EQUIPMENT

STEPS		RATIONALE
1. Assess patient for risk factors for venous thromboembolism to determine need for elastic stockings.		Potential candidates for elastic stockings are patients who have an alteration in one of the elements of Virchow’s triad.
2. Observe for signs, symptoms and conditions that might contraindicate the use of elastic stockings:
	• Dermatitis or open skin lesion	Elastic stockings may aggravate skin condition or cause it to spread. Also, medication and dressings may need to be applied to lesion.
	• Recent skin graft	Continuous pressure is necessary to keep graft adherent to recipient bed, but pressure should not be so firm as to cause death of graft.
	• Disproportionately large thighs	Elastic stockings may not fit correctly, causing excessive pressure and constriction around thighs, thereby reducing venous return.
	• Decreased circulation in lower extremities (e.g. peripheral vascular disease) as evidenced by cyanotic, cool extremities	Elastic stockings may further impede circulation.
3. Obtain medical prescription.		May be needed for legal or reimbursement reasons.
4. Assess patient’s or caregiver’s understanding of application of elastic stockings.		Identifies potential educational needs of patient or caregiver.
5. Assess and document condition of patient’s skin and circulation to legs (i.e. presence of pedal pulses, oedema, discolouration of skin, temperature, lesions or cuts).		Identifies a baseline for skin integrity and quality of peripheral pulses in lower extremities.
6. Explain procedure and reasons for applying stockings.		Reduces anxiety and encourages patient cooperation.
7. Use tape measure to measure patient’s legs to determine proper stocking size.		Stockings must be measured according to manufacturer’s directions. Elastic stockings come in two lengths: knee length and thigh length. The choice of length depends on the prescription.
Critical decision point: Compare patient’s measurements with the manufacturer’s sizing chart. If too large, stockings will not adequately support extremities. If too small, stockings may impede circulation. The optimum stocking pressure is 20-30 mmHg at the ankle, decreasing to 8 mmHg at the middle to upper thigh. This change in pressure produces the greatest increase in 1 venous flow velocity that is both safe and practical.
8. Perform hand hygiene.		Reduces transmission of microorganisms.
9. Position patient in supine position. Elevate head of bed to comfortable level.		Promotes good body mechanics for nurse. Patient position eases application. Also, the stockings should be applied before standing to prevent stagnation of blood in lower extremities. If patient has been standing, patient should sit in chair or lie in bed for 15 minutes with legs elevated before applying elastic stockings.
10. After legs are cleaned, apply small amount of talcum powder to legs and feet, provided that patient does not have sensitivity to talcum powder.		Talcum powder reduces friction and allows for easier application of stockings.
11. Apply stockings.
	a. Turn elastic stocking inside out by placing one hand into sock, holding toe of sock with other hand, and pulling (see illustration). Leave the toe of the stocking tucked inside to form a pocket.	Allows easier application of stocking.
	b. Place patient’s toes into foot of elastic stocking, making sure that sock is smooth (see illustration).	Wrinkles in sock can impede circulation to lower region of extremity.
	c. Slide remaining portion of sock over patient’s foot, being sure that the toes are covered. Make sure the foot fits into the toe and heel position of the sock. Sock will now be right side out (see illustration).	If toes remain uncovered, they will become constricted by elastic and their circulation can be reduced.
	d. Slide sock up over patient’s calf until sock is completely extended. Be sure sock is smooth and no ridges are present (see illustration).	Ridges impede venous return and can counteract overall purpose of elastic stocking.
	e. Instruct patient not to roll socks partially down.	Rolling sock partially down has a constricting effect and can impede venous return.
Step 11a Turning stocking inside out.		Step 11b Placing foot into sock.
Step 11c Sliding stocking over foot.		Step 11d Applying stocking over calf.
12. Reposition patient to position of comfort and wash hands.		Maintains proper body alignment and promotes comfort. Reduces transmission of microorganisms.
13. Inspect stocking to make sure there are no wrinkles or binding at top of stocking.		Wrinkles lead to increased pressure and alter circulation.
14. Observe patient’s reaction to stockings.		Ensures patient is adapting to stockings and is not experiencing any discomfort from stockings.
15. Observe patient or caregiver applying stockings.		Determines ability to perform skill accurately.
16. Remove stockings at least once a shift, and assess skin and circulatory status.		Stockings may shift or be too tight, and this step ensures skin and circulation are intact.
17. Ensure shoes/slippers are available for patient.		Wearing shoes/slippers decreases risk of patient slipping.

