Grosse Pointe Hospital
Nursing Student
Clinical
Resource Book
Beaumont GP Nursing Standards
Service Excellence
Clinical Resources
Clinical Equipment
Body Mechanics
Beaumont Grosse Pointe (BGP) Nursing Standards
Service – Ownership – Attitude – Respect
Revised 3/2015
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Beaumont Grosse Pointe Nursing Standards
Service – Ownership – Attitude – Respect
BGP Nursing Mission Statement
Provide compassionate quality care to our patients, families and co-workers
utilizing evidence-based practice and respectful communication.
BGP Nursing Vision Statement
Nursing will foster a professional environment to practice their passion and lead
in exceptional patient care and service excellence.
Service
We make those we serve our highest priority
 Response
Provide prompt and appropriate attention to our patients and visitors. If a
patient’s call light goes on, anyone and everyone is responsible to respond
regardless of job classification.
 Information
Provide clear explanations and accurate information every 20 minutes or as
appropriate.
 Assistance
Proactively take any concern or complaint seriously and seek resolution
with empathy and understanding
 Introductions
In person, or by phone, smile and introduce yourself by name, function and
service you are offering. Address patients/families by their name and
proper title (i.e. Mr., Mrs., Ms.). Answer phone calls within three rings, ask
for permission to put a caller on hold (if needed) and always ask, ‘How may
I help you?’
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Ownership
We are positive ambassadors who take responsibility for creating the Beaumont Experience
 Directions
Offer to escort those who appear lost and in need of assistance. Use full hand gestures when directing.
 Safety
Support a safe environment by being pro-active. Report potential hazards and remember to wash your
hands.
 Environment
Promote a clean, quiet and healing atmosphere. Refrain from loud talk and excessive noises.
 Eco-friendly
Pick up litter and recycle or reuse materials when possible.
 Innovation
Create a culture of excellence through suggestions, performance improvement and continued personal
growth and development.
Attitude
We demonstrate and encourage positive behaviors with the highest degree of integrity
 Courtesy
Use professional behaviors and language in all interactions. Greet everyone with an empathetic smile and
eye contact. Offer to exit elevators if needed for patients/visitors
to use first.
 Image
Observe the highest standards of professional behavior and appearance. Wear your nursing school
identification at all times.
Respect
We treat everyone with dignity and respect
 Teamwork
Work together respectfully to create a team atmosphere. Avoid the use of hand held devised and cell
phones in meetings
 Dignity
Respect diversity including cultural differences. Affirm patients’ rights to make choices regarding their
care. Support emotional needs.
 Confidentiality
Hold all patient and employee information in the highest confidence. Discuss patient information and use
patient names in private areas.
 Privacy
Knock or ask permission before entering. Close doors and curtains during exams, procedures and
interviews; explain this is for privacy. Provide second gowns to cover patients as needed.
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Nursing Philosophy
Nursing plays a vital role in assisting individuals who are sick or well to respond to a variety of new
stressors, move toward optimal well-being, and improve the quality of their lives through adaptation.
Beaumont nurses believe in the need to address the adaptive need of individuals, families, and the
community.
For human beings, life is never the same. It is constantly changing and representing new challenges. The
