Transfers, Ambulation and
Restraints
M. Freeman-McGuire, R.N., MSN
Revised by: Jean D. Lansang, RN, MSN, HHRN
Lesson Objectives (Transfers), By
the end of this lesson the student
vocational nurse will be able to:
Describe the procedure for transferring the
client: moving up in bed, bed to chair, bed
to stretcher, chair to bed,
Explain at least three safety factors
practiced while performing a transfer
List common hazards encountered during a
transfer
Explain the importance of knowing the
diagnoses and capabilities of the client
Lesson Objectives (Ambulation), By
the end of this lesson the student
vocational nurse will be able to:
List common hazards of ambulation and of
using assistive devices
Explain the importance of knowing the
diagnoses and capabilities of the client
Describe methods to support the client
during ambulation
Discuss various gaits used for walking with
a cane, walker or crutches
Create sample charting after ambulating a
client, including the important data
Lesson Objectives (Restraints), By
the end of this lesson the student
vocational nurse will be able to:
Discuss rationale for using restraints
Define the terms immobilize, legal
rights, limb holder, chemical restraints
Explain the patient’s Bill of Rights
regarding consent of the client, family
or guardian and written medical
orders for use of restraints
Discuss the procedure for applying
various physical restraints
Transfers, Ambulation,
Restraints
Safety !!!!
Transfers, Ambulation, Restraints
(Safety Interventions):
Assess for Orthostatic Hypotension
Dangle
Client with special needs: (eg.) blind
Lock wheel chairs, stretchers and
beds
Check floors for safety (wet or clutter)
Tub and shower surfaces
Non-skid slippers
Common Hazards Encountered:
Unable to assist or follow directions
Client fear
Client fatigue
Client weak
Problem with assistive devices
Inexperience of nurse
Size of client
Size of nurse
Supporting The Client:
Physically
Emotionally
Psychologically
Tips:
Moving from bed to chair:
Chair on strong side
Pivoting (client’s hand on arm of
chair)
Ambulating A Client:
Support weak side
Match client’s gate
Basic Nursing Care:
Comfort
Safety
Change Position
Chair Cushions
ROM Exercises
Orientation of Client
Therapeutic Touch
Personal Items near Client
Client Daily Habits
ADL’S
Documentation:
Time
Distance
Use of Assistive Devices
Client’s Feelings
Weakness
Poor Balance Dizziness
Posture
Other Problems
Number of People to Assist
Procedure for Transfers:
Check the doctor’s orders
Dangle (usually necessary-after BR)
Assist client to a sitting position, legs
at side of bed, not touching the floor
Allow client to dangle for several
minutes
May be necessary to return client to
bed
Orthostatic Hypotension (Signs and
Symptoms):
Dizziness
Weakness
Faint
Fatigue
Lightheadedness
Orthostatic Blood Pressures:
Lying
Sitting
Standing
Orthostatic Hypotension:
Systolic Blood Pressure
drop < 25 mm Hg
Diastolic Blood Pressure
drop < 10 mm Hg
Equipment (Transfers):
Wheel Chair with Replacement Arm
Geri Chair
Transfer Belt
Sliding Board
Mechanical Lifts (Hoyer)
Bed Scale
Pull Sheet
Moving Client Up In Bed:
Position on back
Ask client to bend knees and push
with feet on the count of three
Nurse assist client to the top of the
bed (usually two person assist)
Use good body mechanics
Transfer (Two Person):
Very overweight client
Confused client
Uncooperative client
Transfer To Chair from Bed:
Dangle Position (may be first step)
Stand
Pivoting (client’s arm on the arm of
chair)
Place chair on the client’s strong side
Ambulation (common hazards with
assistive devises):
Broken
Client not know how to use
Pathways are not clear
Equipment (ambulation)
Same with few exceptions
Gait Belts
Crutch
Walker
Ambulation: Prevent Falls !!!
Client Posture (head up, eyes open,
looking forward)
Non-skid slippers
Walk at client’s side
Match client’s gate
Ambulation (Procedure):
Walk on client’s weak side/match gate
Stabilization (allow client to hold your
elbow or hand)
Minimal Support (hold client’s arm
with your hand)
Moderate Support (encircle client’s
waist with your hand)
Maximum Support (two persons, one
on each side of client)
Preventing Falls:
Floors Clean and Dry
Floor Free from Clutter
Anticipate Client Needs (toileting etc.)
Know Client’ Diagnosis (eg.) CVA
Blind Client’s, Alzheimer's
Keep Belongings and Call Light in
Reach, Bed in Low Position and
Locked, Side Rails (!!!)
Breaking Client’s Fall:
Stand with your feet apart slightly behind
the client
Grasp the client firmly at waist/axilla
Your near leg against the client’s leg
Slowly lower the client to the floor
Examine for injury
Call for help
Document as per agency policy
Doctor notified
Restraints:
Purpose
Applied for safety
Prevent injury
Prevent dislodgement of
tubes
Psychiatric Setting
Restraints
Legal Consideration:
Must be ordered by a physician in
writing
Emergency (can be applied by a
nurse, orders within 24-48 hours)
Documentation (all that was done to
remedy situation before applying)
Restraints:
Must !!!
Must help client or be needed for medical
therapy
Must be ordered by a physician
Must not be used as a means of pushing or
disciplining the client
Must be applied snugly/not tightly
Must be removed/Reposition Q2
Must notify doctor when no longer needed
Must intervene to promote safety
Must be documented
Restraints
Types:
Safety Belts
Wrist Extremity Immobilizer
Vest (Posey)
Hand Mittens
Leather
Chemical
Restraints
Basic Principals:
Know agency policy
Check client Q 15 minutes
Remove and reposition Q 2 hours
Assist with ROM
Call light in reach
Comfort measure (eg) water, food, rest room
Family
Diversional Activities
Psycho/Social (tough, isolation, confusion)
Client’s daily habits (eg) news paper
Neuro/Vascular Assessment
Rapid Release of Restraints
Restraints
Long Term Use (problems):
Muscle weakness, atrophy
Loss of bone mass, joint contractures
Constipation/incontinence
Pressure Ulcers
Cognitive Impairment
Decrease confidence in ambulation
Withdrawn, detached
Depression
Loss of independence
Conclusion
Ask Yourself:
Is my client safe from harm?
Does my client need anything?
Is the bed locked?
Is the bed in the low position?
Is the call light in reach?
Does my client have anything to do?
How is my client’s neuro/vascular
assessment?
Physical Restraints
Restrict or control movement or
behavior. They may be attached to a
person's body or create physical
barriers.
wrist
vest
side rails
wheelchair safety
hand mittens
Chemical Restraints - are any medication
used for the purpose of restraining patients
involuntarily to prevent them from harming
themselves or staff.
Advantages of chemical restraints
Control violent behavior and patient
agitation
May reduce need for physical restraints
Allow examination and performance of
radiographic imaging
Disadvantages of
chemical restraints
•May result in
complications, such as
respiratory depression and
loss of gag reflex
•Occasional paradoxical
reaction results in
increased agitation
•Limit mental status
assessment and neurologic
examination during
sedation
Environmental restraints
change or modify a person's
surroundings to restrict or
control movement. For example,
a locked door.
Title XXII and Legal Rights of
the Elderly
Policies and procedures which contain
competency standards for staff
performance in the delivery of patient care
shall be established, implemented, and
updated as needed for each nursing unit,
including standards for the application of
restraints. Standards shall include the
elements of competency validation for
patient care personnel other that registered
nurses as set forth in Section 70016
Rights of the Elderly