Safety; Basic Body Mechanics; Moving

1
Safety Basic Body Mechanics Moving Positioning

• Nursing 125

2
Patient Safety

• Technically the biggest safety system in
  healthcare is the minds and hearts of the workers
  who keep intercepting the flaws in the system and
  prevent patients from being hurt. They are the
  safety net, not the cause of injury.
• Don Berwick

3
Patient Safety 1

• A clients health and wellness depend upon
  safety. Safety is the number 1 priority in all
  aspects of care.
• Nurses need to be aware of safety. The hospital
  setting is complex, potentially dangerous
  unfamiliar to clients.

4
Ensuring Client safety

• Reduces length of stay cost of treatment
• Reduces frequency of treatment
• Reduces potential for law suits
• Reduces the number of work-related injuries to
  personnel

5
Institute of Medicine Report, 1999

• Estimated 48,000-98,000 deaths per year from
  medical errors.
• Adverse events ranked as the 8th leading cause of
  death, ahead of MVAs, breast cancer and AIDS
• Extrapolating from the U.S. data, adverse events
  would account for 4,000-10,000 deaths per year in
  Canada.

6
Impetus for action Threefold

• 1. Health system has a moral imperative to ensure
  the safety of patients
• Adverse events have a tremendous cost to the
  system in extended hospital stays additional
  medical procedures
• Adverse events expose health organizations to
  legal liability

7
A safe environment is one in which basic needs
are met, physical hazards are reduced or
eliminated, transmission of organisms is reduced
and sanitary measures are carried out.
8
Falls

• Fall risk, especially in the elderly, is growing.
  In hospitalized patients, 4-12 falls occur per
  1,000 bed days, ranking them among the 10 most
  common claims presented to insurance agencies
• Nursing Management, September 2002
• 30 of people 65 yrs and older (in the community)
  fall at least once each year.

9
Focus Assessment

• To ensure patient safety the nurse should
  conduct a focus assessment during every
  nurse-patient encounter which includes
• A visual scan of the environment for potential
  hazards
• A quick appraisal of patient related factors

10
Strategies to help reduce falls Physical
environment

• Appropriate furniture and lighting
• Call bell easily accessible/personal items within
  reach
• Traffic areas free from obstruction
• Secure/remove loose carpets or runners
• Eliminate clutter
• Grab bars in appropriate areas in washroom
• Handrails in the halls
• Keep bed in a low position lock
  bed/wheelchairs/stretcher
• Identify clients at risk for falls.
• If a client experienced falls at home, they will
  likely continue to be at risk for falls in the
  hospital setting. Place them close to nsg
  station.

11
Strategies to help reduce falls
(Communication/Assessment)

• Orient client to physical surroundings
• Explain use of call bell
• Assess clients risk for falling
• Alert all personnel to the clients risk for
  falling
• Instruct client and family to seek assistance
  when getting up
• Maintain clients toileting schedule
• Observe/assess client frequently
• Encourage family participation in clients care

12
Body Mechanics

• The coordinated efforts of the musculoskeletal
  nervous system to maintain balance, posture
  body alignment during lifting, bending, moving
  performing ADLs.
• Knowledge practice of proper body mechanics
  protect the client and nurse from injury to their
  musculoskeletal systems.
• Correct body alignment reduces strain on
  musculoskeletal structures, maintains muscle
  tone, contributes to balance.

13
Body Mechanics (cont.)

• Body balance is achieved when a wide base of
  support exists, the center of gravity falls
  within the base of support a vertical line can
  be drawn from the center of gravity through the
  base of support.
• When lifting an object, come close to the object,
  enlarge the base of support lower the center of
  gravity.

14
Body Mechanics (cont.)

• Proper body mechanics facilitates movement
  without muscle strain excessive use of muscle
  energy.
• Improper body mechanics can lead to injury for
  both the nurse the patient, especially back
  injury when lifting.