person has the ability to make new responses to these changing conditions. As the environment
changes, the person has the opportunity to continue to grow, to develop, and to enhance the meaning
of life for everyone. Nurse’s guide and support patients and families through the challenging choices.
Nursing Values
Nursing at Beaumont espouse values that characterize the finest traditions of nursing practice,
education, leadership, and research.
These are:
-accountability
-advocacy
-caring
-collaboration
-creativity
-curiosity
-diversity
-teamwork
-integrity
-professionalism
-evidence based practice
-respect
-stewardship
-safety
-excellence
-research
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Scavenger Hunt
Name:
Term:
Assigned Unit:
Instructor:
1.
2.
Locate the following on the nursing unit:
___
Locker Room
___
Day Room
___
Clean Utility Room
___
Patient Bathroom
___
Soiled Utility Room
___
Public Bathroom
___
Conference Room(s)
___
Public Telephone
___
Pantry
___
Pharmacy Box
___
Unit Rings
Answer the following questions:
How many fire exits are on the unit?
______
Where are they located?
How many fire extinguishers are on the unit?
______
Where are they located?
3.
How many patient rooms are on the unit?
______
How would you find out where an empty bed is on the unit?
______
Locate the following in an empty patient room:
___ Room Temperature Control
___ Head Up Control on Bed
___ Bed Alarm
___ Suction Panel
___ Used Tray Storage
___ Hand Sanitizer
___ Blood Pressure Equipment
___ Head Down Control on Bed
___ Television & Operation Controls
___ Oxygen Panel
___ Wastebasket
___ Patient Bathroom
___ Bed Controls
___ Put Side Rails Up & Down
___ All Room Lights
___ Soiled Linen
___ Sharps Container
___ Nurse Server
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___ Gloves
4.
Locate the following equipment for your unit:
___ Crash Cart
___ Oxygen (portable)
___ Shower Chair
___ Supplies in Clean Utility
___ Tube System
5.
___ Defibrillator
___ IV Poles and Pumps
___ Commode
___ Ice Machine
___ Suction Machine (portable)
___ Standing Scale
___ Linen Cart
___ Kitchen Supplies
Locate the following reference materials on Inside Beaumont Page:
___ Nursing Policies
___ Emergency Management Manual
___ Laboratory Specimen Collection
___ Nursing Reference Site
___ Infection Control Manual
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Volunteer Companion Program
Goals:
1. To provide a safe environment for patients who would benefit from having a
bedside companion by engaging in diversional activities that:
 Provide a safe and calming environment
 Increase attention, daytime wakefulness, and re-orientation.
2. To provide companionship to patients.
3. To enhance the patient experience during hospitalization.
4. To improve patient/family and staff satisfaction.
Patient Selection for Companion Volunteer:
Inclusion Criteria:
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Patients who are pleasantly confused due to:
o Acute mental status changes related to dementia, Alzheimer’s, drugs, sleep
deprivation
Patients with a history of falls who are at risk of falling again
Patients who wander
Patients who are lonely
Patients who would benefit from having a companion visit to break up the day,
decrease anxiety, and provide a diversional activity.
Developmentally disabled patients who would benefit from a diversional activity.
Pediatric patients.
Exclusion Criteria:
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Patients with aggressive behavior
Patients who need supervision because of behavioral issues.
Patients who need a suicide sitter.
Patients in isolation.
Patients in restraints.
Stroke patients requiring assistance with feeding that have difficulty with swallowing
or speech.
Companion Commitment at Bedside:



