Body Mechanics and Mobility Aides

Sitting in a chair with crutches

-First the patient positions himself or herself at the centre front of the chair with the posterior aspect of the legs touching the chair -Then the patient holds both crutches in the hand opposite the affected leg -If both legs are affected, as with a patient with paraplegia who wears weight-supporting braces, the holds the crutches in the hand of his stronger side, -With Bothe crutches in one hand, the patient supports body weight on the unaffected leg and the crutches -While still holding the crutches, the patient grasps the arm of the chair with the remaining hand and lowers the body into it *to stand the procedure is reversed, and the patient when fully upright assumes the tripod position before beginning to walk

Remember following points to ensure safe patient handling and individualized patient centred care

-Mentally review the transfer steps before beginning the procedure (ensures safety of you +patient) -Before transferring patient perform a functional assessment to determine patient's mobility, strength, and the assistance that her or she is able to offer during transfer. Stand on patients weak side when assisting -Determine the amount and type of assistance required for transfer. # of personnel and type of transfer equipment needed to safely transfer and prevent harm to patient + any HC personnel -Raise the side rail on the side of the opposite where you are standing to prevent patient from falling out of bed on that side -Arrange equipment in such a way that it does not interfere with positioning or transfer process -Evaluate patient for correct body alignment and pressure risks after the transfer -Make sure that all personnel understand how the equipment functions before it is used -Educate patient about how equipment functions to reduce their anxiety and enlist their cooperation

Pathiological influences on mobility

-Postural abnormalities -Impaired muscle development -Damage to the central nervous system -Direct trauma tp the musculoskeletal system *don't think this is important for more detail see pages 1247-1248

Assessment when patient is standing

-The head is erect and midline -When observed posteriorly, the shoulders and hips are straight and parallel -When observed posteriorly, the vertebral column is straight -When observed laterally the head is erect and the spinal curves are aligned in a reversed S pattern. The cervical vertebrae are anteriorly convex, the thoracic vertebrae are posteriorly convex, and the lumbar vertebrae are anteriorly convex -when observed laterally, the abdomen is comfortably tucked in and the knees and ankles are slightly flexed. The person appears comfortable and does not seem conscious of the flexion of knees or ankles -the arms hang comfortably at the sides -the feet are placed slightly apart to achieve a base of support, and the toes are pointed forwards -When viewing the patient from behind, the centre of gravity is in the midline, and the line of gravity is from the middle of the forehead to a midpoint between the feet. Laterally the line of gravity runs vertically from the middle of the skull to the posterior third of the foot body alignment: ear over shoulder shoulder over hip hip over knee knee in front of Ankle tight abdomen/ buttock pelvic tilt knee slightly unlocked feet shoulder width

Assessment of sitting

-The head is erect, and the neck and vertebral column are in straight alignment - the body weight is evenly distributed on the buttocks and thighs -The thighs are parallel and in a horizontal plane -both feet are supported on the floor or on wheelchair footrests. With patients of short stature, a footstool can be used to ensure ankles are comfortably flexed -A 2.5- to 5-cm space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee. This space ensures that no pressure is on the popliteal artery or nerve to decrease circulation or impair nerve function -the patients forearms are supported on the arm rest, in the lap, or on a table in front of the chair -upper body alignment as in standing -hips and knees flexed at 90/90 -feet on floor/ supported -hardes on back

Alignment and balance

-The terms body alignment and posture are analogous and tiger to the positioning of joints, tendons, ligaments, and muscles while standing, sitting, and lying, -Being in correct body alignment means that the individuals centre of gravity is is stable -Correct body alignment reduces strain on musculoskeletal structures, minimizes the risk of injuries and falls, aids in maintaining adequate muscle tone and contributes to balance. -Balance is inhaled with a wide base of support and correct body posture and when the body's centre of gravity is kept low and within the base of support -balance is required for maintaining a static position, moving, and performing ADLs. - Things that compromise ability to stay balanced: Disease, injury, pain, physical development (ex age), life changes (ex pregnancy), medications and reconditioning.

