ASSISTING THE MOBILE AND PARTIALLY MOBILE CLIENT
Some clients are allowed out of bed (OOB) for the entire day; others are up for certain lengths of time each day, as their conditions permit.
Follow these basic principles when assisting clients out of bed:
• Check the provider’s order to determine the client’s prescribed level of activity.
• Assist the client to put on a bathrobe and slippers. Provide a bedpan, if necessary. Offer a blanket to avoid chilling.
• Being up after an illness or surgery is tiring. Ask the client to tell you if he or she is becoming tired, faint, or weak.
• Offer PRN pain relief medication approximately 30 minutes before the client is to get up. (This will increase client comfort and may increase the length of time he or she is able to be up.)
• Make sure the client’s nurse call signal is within reach, if you leave the client while he or she is sitting up. (A client protective device may be necessary, to prevent the client from falling out of a chair.)
• Start with short periods of being out of bed and increase as the client is able.
Evaluating Fall Risk
It is everyone’s duty to prevent clients from falling. Clients who have difficulty moving or walking or who have had a recent fall are particularly vulnerable. All clients in a healthcare facility must be continuously evaluated for the risk of falling. This is done on admission to the facility and throughout the client’s stay. Most acute care facilities formally evaluate clients and document this at least twice a day. Long-term care facilities usually do at least a daily assessment. Although the formal Fall Risk Assessment is done by an RN, the LPN/LVN plays a vital role in observing and reporting observations. All nurses are expected to assist and move clients in such a way as to prevent falling. Clients at risk for falling are often identified by special slippers (yellow), a yellow name band, and a special sign attached to the door of the room (see Fig. 39-1).
Use of the Transfer Belt
The nurse can provide support to the weak or unsteady person by using a transfer belt (also called a gait belt). This belt is a sturdy webbed belt with a buckle that easily secures around the client’s waist. Explain to the client that the transfer belt provides safety and protection for both client and nurse. In Practice: Nursing Procedure 48-4 discusses considerations in the use of the transfer belt.
Key Concept It is important to use a transfer belt whenever assisting an unsteady weak, faint, or partially paralyzed person to walk. Preventing falls is a primary nursing function for all nurses.
FIGURE 48-9 · (A) If a client feels faint and falling is inevitable, gently ease him or her to the floor. Put your arms around the person’s torso. (Grabbing the arm could cause more damage.) (B) As the person slides down, lower yourself to the floor, cradling the client’s head in your lap, to prevent injury. Stay with him and call for help.
The Client in Danger of Falling
If a client feels faint, try to assist the person into a sitting position. If no chair or bed is available, carefully guide the client to the floor (Fig. 48-9). Place the client’s head as close to his or her lap as possible when sitting. If the client is on the floor, assist him or her to lie down. If help is not readily available, elevate the client’s feet.
Nursing Alert Even if a client is falling, the nurse must avoid letting the client grab him or her around the neck. (One’s neck cannot withstand the force if the client falls.) If a client grabs for the nurse’s neck, the nurse puts his or her head down so the client cannot get a grip. The nurse must immediately lower the client to safety and explain why he or she reacted in that manner.
NCLEX Alert You should be alert to NCLEX situations or conditions that put clients of any age at risk for falls. It is the responsibility of all healthcare professionals to prevent clients from falling. Teaching family members, visitors, or healthcare assistants may be part of your nursing responsibilities.
Dangling
Dangling refers to allowing the client to sit on the edge of the bed, with the legs down and the feet supported on a footstool or on the floor. This helps the client who has been in bed to prepare to sit in a chair and eventually, to walk. Be careful: Allow the person to sit in the bed for a few minutes before assisting him or her out of bed. (It may be necessary to raise the head of the bed.) The client may experience light-headedness or weakness due to a temporary fall in blood pressure (orthostatic or postural hypotension). It is important for the nurse to be aware of the client’s limitations. He or she may be strong enough only to dangle and then lie down again. In Practice: Nursing Procedure 48-5 discusses the steps for dangling.
Helping the Mobile Client out of Bed
Clients who are weak from long periods of bedrest or who are unsteady because of illness require assistance from bed. Care should be taken to ensure that the client has a good sense of balance before helping him or her out of bed. In Practice: Nursing Procedure 48-6 discusses the steps in helping the mobile client out of bed.