Companions are providing care based on the level they are comfortable with. Please
see table of services provided for level one and level two volunteers.
Companions will be available between the hours of 8:00 am and 8:30 pm.
Call the staffing office to schedule a companion.
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
Companion’s maximum length of time at bedside is 4 hours. Length and activity for
the patient visit will be dictated by:
o Patient individual needs.
o Ability to schedule volunteer companion.
Activity
Accompanying patients to tests/procedures
Ambulation
Assisting at mealtime
 Providing washcloth/water/soap for hand-washing
 Assisting with positioning
 Assist with cutting up food
Diversional Activities:
 Assisting with menu selection
 Cards
 Coloring
 Crafts
 Engaging in conversation/re-orientation
 Games
 Letter and card writing
 Playing music
 Puzzle building
 Reading books, poetry, mail, journals, magazines, and/or
newspapers
Feeding a Patient (no stroke patients or patients with a swallow
issue)
Providing a Backrub
Personal Care Activities:
 Brushing hair
 Providing hand massage
 Applying lotion to hands, arms
 Assisting with hand washing/washing face
 Assisting with slippers, gown
Straightening linens
Sitting with actively dying patients when family/SO is not present
Level 1
X
X
Level 2
X
X
X
X
X
X
X
X
X
X
X
X
To Schedule a Volunteer:

