PCC Ambulation/Transferring/Range of Motion ATI

bending the toes and foot downward

plantar flexion

How can we prevent complications that arise in bedridden patients like pressure ulcers, contractures, and foot drop?

Because these complications can develop over a short period of time, it is essential to position your patients properly and reposition them at least every 2 hours, or according to your facility's policy.

What should you do before moving a patient?

Before beginning the process of transferring a patient, it is important to determine how capable the patient is of physically participating in the transfer and what assistive devices or additional staff you'll need. It is also important to explain the transfer process so that the patient understands what you are doing and is willing to cooperate. That usually makes the transfer less stressful.

What must we do before performing passive range of motion exercises on patient?

Before patients begin range-of-motion exercises, complete a thorough assessment to determine their range-of motion-capabilities and the extent of range of motion to include in each patient's plan of care.

How to ambulate a patient with crutches?

Before starting, confirm that patient is tolerating upright position and does not feel any dizziness or weakness. Have the patient hold both crutches on the unaffected side and push up on the bed side rail on the affected side. Stand then put one crutch under each arm. 6 inches to side of one foot, and 6 inches in front, to provide wider base of support.

What does a stepwise approach to ambulation look like?

Begin the ambulation process by having patients sit up in bed for a few minutes. If they tolerate sitting up, have them dangle their legs at the side of the bed. If they tolerate dangling, help them to a standing position at the side of the bed. If they tolerate standing, the next step is ambulation.

sitting on the side of the bed with the legs suspended freely from the knees

dangling

Before helping patients out of bed and assisting them in walking, what must nurses do first?

determine the level of assistance each patient requires. This varies with each patient's health status and the length of time the patient has been inactive. The patient's weight-bearing capability and upper extremity strength should be evaluated, along with the patient's level of cooperation and comprehension.

farthest from the origin of a part

distal

directed toward or situated on the back surface

dorsal

upward bending of the toes and the foot

dorsiflexion

turning of a body part away from the body's midline

eversion

How to transfer patient from bed to stretcher?

explain transfer. place bath blanket or sheet over patient. raise bed so that it is slightly higher than gurney. Place transfer board under patient. Have two nursing staff members on one side of the patient. Have a third staff member on the other side of the bed. Roll both sides of the draw sheet in towards the patient. Grasp draw sheet and gently roll patient onto her side. Other staff member will roll transfer board under draw sheet and patient. Roll patient back. Move gurney to side of bed- check brakes in locked for both bed and gurney. Two staff members will pull patient onto gurney, third will hold transfer board and keep it off gurney.

outward rotation (turning around an axis) of a joint

external rotation

movement that decreases the angle between two adjoining bones, bending of a limb

flexion

the pattern of how a person walks

gait

a device, usually a strap of cotton webbing with a buckle, designed to be placed around a patient's waist to assist with transferring and ambulation

gait belt

movement of a body part beyond its usual resting and extended position

hyperextension

increase in the volume of a tissue or organ produced entirely by enlargement of existing cells

hypertrophy

What must we keep in mind if patients are being transferred? EX: for muscle supports and adaptations to bedrest that may cause discomfort when transferred.

it is important to remember that some patients have muscle weakness or paralysis of an extremity and that you must support that extremity during the transferring process to prevent injury. It is also important to keep in mind that patients who have been on bedrest or have been inactive for several days or weeks may experience weakness, dizziness, and orthostatic hypotension when transferred.

the act of bending to one side

lateral flexion

3 key nursing principles for maintaining safe patient transfer

maintaining a wide base of support, ensuring a lower center of gravity, and facing the direction of the movement.

being able to support some percentage of the body's weight

partial weight bearing

the process of putting a joint through its full extent of movement by someone other than the patient

passive range of motion

movement of a body part so that its front or ventral surfaces face downward

pronation

lying on the abdomen with the legs extended and the head turned to the side

prone

nearest to the origin of a part

proximal

the process of turning around an axis

rotation

Where should the nurse stand when teaching crutch gait

slightly behind and to the side of patient in case patient needs assistance

movement of a body part so that its front or ventral surface faces upward

supination

lying on the back usually slightly elevated with a small pillow

supine

Before assisting a patient with ambulation, transferring, or range-of-motion exercises, what must we do?

thorough assessment of muscle strength, ability to move and activity tolerance. Assess need for devices and additional staff.

being able to support some percentage of the body's weight

weight-bearing

How do you properly put patient into Sims' position? Why do we use Sims' position?

