Ergonomic Principles, Body Mechanics, Ambulation, Transferring and Range of Motion (ATI Chapter 14,40)
Ambulation with crutches 3 point gait
(No weight on one leg) -Move affected leg with weight on crutches -Move unaffected leg and crutches forward
Ambulation with crutches 4 point gait
(partial weight on both feet) -Move R crutch forward -left foot forward and inline with left crutch -Move L crutch forward (6-10 inches) -Move R foot forward and even w/ R crutch
Ambulation with walkers
-Walker + affected leg forward -move unaffected leg parallel to affected leg
Ambulation with crutches 2 point gait
-left foot and right crutch forward -right foot and left crutch forward
Elastic stocking and compression devices
-remove every 8 hrs/facility policy to assess skin condition -no rolling top of stockings down -measure for proper size (circumferences of pt leg) -2 finger rule
Ambulation Bed to chair
1. Can pt bear weight 2. Position chair etc on strong side 3. Dangle 4. Use stand and pivot technique (align knees)
Ambulation with cane
1. Cane on unaffected side 2. Support and push up (from bed/chair) 3. Cain 6-12 inches to side and in front this promotes balance and gives a wider range of support 4. Affected leg forward - even with cain 5. Shift weight to affected leg and move unaffected leg forward + ahead of cain 6. Move cain forward and move affected leg level with cain.
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg
A. INCORRECT: In the supine position, the client lies on his back with his head and shoulders elevated on a pillow. This angle is not adequate to prevent regurgitation. B. CORRECT: In the semi-Fowler's position, the client lies supine with the head of the bed elevated approximately 30°. This position is frequently used to prevent regurgitation and aspiration in clients who have difficulty swallowing. This is the safest position for the client receiving a tube feeding. C. INCORRECT: In the semi-prone or Sims' position, the client is on his side halfway between lateral and prone positions. This position is not safe because it may promote regurgitation. D. INCORRECT: In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe because it may promote regurgitation.
A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I will A. lie on my back with my head and shoulders elevated on a pillow." B. lie flat on my stomach with my head to one side." C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table." D. lie on my side with my weight on my hips and shoulder with my arms flexed in front of me."
A. INCORRECT: The client is describing the supine position, not the orthopneic position. B. INCORRECT: The client is describing the prone position, not the orthopneic position. C. CORRECT: The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial to clients who have COPD. D. INCORRECT: The client is describing the lateral or side-lying position, not the orthopneic position.
You decide that both patients should get out of bed and plan to delegate assisting one of the patients to the nursing assistant. Which patient will you delegate to him? A. The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair B. The patient who had a lumbar repair and has a new activity order to ambulate with a walker
A - CORRECT Yes. This is the correct choice. In report, you learned that this patient is moving well and needs only the assistance of one person to get out of bed. Assisting patients with ambulation is a task you can delegate to nursing assistants, and, of the two patients, this one is the most appropriate choice. B - INCORRECTNo. This is not the correct choice. This patient has been on bed rest for 2 days since having surgery. The patient will need teaching about how to apply the brace, how to sit up, and how to use the walker to stand and to walk. You will also have to evaluate how well she tolerates changing position and ambulating with the walker. It is not appropriate to delegate teaching and assessment to a nursing assistant.
Which instruction is appropriate regarding ambulation with a cane? A. Hold the cane on your stronger, unaffected side. B. First move the cane forward about 12 to 15 inches. C. While moving the cane forward, keep your weight on your unaffected side.
A - CORRECT Yes. This is the correct choice. Placing the cane on the side opposite the involved leg provides added support for the weak (and painful) affected side. B - INCORRECTNo. This is not the correct choice. The patient should first move the cane forward 6 to 10 inches. C - INCORRECT No. This is not the correct choice. While placing the cane forward, the patient should keep her body weight on both legs. Then, when she moves the weaker leg forward to the cane, her body weight will be divided between the cane and the stronger side.
