POLICY & PROCEDURE DATE: 04-22-09 TRANSFER ACTIVITIES ...

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POLICY & PROCEDURE


DATE: 04
-
22
-
09

SHIAWASSEE COUNTY MEDICAL CARE FACILITY

APPROVED BY SOCIAL SERVICES BOARD

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TRANSFER ACTIVITIES


BASIC RESPONSIBILITY: LICENSED NURSE, NURSING ASSISTANT, RESTORATIVE
NURSING ASSISTANT AND PHYSICAL THERAPIST


If performed by individuals other than those listed in Basic Responsibility, check all that
apply.


PROCEDURE

PERFORMED B
Y:

CENA

LPN

RN



PURPOSE



To transfer the resident from bed to chair, toilet or tub safely.


GENERAL RESIDENT RIGHTS GUIDELINES






If resident is in his/her room, knock on the door, wait for a response and identify yourself.





Identify resident and explain reason for procedure.





Explain benefits of the procedure to the resident.





Explain safety measures of the procedure to t
he resident.





Explain the adverse effects and/or complications of the procedure to the resident.





Place call light within reach and instruct resident to call for assistance, if needed.





Screen and drape resident for maximum privacy.





Include re
sident’s family and surrogate health care decision
-
makers in care planning when
possible.


GENERAL GUIDELINES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO:






Range of motion.





Location of pain or discomfort.





Ability to perform ADLs.





Con
tractures.





Deformity.





Ability to stand and bear weight.





Loss of balance.





Loss of voluntary control of lower extremities.





Paresis or paralysis.


GENERAL INFECTION CONTROL GUIDELINES




1.

Observe (standard) universal precautions or other

infection control standards as approved by
appropriate facility committee.



2.

Wash your hands before and after all procedures. Wear gloves when appropriate.



3.

Gather equipment, maintaining sterility and cleanliness.



4.

Clean and dry skin well befo
re and after procedure.



5.

Apply preventive measures to maintain skin integrity, if necessary.



6.

Dispose of disposable equipment appropriately.



7.

Thoroughly clean all equipment used and return to appropriate storage area.



8.

Dispose of soiled lin
en appropriately.

POLICY & PROCEDURE


DATE: 04
-
22
-
09





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EQUIPMENT




1.

Appropriate type and size of wheelchair.



2.

Mechanical lift, if necessary.



3.

Pressure
-
reducing devices.



4.

Positioning devices as necessary.



5.

Appropriate seat belt if necessary.


GENERAL INSTRUCTIONS




1.

Res
ident should move toward the unaffected side.



2.

Wheelchair brakes must always be locked and foot pedals raised.



3.

The nurse should use good body mechanics, bend knees and pivot to turn. Do not twist or
lift with back bent.



4.

Obtain help when nece
ssary.


5. Transport resident in wheel chair to bath area then transfer to bath chair.


PROCEDURE



TRANSFER FROM BED TO WHEELCHAIR

OR FROM WHEELCHAIR TO BATH CHAIR



1.

Brakes on wheelchair should be locked, foot pedals raised and chair placed at an

angle at
the side of the bed nearest resident’s unaffected side. If the chair is equipped with
removable armrests, place parallel to bed and remove armrest next to bed.



2.

Obtain assistance of another individual if necessary for safe transfer.



3.

If
resident is able to participate in transfer, have resident place unaffected foot under the
ankle on the affected side. IF NECESSARY, PLACE UNAFFECTED FOOT UNDER THE
AFFECTED KNEE AND SLIDE DOWN TO ANKLE. With unaffected leg, lift or wiggle
affected extre
mity over side of bed.



4.

Assist resident to a sitting position by:




a.

Placing unaffected hand on bed next to chest and pushing up to sitting position or,




b.

Pulling up with the aid of a rope attached to the end of the bed or,




c.

Grasping onto
the edge of the mattress.



5.

Have resident sit on edge of bed with feet uncrossed and resting on the floor. He/She may
use this as an opportunity to practice sitting balance. Put on gait belt and shoes.



6.

With your knees flexed and your legs slightl
y apart, face the resident. Grasp resident around
the waist, supporting his/her back and head. Raise to a standing position, at a prearranged
signal, by straightening your knees and supporting the resident’s knees. Allow the resident
to gain his/her bal
ance before proceeding. Support weak leg with your knee if necessary.





NOTE:

DEPENDING UPON THE AMOUNT OF ASSISTANCE REQUIRED, THE NURSE
MAY EITHER SUPPORT THE RESIDENT ON HIS/HER AFFECTED SIDE OR STAND IN
FRONT OF THE RESIDENT. SUPPORT MAY BE PROVID
ED BY USE OF A WAIST BELT.
DO NOT SUPPORT THE RESIDENT UNDER THE ARMS AS THIS PREVENTS THE
RESIDENT FROM USING HIS/HER UNAFFECTED EXTREMITY. DO NOT ALLOW
RESIDENT TO PUT ARMS AROUND YOUR NECK.




7.

Encourage resident to stand erect with trunk straight a
nd both knees extended if possible.



8.

Resident then places unaffected arm on wheelchair arm farthest away from him/her, pivots
on his/her unaffected leg, “feels” location of chair with back of leg and lowers himself/herself
into the chair. Do not allow

him/her to “fall” into the chair.