Canes

-light weight easily moveable devices made of wood or metal -provide less support than a walker and are less stable -to determine correct cane length for a patient, measure from the patient's greater trochanter to the floor -The patient should keep the cane on the stronger side of the body -Two common types of canes: straight legged cane: more common and is used to support and balance a patient with decreased leg strength quad cane: provides more support and is used when there is partial or complete leg paralysis or some hemiplegia -Teach following threes steps to promote maximum support when walking: 1) instruct patient to place the cane forward 15-25 cm, keeping body weight on both legs 2)coach patient to move the weaker leg forward to the cane so bodyweight is divided between the cane and stronger leg 3) have the patient advance the stronger leg past the cane so the cane supports the body weight and weaker leg. According to Perry and potter 3 types of canes: standard crook: least support tripod quad cane

When a patient is unable to assist remember the following principles

-the wider the base of support, the greater the stability -The lower the centre of gravity, the greater the stability -facing the direction of movement prevents abnormal twisting of the spine -dividing balanced activity between arms and legs reduces the risk of back injury - leverage rolling, turning, or pivoting requires less work than lifting -Use transfer sheets to reduce friction between the patient and the surface over which the patient is moved, to reduce the force required to reposition the patient -reducing the force of work reduces the risk of injury -maintaining good body mechanics reduces fatigue of the muscle groups -Alternating periods of rest and activity helps reduce fatigue -When transferring a patient who is in the supine position with another health care provider, always work at the height of the taller person

Injury prevention and statistics

30% of the population have back problems by age 30 In healthcare, most injuries occur at the bedside Rarely are musculoskeletal (MSK) injuries the result of one occurrence or factor According to Fraser Health Authority Injury Statistics, 2014 Total number of claims (WSBC / LTD) due to MSI was 1146 Rank the professions (highest to lowest) for injury claims: CHW, HCA, LPN, RN

When transferring a patient what do you have to perform?

6 check points: 1. Three for the top: Ears (1) inline with shoulders (2), shoulders in line with hips (3) 2. Three for the bottom: tighten stomach (1) and push your buttocks back (2) while keeping your body weight over the heels (3) move your trunk forward, bending at the hips, not the waist 3) elbows are tucked into your sides. 4) Use palms-up grip 5)work in your comfort zone: Bend and tuck elbows into your sides, move hands from shoulders to hips 6) Weight transfer: Stand with a stable base of support, transfer weight side to side and front to back

Crutch walking on stairs descending

A three-point sequence is also used to descend the stairs -The patient transfers body weight to the unaffected leg -The person then places the crutches on the stairs and begins to transfer body weight to the crutches, moving the affected leg forward. -Finally the patient moves the unaffected leg to the stairs with the crutches.

Crutches

A wooden or metal staff The use of crutches is often temporary. However some patients with paralysis of the lower extremities need them permanently. Two types of crutches: -Double adjustable or forearm crutch -The axillary wooden or metal crutch Axillary crutch: -Metal band and handgrips are adjusted to fit the patient's height -the axillary crutch has a padded curved surface at the top, which fits under the axilla -A handgrip in the form of a cross basis held at the level of the palms to support the body According to Perry and potter 3 types: axillary lofstrand (hand grip and a metal band that fits around patients forearm) platform (has a horizontal trough for resting the forearm and wrist and a vertical hand grip. For patients who are unable to bear weight on their wrists.)

Comprehensive safe patient handling programs are being implemented over Canada. They include the following elements:

An ergonomics assessment protocol for HC environments Patient assessment criteria and algorithms for safe patient handling and movement Special equipment kept in convenient locations to help transfer patients Back-injury resource nurses An "after-action" review that allows the HC team to apply knowledge about moving patients safely in different settings A no-lift policy

Ergonomics

Applied science concerned with designing and arranging workplace setting in such a way that people interact more effectively with the objects they encounter in that environment.