In Sims' position, the patient is halfway between the lateral and the prone positions. The upper arm is flexed at the shoulder and elbow, and the lower arm is positioned behind the patient. Both legs are in a flexed position in front of the patient, with the upper leg more flexed than the lower one. This position is most often used when patients are receiving an enema or for an examination of the perineal area. To keep the body in proper alignment in this position, place a pillow underneath the patient's head and under the upper arm to prevent internal rotation. Place another pillow between the legs.

How do you position patients in lateral position?

In the lateral or side-lying position, the patient lies on one side of the body with the top leg in front of the bottom leg and the hip and knee flexed. This position helps relieve pressure on the sacrum and is especially useful for patients who are on bed rest and spend a lot of time supine or in Fowler's position. To maintain proper body alignment in this position, place a pillow under the patient's head and neck, another under the upper arm (with the lower arm flexed), and another between the legs to keep the hips properly aligned.

What should you do if a patient becomes weak or dizzy during ambulation and begins to fall?

If a patient becomes weak or dizzy during ambulation and begins to fall, it is important to protect both yourself and her from injury. Instead of trying to hold the patient up or catch her, help ease her gently to the floor. You can do this safely by placing your arms on the gait belt or around the patient's waist and then placing one leg forward and allowing her to use it for support as you ease her to the floor. To help prevent injury to your lower back, bend at the knees as you help the patient to the floor.

How can you best support a patient in a prone position?

In the prone position, the patient lies on the abdomen with the head turned to one side. The hips are not flexed. Sometimes, one or both arms are flexed on each side of the patient's head. Because this position can cause hyperextension of the lower back, difficulty breathing due to pressure on the chest, and foot drop, it is not a position you'll use often. If a patient does lie prone, place a pillow under the patient's head and a small pillow or towel roll under the abdomen just below the diaphragm. Also, place a pillow under the lower legs to keep the toes from touching the bed.

How to ambulate a patient with a walker

Make sure equipment is locked before moving onto walker. Tell patient to put one hand on the bed and one on a side rail for support to stand- push her up. Have her place her hands on handgrips of walker one at a time. Help patient turn around. Push walker and affected leg four inches forward, then shift weight to arms, then move unaffected leg forward to meet other leg.

Describe a nurse assist for sitting to standing to ambulate.

Make sure patient is tolerating sitting position- does not feel dizzy, lightheaded, etc. Put on gait belt around waist if necessary. Assist patient to standing by standing in front of her and grasping both sides of gait belt or waist, while holding onto gait belt, gently rock back and forth 3 times. On 3rd motion, pull client into standing position. Once client stable and on feet, move to affected side. Grasp gait belt in middle of client's back, hold onto client's hand closest to you at the same time. If patient lightheaded, move back to bed or chair. If not, begin walking. Instruct client to pick up and put down each foot and not to shuffle, with you at side for support.

Why would we use mechanical lifts?

Mechanical lifts are used to transfer patients who weigh more than 200 pounds, are unable to assist with transfer, or are uncooperative. They can be suspended from the ceiling or consist of a wheeled base. All have an overhead bar with a sling suspension system and a sling that supports the patient's weight. Depending on the lift used, the lifting bar may be moved using a manual hydraulic pump or a remote-control electrical device.

How do we use assistive devices for transfer and ambulation?

Numerous types of assistive devices can help you with ambulating and transferring patients. The most common include a gait or transfer belt, a transfer board, and a draw sheet. You'll use a gait belt for patients who need help with ambulation or with transferring from the bed to a chair. You'll use a transfer board to move a patient from a stretcher to a bed. You'll use a draw sheet to reposition a patient in bed.

For those who have been immobile or on bed rest, what happens when they stand or sit up in bed? How can we help the ambulatory process along?

