3.

1 Lesson Objectives Upon completion of this lesson, you will be able to: Describe how to move a patient up in bed by using a lift/draw/slide sheet or slide board. Identify signs and symptoms of orthostatic hypotension. Describe precautions for orthostatic hypotension. Discuss how to safely transfer a patient from bed to chair. 3.2 Introduction Patients with impaired nervous or musculoskeletal system functioning with increased weakness, or those restricted to bed rest, benefit from repositioning. In general, patients should be repositioned as needed and at least every 2 hours if they are in bed and every 20 to 30 minutes if they are sitting in a chair. Care must be taken to protect the skin from damage caused by shearing forces that result from sliding rather than lifting the patient. Shear is the force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface. Shear injuries occur when the skin remains stationary and the underlying tissue shifts, resulting in tissue damage. A shear is more likely to occur when the patient is thin, has fragile skin, is nutritionally compromised, or is unable to move independently. For example, a shear injury can occur when the head of the bed is elevated and the sliding of the body starts but the skin is fixed because of the friction with the bed. Orthostatic or postural hypotension involves a drop in blood pressure when changing from a horizontal to a sitting or standing position. A drop in blood pressure of approximately 20 mm Hg or more in systolic pressure or a drop of 10 mm Hg or more in diastolic pressure with symptoms of dizziness, pallor, or fainting indicate orthostatic hypotension. Orthostatic hypotension is associated with:

Bed rest Hypovolemia (decreased circulating blood volume) Hypokalemia (low serum potassium level) Medications, including:

Sedatives Hypnotics Analgesics Antihypertensives Antiemetics Antihistamines Diuretics Antianxiety agents Muscle relaxants Moving patients to a chair after bed rest stimulates them physically and mentally and promotes involvement in self-care activities. It is important to allow patients to proceed at their own pace, encouraging as much independence as possible. Transfers may be from bed to chair, wheelchair, or bedside commode. 3.3 Delegation The skill of moving and positioning patients in bed and maintaining correct body alignment can be delegated to nursing assistive personnel (NAP). The nurse directs the NAP by: Instructing about any moving and positioning restrictions (e.g., avoid prone position, patient has onesided weakness). Designating specific times throughout the shift that NAP must reposition the patient. Providing information about the patient, so shearing is prevented. Assisting and supervising when moving patients who are transferred for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. Explaining the patient's mobility restriction, changes in blood pressure, or sensory alterations that may affect safe transfer. The following information is needed when delegating the skill of position changes to minimize orthostatic hypotension to nursing staff or family members. Notify the caregivers if the patient is at risk for orthostatic hypotension.

Instruct caregiver to have the patient dangle before ambulation. Instruct the NAP to immediately return the patient to a chair or bed if the patient is dizzy, nauseated, pale, or diaphoretic. 3.5 Assessment For assisting with moving a patient up in bed: Assess the patient's weight, age, level of consciousness, ROM, strength, coordination, disease process, and ability to cooperate. This determines how much assistance will be needed. If your patient weighs more than 200 pounds, obtain the assistance of two additional staff. Assess for tubes, incisions, and equipment. This will alter the positioning procedure. Assess patient's skin. Provides baseline to determine effects of positioning. Check health care provider's order before positioning patient. Some positions may be contraindicated. For minimizing orthostatic hypotension: Assess blood pressure, pulse readings, and the patient's current activity level. This provides a baseline to determine if the patient tolerates position change. Identify factors that may precipitate orthostatic hypotension, including decreased intravascular volume, hypokalemia, prolonged immobility, and medications. This alerts the caregiver to potential preexisting medical conditions that contribute to orthostatic hypotension. For transferring the patient from bed to chair: Assess the muscle strength of the legs and upper arms. Immobile patients have decreased muscle strength, tone, and mass. Affects ability to bear weight or raise body. Assess joint mobility and contracture formation. Immobility or inflammatory processes (i.e., presence of arthritis) may lead to contracture formation and impaired joint mobility. Assess for paralysis or paresis (spastic or flaccid). A patient with central nervous system damage may have bilateral paralysis (requiring transfer by a swivel bar, sliding bar, mechanical lift) or unilateral paralysis, which requires belt transfer to strong side. Weakness (paresis) requires stabilization of knee while transferring. Flaccid arm must be supported with sling during transfer.