Principles of lifting

Assess the load first... ALWAYS! Clients - consider their cognitive, physical, functional status Do not bend, twist & lift with your back Bend knees, pivot, weight shift/push/pull/roll/slide load Smarter not harder Bring load closer to center of gravity Increase base of support Use large muscles, use your legs not your back Know your limits and seek assistance Use assistive devices (i.e. sliders)

tips for safe use of mobility aids

Cane: Opposite hand/side of weak leg Tip is 6-8 inches out from feet Moves with weak leg Crutches: Move with weak leg Tip is 6-8 inches out from feet Walker: Feet in line with back walker legs Stairs: Good / strong leg goes up first Bad / weak leg goes down first Wheelchair Portering: Backwards over uneven terrain (big wheels first) Stay on downhill side of wheelchair Brakes on when left unattended Client's hands in the chair and feet off ground Clear communication with client Inclusive orientation of client to situation (Consider... Which way would you want to face? )

Types of mobility aids

Canes Single point Quad canes Offset Crutches Traditional Gutter Forearm Walkers 4 point 2 wheel 4 wheel Wheelchairs Manual Power Tilt Recline

set up/ fitting

Canes: Handle height Walkers: Handle height Crutches: Crutch height & Handle height Wheelchairs: Sizing: seat width, depth, height Foot rests, armrests

Pathological influences on body mechanics and movement

Congenital Abnormalities: affect musculoskeletal alignment, balance, and appearance (osteogenesis imperfecta) degenerative diseases Disorders of Bone, Joints, and Muscles: Joint mobility altered by inflammatory and non inflammatory joint diseases and articular disruption (ex osteoporosis is a bone disorder) Central nervous system disorders: damage to part of CNS that regulates voluntary movement, impairs mobility and body alignment Musculoskeletal trauma: (ex fracture) Other chronic diseases (ie. those that affect the organs)

Crutch gait

Determine the gait by asessing the patients physical and functional abilities and the disease or injury that resulted in the crutches. four standard gaits (see figure 36-22): -four point -alternating gate -two point gait -swing-through gait

Factors Influencing Activity and Exercise

Developmental changes: Infants through school aged children Adolescence Young to middle aged adults Older persons behavioural changes see pg 48-50 for more detail but don't think its important

Four-point alternating, or four point gait

Gives stability to the patient but requires weight weight bearing on both legs. Each leg is moved alternatively with each opposing crutch, so three points of support are on the floor at all times

Swing through gait

Individuals who have paraplegia who wear weight-supporting braces on their legs frequently use the swing through gait. With weight placed on the supported legs, the patient places the crutches one stride in front and then swings to or through them while supporting his or her weight.

why are body mechanics important

Knowledge gained from such studies is especially important in the prevention of injury during the performance of tasks that require the body to lift and move.

Measuring for crutches

Measurement for the axillary crutch includes the patient's height, the angle of elbow flexion, and the distance between the crutch pad and the axilla. When crutches are fit, the length of the crutch needs to be two to three finger widths from the axilla and the tips positioned approximately 5 cm lateral and 10to 15 cm anterior to the front of the patients shoes. Position the handgrips so the axillae are not supporting the patients body weight (pressure on the axillae increases the risk to underlying nerves, which sometimes result in partial paralysis of the arm) Determine the correct position of the handgrips with patient upright: -Elbows should be flexed at 20-25 degrees -verify distance between patients crutch and axilla is approximately 5 cm (2 or three finger widths)

What should nurses do for patients in acute care settings?

Nurses must promote inpatient activity to prevent deconditioning + other complications of immobilization (see table 36-1 pg 838 for risks associated with deconditioning, probably not important) additional physical benefits of impatient mobilization include less delirium, pain, urinary discomfort, urinary tract infection, fatigue, deep vein thrombosis, and pneumonia, and improved ability to void

why must nurse use proper transfer techniques

Nurses must use proper transfer techniques as body mechanics alone cannot prevent injury to musculoskeletal injury Knowledge of Ergonomics and safe patient handling is crucial in maintaining caregiver + patient safety

Lying

People who are concious have voluntary muscle control and normal perception of pressure, As a result they usually assume a position of comfort when lying down, and change positions when they perceive muscle strain and decreased circulation. Assessment of body alignment who is immobilized or bedridden is done with patient lying in lateral position all positioning supports removed from bed except for pillow under head and mattress This postition allows for full view of spine and back and provides other baseline data such as whether the patient can remained positioned without aid. The vertebrae should be aligned and the position should not cause discomfort side lying: bend 1 or both legs supine: bend knees prone: hardest on back -head and spine straight and not rotated shoulders and pelvis are square to spine

Mobility

Refers to the ability to move easily and independently. To maintain optimal physical mobility, the musculoskeletal and nervous system of the body must be intact and functioning.