9.

Position the resident so that his/her back is as straight as possible against the back of the
chair.


10.

Lower the foot rests, placing the resident’s feet on them.


11.

Apply a seat belt as ordered, taking care th
at resident has sufficient circulation and

mobility.
Secure seat belt so that it may be speedily removed in an emergency.

POLICY & PROCEDURE


DATE: 04
-
22
-
09





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12.

Place resident in supervised area. If resident is to remain at the bedside, place call light
within reach.


13.

The procedur
e is reversed for transferring the resident from the wheelchair back to bed.



TRANSFER FROM BED TO WHEELCHAIR
OR FROM WHEELCHAIR TO BATH CHAIR
(RESIDENT UNABLE TO ASSIST)



1.

Obtain equipment from designated area and bring to bedside.



2.

Obtain assista
nce of another person, if necessary, for safe transfer.



3.

Explain procedure to resident.



4.

Lock wheels on wheeled vehicle; raise foot rests if applicable.



5.

Place chair at an angle to the bed, facing the foot of the bed (if equipped with removable

arm
rests, place parallel to bed and remove arm rest facing foot of bed).



6.

Place resident in sitting position by either:




a.

Raising head of bed to sitting position.




b.

Standing in front of chair at side of bed, placing one arm behind resident’s
shoulders and
other arm under resident’s knees. Pivot as you lift resident to sitting position and place
resident’s legs over side of bed.



7.

Place yourself with your legs apart and your knees flexed, facing the resident.



8.

Grasp the resident around
the waist, supporting his/her back. Assist to a standing position
by

straightening your knees and supporting the resident’s knees inside your knees.



9.

Step toward the chair, supporting the resident in the same manner, until resident is
positioned in f
ront of the chair.


10.

Flex your knees again to lower the resident into the chair.


11.

Position the resident so that his/her back is as straight as possible against the back of the
chair.


12.

Lower the foot rests, placing the resident’s feet on them.


13.

Apply a seat belt as ordered, taking care that circulation is not impaired and resident
has
sufficient mobility. Secure seat belt so that it may be speedily removed in an emergency.


14.

Place resident in supervised area. If resident is to remai
n at the bedside, place call light
within reach.


15.

The procedure is reversed for transferring the resident from the chair back to bed.



TRANSFER OF RESIDENT FROM PRESSURE REDUCING BED



1.

Obtain equipment from designated area and bring to bedside.



2.

Identify resident, explain procedure and screen for privacy.



3.

Lock wheels on wheelchair; raise foot rests if applicable.



4.

Place chair at angle to the bed, facing the foot of the bed (if equipped with removable arm
rests, place parallel to bed a
nd remove arm rest).



5.

Turn pressure reducing bed off.



6.

Lower rails or side supports of bed.



7.

Place resident in sitting position by standing in front of chair at side of bed. Place one arm
behind resident’s shoulders and other arm behind reside
nt’s knees.



8.

Pivot as you raise resident to sitting position with legs over the side of the bed.



9.

Place yourself with your legs apart and your knees flexed, facing the resident.


10.

Grasp the resident around the waist, supporting his/her back, as
sist to a standing position by
straightening your knees and supporting the resident’s knees inside your knees.


11.

Pivot toward the chair, supporting the resident.


12.

Position the resident so that his/her back is as straight as possible against the ba
ck of the
chair.


13.

Lower foot rests. Place resident’s feet on foot rests and secure if necessary.


14.

Apply a seat belt as ordered, taking care that circulation is not impaired and resident
has
sufficient mobility. Secure seat belt so that it may
be removed quickly in an
emergency.


15.

Place resident in a supervised area. If resident is to remain at the bedside, place call light
within reach.


16.

The procedure is reversed for transferring the resident from chair back to bed.

POLICY & PROCEDURE


DATE: 04
-
22
-
09





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POSSIBLE RELATE
D MINIMUM DATA SET TRIGGERS




1.

Delirium.



2.

ADL function/rehabilitation potential.



3.

Psychosocial well
-
being.



4.

Falls.



5.

Nutritional status.



6.

Dehydration and fluid balance.



7.

Pressure ulcers.



8.

Psychotropic drug use.



9.

Physical r
estraints.


GENERAL DOCUMENTATION GUIDELINES






Date, time (or shift), as appropriate.




Other Documentation May Include:





Date, time.





Amount of assistance resident requires.





Whether or not resident is able to stand independently.





Conditi
on of skin.





How long resident is able to sit in chair.





Pain or discomfort.





Name and title.


GENERAL RESIDENT CARE PLAN DOCUMENTATION GUIDELINES



PROBLEM





Identify the appropriate problem under which to list transfer activity as an approach.





Consider listing possible risks and complications.



GOAL





List
MEASURABLE

goal(s) to be accomplished.





List target date.



APPROACHES





List responsible discipline for each approach.





List instructions unique to this resident.





List nec
essary monitoring and observation of the resident’s ability to participate in care.





List medication for pain as ordered.





List method of positioning.





List monitoring for proper body alignment.





List monitoring for pressure ulcers.





List fr
equency of positioning and toileting.





List type of restraint required.





List period of time resident is to be up in chair if limited.





List type of chair to be used.