The RN is to call:
o As the NA/CA you can suggest that a patient is a candidate for a volunteer
companion
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Cardio-Pulmonary Arrest (CPR)
Grosse Pointe
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When a Patient is Unresponsive Call CPR Team
by dialing “555”
Immediately upon discovery, an attempt will be made to resuscitate all victims of
respiratory and/or cardiac arrest unless a written physician’s order exists to the contrary.
Dial ‘555’; tell the operator that you need the CPR Team and location. The CPR Team
will be paged. Documentation will be performed on the Cardiopulmonary Resuscitation
(CPR) Flowsheet which serves as the permanent record of the events and doctor’s
orders.
What is your role in a CPR/Code ?
1.
2.
3.
4.
5.
Assessment and call the CPR Team, include the location
Begin CPR
Obtain CPR cart
Apply defibrillator pads using AED component
Maintain effective compressions and adequate ventilation
Duties After the Code has Ended:
1. What do you do with the 3 copies of the CPR Flowsheet?
a. White copy - Stays with the chart
b. Yellow copy - Send to “Nursing Education”
c. Pink copy - Place in “Top drawer of crash cart”
2. Exchanging the used crash cart
a. Call Pharmacy at 1643 to exchange the cart
b. If the Suction and backboard were used, send to SPD to be cleaned
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RAPID RESPONSE TEAM (RRT)
To Activate: Dial ‘555’
State that you are calling a Rapid Response and give location
What is it?
The Rapid Response Team (RRT) consists of an RN/Nursing Coordinator,
Respiratory Therapist and Physician. The purpose of the RRT is to respond to patients showing
signs of deterioration and provide acute care interventions in order to prevent progression of
patient status to a life-threatening situation. It is a resource to bring needed help for perceived
or actual changes in a patient’s medical status/stability.
What is the role of the team?
1.
2.
3.
4.
5.
Assessment
Stability
Assist with communication with the patient’s physician
Educate and support the staff
Assist with transfer if necessary
Reasons for calling the RRT:
1.
2.
3.
4.
5.
6.
7.
8.
Staff member is worried about the patient
Acute change in heart rate < 40 or >130 bpm
Acute change in systolic blood pressure < 90 mmHg
Acute change in respiratory rate < 8 or > 28 per minute
Acute change in O2 saturation < 90% despite oxygen therapy
Acute change in conscious state
Acute change in urinary output to < 50ml in 4 hours
New onset of stroke symptoms or worsening of existing stroke symptoms:
o Sudden numbness or weakness of the face, arms, or legs (especially on one side
of body)
o Sudden confusion, trouble speaking or understanding speech
o Sudden trouble seeing in one or both eyes
o Sudden sever headache, with no known cause
To Activate Rapid Response Team (RRT)
1. Dial “555” Tell the operator that you need the, “Rapid Response Team to Room ____”.
In addition, have operator page attending physician.
2. Team arrives (goal of less than 5 minutes)
3. The following members of the RRT will respond
o
o
o
o
Critical Care RN/Nursing Coordinator (#6205)
Respiratory Therapist assigned to the unit requesting the RRT
House Officer (#6207)
Additional resources as team feels necessary
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Code Stroke, Dial “555”
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SPIRITUAL CARE DEPARTMENT
Purpose:
The Spiritual Care Department is committed to the care of the Whole person,
Body, Mind and Spirit.
Goal:
To provide spiritual and emotional support to patients, family members, and
personnel.
Procedure:
A chaplain is on duty from:
0630-2000 Monday through Friday (on-site)
Call: 313-473-1656
0800-1200 Saturday, Sunday, and holidays (on-site) Call: 313-473-1656
1201-1600 Saturday, Sunday, and holidays (on-call) Call: 313-473-1000
ask operator to page the on-call chaplain.
Office Location:
Second floor next to chapel.
Who can Request Spiritual Care:
Requests for spiritual care may be initiated by the staff, patient, or family
member.
Examples of Needs:
1.
Patient or a patient’s family may request a visit from a chaplain.
2. A request for any sacramental ministry.
3. A critically ill or dying patient. (mandatory to call spiritual care)
4. At the time of a patient’s death (mandatory to call spiritual care,
leave voice mail if off hours)
5. When the nurse feels a family can be assisted by the presence of a
chaplain (i.e., a time of emergency, etc.)
Chapel:
We also invite you to visit the Chapel on the second floor


Father Rich presides over masses Sunday through Thurs at 1000
Mass can be viewed live on channel #38 on all hospital televisions
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EKAHAU PERSONAL ALARM SYSTEM
WHAT is Ekahau?


Ekahau is the only Wi-Fi-based life safety and security solution to combine real-time
location visibility with 2-way communications to help reduce emergency response
times and prevent injuries wherever Wi-Fi works.
2 Levels of Assistance:
o BLUE BUTTON=Nurse Assist Needed
 Press blue button
 Nursing unit staff response only
 Urgent PFV or safety situations not requiring security
 EXAMPLES:
 Pt has thrown food tray on floor
 Ambulating patient and they go into the wrong room and are
not re-directable
o


