replaced  The crutch must be inspected before us; if bends or cracks are present. 3.2 Measurement of Crutches The following techniques can be used to measure the patient for axillary crutches: • • • Have the patient lie flat in bed on the back wearing the shoes to be used when walking. Measure the distance from the anterior fold of the axilla straight down to the heel, and then add 2.5cm (1 inch). With the patient standing, position the crutch pad three fingerwidths below the axilla, with the bottom tip of the crutch placed diagonally out to a point 10 to 15cm (4-6 inches) to the side of the heel. To obtain an approximate crutch length, use the patient’s height and subtract 16inches (60cm). After the crutches have been adjusted to the proper length, have the patient stand to adjust the handgrips. Secure the handgrips while the patient grasps them in the hands, with elbows slightly bent and wrists bent backward. Teach the patient that the support of the body weight should come primarily on the hands and arms while using the crutches, not in the axillary areas, where pressure may damage nerves and cur off circulation. Also, the crutches should not be forced into the axillae each time the body moves forward.

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3.3 Proper use of Crutches  Follow the plan developed for you before beginning walking.  Have a health care professional establish the correct length for your crutches and the correct placement of the hand pieces.  The weight of the body should be borne by the arms rather than the armpits.  Maintain an erect posture as much as possible to prevent strain on muscles and joints for balance.  Each step taken should be a comfortable distance for you. Start with small steps rather than big.  Inspect crutch tips regularly and replace them when worn.

 Keep the crutch tips dry and clean to maintain their surface friction.  Wear a show with a low heel that grips the floor.  Adjust shoelaces so they cannot come untied or reach the floor. 3.4 Different gaits using: 3.4.1 two-point gait  Requires at least partial weight bearing of both legs: Lt foot & Rt crutch move together ahead 10-15 cm (4-6inches) Rt. foot & Lt crutch move together ahead

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3.4.2 three-point gait    all weight bearing on strong leg move both crutches ahead follow through with body and only strong foot touches the floor

3.4.3 four-point gait  Provides best balance & stability for person but must be able to weight bear on both legs. Rt. crutch forward Lt. foot forward Lt. crutch forward Rt. foot forward

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3.4.4 swing to-gait  Weight bearing both feet, Provides stability, requires arm length And can be used with walker. Beginning stance Advance both crutches Lift both feet/Swing forward/land feet next to crutches Advance both crutches Lift both feet/Swing forward/land feet next to crutches

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3.5 Types of Carry 1. Firemans carry 2. Side carry 3. Roll over carry 4. Chair carry 5. Carry of your baby 6. Wrap around carry

4. Beginning Skills in 4.1 Transferring patients from bed to chair to wheelchair Procedure Rationale

Explain the procedure to the patient Offer This facilitates cooperation of the patient. bedpan. Empty bladder will increase patient comfort. 1. Perform hand hygiene. 2. Asses the patient’s ability to assist with transfer. Move equipment as necessary to make room for the chair. Close the door or curtain. 3. Place the bed in the low position. Hand hygiene deters the spread of microorganisms. This ensures patient safety and facilitates the transfer. Closing the door or curtain provides for privacy. This facilitates transfer to chair.

4. Assist the patient to put on a robe and This provides warmth. Slippers provide slippers with non-skid soles. protection and stability. 5. Position the chair at the bedside: a. For a patient with unimpaired mobility: Bring chair close to the bedside facing the foot of the bed and, if possible, brace the back of the chair against a bedside table. b. For a patient with impaired mobility: Position the chair facing the head or foot of the bed. When sitting on the side of the bed, the patient should be able to steady self by using the hand on the unaffected side to grasp the arm of the chair. 6. Lock the wheels on the chair and bed if appropriate. Raise the foot pedals on the wheelchair to the up position. This increases stability and ensures patient safety during the transfer.

This uses the strong side to provide balance and improve stability during transfer.

This ensures patient safety.

7. Raise the head of the bed to the highest position. 8. Assist the patient to sit on the side of the bed by supporting the patient’s head and neck while moving the patient’s legs off the bed to dangle. Steady the patient in that position for a few minutes. 9. Assist the patient to the standing position: a. For a patient with unimpaired mobility: Face the patient and brace your feet and knees against the patient. Place your hands around the patient’s waist while the patient holds onto you between the shoulders and waist. Use your legs to help you raise the patient to the standing position. b. For a patient with impaired mobility: Face the patient and brace your feet and knees against the patient, especially against the affected extremity. Place your hands around the patient’s waist. The patient may place the unaffected arm around your shoulder or use the unaffected arm to reach for the arm of the chair and to push while raising to the standing position. 10. Pivot the patient (on the unaffected limb if applicable) into position in front of the chair with legs positioned against the chair. 11. The patient may use one arm (the unaffected limb if applicable) to place on the arm of the chair and steady self while slowly lowering to the sitting position. Continue to brace the patient’s knees with your knees and flex your own hips and knees when seating the patient. 12. Adjust the patient’s position using pillows where necessary. Cover the patient and use restraint if necessary. Position the call bell so it is available for use. 13. Perform hand hygiene. 14. Document the patient’s tolerance of the procedure and length of time in chair.

Moving from the sitting to the standing position requires less energy. The sitting position facilitates transfer to the chair and allows the circulatory system to adjust to a change in position.

This provides for stability and for use of major muscle groups to facilitate movement. Allowing the patient to grasp the nurse around the neck could injure the nurse if the patient should fall.

This provides for stability and makes use of the unaffected extremities to facilitate movement.