Which action is appropriate when getting a patient out of bed via a mechanical/hydraulic lift? A. Place the sling under the patient's center of gravity and greatest portion of body weight. B. Position the patient's wheelchair alongside the foot of the bed, facing the head of the bed. C. Remove the sling from under the patient once he is safely positioned in the chair.
A - CORRECT Yes. This is the correct choice. The sling (or hammock) is supplied with the lift. Hammocks that provide neck support are best for patients who are flaccid or have poor muscle tone. This helps ensure the patient's safety. B - INCORRECTNo. This is the incorrect choice. You should place the chair near the head of the bed, leaving room for the equipment to maneuver to allow for a safe transfer. C - INCORRECT No. This is the incorrect choice. You should leave the sling in place so that the patient can be safely transferred back to bed.
On assessment, you note that the patient is lying flat in bed, has labored breathing, and has undigested tube feeding in his oral and nasal cavities. You auscultate rhonchi over the bronchus and wheezing in the anterior lung fields. You stop the tube feeding, elevate the head of the bed, suction the oral and nasopharynx and notify the patient's provider, who prescribes a stat chest x-ray. You will have to transfer the patient to a gurney for transport to the radiology department. You ask the nursing assistant to obtain help and a slide board. Which action is appropriate when transferring the patient to the gurney using a slide board and three team members? A. Have one person hold the slide board steady while the other two pull the patient onto the gurney. B. Position the slide board under the patient and over the draw sheet. C. Adjust the height of the gurney so it is slightly higher than the height of the bed.
A - CORRECT Yes. This is the correct choice. Using this method, the slide board remains stationary as two team members pull the draw sheet and move the patient. This slippery surface reduces friction and makes it easier for the staff to pull the patient onto the gurney. B - INCORRECTNo. This is not the correct choice. Placing the slide board between the patient and the draw sheet would create friction against the patient's skin. C - INCORRECT No. This is not the correct choice. You should align the gurney slightly lower than the bed and lock all the wheels. This ensures an easier transfer without inadvertent movement of the bed or the gurney.
Your assessment does not indicate any new complications, and the patient's skin appears intact. In addition to routine hygiene care, you provide perineal care and G-tube site care. You reposition the patient with the head of bed elevated and administer the morning feeding.After the G-tube feeding is complete, which action will you direct the nursing assistant to perform next? A. Range-of-motion exercises B. Assistance out of bed via a mechanical/hydraulic lift
A - CORRECT Yes. This is the nursing action you should perform next. It is easiest to perform full range of motion of all the patient's joints and limbs while the patient is positioned in bed. B - INCORRECTNo. This is not the correct choice. Although this patient needs to be out of bed for therapy, it is not the next nursing action you should perform for this patient.
Which of the following nursing actions will help improve your patient's tolerance of getting out of bed? (select all that apply) A. Administer the prescribed oral pain medication to your patient about 20 minutes before she gets out of bed. B. Have your patient dangle her legs at the side of the bed first for a few minutes before getting out of bed. C. Assign the nursing assistant on your team to help your patient get out of bed. D. Explain the steps involved in getting out of bed to your patient prior to the procedure. E. Have the patient use crutches to help her get out of bed.
A - CORRECT Yes. You have selected a correct response. Oral pain medication typically has a time of onset of about 20 minutes, so the patient will have the benefit of pain relief while moving - the most difficult and painful aspect of getting up. B - CORRECT Yes. You have selected a correct response. Dangling allows the patient's circulation to equilibrate and helps prevent episodes of dizziness due to orthostatic hypotension and, therefore, injuries from falling. C - INCORRECT No. This is not a correct choice. If your assessment tells you that your patient might need two people to help her get out of bed, you may ask the nursing assistant to provide that additional support. However, since this is the patient's first time out of bed, you should be there to assist her. D - CORRECTYes. You have selected a correct response. Teaching and demonstrating the techniques to be used enhance the patient's understanding, reduce anxiety, and encourage her to cooperate with the procedure. E - INCORRECTNo. This is not a correct choice. Getting from the bed to the chair requires that the patient stand and bear weight on her nonoperative (right) leg and pivot into the chair. With you standing there to help her maintain stability, there is no need for crutches. They may be prescribed when she begins to ambulate, however.