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

SAFETY ALERT SWITCH/CODE V=Potential for Physical Violence/Life
threatening Situation
 Pull on badge firmly to release switch at the top of badge
 Alerts Security and nursing staff to respond
 Situations of immediate danger that you cannot remove yourself from
and are in need of help from security and unit co-workers
 EXAMPLES:
 Patient is standing on the bed threatening to jump-screaming
in fear
 Patient has cornered you in the bathroom and is threatening
harm
 Patient hallucinating, trying to elope, or leaving unit
 Patient has some sort of weapon or object that he/she is
threatening to hurt you or themselves
WHERE will Ekahau be used?
Ekahau security badges will be effective on all in patient units within BGP
Ekahau badges must be worn around the neck on the Ekahau break away safety
lanyard.
Ekahau badges will be stored in the docking station when not in use
Ekahau badges are assigned to each individual in-patient unit, if your assignment
changes you must leave the Ekahau on that unit in the charging base and retrieve an
Ekahau badge from the new unit
WHO must wear Ekahau?
Any staff caring for a patient that has a potential for violence
Any staff that would like to wear an Ekahau badge
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
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WHEN the badge is in use:
Two green lights will flash approximately every 15 seconds while device is out of the
docking station—this indicates the badge is working
Orange light on top right will flash if battery is low while the badge is in use
You will receive a ‘change battery NOW’ message when 20% battery life remaining
You will receive a ‘critically low battery’ alarm when battery is at 5% (you must
acknowledge this alarm by pressing menu button)
Activation of the alarms will alert staff wearing a badge on the unit where the badge
originated
Clear all messages at the end of your shift by pressing and holding the menu button
until the message disappears. Do so for every message.
Return the badge to base for charging and get a new badge
WHEN the badge is not in use:
Place badges in docking station (orange/red light=re-charging, green light=fully
charged)
Recharging time=approximately 2-3 hours
If there is not a light display on the badge when inserted into the docking station,
immediately take it to your nurse manager—badge needs servicing—or call ext.
1429
Should you attempt to leave the building with the badge; an alarm will sound as a
reminder for you to return the badge to its docking station on the unit..
IF YOU TAKE THE BADGE HOME, IT MUST BE RETURNED IMMEDIATELY
AT THIS TIME, IT IS RECOMMENDED THAT THOSE STAFF MEMBERS WITH A
PACEMAKER NOT WEAR AN EKAHAU BADGE
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Potential For Violence (PVF) Magnet
Purpose:
 Post on door frame of patient’s room
 Any ancillary staff entering the room will report to
nurses desk
 Ancillary staff will be informed about PFV
 Ancillary staff can use an Ekahau badge while
performing duty in patient’s room, then return badge
to docking station prior to leaving the unit
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LIBRARY SERVICES INFORMATION
The Beaumont Libraries are here to help you in learning how to find the biomedical and clinical
information that you will need for patient care decisions and medical research.
Library Home Page
On the Inside Beaumont page, you can access the Library home page by clicking on the
website http://employee.beaumont.edu Departments tab and then selecting the Medical
Library link.
Remote Access to Online Library Resources
To access the Library resources offsite, use the link https://neo.beaumont.edu/employee and
click on the Inside Beaumont Link to access the Library Home page under the Departments tab.
Print Resources
The Library has a large collection of books, print journals and audiovisual resources and is one
of the largest hospital library collections in the state. The Libraries’ books are classified in the
Library of Congress Classification scheme and can be located using the Beaumont online
catalog called Horizon on the Inside Beaumont page or the URL
http://beaumont.dalnet.lib.mi.us. Due to space restraints, journals published prior to 1995 are
in offsite storage.
Electronic Resources
On the Library Homepage, you have access to a variety of electronic resources including:
- Over 65 databases such as PubMed, Ovid databases, UptoDate, MD Consult.
- 155 electronic books such as Harrison’s Internal Medicine, ACP Medicine, etc...
- Over 15,500 electronic journals such as New England Journal of Medicine, JAMA, Lancet, and
other specialty journals.
Need More Information?
Please contact Janet Zimmerman, Library Director at (248)898-1751 or at
janet.zimmerman@beaumont.edu if you have any questions about the Beaumont Libraries or
services.
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BLADDER SCAN STEPS
1. Make sure that the scan head is plugged in and the battery is installed (the charge should be
greater than 25%).
2. Press the button to turn the Bladder Scan on.
3. Press the SCAN button and then select the patient gender with the MALE/FEMALE button.
4. Put the ultrasound gel on the scan head or the patient, being careful not to create air bubbles
and removing any that are present.
5. Place the scan head about 3 cm/1inch superior (above) the symphysis pubis pointing toward the
expected bladder location. Make sure the head of the male/female icon on the scan head is
pointed toward the patient’s head.
6. Press the scan head button on hand held device or press “SCAN” on the Bladder Scan unit. Hold
the scan head steady until you hear a beep. The unit will display the volume measured and an
aiming display with crosshairs.
7. If the bladder is not centered on the crosshairs, adjust the scan head and repeat the scan until
the bladder is properly centered. The unit will save the ‘largest’ bladder volume from any series
of scans you do with this patient.
8. When you are satisfied that the result is accurate, press the DONE button. The unit will display
on the printout the largest volume measure and the longitudinal and horizontal B-mode scans.
9. For a printed copy of the results, press the PRINT button.
10. Print the patient’s name on the printout, along with their medical record #, (no need to write in
any procedure code), and sign you name with your job category (e.g. NCA). Place the printout in
the progress notes.
Remember:
 If a woman has had a hysterectomy, select the male setting (no uterine tissue to detect)
 Do NOT scan pregnant women as the scans are inaccurate as it cannot tell the difference between the
fluid in the uterus or bladder, and will give you a combined total.
 Line up the stick figure on the scan head with the patient.
 Hold the probe steady during the scan.
 No need to hold the scan button, just press and release.
 Do not scan over scar tissue, bandages, or the pubic bone of your patient.
 The application of the gel is very important: for very thin and obese patients, or those with more body
hair, more gel is required. A dry probe will give you inaccurate results.
 Patient can be sitting or supine.
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Perineal Hygiene w/wo Urinary Foley Catheter
For those patients that are unable to bathe themselves, we must provide perineal care at least once
daily
Male - Without a Foley Catheter

