Safety; Basic Body Mechanics; Moving & Positioning

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Safety; Basic Body Mechanics;
Moving & Positioning

Nursing 125

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


Patient Safety #1


A client

s 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.

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

Institute of Medicine Report,
1999


Estimated 48,000
-
98,000 deaths per year
from medical errors.



Adverse events ranked as the 8
th

leading
cause of death, ahead of MVA

s, breast
cancer and AIDS



Extrapolating from the U.S. data, adverse
events would account for 4,000
-
10,000
deaths per year in Canada.



Impetus for action: Threefold

1.

Health system has a moral imperative to
ensure the safety of patients


2.
Adverse events have a tremendous cost to
the system in extended hospital stays &
additional medical procedures


3.
Adverse events expose health organizations
to legal liability

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.

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.



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

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.


Strategies to help reduce falls:
(Communication/Assessment)



Orient client to physical surroundings



Explain use of call bell



Assess client

s risk for falling



Alert all personnel to the client

s risk for falling



Instruct client and family to seek assistance when getting up



Maintain client

s toileting schedule



Observe/assess client frequently



Encourage family participation in client

s care



Body Mechanics


The coordinated efforts of the musculoskeletal &
nervous system to maintain balance, posture & body
alignment during lifting, bending, moving &
performing ADL

s.



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.

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.




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.


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


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 client

s 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.

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
client

s 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.

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).



Moving & Positioning (cont.)


Pressure Sores


tissues are
compressed, decreased bld supply to
area, therefore, decreased oxygen to
tissue & cells die.



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 patient

s 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.

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 client

s functional status,
promote self care, maintain psychological well
being, and reduce the hazards of immobility.





(Potter and Perry, 2006)

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




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.)



Nursing Process (cont.)


Evaluation


Assess body alignment, comfort


Ongoing assessment of skin condition


Use of proper body mechanics (nurse)

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.

CRNNS Position Statement on

Use of Physical Restraints



The Registered Nurses

Assoc. 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.

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


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.






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.













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

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.

Physical Restraints (cont.)


Mitts are used for those confused & pulling at@
edges of dsgs, tubes, iv

s, wounds. Doesn

t limit
arm movement, soft boxing glove that pads the
hand, remove, wash & exercise.


Ensure not too tight



Use quick release tie for all restraints




















Chemical Restraints


Medication



Patient must be closely observed and assessed
frequently post medication.



Remains a high risk for injury.

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 patient

s condition,
including the frequency of observation
(not just at
the end of your shift)

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

Civil Actions


Most civil cases are based on allegations of
negligence.



Important to support your judgment/actions
with quality documentation

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 client

s safety is
at risk, and subsequent nursing interventions are
implemented. Assessment of a client

s safety should
occur in the home, healthcare facility, and community
environment.




(Perry and Potter, 2002)


Canadian Nurses Association

s (CNA)
online Patient Safety Resource Guide



www.cna
-
aiic.ca

Nursing 125 LAB

Safety; Basic Body Mechanics;
Moving & Positioning

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 @ 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, 1
st

nurse
at HOB arms under head & shoulders, face foot of
bed, 2
nd

nurse under hips facing foot of bed, on
same side


count to 3.

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 patient

s body.

3. Lifter supports the entire body (except the
head) making it easier to keep the patient
straight.


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
client

s 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 patient

s back & pillow
under semi flexed upper leg

Assess need to support feet (footboard, high
top sneakers).

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.

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)

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.