Oftentimes they will experience vertigo or orthostatic hypotension the first few times they stand/sit up in bed. Breaking the ambulatory process into stages ensures safety.

What type of patients usually use the swing-to gait? How does this work?

Used by patients who can bear weight on both leg. Provides stability and requires arm strength. Move both crutches forward. Shift weight and swing forward, lift feet and put next to crutches. Repeat sequence.

What type of patients usually use the swing-through gait? How does this work?

Used by patients who can bear weight on both legs. Move crutches forward. Lift weight onto crutches and swing just past crutches, feet landing here.

Why is it beneficial for patients to be able to get out of bed, sit in a chair, or leave their room?

When patients are able to get out of bed, sit in a chair, or leave the room, their physical and psychological well-being improves. When patients are unable to do these things on their own, it becomes your responsibility to help them with these tasks.

How do we perform passive range of motion exercises on a patient?

When performing passive range-of-motion exercises, cradle the patient's joint to support it both above and below. Put each joint being exercised through as full a range of motion as possible, starting with the neck and moving down to the lower extremities. If the patient reports pain or discomfort at any time, stop the exercise.

What type of patients usually use the 2-point crutch gait? How does this work?

Works well for patients who can manage some weight bearing on both legs but don't need the support of the 4-point gait. Move left foot and right crutch forward. Move right foot and left crutch forward. Repeat.

Why do we use hand rolls?

You'll help prevent deformities and contractures by placing a hand roll in the patient's hand to position and maintain the wrist and fingers in a functional position. You can roll up a washcloth to make a hand roll.

Why do we use a trochanter roll?

You'll use trochanter rolls for patients who have muscle weakness or paralysis on one side of the body. The roll keeps the patient's hips in a neutral position. You can make a trochanter roll by folding and rolling up a bath blanket.

Movement away from the midline of the body

abduction

the process whereby a patient puts a joint through its full extent of movement

active range of motion

movement toward the midline of the body

adduction

an object or piece of equipment designed to help a patient with activities of daily living

assistive device

decrease of size, wasting away, or progressive decline of a body part or tissue

atrophy

__________ range-of-motion exercises are those the patient performs with nurse or PT supervising to ensure patient is doing them correctly. What do these accomplish?

Active; They involve moving each joint through its complete range of motion. These exercises maintain and increase muscle strength and help keep joint problems and contractures from developing.

Why is ambulation, if at all possible, so beneficial to our patients?

Ambulation not only maintains muscle tone, muscle strength, and joint flexibility, but it also stimulates the respiratory, circulatory, and gastrointestinal systems to help each one function properly. When patients are immobile because of surgery, injury, or illness, all of these systems are affected, putting them at risk for developing complications, such as decreased muscle strength, deep vein thrombosis, and paralytic ileus. It is important to keep this in mind and start the patient ambulating and exercising early on in the recovery process.

Besides doing active or passive range of motion exercises what can you do to exercise a patient's joints? When is it most commonly used?

Another way to exercise a patient's joints is with a continuous passive range of motion (CPM) device. It is used to restore range of motion in a variety of joints, including the ankle, knee, shoulder, and wrist. It is most commonly used after knee surgery; the provider usually prescribes it on the day of surgery or on the first postoperative day.

People who are on bed rest or immobile because of an illness, injury, or surgery are at risk for developing venous thromboembolism (VTE). What can we do to help them if ambulation is not an option?

Anti-embolism elastic stockings, sequential compression devices, and venous foot pumps are used to promote venous return.

What are some compression options to prevent VTE?