15
In 1990, Canadian hospitals reported 30,487 time
loss injuries. Fifty-three percent were
sustained by nurses. Almost half (of the
injuries) were back injuries. Back injury is now
recognized as one of the major reasons for
ill-health retirement from nursing. Not only is
it the most frequent injury sustained by nurses,
it is the most debilitating
16
Action Rationale
When planning to move a client, arrange for adequate help. Use mechanical aids if help is unavailable. Two workers lifting together divide the workload by 50.
Encourage client to assist as much as possible. This promotes the clients abilities strength while minimizing workload.
Keep back, neck, pelvis and feet aligned. Avoid twisting. Reduces risk of injury to lumbar vertebrae muscle groups. Twisting increases risk of injury.
Flex knees keep feet wide apart. Position self close to client (or object being lifted). A broad base of support increases stability. The force is minimized. 10 lbs at waist height close to the body is equal to 100 lbs at arms length.
17
Action Rationale
Use arms and legs (not back) The leg muscles are stronger, larger muscles capable of greater work without injury.
Slide client toward yourself using a pull sheet. Sliding requires less effort than lifting. Pull sheet minimizes shearing forces, which can damage clients skin.
Set (tighten) abdominal gluteal muscles in preparation for move. Preparing muscles for the load minimizes strain.
Person with the heaviest load coordinates efforts of team involved by counting to three. Simultaneous lifting minimizes the load by any one lifter.
18
Moving Positioning

• Mobility persons ability to move about freely.
• Immobility person unable to move about freely,
  all body systems at risk for impairment.
• Frequent movement improves muscle tone,
  respiration, circulation digestion.
• Proper positioning at rest also prevents strain
  on muscles, prevents pressure sores (decubitus
  ulcers within 24 hours) joint contractures
  (abnormal condition of a joint, characterized by
  flexion fixation caused by atrophy
  shortening of muscle fibers or by loss of normal
  elasticity of the skin).

19
Moving Positioning (cont.)

• Pressure Sores tissues are compressed,
  decreased bld supply to area, therefore,
  decreased oxygen to tissue cells die.

20
Correct Positioning

• Is crucial for maintaining body alignment and
  comfort, preventing injury to the musculoskeletal
  system, and providing sensory, motor, and
  cognitive stimulation.
• It is important to maintain proper body alignment
  for the patient at all times, this includes when
  turning or positioning the patient.
• Aim least possible stress on patients joints
  skin. Maintain body parts in correct alignment
  so they remain functional and unstressed.
• Patients who are immobile need to be repositioned
  q 2 hrs.

21
Application of proper body mechanics

• By applying the nursing process and using the
  critical thinking approach, the nurse can develop
  individualized care plans for clients with
  mobility impairments or risk for immobility. A
  care plan is designed to improve the clients
  functional status, promote self care, maintain
  psychological well being, and reduce the hazards
  of immobility. (Potter and Perry, 2006)

22
Moving Positioning Nursing Process

• Assessment
• Comfort level alignment while lying down
• Risk factors - Ability to move, paralysis
• Level of consciousness
• Physical ability/motivation
• Presence of tubes, incisions, equipment
• Nursing Diagnosis
• Defining characteristics from the assessment
• Activity intolerance
• Impaired physical mobility
• Impaired skin integrity
• refer to Perry and Potter

23
Nursing Process (cont.)

• Planning
• Know expected outcomes good alignment,
  increased comfort
• Raise bed to comfortable working height
• Remove pillows devices
• Obtain extra help if needed
• Explain procedure to client
• Implementation
• Wash hands
• Close door/curtain
• Put bed in flat position
• Move immobile patient up in bed
• Realign patient in correct body alignment
  (pillows etc.)