Since the nursing assistant is a new employee, you plan to supervise and observe her while she performs the range-of-motion exercises. Based on the patient's condition, which type of range of motion (ROM) exercises should the nursing assistant initiate? A. active ROM. B. active-assisted ROM. C. passive ROM.
A - INCORRECT No. This is not the correct choice. Active ROM exercises are those that the patient is able to perform independently according to your instructions. In report you learned that this patient was totally dependent and unable to follow directions (total receptive and expressive aphasia). B - INCORRECTNo. This is not the correct choice. Active-assisted ROM exercises are those that are performed by the patient with your assistance and support. In report you learned that this patient was totally dependent and unable to follow directions (total receptive and expressive aphasia). C - CORRECTYes. This is the correct choice. Passive ROM exercises are performed without the patient's assistance to prevent joint contracture. These are most appropriate for a patient who is totally dependent and unable to follow instructions.
Prior to morning therapy, the patient requires several nursing interventions. Which nursing action do you and the nursing assistant perform first? A. Range-of-motion exercises B. Assistance out of bed via a mechanical/hydraulic lift C. Morning hygiene care and assessment
A - INCORRECT No. This is not the correct choice. Although this patient might need range-of-motion exercises performed this morning, it is not the first nursing action you should perform for this patient. Also, the nursing assistant can perform these exercises without your help. B - INCORRECTNo. This is not the correct choice. Although this patient needs to be out of bed to attend physical and occupational therapy sessions and this action requires at least two individuals, it is not the first nursing action you should perform for this patient. C - CORRECT Yes. This is the action that you should perform first. Patients who need total care are at increased risk for skin breakdown due to impaired mobility, and increased risk for other complications of immobility, including respiratory failure, impaired circulation, and sluggish digestion. It can be helpful to use the nursing process when deciding the order of nursing actions, Assessment is first; it guides your subsequent actions, and performing the morning assessment while providing hygiene care is an efficient use of your nursing time.
When teaching the patient how to ambulate with a cane, you say, A. "When properly fitted, the cane length is twice the distance between the greater trochanter and the floor." B. "Place the cane on your stronger side for support." C. "After moving the cane, bear weight on the stronger side and swing yourself forward."
A - INCORRECT No. This is not the correct choice. The cane length should be equal to the distance between the greater trochanter and the floor. B - CORRECT Yes. This is the correct choice. Patients who use a cane should place the cane in the hand on the stronger side so that the cane and the stronger leg provide support and balance when ambulating. C - INCORRECTNo. This is not the correct choice. The patient should move the cane forward, followed by moving the weaker leg so that body weight is divided between the cane and stronger leg.
You ask the patient how she is feeling and explain that her care plan calls for her to get out of bed to a chair today for the first time. The patient responds as follows: "I guess I am doing as well as can be expected, but I really don't think I am doing well enough to get out of bed. I am sure that it will be very painful." Which of the following should be your therapeutic response to this patient? A. "Your doctor's orders call for you to get out of bed today." B. "Everyone is a bit nervous about getting out of bed for the first time." C. "Why don't you think you aren't able to get out of bed?" D. "It sounds like you are concerned that getting out of bed will be painful."