This provides security and proper position before sitting. The patient uses own arm for support and stability. The nurse flexes the knees and hips to use a major muscle group to aid in movement and reduce strain on the back. This maintains proper body alignment and provides for comfort and safety.

Hand hygiene deters the spread of microorganisms. This provides accurate documentation and ensures continuity of care.

4.2 Transferring a patient from bed to stretcher and vice versa Procedure 1. Explain the procedure to the patient. 2. Perform hand hygiene. 3. Move the bed and equipment in the room to make room for the stretcher. Make sure that assistants are available. Close the door or curtain. 4. Raise the bed to the same height as the stretcher and adjust head of the bed to the flat position if the patient can tolerate it. Lower side rails. Rationale This facilitates the cooperation of the patient. Hand hygiene deters the spread of microorganisms. This facilitates transfer movement and provides for privacy.

Pushing and pulling require less effort than lifting. This position facilitates moving the patient.

5. Place a draw sheet under the patient if one is This facilitates movement of the patient not already there. Use the draw sheet to to the stretcher. move the patient to the side of the bed where the stretcher will be placed. 6. Position stretcher next to the bed and parallel to it. Lock wheels on the stretcher and bed. Remove the pillow from the bed and place it on the stretcher. 7. To move the patient: a. The first nurse should kneel on far side of the bed away from the stretcher. Position the knee at the upper torso closer to the patient than the other knee. Grasp the draw sheet securely. b. The second nurse should reach across the stretcher and grasp the draw sheet at the head and chest areas of the patient. c. The third nurse should reach across the stretcher and grasp the draw sheet at the patient’s waist and thigh area. Ask the patient to fold arms across the chest. The nurse uses a major muscle group to assist in movement. The nurse’s flexed hips help avoid back injury. Positioning of the stretcher and locking the wheels facilitate safe transfer of patient.

This promotes safe transfer by supporting the patient’s head and upper body. This supports the lower part of the patient’s body for safe transfer.

d. At a signal given by the first nurse, the second and third nurses pull while the first nurse lifts the patient from the bed to the stretcher. 8. Secure the patient on the stretcher until Side rails are raised. Assist the patient to a comfortable position with the covering in place. Leave the draw sheet in place for transfer back to bed. 9. Perform hand hygiene.

Working in unison distributes the work of moving the patient and facilitates the transfer.

This ensures patient safety and comfort.

Hand hygiene deters the spread of microorganisms.

4.3 Proper transport of patient on: 4.3.1 Stretcher  Use hall ceiling mirrors at intersections before turning corners. Lock elevator door open when entering or exiting. Stand at head of stretcher to push stretcher up a ramp. Back down a steep ramp while positioned at head of the stretcher. Lock stretcher brakes when standing still. Always push a stretcher from the end where the client’s head is positioned This position protects the client’s head in the event of a collision.  Maneuver the stretcher when entering the elevator so That the client’s head goes in first.  Fasten safety straps across the client on a stretcher, and raise the side rails. 4.3.2 Wheelchair 4.3.2.1 Flat or level surfaces   Lock brakes when the wheelchair is standing still. Intravenous infusion bags can be placed on portable IV poles attached to the wheelchair during transport. Ensure the client is positioned well back in the seat of a wheelchair.  Use seat belts that fasten behind the wheelchair to protect confused patients from falls.

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4.3.2.2 Ramps or Inclines surfaces   or inclined surfaces.  of an incline. 4.3.2.3 Through doors and elevators  If going through a self-closing door, back the wheelchair out of the room. You can keep the door open by backing against the door. The wheelchair can then be guided out of the room.  large wheels first. When pushing a wheelchair, back into and out of elevators. Rear Place your body between the wheelchair and the bottom Back slowly down wheelchair ramps. Push the wheelchair ahead of you when going up ramps

4.3.3 Using canes  Use cane on unaffected side  Hold the cane close to the body; do not move cane forward beyond the toes of the affected foot.

Advance cane simultaneously with affected limb. 4.3.4 Using crutches   Always use good posture. Maintain proper foot position on the affected side (foot drop can result from walking on toes or ball of foot). Eliminate obstacles in ambulatory path.

4.3.5 Using walkers For clients with weight-bearing status: Use advance Walker and step normally. For partial or non-weight bearing on the limb: Thrust weight forward, then lift the walker and replace all four legs on the floor.

5. Safety points or issues when a patient is on: 5.1 Stretcher • Lock the wheels of the bed and stretcher before the client transfers in or out of them. • Fasten safety straps across the client on a stretcher, and raise the side rails. • Never leave a client unattended on a stretcher unless the wheels are locked and the side rails are raised on both sides and/or the safety straps are securely fastened across the client. • Always push a stretcher from the end where the client’s head is positioned. This position protects the client’s head in the event of a collision. • If the stretcher has two swivel wheels and two stationary wheels: a) Always position the client’s head at the end with the stationary wheels and b) Push the stretcher from the end with the stationary wheels. The stretcher is maneuvered more easily when pushed from this end. • Maneuver the stretcher when entering the elevator so that the client’s head goes in first. 5.2 Wheelchair • Always lock the brakes on both wheels of the wheelchair when the client transfers in or out of it. • Raise the footplates before transferring the client into the wheelchair. • Lower the footplates after the transfer, and place the client’s feet on them. • Ensure the client is positioned well back in the seat of the wheelchair. • Use seatbelts that fasten behind the wheelchair to protect confused clients from falls.
Note: Seatbelts are a form of restraint and must be used in accordance with the policies and procedures that apply to the use of restraints.

• Back the wheelchair into or out of an elevator, rear large wheels first. • Place your body between the wheelchair and the bottom of an incline.

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