Position the male patient on his back

Wash the groin from the front to the back starting at the groin area and then going to the inside
of the thighs

Rinse the cloth or use a new washcloth

Pull back the foreskin if the patient is not circumcised

Wash and rinse the tip of the penis downward while using gentle, circular motions and then the
scrotum

Rinse the cloth

Turn the person on their side

Wash, rinse and dry the rectal area
Female - Without a Foley Catheter

Position the female patient on her back

Separate the labia and wash, rinse and dry the urethral area first with short downward strokes
alternating from side to side and proceeding until the exposed area around the urethra is done

Rinse the cloth or use a new washcloth

Wash the groin on the outside of the labia from the front to the back starting outside the labia
and then going to the inside of the thigh, rinse the cloth

Turn patient on her side

Wash, rinse and dry the rectal area
Male & Female - WITH a Urinary Foley Catheter
Male and female patients with a urinary catheter has the above steps followed by these additional steps

With a clean washcloth and soap, wash the catheter starting at the urinary opening with short
strokes to about 4 inches away from the body

Using a new washcloth, rinse the catheter starting at the urinary opening with short strokes to
about 4 inches away from the body
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So Your Patient Has A Nasogastric Tube (NGT)
Basic Facts
Complications
 NGT’s are usually inserted to
decompress (remove air & fluid) the
stomach
 When the patients NGT becomes
clogged the patient may complain of
epigastric pain and/or start vomiting
o You MUST notify the RN
 NGT’s may be used to temporarily feed
patient
 Normally the patient has the NGT for
48-72 hours after surgery, by which
time peristalsis resumes
 The NGT may move. Tape may become
loose or fall off the patient’s skin. This
can be very dangerous
o You MUST notify the RN
o Check for placement
 An NGT may remain in place for
shorter or longer periods, however,
depending on its use and the patient’s
progress
 When the NGT is attached to suction;
the patient may become dehydrated
because fluids and electrolytes are
being removed
 Frequently an NGT is used to assess
and treat GI (gastrointestinal) bleeding
 Aspiration pneumonia could result
from gastric reflux, vomiting or a NGT
that has moved (not in stomach)
 Other uses can include: Diagnostic &
therapeutic applications, collecting
gastric lavage, aspirating gastric
secretions, & administering
medications and nutrients
Inserting an NGT requires close observation
of the patient by all health care members!
 The RN must verify the proper
placement of the tube, and is
responsible for its insertion and
removal
 Insertion of an NGT may cause skin
breakdown and discomfort and
increased mucous membrane
secretions
o Notify RN is you notice skin
breakdown
 A level of suction that is too high or
vigorous can lead to damaged gastric
stomach lining.
o Notify RN if you notice fresh
bleeding, coffee ground or bean
colored drainage
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 Pain is the 5th vital sign
 Use the 0 - 10 pain scale
 Ask the patient to rate their pain from 0 (no pain) to
10 (the worst pain imaginable)
 Always document pain score in docFlow sheet and
Notify the RN when a pain score is 4 or above
 Always document pain scale prior to treatment, then
reassess pain level within 59 minutes of treatment
and document
 Pulse Oximetry
95 – 100% is normal
 Anything below usually indicates the need for oxygen
 Notify the RN
21
Orthostatic Vital Signs
1. Have patient lay in supine position for 5-10 minutes
prior to taking blood pressure (BP) and heart rate (HR)
2. Then have the patient either sit or stand and
immediately repeat the BP & HR
Orthostatic Hypotension is usually diagnosed when, after
changing position from supine to upright, a patient
experiences light-headedness, an increase in HR of 20-30
bpm, a decrease in systolic BP of at least 20 mm/Hg, and/or
a decrease in diastolic BP of at least 10 mm/Hg.
Upright
Supine
Positive orthostatic vitals may indicate dehydration, blood loss or any
condition that will decrease fluid volume in the patient.
Always notify RN of positive orthostatic changes
Sample:
 Supine position BP 120/80
 Upright BP 100/72
 Systolic BP: A drop of 20 mm/Hg is considered
positive
 Diastolic BP: A drop of 10mm/Hg is considered
positive
 Mental Status Changes (i.e. dizziness) is considered
positive
22
Pick-Up & Delivery of Blood Products
1. When you receive completed ‘Request for Blood Products’ (pink slip) from RN, both
parties must verify:
 Patient Name
 B-Number
 Date of Birth
2. Take ‘pink slip’ to the Blood Bank (located on the Lower Level – in the Lab)
3. Verify patient name with blood bank staff
4. Immediately return to unit
5. Give blood directly to the RN. Again, verify for accuracy of patient
 Name
 B-Number
 Date of Birth
23
Causes of Pressure Ulcers
Pressure – Results in decreased blood flow to the skin causing edema (swelling), hypoxia (lack
of oxygen) and necrosis (death of tissue). Pressure occurs from sitting, or lying in one position
for toll long. This time should never exceed two hours.
Friction – Skin rubbing against resistive surfaces such as a bed sheet. This damage can occur if
the resident is dragged over the bed linen. It can rub off the top layer of skin or cause
superficial irritation.
Moisture – Urinary incontinence, fecal incontinence and/or perspiration increases the risk of
pressure sore formation. Wet skin is more vulnerable to both friction and pressure because the
excessive moisture weakens the cell walls and leads to skin breaking down.
Shearing Forces – This causes deep tissue damage. If the patient’s head of bed is elevated more
than 30 degrees, they tend to slide down. The skin tends to stick to the sheets and it pulls away
from the underlying tissue. The sacrum (lower back) is frequently affected by shearing forces
and can result in pressure ulcers.
Skin Injury – Any break/tear in the skin.
Patients Susceptible to Skin Breakdown