Body mechanics terminology: Weight bearing

The ability to resist weight or force through the bones, joints and associated structures, ligaments and joint capsules structure vs function In order to have weight bear order something must have happened to the skeleton. Weight bearing refers to structure not function. Nothing to do with function you have to assess for function

What is body alignment?

The arrangement of joints, tendons, ligaments, and muscles while in a standing, sitting or lying positions decreases strain on muscles, joints, ligaments, and bones

Body mechanics

The coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living. The field of physiology that studies muscular actions and the function of muscles in maintaining body posture

Unit standard fall prevention protocol (use for all patients at risk of falls):

Use appropriate orientation strategies Use clear communication Assist patients with sensory aids (ex glasses) Do comfort rounds every 2-3 hours (ex toileting needs, hydration, position changes) Tech patient + family about fall risk and prevention strategies Ensure that call bell, personal items, and walking aids are within easy reach Assess patient's understanding of the call bell system and determine if patient is able to use call bell Remind patients to call for help when transferring, ambulating and toileting Assess whether patient is using assistive devices correctly Have patient where non slip footwear for all transfers and ambulation Clear barriers (ex clutter) prior to ambulating

Gravity

Weight is the force exerted on a body by gravity The force of weight is always directed downwards which is why an unbalanced object falls unsteady patients fall when their centre of gravity becomes unbalanced; the gravitational pull of their weight moves outside their base of support To lift an object or person safely, the lifter had to overcome the weight of the object and know its centre of gravity. Since people are not symmetric, centre of gravity is usually at 55%-57% of standing height and is located in the midline

Risk factors for back injuries

What's putting you at risk? Lifting with your back bowed out flexed Bending and reaching with your back flexed Slouched sitting Twisting or jerking movements Lack of proper rest Obesity and poor nutrition Stressful work and living habits

Crutch walking on stairs ascending

When ascending stairs patient usually uses a modified three-point gait. -Patient stands at the bottom of the stairs and transfers body weight to the crutches -patient then advances the unaffected leg between the crutches and the stairs -patient then shifts weight from the crutches to the unaffected leg -finally patient aligns both crutches on the stairs

Movement

a complex process that requires coordination between the musculoskeletal and nervous system

Friction

a force that occurs in direction opposing movement greater the surface area of the object to be moved the greater the friction shear: the force exerted against skin while the skin remains stationary and the bony strucutres move. Often pressure ulcers develop. To decrease the surface area and reduce friction when a patient is unable to assist in moving up in bed, nurses use ergonomic assistive devices (ex friction reducing transfer sheets, full body slings.

Body mechanics terminology: Centre of gravity

a point from which the weight of a body or system may be considered to act. In uniform gravity it is the same as the center of mass.

Body mechanics terminology: balance

an even distribution of weight enabling someone or something to remain upright and steady

Body mechanics terminology: Line of gravity

an imaginary vertical line from the centre of gravity to the ground or surface the object or person is on

safety checks

canes: adjustment pins collars cane ends crutches: adjustment pins wingnuts crutchends walkers: adjustment pins (legs and handles) wheels leg ends brakes (4 wheel only) Wheelchairs: -previous components -seat and backrest fabric -brakes -wheels -seatbelt

What does using principles of safe patient transfer and positioning during routine activities do?

decreases work effort and places less strain on musculoskeletal structures Reduces risk of injury to nurse and patient

which mobility aid is best suited for full- bam partial-pub, non weight bearing-nwb)

don't know

Factors affecting mobility--imobilty

don't think its necessary for more info see page 1249 -Bed rest -associated with cardiovascular, skeletal and other organ changes -disease atrophy: the tendency of cells and tissues to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting of a body part, or local nerve damage

systematic effects of immobility

don't think its necessary for more info see page 1249-1252 Metabolic changes Respiratory changes Cardiovascular changes Musculoskeletal changes Urinary elimination changes integumentary changes

