Transfers, Ambulation
Safety and Restraints
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
Lesson Objectives (Safety), By the end of
this lesson the student vocational nurse
will be able to:
 Define vocabulary related to
hospital/client environment.
 Discuss the effects of sensory
deprivation for the client.
 Discuss purposes of space and how  Identify personnel and
committees that are involved in
a nurse can respect the client's
maintaining a safe, comfortable
space.
and the therapeutic environment
in the hospital.
 Describe how to maintain the
client's right to privacy.
 Discuss rationale for using
restraints.
 Describe specific environmental
factors that contribute to the
 List the common types of injury
comfort and safety of the client.
that may occur in the hospital
setting
Lesson Objectives (Safety), By the end of
this lesson the student vocational nurse
will be able to:
 Define the terms:
a. Immobilized
b. Legal rights
c. Limb holder
d. Chemical restraints
 Explain the 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
 Check diagnosis of the patient
 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 devices):
 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)
Safety
Define vocabulary related to hospital/client environment.
 Air Pollution – the introduction of checmicals, particulate
matter or biological materials that cause harm or discomfort
to human or other living
Carbon Monoxide - (CO), also called carbonous oxide, is a
colorless, odorless, and tasteless gas which is slightly lighter
than air. It is highly toxic to humans and animals in higher
quantities, although it is also produced in normal animal
metabolism in low quantities, and is thought to have some
normal biological functions.
 Carcinogen - s any substance, radionuclide or radiation
that is an agent directly involved in causing cancer.
Vocabulary related to hospital/client
environment:
 Decibels - logarithmic unit that indicates the ratio of a
physical quantity relative to a specified or implied
reference level ( noise ratio).
 Relative humidity - is a term used to describe the
amount of water vapor in a mixture of air and water
vapor
 Sensory overload
 Parasites - Parasites are organisms that obtain food and
shelter by living on or within another organism.
 Pathogens – microorganism that cause disease.
Space and Privacy
 Purpose of Space
1.
Importance of space
2.
Nurse's role in
protecting client
space
 Maintaining the client's right to
privacy
1. Screening
2. Requesting family/
friends to leave the
room
3. Draping
4. Client consent to
view procedures
Environmental factors related to
comfort & safety
 Temperature of room
 Relative humidity
 Physical hazards
 Carcinogens
 Pathogens
 Pollution
 Developmental factors
Effects of Sensory Deprivation
Cognitive
 Decreased learning
 Bizarre thinking
Affective
 Boredom
 Restlessness
 Increased anxiety
Perceptual
 Decreased attention span
 Confusion
Personnel Maintaining Client
Environment
Medical and Nursing staff
Housekeeping
Engineering /Maintenance
Common Hospital Injuries/Safety
Common Hospital
Injury
Safety
 Falls
 Fire Safety
 Client-Incurred Accidents
 Earthquake Safety
 Procedure-Related
Accidents
 Disaster Preparedness
 Equipment-Related
Accidents
Preventing Fall
 Identifying at-risk patients
 Assess for a history of falls
 Assess for additional risk factors
 Combining an assessment tool with a care plan
 Accurate assessment and use of appropriate fall
intervention
Preventing Falls:
 Determine the client's diagnoses and capabilities
 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
Interventions for a Patient Who
Experiences a Fall
 Immediately assess the patient’s condition
 Provide care and interventions appropriate for
status/injuries
 Notify patient’s physician or primary caregiver of
incident and your assessment of the patient
 Ensure prompt follow-through for any test orders
 Evaluate circumstances of the fall and the
environment; institute preventive measures
 Document the fall and complete an event report
Alternatives to Restraints
 Determine whether a behavior pattern exists
 Assess for pain and treat appropriately
 Rule out physical causes for agitation
 Involve family members
 Reduce stimulation, noise, and light
 Check environment for hazards and modify, if necessary
 Use therapeutic touch
 Investigate discontinuing bothersome treatment devices
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
 Document use of restraints and patient
monitoring
 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
Restraints
Basic Principals:
 Family
 Diversional Activities
 Psycho/Social (tough, isolation, confusion)
 Client’s daily habits (eg) news paper
 Neuro/Vascular Assessment
 Rapid Release of Restraints
R-E-S-T-R-A-I-N-T Acronym
 R: Respond to the present, not the past
 E: Evaluate the potential for injury
 S: Speak with family members or caregivers
 T: Try alternative measures first
 R: Reassess the patient to determine success of
restraint
 A: Alert the physician and family of need for restraint
 I: Individualize restraint use
 N: Note important information on chart
 T: Time limit the use 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
Securing Restraint to Bed Frame
Restraint Secured Behind Chair
Using a Hand Mitt
Child With Elbow Restraint in Place
Chemical Restraints
 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.