Assess bone continuity (trauma, amputation). Patients with trauma to one leg or hip may be nonweight bearing when transferred. Amputees may use sliding board to transfer. Assess presence of weakness, dizziness, and blood pressure when changing position. Determines risk for fainting or falling during transfer. Assess level of endurance (level of fatigue, vital signs). Ability to transfer may be limited by fatigue. Planned rest periods before transfer may enhance function. Vital sign changes such as increased pulse and respiration may indicate activity intolerance. Patient with low blood pressure may not tolerate sudden position change and is at risk for orthostatic hypotension. Assess patient's prorioceptive function such as awareness of posture and changes in equillibrium (e.g. can the patient touch his/her forefinger to his/her nose with eyes closed). Determines stability of patient's balance for transfer. Assess vision, hearing, and altered sensation. Assess the ability to follow verbal instructions and the appropriateness of responses to simple commands. Determines the extent to which the patient is able to assist during a transfer. Assess the patient's level of motivation. Patients who fear falling may avoid activity and/or make excuses. Determine the position and functioning of IV tubing and poles and the need for oxygen therapy, a Foley catheter, surgical drains, and other drains or tubes. Prevents accidental removal of a patient's tubes and drains. Assess the need for prescribed analgesic medication before transfer. Plan activity for the period when adequate pain relief is apparent without dizziness and/or excessive sedation. Analgesics enhance a patient's ability to tolerate movement. Peak levels vary according to the specific analgesic and route of administration. Determine the number of people needed to assist with transfer by considering patient's weight and ability to assist with moving. Do not start procedure until all required caregivers are available. Ensures safe patient transfer. During any patient transferring task, if any caregiver is required to lift more than 35 pounds of a patient's weight, the patient should be considered fully dependent and an assist device should be used. 3.7 PlanningEquipment Assisting a patient to move up in bed when the patient is unable to assist:

Draw sheet or slide board (if unavailable, fold a small sheet in half) or other patient-moving device Precautions for orthostatic hypotension: Blood pressure equipment Stethoscope Transferring a patient from bed to chair: Gait belt/transfer belt/slide board (friction-reducing board) Nonskid footwear Bath blanket Pillows Wheelchair: position chair at 45-degree angle close to bed, lock brakes, and remove or fold footrests out of the way Bedside commode or supportive chair at 45-degree angle close to bed 3.9 PlanningExpected Outcomes Expected outcomes when assisting patients to move in bed focus on mobility, self-care, interaction, and prevention of complications within the confines of the prescribed activity. The patient's skin remains intact without redness or breakdown. The patient verbalizes a sense of comfort after each repositioning. The patient's level of independence in completing ADLs increases. The patient maintains assisted changes in position in bed for at least 1 hour. Expected outcomes for preventing orthostatic hypotension focus on preventing hypotension and increasing tolerance of activity while reducing the risk of falls. The patient does not demonstrate evidence of weakness, light-headedness, diaphoresis, dizziness in response to sitting or standing. The patient does not experience a decrease in blood pressure greater than 20 mm Hg systolic or 10 mm Hg diastolic in response to sitting or standing. The patient describes interventions to minimize orthostatic hypotension and prevent injury. The patient ambulates 10 feet while maintaining blood pressure within the systolic baseline.