24
Nursing Process (cont.)

• Evaluation
• Assess body alignment, comfort
• Ongoing assessment of skin condition
• Use of proper body mechanics (nurse)

25
Restraints

• Device used to immobilize a client or an
  extremity
• A temporary means to control behavior
• Restraints are used to
• Prevent falls wandering
• Protect from self-injury (pulling out tubes)
• Prevent violence toward others
• Restraints deprive a fundamental right to control
  your own body.

26
CRNNS Position Statement on Use of Physical
Restraints

• The Registered NursesAssoc. of N.S. recognizes
  the right of all persons to be treated in a
  respectful and dignified manner. Additionally,
  the CRNNS believes that all individuals have an
  inherent right to autonomously and independently
  make decisions regarding their health care.
  (RNANS, 1997)
• Use of physical restraints may violate these
  inherent rights.
• The CRNNS does not endorse the use of physical
  restraints.

27
Cautious Use of Restraints

• While restraint-free care is ideal, there are
  times that restraints become necessary to protect
  the patient others from harm.
• Highly agitated, violent individual
  Physical/Chemical restraints
• Intubated patient pulling out endotracheal tube
• Suicide patient - ? Chemical restraints

28
Use of Restraints

• Use only when absolutely necessary.
• Attending physician is responsible for the
  assessment, ordering continuation of restraint.
• Can be instituted on your nsg judgment must
  have a doctors order ASAP.
• Continued use of restraints must be reviewed
  daily by the RN documented on the health
  record.
• Always explain what you do why, to reduce
  anxiety promote cooperation.

29
Goals of Restraint Use

• To avoid the use of restraints whenever possible.
• Encourage alternatives
• Family member to sit with patient
• Geri chair vs. bed
• Non restraint measures safety belt, wedge
  pillows, lap tray
• Consider restraints as a temporary measure
  decrease likelihood of injury from restraint use.
  
• Remove restraints as soon as the patient is no
  longer at risk for injury.

30
Complications assoc. with restraints

• Hazards of immobility
• Death
• Pressure sores, pneumonia, constipation,
  incontinence, contractures, decreased mobility,
  decreased muscle strength, increased dependence
• Altered thought processes
• Humiliation, fear, anger decreased self-esteem
• Strangulation
• Compromised circulation
• Lacerations, bruising, impaired skin integrity
• Must release restraint every 2 hours for
  assessment ROM

31
Physical Restraints device that limits a
clients ability to move

• Side rails stop patient from rolling out, but
  does not stop them from climbing out side rail
  down when working on that side.
• Jackets Belts patient who is confused
  climbing over rails may need a jacket or belt to
  restrain them to bed. Sleeveless with cross over
  ties, allows relative freedom in bed.
• Arm Leg Undesirable, limits patients
  movement, injury to wrist/ankle from friction
  rubbing against skin use extra padding.
  Restrain in a slightly flexed position, if too
  tight could impair circulation. Never tie to a
  bed rail.

32
Physical Restraints (cont.)

• Mitts are used for those confused pulling at_at_
  edges of dsgs, tubes, ivs, wounds. Doesnt
  limit arm movement, soft boxing glove that pads
  the hand, remove, wash exercise.
• Ensure not too tight
• Use quick release tie for all restraints
  

33
Chemical Restraints

• Medication
• Patient must be closely observed and assessed
  frequently post medication.
• Remains a high risk for injury.

34
Supporting Documentation

• Rationale for the use of restraints, including a
  statement describing the behavior of the patient.
• Previous unsuccessful measures or the reason
  alternatives are not feasible.
• Decision to restrain with the type of restraint
  selected and date time of application.
• Observations regarding the placement of the
  restraint, its condition and the patients
  condition, including the frequency of observation
  (not just at the end of your shift)

35
Supporting Documentation (cont.)

• Assessment of the need for ongoing application of
  restraint.
• Care of the patient which may include
  re-positioning, toileting, mobilization and/or
  skin care

36
Civil Actions

• Most civil cases are based on allegations of
  negligence.
• Important to support your judgment/actions with
  quality documentation