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Incontinent patients
Obese or thin patients
Patients who are unable to move freely
Diabetic patients
Patients with poor circulation, malnutrition, anemia, or dehydration
Patients in a cast
Patients with a decreased level of consciousness and/or coma
Patients with contractures or rigid/spastic limbs
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Applying 3 or 5 Lead Monitoring
Skin Preparation:
If the skin is oily, wipe it with soap and water and let it air dry. To remove dead skin and
improve contact where you’ll place the electrodes, rub the skin with gauze until it’s
slightly red.
Connect the leads to the cable and monitor, making sure that the initials and colors on
the leads match those on the terminals. For example connect RA (white) to RA (white)
etc. Attach an electrode to each lead and turn on monitor.
White-RA (right arm), below R clavicle
Black –LA (left arm), below L clavicle
3 Lead System
Red-LL (left leg), on the lower chest just above
umbilicus
White-RA (right arm), below R clavicle
Black –LA (left arm), below L clavicle
5 Lead System
Red-LL (left leg), on the lower chest just above umbilicus
Green-RL (right leg), on lower chest just above & to
right of umbilicus
Brown-In V1 position at fourth intercostal space, right
sternal borders
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Important Facts about Chest Tubes
Chest tubes may be drainage or to suction
Discuss with RN to know which it is
1. Always keep the drainage system below the level of the patient’s chest and in an upright
position.
2. If the chest tube gets disconnected from the drainage system, immediately notify RN
3. Never clamp tubing; this can only be done by an RN with a physician order.
4. Keep loops of the chest tube drainage system off the floor. ‘Coil’ tubing loosely and secure
on bed to prevent the patient or hospital staff from stepping on them.
5. Make sure there is always ‘slack’ on the tubing.
6. Routinely evaluate patient’s respiratory status.
7. Do NOT disconnect chest tube suction, only the RN may do this. Suction may be
disconnected then reconnected after the patient ambulates or travels to another area, but
the RN must do this.
Your patient has a chest tube and is anxious, heart rate is fast and they are breathing
fast. You can’t tell if the suction to the chest tube is working properly.
What should you do?
1.
2.
3.
4.
Call the nurse
Check to see if chest tube is clamped (If so, unclamp it immediately)
Check tubing for kinks or bends
Check to see if patient is laying on tubing
While turning over in bed, your patient pulls out their chest tube, what should you
do?
1. ACT FAST!!
2. Notify the nurse immediately
Your patient’s chest tube has no drainage in the collection chamber, what should you
do?
1.
2.
3.
4.
5.
Is the chest drainage system low enough so gravity can assist drainage?
Reposition patient
Examine the tubing for kinks bends
Let the nurse know
Maybe the drainage has stopped and this is normal for the patient
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BODY MECHANICS
HANDBOOK
BODY MECHANICS
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NURSING EDUCATION DEPARTMENT
BODY MECHANICS
Anatomy: Your spine has 3 natural curves (cervical, thoracic, and lumbar). Your spine consists of 24
interlocking bones with flexible joints called vertebrae that support the body and protect the nerves of
the spinal cord. Shock-absorbing discs are located between each pair of vertebrae. Ligaments connect
the vertebrae together and back muscles help support the spine.
Poor posture and improper lifting puts you off balance and causes stress to your spine. Damage to your
back is cumulative, over time the stress and strain over the years can catch up to you, that’s why it is
important to use proper body mechanics when you lift or move your patients
Tips for Lifting & Moving Patients:
Ready:
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Assess patient’s ability to participate in transfer (check weightbearing status)
Assess patient’s ability to comprehend instructions
Ensure safe surroundings (check for: electrical cords, loose carpeting, wet or slippery floors, etc.)
Use assistive devices if needed (sliding board, gait belt, mechanical lift, draw-sheet)
Align all equipment properly (a wheelchair should be placed either parallel or at a 45 angle to the
bed, depending on the type of move)
Position IV lines or other tubing so that it will not pull or get in the way
Lock all wheels on equipment (stretches, wheelchairs, beds, mechanical lifts, draw sheet, etc.)
Patients should have proper footwear when being transferred (non-skid footwear)
Put the side rails down prior to transferring or moving patients
SET:
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Obtain assistance from others. THIS IS A MUST!
Give the patient clear instructions regarding the process of transfer so there is no confusion.
Position yourself close to the object/patient with wide stance, back erect, knees bent, head up (“the
power position”)
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MOVE:
 Avoid bending at the waist, keep your back erect, keep the load close to you
 Bend at the hips & knees, use the stronger and larger muscles of the upper arms, shoulders, thighs,
& hips. Focus on lifting through the knees. Spine should be in a postural alignment, maintain natural
curves
 Avoid twisting motion, instead move your feet during turns.
 Never have patients put their arms around your neck: they should use their arms to push up if able
BOOSTING PATIENT UP IN BED (One –Nurse Technique):
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Remove pillow from under patient’s head and place against the headboard
Lock all the brakes on the bed
Adjust the height of the bed to the waist level, trendenlenberg the bed
Instruct patient to bend both knees while keeping feet flat on bed
Instruct patient to push through feet and scoot towards top of bed, using hands on bedrails as
needed
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BOOSTING PATIENT UP IN BED (Two –Nurse Technique):