Elastic stockings, also called antiembolic or thromboembolic device (TED) hose, provide continuous pressure to the lower extremities to keep blood from pooling and blood clots from developing in the deep veins of the lower extremities. Surgical patients wear them preoperatively, intraoperatively, and postoperatively as prescribed. Elastic stockings are available in either knee length or thigh length and in sizes ranging from small to extra large. They are also available in a variety of compression strengths, with the most common providing 8 to 15 mm Hg of compression. Elastic stockings can be difficult to apply because of their firmness and lack of stretch. Thus, using an "inside out" technique can make the process much easier and more comfortable for the patient. Sequential compression devices (SCDs), also known as intermittent pneumatic compression (IPC) devices, provide intermittent compression to the lower extremities to promote venous return and to help prevent DVT. They can be applied to one or both lower extremities, depending on the patient's specific needs. SCDs are contraindicated for patients who have severe arterial disease. SCDs are available in either knee length or thigh length and consist of an air pump, connection tubing, and sleeves that fit over or around the lower extremity. The provider generally specifies the amount of compression to apply. For elastic stockings and sequential compression devices to be effective, they must fit properly. If they are too large, the patient's lower extremities will not be supported properly and too little compression will be applied. If they are too small, they can impair circulation in the lower extremities, resulting in injury.

What is semi-Fowler's position and what is it used for?

For semi-Fowler's position, the head of the bed is elevated 30 degrees. This position is useful for patients who have cardiac, respiratory, or neurological problems and is often optimal for patients who have a nasogastric tube in place.

How should you move a patient up in bed?

One of the most common transfers you'll assist with is moving a patient up in bed. It is more easily accomplished and safer with two people and with the patient's help. Always consider the use of lifting and transfer equipment, such as a ceiling- or floor-based lift or a friction-reducing device, if the patient's weight exceeds 200 pounds or if the patient is unable to assist. Prepare by laying the bed flat, if tolerated by the patient, and raising it to a comfortable height for both caregivers. To move the patient up in bed, place a draw sheet under the patient, extending from the shoulders to the thighs. Place a pillow between the patient's head and the top of the bed to keep the patient's head from hitting the bed's headboard. Roll the draw sheet close to the patient and then grasp the sheet at the shoulders and hips (with one person at each side of the bed). Ask the patient to bend the knees and push, if able, as you signal and move the patient up in bed.

What are passive range of motion exercises? What do they accomplish?

Passive range-of-motion exercises are performed for patients by a nurse or a physical therapist. They also involve moving each joint through its complete range of motion. These exercises are performed so that patients who are completely immobilized can retain as much joint range of motion as possible. Because muscles do not contract during passive range-of-motion exercises, muscle strength is neither maintained nor increased.

What is Fowler's position and what does it promote?

Patients are often placed in Fowler's position to increase comfort, to improve ventilation, and to promote relaxation after thoracic surgery or for patients with cardiovascular problems. For this position, the head of the bed is elevated 45 degrees. The patient's hips may or may not be flexed. You'll place pillows behind the patient's head and lower back and underneath the forearms, thighs, and ankles for support. You might also use a footboard to keep the patient's feet in proper alignment and to help prevent footdrop.

What type of patients usually use 4-point crutch gait? How does this work?

Patients who can tolerate some weight-bearing on both legs. Have patient move right crutch forward 6-10 inches, then move left foot forward to match left crutch. Then move left crutch forward 6-10 inches. Move right foot forward and even with the right crutch.

Why do we use orthopneic position for patients? How do we position them?

Patients who have breathing problems are often placed in the orthopneic, or tripod, position since it allows maximum expansion of the chest. For this position, the patient sits in bed or on the side of the bed with an overbed table in front to lean on and several pillows on the table to rest on.

Why do we use pillows to support patients?

Pillows help you support and maintain the patient in specific positions. For example, place several behind the patient's back to help maintain a lateral position or between the patient's knees and ankles for comfort and to keep them from rubbing together and possibly causing skin breakdown. Use pillows to elevate the patient's extremities or upper body as well.

What is Trendelenburg's position and what is it used for?

Placing a patient in Trendelenburg's position involves lowering the head of the bed and raising the foot of the bed. Patients with poor peripheral circulation can benefit from this position because it promotes venous return.

What type of patients usually use the 3-point crutch gait? How does this work?

Prescribed for patients who cannot bear weight on one leg. Move both crutches forward with weight on unaffected leg. Move affected leg forward while shifting/ bearing weight on crutches. Move unaffected leg.

What is reverse Trendelenburg's position and what is it used for?