A - INCORRECT No. This is not the correct choice. This is not a therapeutic response. "Passing the buck" to another professional represents the nontherapeutic response of focusing on someone other than the patient. This non-patient-centered response suggests that the doctor's priorities are more important than the patient's needs. B - INCORRECTNo. This is not the correct choice. This is not a therapeutic response. Using a "cliché" response devalues the patient's feelings by suggesting that her feelings really don't matter since "everyone" feels that way. C - INCORRECT No. This is not the correct choice. Asking the patient "why" is neither an appropriate nor a therapeutic response. Asking why tends to make patients defensive, and in this particular situation, it suggests that you weren't listening to the patient since she has already stated why she is afraid to get up (pain). D - CORRECT Yes. You have identified the therapeutic response. When responding therapeutically to patients' questions, always remember that you must use communication skills and avoid communication blocks. In general, therapeutic responses are open-ended, patient-centered, and focused on the patient's feelings. This response meets all of these criteria. By acknowledging that you have heard the patient's message, this response encourages further communication.
To assist the patient in transferring from the bed to the chair, you A. position the chair at a 90° angle to the head of the bed. B. keep your feet together while rocking the client up to a standing position. C. flex your hips and knees while lowering patient to the chair.
A - INCORRECT No. This is not the correct choice. While you are correct about placing the chair at the head of the bed, the proper position for the chair is at a 45° angle. This reduces the risk of injury to you and the patient during the transfer; it allows adequate room for you to pivot the patient into the chair while you maintain an appropriately wide base of support. B - INCORRECTNo. This is not the correct choice. To keep your balance and ensure a wide base of support, you need to spread your feet apart while assisting the patient up from the bed. C - CORRECT Yes. This is the correct choice. Flexing the hips and knees while lifting weight reflects good body mechanics as this prevents injury due to poor body alignment. Flexion of the knees and hips lowers your center of gravity in relation to the object you are raising or lifting.
A nurse is instructing a client who has an injury of the lower left extremity about the use of a cain. Which of the following instructions should the nurse include? (select all that apply) A. Hold the cane on the right side B. Keep two points of support on the floor C. Place the cane 38 cm (15 in) in front of the feet before advancing D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.
A. CORRECT. The client should hold the cane on the uninjured side to provide support for the injured leg. B. CORRECT. The client should keep two points of support on the ground at all time for stability. C. INCORRECT. The client should place the cane 15-25 cm (6-10 in) in front of her feet before advancing D. CORRECT. The client should advance the weaker leg first, followed by the stronger leg. E. INCORRECT. The client should advance the stronger leg past the cane.
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2hr B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake D. Reposition the client every 4 hr.F
A. CORRECT. The nurse should encourage the client to preform antiembolic exercises q1-2hr to promote venous return and reduce the risk of thrombus formation
Which patient will you see next? A. The patient who had a fractured femur repaired and must demonstrate proper crutch walking B. The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair C. The patient who had a lumbar repair and has a new activity order to ambulate with a walker
A. CORRECT. Yes. This is the patient you will see next. The patient's discharge is written, his escort has arrived, and you need to evaluate his ability to ambulate appropriately with crutches before he leaves. Although this is not an urgent situation from a medical standpoint, it is inappropriate to keep this patient waiting if your other two patients' needs are not urgent, either. B. INCORRECT. No. This is not the correct choice. Although this patient has to be out of bed three times a day, it is not the highest priority among these three clinical scenarios. C. INCORRECT. No. This is not the correct choice. It was reported to you that this patient is resting comfortably in bed; therefore, seeing this patient is not the highest priority among these three clinical scenarios.
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.
A. CORRECT: It is preferred that two or more personnel assist with any positioning in order to reduce the risk of injury. B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the nurse's risk for injury. C. INCORRECT: When sitting for long periods of time, the nurse should keep knees slightly higher than, not lower than, the hips in order to decrease strain on the lower back D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements is recommended to prevent injury E. INCORRECT: The nurse should take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly hired nurse indicates the need for further teaching? A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."
A. CORRECT: The line of gravity should fall within the base of support, not outside, which increases the risk of falling. B. INCORRECT: Being closer to the ground causes a lower center of gravity, which leads to greater stability and balance. C. INCORRECT: Spreading the feet apart increases and widens the base of support. D. INCORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity, which can prevent injury and instability.