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Remove pillow from under patient’s head and place against the headboard
Adjust the height of the bed to the hip level
Lock all the brakes on the bed and place all the siderails down
Use the pad draw-sheet beneath the patient (draw sheet should be placed under thighs and
buttocks, if not, roll patient and reposition first)
Stand on opposite sides of patient and grasp the folded sheet or draw-sheet. Instruct patient to
bend both knees while keeping both feet flat on the bed. MAKE SURE THE PATIENT HUGS
THEMSELVES IF ABLE.
Bend your hips and knees, spread your feet
Gently slide the patient up the bed on the count of 3 by shifting your weight toward the head of the
bed.
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DANGLING PATIENT AT SIDE OF BED:

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Raise the head of the bed
Lower the side rail on your side of the bed
Help patient put on non-skid slippers
Ask the patient to move to the edge of the bed if able to assist. Log roll pt to edge of bed if possible
Use the drawsheet to help move pt to edge of bed and slide his or her legs over the edge of the
mattress
Tell the patient to provide support by pushing his or her fists into the mattress
Stand blocking the patient’s knees until you are sure he or she is stable
If the patient is getting out of bed, be sure the patient is feeling well before continuing (the patient
may feel dizzy for the first minute of dangling, but this should pass, if it doesn’t return the patient to
a lying position )
Log Rolling: Have the patient roll onto their side and bring legs off the bed. Assist the patient by
supporting their shoulders until they are safely sitting erect at the side of the bed.
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TRANSFERRING PATIENT (Bed to Wheelchair/Chair): Sitting Pivot/ Standing Walking Transfer

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Position and lock the wheelchair close to the bed so that the patient can be pivoted smoothly from
bed to chair (Note: If the patient has a stronger side and a weaker side, position the chair on the
patient’s stronger side)
Assist patient to put on non-skid footwear
Assist the patient to dangle
Stand in front of the patient with your feet , alternate your feet with the patient’s (have your feet in
position to pivot toward the chair)
Attach a gait belt
Bending at the knees and waist and keeping your back straight, grasp the gait belt at the sides. Have
the patient place his or her hands on or under your arms
Use your knees on outside of patients legs to support patient
Tell the patient to be ready to stand on the count of three. Maintaining good body mechanics,
straighten your legs and help bring the patient to a standing position
Using a pivot rather than a twisting motion, turn the patient toward the chair
Have the patient reach for the chair arms. Lower the patient into the chair, keeping your back
straight and bending at the hips and knees
Avoid twisting at the back. When transferring the patient onto another surface, use your body
weight not just your arms.
Keep transfer surfaces close to the same height when moving a patient.
It may be helpful for the patient to use a walker to perform the transfer
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Wheelchair Mobility
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Have patient transfer towards his/her strong side whenever possible
Be careful with patient’s arms and legs in/out of doorways and around corners
Have patient keep hands in his/her lap
Be sure IV lines/Foley catheters not dragging on floor or near wheels
Back into elevators and proceed forward off
MECHANICAL LIFT:
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Raise the bed to a height that places the patient near the nurse’s hip level
Lock the brakes on the bed
Place the canvas sling under the patient from the shoulders to mid-thigh by rolling the patient
Move the lift device on the same side of the bed as the chair or stretcher to which the patient will
be transferred
Position the boom on the lift over the patient’s torso
Lock the wheels on the sara plus lift but not on the hoyer lift
Attach the hooks on the lifting chain or straps to the holes in the canvas sling
Position the patient’s arms across his or her chest
Pump the jack handle/use remote control to elevate the patient to about 6” above the mattress
Unlock the wheels on the lift and move the lifted patient directly over the chair or stretcher
Relock the wheels of the lift
Slowly lower using remote
Disconnect the sling from the mechanical lift, but leave the canvas sling in place beneath the patient
(so that patient can later be lifted back to bed)
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GAIT BELT:





Fasten gait belt securely over clothing (to prevent injuring the skin).
Use the gait belt on a patient who can support most of his or her own weight
Care must be taken to avoid entrapping the breasts of females
Place a gait belt with care if a patient has a:
 PEG tube
 Abdominal incision / Back incision / Brace
 Abdominal drain
 Colostomy / Ileostomy
Use underhand grip when grasping the belt. The health care worker should be able to fit only
fingers into the gait belt.
Obesity has become very prevalent in the U.S. It can be a cause of illness, and can accelerate
deconditioning that occurs during unrelated illnesses. It is important to mobilize these patients,
however, we must know our limitations. If a patient is significantly larger that his helper, he must be
able to do a substantial portion of the work or transfer, or else it may not be safe to get him out of bed.
Consider sitting EOB, or using a cardiac chair. Go back to basic patient assessment for ability to transfer,
and use common sense. Do not compromise the safety of the patient or yourself!
The physical therapists’ role includes educating other staff on a daily basis. Working together to problem
solve is an opportunity to learn from each other, and better serve the patient. We look forward to
helping working with you to help ensure all patients are able to complete daily mobility.
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