The reverse Trendelenburg's position is the opposite of Trendelenburg's position: The head of the bed is elevated with the foot of the bed down. This is often a position of comfort for patients with gastrointestinal problems, and it can help prevent or minimize esophageal reflux.

How do you position a patient in a comfortable supine position?

The supine position provides comfort in general and specifically for patients recovering from some types of surgery. To provide support and maintain body alignment in this position, place a pillow under the patient's head and shoulders and a towel roll or small pillow under the small of the back and under the thighs to keep the patient's knees slightly flexed. You can also elevate the patient's forearms on pillows placed at the patient's sides.

Why should patients perform range-of-motion exercises?

Range-of-motion exercises help patients who are unable to ambulate or exercise maintain joint mobility and muscle strength. They are usually performed once or twice daily, or according to the provider's order and can be performed independently or with assistance.

What are the risks involved in transferring a patient?

Risk of injury to healthcare worker as well as patient

How can we incorporate proper body mechanics when lifting and transferring patients?

The use of proper body mechanics involves bending at the knees instead of the waist to pick items up off of the floor and using the large muscles of the legs instead of the back to lift. It also involves keeping the patient close to your body and the bed at a comfortable working height to avoid leaning or stretching while caring for the patient. The use of proper body mechanics also involves keeping your center of gravity over a wide base of support (your feet) during strenuous activities. When turning, avoid twisting and instead move your entire body in the direction you wish to face.

Why do we use support devices in positioning patients?

They are designed to help ensure proper body alignment and to make the person more comfortable- including pillows, trochanter rolls, footboards, etc.

How do you use a CPM device?

To keep the patient's skin from rubbing on the frame and becoming irritated, sheepskin is usually used to pad the cradle and any other hard surfaces that might touch the leg. Once you place the patient's leg in the CPM machine and make sure it is in proper alignment, secure it to the machine with Velcro straps. When you turn the machine on, the frame will slide back and forth, gently flexing and extending the joint to the prescribed degree and at the prescribed speed. When caring for patients using a CPM machine, it is important to check the alignment and positioning of the leg frequently and to inspect the skin for any areas of redness or irritation. It is also important to rest the joint throughout the day. The provider commonly prescribes the frequency of rest periods and the length of time to keep the CPM machine off.

How to stop ambulating with crutches and get back into hospital bed.

Turn around when near bed and slowly back up using crutches until legs are against bedside. Then, instruct the patient to grasp both crutches in one hand and then lift them out of the way.

How to transfer patient using mechanical lift?

Turn patient to their side-lying position. Position sling or canvas strap under client. Raise side rail. Move around to other side of the bed. Lower the side rail. Turn the client to the side-lying position facing away from you. Pull sling or canvas straps toward you so they're flat on mattress. Assist client to supine- raise side rail. Lower side rail on side where client will be moved. position lift mechanism directly over center of client. Ensure wheelchair is next to bed and locked. Position lift and attach straps to client, raise head of bed. Slide mechanism and client over wheelchair when ready.

How do we prevent foot drop specifically?

Use a footboard- a flat panel composed of either wood or plastic. To help prevent footdrop, place it at the foot of the bed to keep the patient's feet dorsiflexed.

How to ambulate patient with cane?

Use cane and bed side rail to stand. Then nurse helps patient turn around. Then move cane 6-12 inches in front of and to the side of your foot. First move affected leg forward, then do unaffected leg, and move cane. Continue ambulation.

the space between the feet that bears the weight of the body

base of support

For patients who are ill or recovering from surgery, what is the basic level of assistance we provide while walking? what is the next level- for those who have more restricted movement?

basic- Walk alongside the patient or use a gait belt for stability next level- use assistive device such as cane, walker, or crutches

the coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during movement, especially bending, lifting, and walking

body mechanics

the point at which a body's entire weight is concentrated so that, if supported at this point, the body would remain in equilibrium at any position

center of gravity

circular movement of a limb or of the eye

circumduction

a deformity that results from abnormal shortening of muscle tissue, making the muscle highly resistant to stretching

contracture

method of walking with crutches (artificial supports made of wood or metal and used to alternately bear weight on one or both legs and on the crutches)

crutch gait