Expected outcomes for transferring a patient from a bed to a chair focus on improving the patient's functional abilities and strength. It is also essential to promote body alignment and safety. The patient assists with the transfer to a chair by standing erect, pivoting, and grasping the arm of the chair to sit. The patient tolerates sitting in a chair for 30 to 40 minutes and is able to shift weight independently at least every 15 minutes. The patient expresses benefit from the change of environment while in the chair. 3.13 Evaluation To determine whether patients are safely positioned and transferred, you will perform the following evaluation measures: Evaluation of assisting patient to move up in bed when the patient is unable to assist: Inspect the skin overlying pressure areas for erythema (redness), blanching, and abrasions. Observe it again in 60 minutes and every 2 hours afterward. Ask the patient if the position is comfortable. Observe the patient's body alignment and position. Evaluation for minimizing orthostatic hypotension: Observe the patient for signs of weakness, dizziness, and pallor. Obtain blood pressure, pulse, and respirations if the patient experiences weakness or dizziness at any point and on completion of physical activity. Normally blood pressure, pulse, and respirations increase slightly in response to exercise and return to baseline within 5 minutes of resting. Evaluation of transfer: Observe the patient's ability to bear weight (or avoid bearing weight if prescribed), ability to pivot, and number of personnel needed. Ask the patient to describe the level of strength and control. Monitor the length of time the patient sits in the chair and the ability to shift weight every 15 minutes. Ask the patient to describe his or her response to environmental and positional changes.

3.15 Unexpected Outcomes

Unexpected Outcome for Assisting Patient to Move Up in Bed By Using a Lift/Draw Sheet The patient develops areas of abnormal reactive hyperemia (skin redness and warmth), blistering, or skin irritation.

Intervention

Change the patient's position more frequently. Obtain assistance for the next transfer or positioning. Avoid prolonged pressure on any one pressure area.

Unexpected Outcome for Assisting Patient to Move Up in Bed By Using a Lift/Draw Sheet The patient complains of discomfort because of altered alignment.

Intervention

Readjust the position according to the patient's comfort level. Readjust supportive pillows to maintain alignment.

Unexpected Outcome for Assisting Patient to Move Up in Bed By Using a Lift/Draw Sheet The patient turns back to the same position frequently and expresses discomfort with alternate positions.

Intervention

Reinforce the rationale for position changes. Provide diversional activities in various positions.

Unexpected Outcome for Assisting Patient to Move Up in Bed By Using a Lift/Draw Sheet The patient complains of respiratory distress.

Intervention

Readjust the patient's position with head of bed elevated (if allowed).

Unexpected Outcome for Assisting Patient to Move Up in Bed By Using a Lift/Draw Sheet

Intervention

Underlying respiratory and/or cardiac diseases may limit the patient's tolerance of certain positions. Obtain vital signs and determine care needed or contact physician.

Unexpected Outcome for Orthostatic Hypotension Precautions The patient becomes lightheaded and dizzy when upright.

Intervention

Return the patient to the supine position. If the patient faints, lower the patient to the floor safely. Take the patient's blood pressure immediately. Follow agency procedure on when to attempt the procedure again.

Unexpected Outcome for Transferring from Bed to Chair The patient does not follow the directions for transfer.

Intervention

Identify the interfering factors (e.g., anxiety) and provide positive reinforcement for effort and achievement. Demonstrate the procedure for the patient in a step-by-step manner.

Unexpected Outcome for Transferring from Bed to Chair The patient's weakness of lower

Intervention

Consider physical therapy

Unexpected Outcome for Transferring from Bed to Chair extremities makes active transfer difficult and/or impossible.

Intervention

consultation.

Develop a plan for isotonic or isometric legstrengthening exercises to be done while lying in bed or sitting in a chair. Use a gait belt for balance and support. Transfer with another health care person helping. Use mechanical lift.

Unexpected Outcome for Transferring from Bed to Chair Patient sustains injury on transfer.

Intervention

Evaluate incident that caused injury (e.g., assessment was inadequate, change in patient status, improper use of equipment). Complete incident report according to institution policy. Notify health care provider.