Helping a Client Move From Bed to Chair
Some clients have difficulty moving (transferring) from bed to chair or back again because of weakness or paralysis (inability to move a part of the body). Generally, the nurse can transfer even the weakest client safely, using effective body mechanics. In Practice: Nursing Procedure 48-7 outlines the steps for assisting a weak client to move from the bed to a chair or wheelchair. If a client is quite unsteady or heavy, two nurses are required to transfer the client safely from bed to chair or wheelchair. Additional procedures in this topic describe moving the client who is very weak or paralyzed.
Nursing Alert Always request assistance if you are not sure whether you can transfer a client alone. Use a transfer belt if there is any question of the client falling.
FIGURE 48-10 · (A) This client requires the assistance of two people to walk. (B) Two helpers give more support to the very unsteady client while walking.
Key Concept Always apply body mechanics principles to protect yourself and your clients from unnecessary body fatigue, strain, or injury
Helping the Client to Walk
Clients are usually encouraged to be up walking as soon as possible after surgery or serious illness. This helps to prevent the serious complications of immobility (see Fig. 48-4). In many cases, the person needs some support to prevent falling (Fig. 48-10). In Practice: Nursing Care Guidelines 48-2 provides information on how the nurse can assist the client to walk.
Nursing Alert A client may be light-headed or faint when he or she sits up in bed. If this occurs:
• Use a transfer belt the first time the client gets out of bed and each time after that, if needed. Remember: the goal is to keep the client safe and injury-free.
• Help steady the person while he or she sits on the side of the bed. Return to the supine position (lying down) as soon as possible.
• If the client is in a chair have him or her bend over at the waist and lower the head.
• If walking with a client who feels faint, help him or her to lean against a wall and bend over. If this does not help and no one else is there, gently ease the client to the floor (see Fig. 48-9).
Conditioning and Strengthening Exercises
Conditioning and strengthening exercises prepare the client’s body for action. The client dangles, sits in a chair, and practices standing next to the side of the bed. As the client performs these actions, he or she is encouraged to practice correct posture: head up, chest out, back straight, and abdomen in. Encourage the client to press the feet down on a footstool while sitting, to regain the feeling of standing.
IN PRACTICE: NURSING CARE GUIDELINES 48-2
ASSISTING THE CLIENT TO WALK
• One nurse can assist.
• Have the client wear non-slip shoes with wide heels or firm slippers.
• Use a transfer belt for safety.
• Position yourself to the side and slightly behind the client.
If the Client is More Unsteady on the Feet:
• Two assistants are required (see Fig. 48-I0A). Often, one is a family member.
• Hold the client’s arms and support the lower arms and hands.
If the Client Needs Firm Support:
• Two assistants are required.
• The assistants grasp each other’s arms behind the client’s back (see Fig. 48-I0B).
• The client is asked to put his or her arms around the shoulders of the assistants.
Remember, in any case, if the client becomes faint and is going to fall, you can safely ease him or her to the floor, avoiding injury (see Fig. 48-9).
USING MOBILITY DEVICES
Wheelchairs
A wheelchair is often used to move clients who cannot walk or who should be spared fatigue as much as possible (see In Practice: Nursing Procedure 48-7). After the client is in the wheelchair, check to see that he or she is comfortable. If the client is to stay alone, secure the call signal within easy reach. If the client is unable to remain seated upright or may attempt to stand up, a client reminder device or protective device may be needed so the person does not fall out of the chair. An order is required for the use of most protective devices.Check on the client frequently because he or she may become faint or may have pain. Carefully assist the client back into bed. Be sure to lock the wheels of the wheelchair for each transfer.
Sometimes, the client will be moved in a wheelchair to another area for examinations or tests. In Practice: Nursing Procedure 48-8 presents skills to use when pushing a wheelchair. (Many of the same skills are used when pushing a wheeled stretcher [also called a litter or gurney], a fourwheeled bed-like cart. It is used for moving people who cannot sit or walk.)
Canes and Walkers
A cane is a slender, hand-held, curved stick or device meant to provide support while walking. The three basic types of canes are the standard straight-legged cane, the tripod cane (which has three feet), and the quad cane (which has four feet) (Fig. 48-11A). The cane supports balance and helps the client to walk. It provides additional support when one side of a person’s body is weak or if the client has pain in one hip or knee. The cane is held on the client’s strong side and is adjusted to the appropriate height. (This is known as the side contralateral to the weak or painful side.) In Practice: Nursing Procedure 48-9 describes additional considerations when your client is using a cane.