37
Promoting Safety

• Measures designed to promote client safety are
  the result of individualized assessment findings.
  Often it is the conclusion of the nurse that a
  clients safety is at risk, and subsequent
  nursing interventions are implemented.
  Assessment of a clients safety should occur in
  the home, healthcare facility, and community
  environment.
• (Perry and Potter, 2002)

38

• Canadian Nurses Associations (CNA) online
  Patient Safety Resource Guide
• www.cna-aiic.ca

39
Nursing 125 LAB

• Safety Basic Body Mechanics Moving Positioning

40
Moving the patient up in bed
Move close to the side of the bed Back straight, knees bent, one foot forward (broad base of support)
Up in bed (1 nurse) (Patient alert cooperative) Encourage independence foster self-esteem. Patient bends knees, feet firmly on the bed grasps side rail _at_ shoulder level. Nurse positions hand arms under patients hips, back straight, bend knees, feet apart, count to 3. Nurse pulls patient up in bed pt pulls arms pushes feet up into bed.
Up in bed (2 nurses) (heavy patient or one who cannot help) Patient bends knees, feet firmly on bed, 1st nurse at HOB arms under head shoulders, face foot of bed, 2nd nurse under hips facing foot of bed, on same side count to 3.
41
Moving the patient lifter
Up in bed using the pull sheet/lifter (2 nurses) Do not lift, always slide One nurse on each side of the bed, firmly grasp the lifter in both hands, ask the patient to lift their head. Slide the patient up in bed on the count of 3. Benefit 1. movement b/w 2 layers of cloth has less friction than skin on cloth. 2. Much easier to grasp sheet firmly than it is to hold a patients body. 3. Lifter supports the entire body (except the head) making it easier to keep the patient straight.
42
Moving the patient lateral
From the back to the side (lateral) position Move the patient to the side of the bed, so the patient will be in the center when complete. Raise rail, move to other side of bed, roll patient toward you far ankle over near ankle, far knee over near knee. Place one hand on clients hip and one hand on his/her shoulder and roll pt. onto side toward you. Place pillow under head neck, bring shoulder blade forward, position both arms in slightly flexed positions (protects joints). Upper arm supported by pillow. Place pillow behind patients back pillow under semi flexed upper leg Assess need to support feet (footboard, high top sneakers).
43
Moving the patient prone
From the back to the abdomen (prone) Move to the extreme edge of the bed, raise rail on that side, move to other side. Pillow for support under abdomen, near arm over head, turn face away, roll as above, check arm face, continue rolling. Prone - infrequently used because respirations can be compromised Good position for pressure sores on hips/buttocks. Important to turn head to the side, no pillow b/c it hyper extends the neck can use small towel, small folded towel under each shoulder to prevent slumping, flat pillow at abdomen (esp. women with large breasts) Arms at either sides or flexed by head, hand rolls, feet in dorsiflexion sandbags under ankles.
44
Tips for positioning the patient

• After turning use aids i.e. pillows, towels,
  washcloths, blankets, sandbags, footboards etc.
• Joints should be slightly flexed b/c prolonged
  extension creates undue muscle tension strain
• Supine
• Low or flat pillow (prevents neck flexion)
• Trochanter role (supports hip joint prevents
  external rotation)
• Hand roll used if hands are paralyzed (thumb
  fingers flexed around it)
• High top sneakers, foot board, sandbags (support
  feet with toes pointing upward. Prolonged
  plantar flexion leads to foot drop (permanent
  plantar flexion inability to dorsiflex)

45
Tips (cont.)

• Side lying
• Even if paralyzed on one side a patient can be
  placed on that side. Take care not to pull on
  the affected extremity.
• Head on low pillow, pillow along back supports
  back holds body in position, underlying arm
  comes forward flexed onto pillow used for head,
  top arm flexed forward resting on pillow in
  front of body, hand rolls if necessary, flex top
  leg forward place on pillow, feet at right
  angles with sandbag.