Body Mechanics and Positioning (Client Care) (Nursing) Part 5

Moving the Client to and From a Stretcher

The wheeled stretcher (also called a gurney or litter) is used to move immobile clients who cannot sit up or who have appliances or casts that do not fit into a wheelchair.

(A) Four nurses grasp the lifting sheet in preparation for a transfer without a transfer board. (B) The client is lifted with the lifting sheet and moved to the stretcher (C) In some cases, three nurses can accomplish a transfer with a lifting sheet. In this case, the nurse on the far side may need to kneel on the bed in order to have enough power to lift the client and in order to reach.

FIGURE 48-18 · (A) Four nurses grasp the lifting sheet in preparation for a transfer without a transfer board. (B) The client is lifted with the lifting sheet and moved to the stretcher (C) In some cases, three nurses can accomplish a transfer with a lifting sheet. In this case, the nurse on the far side may need to kneel on the bed in order to have enough power to lift the client and in order to reach.


Safety precautions to follow when using a wheeled stretcher:

•    Be sure a waist strap and side rails are in place to protect the client from falling

•    Be sure the stretcher covering is clean. Provide enough blankets to keep the client warm.

•    Protect clients from injury by lifting them correctly and putting them down carefully on the stretcher. Make sure enough people participate to ensure safe lifting of the client.

•    Never leave a client alone on the stretcher.

In Practice: Nursing Procedure 48-12 describes the use of a transfer board to move a client from bed to a wheeled stretcher. The principles of using a transfer board are the same, whether from bed to chair or bed to stretcher.

Assisting the Client Confined to Bed

Clients confined to bed need exercise and regular changes in body position to preserve their muscle tone, normal body functions, and morale. A schedule is usually set up to turn such a client at regular intervals. Doing so helps prevent untoward events, such as musculoskeletal deformities, respiratory complications, circulatory disorders, constipation, and skin breakdown.

Adjusting the Backrest and Pillows

Raising and lowering the head of the bed is a simple yet easy way to change the client’s body position. The nurse lifts the client’s head and shoulders to adjust the pillows.

Assisting the Immobile Client to Move Up in Bed

Gravity causes the immobile client to slide down in bed. This is uncomfortable and often interferes with breathing. The nurse will often need to adjust the client’s position or move the client up in bed. In Practice: Nursing Procedure 48-13 discusses the moving of clients confined to bed. Before beginning, the nurse determines the client’s ability to participate, encourages him or her to help as much as possible, and gives clear instructions on what the client is to do. The nurse must be aware of his or her own limitations and capabilities and ask for assistance if the client cannot be safely moved without more help. Usually two nurses are required for this procedure.

Assisting the Immobile Client to Move to the Side of the Bed

Sometimes the nurse needs to move the client to the side of the bed so that he or she is closer for a treatment or injection. Moving the client to the side of the bed allows space in the bed so the client can be rolled into a side-lying position. One nurse, using proper body mechanics, can move most clients to the side of the bed. Whenever possible, encourage the client to assist in the movement. The client can be encouraged to use the side rail or overhead trapeze to help in moving. The nurse serves as a support to the client. Before beginning, the nurse determines if the client is able to understand the instructions and also judges the client’s size and weight, as compared with the nurse’s capabilities. In Practice: Nursing Procedure 48-14 outlines tips for moving this client.

USING CLIENT SAFETY DEVICES

A piece of equipment used to ensure the safety of the client and the healthcare environment is called a protective device or a client reminder device. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and OBRA (Omnibus Reconciliation Act of 1987) have established firm standards for the use of any protective device or restraint. (The regulations are different for psychiatric situations than for other settings.) In Practice: Nursing Care Guidelines 48-3 includes important factors to consider before using any protective devices.

Key Concept Any protective device, safety device, or restraint can only be used to provide safety to the client or to others. The regulations differ from one type of device and one healthcare setting to another. All staff must be thoroughly trained before using any safety device. The goal is a restraint-free setting.

Types of Safety Devices

The client safety device is used when the client’s behavior puts himself or herself at high risk for self injury. There are three classifications of client safety devices or restraints:

•    The medical healing restraint is a device used to prevent the client from interfering with necessary medical care. For example, it may be necessary to prevent the pulling of tubes, catheters, or IV lines, or to prevent a child from scratching an irritated area or suture line. This device may also be used with a confused client who is unable to understand instructions, who is likely to wander away, or who may be unsafe if ambulating.

•    A chemical restraint is a drug used to calm or manage a client’s dangerous behavior.