Which of your four patients should you see first? A. The patient who had a fractured femur repaired and must demonstrate proper crutch walking B. The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair C. The patient who had a lumbar repair and is on strict bed rest D. The patient with quadriplegia who had sacral redness when last turned 2 hours ago
A. INCORRECT. No. This is not the correct choice. Although this patient might be eager to go home, it is not the highest priority among these four clinical scenarios. B. INCORRECT. No. This is not the correct choice. Although this patient is moving well and needs to be out of bed three times a day, it is not the highest priority among these four clinical scenarios. C. INCORRECT. No. This is not the correct choice. This patient is due for repositioning in 1 hour; therefore, seeing her is not the highest priority among these four clinical scenarios. D. CORRECT. Yes. This is the patient you should see first. Patients who have quadriplegia are at an increased risk for skin breakdown due to impaired mobility, infrequent repositioning, impaired sensation, and skin exposure to such irritants as rough linen, urine, and stool. Any of these conditions may result in tissue damage from impaired circulation or skin breakdown. It was reported to you that the patient had sacral redness when last turned 2 hours ago so not only is the patient due to be turned again now, but your immediate nursing assessment of the sacral area is your highest priority at this time.
You determine that the patient performs the prescribed three-point gait appropriately when using his crutches because he A. positions each upper crutch pad centered in the axilla. B. leans his upper torso forward slightly in the tripod position. C. advances the crutches first, followed by the unaffected leg
A. INCORRECT. No. This is not the correct choice. The radial nerve passes superficially under the axilla, and prolonged pressure in the axillary area can injure that nerve (a condition called crutch palsy). Following proper sizing, two to three fingers should fit between the crutch pad and the axilla. B. INCORRECT. No. This is not the correct choice. It is true that the patient should assume a tripod position formed by the two crutches and his unaffected leg. However, leaning forward changes the patient's center of gravity and may impair his ability to balance. C. CORRECT. Yes. This is the correct choice. When performing a three-point gait, the correct procedure is to advance the crutches while bringing the affected leg forward. The patient then advances the unaffected leg.
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer. C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer.
A. INCORRECT: Although this might be a necessary assistive device for this client, it is not the priority action the nurse should take. B. INCORRECT: Although this might be necessary for a safe transfer, it is the not the priority action. C. INCORRECT: Although this might be a necessary assistive device for the transfer of this client, it is not the priority action the nurse should take. D. CORRECT: The first action the nurse should take using the nursing process is to assess/collect data from the client. The nurse should assess the client's ability to help with transfers (balance, muscle strength, endurance). Then the nurse can proceed with a safe transfer of the client.
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (select all that apply) A. Instruct the client not to perform the Valsalva maneuver B. Apply Elastic stockings C. Review lab values for total protein level D. Place pillows under the client's knees and lower extremities E. Assist the client to change position often
B. - CORRECT. Elastic stocking promote venous return and prevent thrombus formation. E. - CORRECT. Frequent position changes prevents venous stasis.
A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? A. This device will keep me from getting sores on my skin B. This thing will keep the blood pumping through my leg C. With this thing on my leg muscles won't get weak D. This device is going to keep my joints in good shape.
B. CORRECT. Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation.
What will the stability and decrease back straining when lifting an object?
Bringing a load as closer as possible to your body to the center of gravity
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following is the client at risk for developing? A. stasis of secretions B. muscle atrophy C. pressure ulcer D. fecal impaction
C - CORRECT. the greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. The nurse should instruct the client to shift his weight q15 mins and reposition the client after 1 hr.
When sitting for long periods of time
Keep the knees slightly higher than the hips.
When lifting an object from the floor...
Flex the hips, knees, and back. Get the object to thigh level
Good body mechanics
Promotes safety for the client as well as for health care providers when positioning and moving clients
Before attempting to move the client
The nurse should perform a mobility assessment, ROM, balance, gait, & exercise.