A walker is a four-legged tubular device with hand grips. It provides sturdy support for clients who are unable or too unstable to walk with a cane. The standard walker is made of lightweight aluminum (Fig. 48-11B). The client grips the device, raises it from the floor, moves it away from the body a few inches, sets it securely on the floor, and walks toward it. A moderate amount of upper body strength is necessary for a client to pick up the walker. Some walkers have rubber-tipped feet; others have wheels in the front or back or both. Front wheeled walkers may have sliders on the back legs. Some walkers also have a seat so the client can rest if he or she becomes tired or faint. Some walkers are equipped with a basket, to facilitate carrying items from place to place. The client must feel secure when walking and should stand upright. In Practice: Nursing Procedure 48-10 provides suggestions for helping the client to use a walker.
FIGURE 48-11 · Canes and walkers. (A) Three types of canes are the standard straight-legged cane, the tripod cane (three feet), and the quad cane (four feet). All canes should have a sturdy handle grip and rubber-tipped feet. Ice grips are available for winter use. (B) This walker has lower handholds so the client can have support when getting up or sitting down. The higher handholds are used when the client is walking. Tennis balls can be placed on the back feet, to help the walker slide across the floor easier.
Key Concept When the client gets up to walk, it is important that he or she wear sturdy shoes with non-slippery soles. They should fit well and have low, broad heels. The client should not wear slipper socks. Firm bedroom slippers are acceptable, as long as they have non-skid soles. (These factors help to prevent falls. Slipper socks provide no arch support; extended use may cause serious damage to the feet, arches, and hips. Slipper socks can also be slippery, or the client may step on something sharp and be injured.) Good arch support is important. (This helps to prevent conditions such as sciatica—pain along the sciatic nerve in the thigh and leg and plantar fasciitis, an inflammation of the fascia in the foot.)
Nursing Alert It is important to remember that the wheeled walker is more difficult to use because it does not stay in one place as easily The client must be carefully taught to lean on this walker before shifting his or her weight to prevent the walker from rolling away This could be a dangerous situation.
Crutches
Crutches are walking aids made of wood or metal in the form of a shaft (Fig. 48-12). They reach from the ground to the client’s axillae or forearm (see Fig. 48-13A). The Lofstrand crutch has a single hand bar for the user to grip and a cuff that fits around the arm. People with a permanent disability (such as multiple sclerosis or post-polio syndrome) or a long-term disability (such as a spinal cord injury) often prefer this crutch. The person can drop the hand bar and grasp a handrail or do work without losing the crutch. Although the Lofstrand crutch is more convenient than traditional crutches, it provides less stability. The platform crutch is used in a similar manner. Another type of crutch is called a rocker crutch. This crutch has the two bars extending straight down to the floor, connected by a rounded end or rocker. The rocker end contains a rubber pad, to prevent slipping. This crutch gives more support, because it stays in contact with the floor while the client rocks on the crutch and swings the weight through.
FIGURE 48-12 · Three types of crutches. (A) Axillary. (B) Forearm (Lofstrand). (C) Platform-the client’s forearm is rested on the platform, while grasping the hand hold.
Crutch Adjustment
To adjust crutches:
• Place the bottom of each crutch about 6 inches (15 cm) from the outside of the client’s feet. The top of the crutch should be two to three finger widths below the client’s axillae when his or her elbows are flexed approximately 30° (Fig. 48-13B).
• Adjust the hand bar so that the client can extend the arm almost completely when leaning on the palms. Even if crutches are the correct total length, the position of the hand bar may need to be adjusted. (Some people have long arms in relation to their body height; some people have shorter arms.) If crutches are shortened by more than 1 inch, the position of the hand bar will most likely also need to be changed.
Crutches that fit properly and are used correctly are comfortable and do not create pressure under the arms. Rubber pads may be on the tops of the crutches to protect clothing. In many cases, the rubber pads are removed to discourage clients from leaning on the top of the crutches.
Nursing Alert Leaning on crutches in the axillae can cause a serious disorder known as brachial paralysis or crutch palsy.To prevent this condition, the hands—not the axillae—should bear the weight of the client’s body.
The crutch tip is made of sturdy rubber that fits snugly. A large vacuum tip is a necessity because it provides a firm base of support and prevents slipping. Ice grips are also available for slippery conditions.