•    The behavioral health-behavioral management restraint is used to prevent a client from harming self or others. This is most often used in psychiatry and will be discussed.

The medical healing device is often used simply to help the client avoid slipping out of a chair (Fig. 48-19A and B). The least restrictive measures must be attempted first in all settings. The most commonly used devices in the general or long-term care facility are the netted hand mitt (Fig. 48-19C), the vest (Fig. 48-19D), and the lap belt (Fig. 48-19E). The criss-cross vest and the Posey jacket safety device are two types of safety vests. The netted hand mitt is sometimes used to prevent the client from scratching an open wound or rash, pulling at tubes or drains, or from picking at stitches or staples.

IN PRACTICE: NURSING CARE GUIDELINES 48-3

USING CLIENT REMINDER OR PROTECTIVE (SAFETY) DEVICES

•    Explore all other alternatives before applying any safety device. Examples include:

•    Verbal intervention

•    Diversion, such as television, craft projects, reading, puzzles. Involve a family member if possible.

•    Stress reduction, such as guided imagery backrub, music

•    Medications, if ordered

•    Time out

•    Verify the client’s identity before application of any client reminder device.

•    The client has the right to be free of any restraint applied for the convenience of the staff or for disciplinary purposes. You must have special training before using any safety devices.

•    Specific medical orders are required for the use of any safety device. (In an emergency, a device may be applied immediately but the healthcare provider must interview the client face-to-face within one hour)

•    The legal requirements vary from one type of device to another.

•    Provide privacy for the client.

•    The procedure must be explained to the client and to the family

•    Documentation is vital when any safety device is used. Follow the protocol of your facility Documentation required depends on the type of device being used. but evaluation must include vital signs. circulator), and respiratory status, skin condition, and client behavior.

•    When any device is used, it must be released periodically (at least every one to two hours).

•    The client must be given food, water, and the opportunity to use the bathroom. Range of motion must be provided on a regular basis and documented.

•    Skin integrity must be checked and skin care given.

•    Respiratory status must be monitored constantly

•    The client must be observed carefully. Some devices and situations require one-to-one monitoring (staff at arm’s-length at all times).

•    The client is interviewed after the use of a safety device to determine if other methods might have been used and if the client understands the need for the use of the device.

•    In addition to gloves, other personal protective equipment may be required when applying safety devices.

•    Be sure to obtain enough help when applying any safety device.

•    Remove any device as soon as possible.

•    Use quick-release ties for all safety devices. Be sure the knots are out of the client’s reach. The straps must move with the bed or chair and not change in tension as the bed or chair is moved.

Be sure to check with your team leader or instructor before using any safety device. Improper application can be dangerous and could cause death from choking. Figure 4820 demonstrates a quick-release knot that may be used to secure safety devices to the bed or the chair. It is important to create a knot that can be released quickly in an emergency. The restraint must be tied in a location that will move with the client and will not tighten accidentally. In Practice: Nursing Procedure 48-15 demonstrates the proper application of some protective devices.

Types of commonly used safety devices. These devices limit client movement to various degrees and are used only if there is no alternative. Some devices can be removed by the client; these are for client convenience. (A) Lap buddy. (B) Chair with a tray table (Geri chair). (C) Netted hand mitt. (D) Criss-cross vest. This device may be safely used in bed. (E) Lap belt.

FIGURE 48-19 · Types of commonly used safety devices. These devices limit client movement to various degrees and are used only if there is no alternative. Some devices can be removed by the client; these are for client convenience. (A) Lap buddy. (B) Chair with a tray table (Geri chair). (C) Netted hand mitt. (D) Criss-cross vest. This device may be safely used in bed. (E) Lap belt.

Nursing Alert A client using any safety device or restraint that he or she cannot release independently is considered to be vulnerable and must be carefully monitored. This helps protect the client from assault by other clients.

Key Concept If the client is extremely violent or out of control, locked restraints may be necessary. Many additional regulations apply to the use of these restraints. They are most often used in psychiatry The use and application of locked restraints is discussed.

 (A) This quick-release tie is made using an overhand knot, but slipping a loop (instead of the end of the strap) through the first loop. This must be used when securing any client safety device, for quick release in an emergency, (B) The straps are tied to the stationary portion of the bed frame, never to the side rails.

FIGURE 48-20 · (A) This quick-release tie is made using an overhand knot, but slipping a loop (instead of the end of the strap) through the first loop. This must be used when securing any client safety device, for quick release in an emergency, (B) The straps are tied to the stationary portion of the bed frame, never to the side rails.