Nursing assessment of body alignment

done with patient lying, sitting, or standing. This assessment has the following objectives: -Determining normal physiological changes in body alignment resulting from growth and development for each individual patient -Identifying deviations in body alignment caused by incorrect posture -providing opportunities for patients to observe their posture identifying learning needs of patients for maintaining correct body alignment -identifying trauma, muscle damage, or nerve dysfunction -obtaining information about other factors contributing to poor alignment, such as fatigue, malnutrition, and psychological problems

Non-weight bearing status

equires patient to support weight on assistive device and the unaffected limb. Affected leg is kept of the floor at all times

psychosocial effects of immobility

immobilization can contribute to decreased social interaction, social isolation, sensory deprivation, loss of independance, and role changes. These in turn may lead to emotional reactions, behavioural response, sensory alteration, and changes in coping Every patient responds to immobilization differently Patients who are immobilized can become depressed because of changes in role, self conch, and other factors. don't think its necessary for more info see page 1252

Walkers

lightweight, movable device that stands waist high and consists of a metal frame with handgrips, four widely placed sturdy legs, and one open side. Because it has a wide base of support, the walker provides great stability and security during walking. A walker can be used by a patient who has problems with balance. Walkers with wheels are useful for patients who have difficulty lifting and advancing the walker as they walk because of limited balance and endurance. To determine if the walker is the correct size, instruct the patient to relax the arms at the side of the body and stand up straight. The top of the walker should line up with the crease on the inside of the patients wrist. Elbows should be flexed about 15-30 degrees when standing inside the walker with hands on the hand grips. To ambulate using a walker, the patient holds the handgrips on the upper bars, takes a step, moves the walker forward, and takes another step.

Three principles of body mechanics

maintain body balance increase stability: -increase base of support -lower centre of gravity maintain body alignment

What are essential when a patient is unable to assist?

mechanical lifts

Total weight bearing status

patient distributes equal weight between each limb with minimal weight on the assistive device

Assessment and planning

pg 434 Perry and potter

Teaching mobility devices

pg 435-443 Perry and potter up to sample documentation

Safe and effective transfer techniques

pg 839-847

First step in assessing body alignment

put patient at ease so they do not assume assume unnatural or rigid positions. When assessing the body alignment of a patient who is immobilized or unconscious, pillows and positioning supports should be removed from the bed and the patient placed in the supine position.

Body mechanics terminology: Base of support

refers to the area beneath an object or person that includes every point of contact that object or person makes with the supporting surface

Immobility

refers to the inability to move about freely

The two point gait

requires at least partial weight bearing on each foot. The patient moves a crutch at the same time as the opposing leg, so the crutch movements are similar to arm motions during normal walking.

Three- point alternating, or three point gait

requires the patient to bear all of the weight on one foot, In a three-point gait the patient bears weight on both crutches and then on the uninvolved leg, repeating the sequence. The affected leg does not touch the ground during the early phase of three point gait. Gradually the patient progresses to touch-down and full weight bearing on the affected leg.

Nurses must assess every situation that involves patient handling and movement, to minimize risk of injury

see diagram 848, 849, 850

Partial or touch down weight bearing status

simmilar to non-weight bearing, but either limb can be advanced initially. Partial weight bearing more closely approximates normal walking except that less weight is placed on the affected limb

principles of injury prevention

stress= more tense muscles and toxins build up exercise: best way to reduce stress, people with cardiovascular endurance more resistant to injury flexibility: reduces injury diet: eat healthy

The basic crutch stance

tripod position. Crutches are placed 15 cm in front of and 15 cm to the side of each foot Improves the patient's balance by providing a wider base of support, Body alignment in tripod position: erect head and neck, straight vertebrae, and extended hips and knees. The axillae should not bear any weight. The patient assumes tripod position before crutch walking,

What should the nurse do whenever possible when lifting a patient.

whenever possible nurses should use some of the patients strength to when lifting, transferring, or moving the patient. The procedure should be explained to the patient and the patient told when and what body parts to move. By involving the patient the nurse may have the added benefit of increasing the patients participation in self care, thus promoting his or her sense of accomplishment