Special Considerations :LIFESPAN

Client Reminder Devices for Children

In some extreme cases, a child must be controlled or held immobile. There are several means of accomplishing this. However, any type of restraint is used only as a last resort because the child usually becomes very uncomfortable and frightened. Cases in which a child must be placed in some sort of protective or reminder device or securely held in position include delicate procedures, such as circumcision or lumbar puncture. In addition, the child must be prevented from pulling on tubes or IVs, scratching a rash, or picking at a suture line. Children often cannot understand explanations, so some sort of immobilization or reminder device must often be used. The first choice is for another nurse or the child’s caregiver to hold the child.

If the child must be immobilized or controlled in another way, methods include:

•   Mummy restraint—the child is wrapped tightly in a blanket for a short time (to keep still for procedures).

•    Mitts—the hands are wrapped in Kerlix, or special mitts are used (to prevent scratching or pulling at tubes or sutures) (see Fig. 48-I9C).

•    Padded tongue blade reminder device—prevents bending the elbows (to protect suture line or tubes when mitts will not work, such as after cleft lip repair).

•    Papoose board—the child is held tightly to a specially designed board for a very short time (for a surgical procedure, such as circumcision).

•    Bed net or bubble top—this is placed on the crib (to prevent child from jumping out).

•    Jacket reminder device—similar to that for an adult but smaller is placed (to keep child in a chair).

•    Child can be held or secured in a rocking chair (which allows movement, but prevents scratching or picking at a suture line).

Usually, children are not placed in arm, leg, or waist belts because of the extreme danger of choking.

Alternatives to Client Safety Devices

Safety devices should be used only when there is no alternative. They are used solely to protect the safety of the client or others and never for convenience or retribution. The nurse should always try to find an alternative before using a physical or chemical restraint or safety device. Figure 48-21 illustrates some alternative ways to provide client safety. Additional ways include:

•    Using a device that helps prevent slipping down in a chair, such as wedges, support pillows, non-slip materials, or a seat belt with a front release that the client can operate

•    Providing gait training, exercise

•    Providing reorientation, diversion

•    Using a mild chemical agent to help the client to relax, within strict limits

 Always try to find an alternative before using a physical or chemical restraint or safety device. (A) Allow the client to sit near the nurses’ desk or provide company and diversion. A family member or volunteer may assist. (B) A pressure-sensing monitoring system is located where the client’s buttocks should be. The monitor, shown here next to the mat, is hung from the headboard or back of the wheelchair, out of the person’s reach and sight. If the person tries to get out of bed or the chair, an alarm will sound, alerting the staff that the person needs help. (C) A "wanderer” monitoring sensor is attached to the person’s wheelchair or worn around the wrist or ankle. If the client tries to go through a door leading to an unsafe area, an alarm will sound, alerting the staff. This is useful for clients who are likely to stray away, such as those with dementia.

FIGURE 48-21 · Always try to find an alternative before using a physical or chemical restraint or safety device. (A) Allow the client to sit near the nurses’ desk or provide company and diversion. A family member or volunteer may assist. (B) A pressure-sensing monitoring system is located where the client’s buttocks should be. The monitor, shown here next to the mat, is hung from the headboard or back of the wheelchair, out of the person’s reach and sight. If the person tries to get out of bed or the chair, an alarm will sound, alerting the staff that the person needs help. (C) A "wanderer” monitoring sensor is attached to the person’s wheelchair or worn around the wrist or ankle. If the client tries to go through a door leading to an unsafe area, an alarm will sound, alerting the staff. This is useful for clients who are likely to stray away, such as those with dementia.

KEY POINTS

•    The nurse can learn to transfer and position clients effectively for maximum safety and comfort for both nurse and client.

•    Client reminder devices or protective devices must be used with caution and within agency and federal guidelines.

•    Pulling, pushing, or rolling an object is easier than lifting it. Keeping an object moving requires less energy or force than starting and stopping it.

•    The nurse must observe the principles of good body mechanics to prevent injury.

•    Rocking backward or forward on the feet uses body weight as a force for pulling or pushing.

•    A client may become dizzy or faint when first getting out of bed.

•    The nurse should move so that the client cannot grab him or her around the neck during transfers. Such a force can seriously injure the nurse.

•    Clients are assisted to move and walk using a number of devices, such as the hydraulic lift, the wheelchair, walker, or crutches.

•    The hospital bed should be in low position, except when giving bedside care.

•    The client’s body alignment when lying down should be approximately the same as if the person were standing.

•    Joint movement is never forced when doing ROM.

•    Safety in turning, moving, and transferring clients in and out of bed is a nursing priority.

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