MUSCULOSKELETAL SYSTEM INTERVENTIONS

The immobilised patient must receive some exercise to prevent excessive muscle atrophy and joint contractures. If the patient is unable to move part or all of the body, the nurse must perform passive ROM exercises for all immobilised joints while bathing the patient and at least 2 or 3 further times a day. If one extremity is paralysed, the patient can be taught to put each joint independently through its ROM. Patients on bed rest should have active ROM exercises incorporated into their daily schedules. Nurses can teach patients to integrate exercises during ADLs.

Some orthopaedic conditions require more frequent passive ROM exercises to restore the injured joint’s function after surgery. Patients with such conditions may use automatic equipment for passive ROM exercises (Figure 33-16). The equipment moves an extremity to a prescribed angle for a prescribed period. This is beneficial when the patient must gradually increase the degree and duration of flexion and extension.

FIGURE 33-16 Continuous passive range-of-motion machine.

From Potter PA, Perry AG 2004 Fundamentals of nursing, ed 6. St Louis, Mosby.

Active ROM exercises maintain function of the musculoskeletal system. The nurse should also plan interventions for the gradual return of mobility for patients who will be able to resume normal activity. The best nursing intervention is establishing an individualised progressive exercise program. A progressive exercise program gradually increases the patient’s physical activity to reverse the deconditioning associated with immobility. Progressive exercise programs are used for patients with musculoskeletal, neurological, cardiopulmonary, renal and other chronic diseases. When working with older adults, the nurse should consider gerontological principles that enhance the effectiveness of exercise programs and limit injuries (see Working with diversity).

Teaching, referral and interdisciplinary collaboration are important for patients with limited mobility. Depending on the setting and resources available, the nurse may want to refer the patient for physiotherapy. The therapist sets up the specific exercise program and the nurse plays an important role in reinforcing it.

INTEGUMENTARY SYSTEM INTERVENTIONS

The major risk to the skin from restricted mobility is the formation of pressure ulcers. Nursing interventions therefore focus on preventing or treating these ulcers (see Chapter 30). Early identification of high-risk patients and their risk factors helps the nurse prevent pressure ulcers. Interventions aimed at prevention are positioning, skin care and the use of therapeutic devices to relieve pressure. The immobilised patient’s position should be changed according to the patient’s activity level, perceptual ability, treatment protocols and daily routines. Although turning every 1–2 hours is recommended for preventing ulcers, it may also be necessary to use devices for relieving pressure. The time that a patient sits uninterrupted in a chair should be limited to 1 hour or less, but this time interval is individualised. The patient should be repositioned frequently because uninterrupted pressure will cause skin breakdown. The nurse should teach patients who are able to do so to shift their weight every 15 minutes. Chair-bound patients should have a device for the chair that reduces pressure (Reddy and others, 2006).

ELIMINATION SYSTEM INTERVENTIONS

The nursing interventions for maintaining optimal urinary functioning are directed at keeping the patient well hydrated and preventing urinary stasis, calculi and infections without causing bladder distension.

Adequate hydration (e.g. 2000–3000 mL of fluids per day) helps prevent renal calculi and UTIs. The well-hydrated patient should void a large amount of dilute urine that is approximately equal to fluid intake. If the patient is incontinent, the nurse should modify the care plan to include toileting aids and a hygiene schedule so that the increased urinary output does not cause skin breakdown.

To prevent bladder distension, the nurse assesses the frequency and amount of urinary output. A patient who continually dribbles urine and whose bladder is distended may have reflex incontinence. If the immobilised patient does not have voluntary control of bladder elimination, bladder retraining may be necessary. If the patient experiences bladder distension, the nurse may be required to insert a straight catheter or an indwelling Foley catheter (see Chapter 38).

The nurse can also record the frequency and consistency of bowel movements. A diet rich in fluids, fruits, vegetables and fibre can facilitate normal peristalsis. If a patient is unable to maintain regular bowel patterns, a medical prescription for stool softeners, cathartics or enemas may be indicated (see Chapter 37).

PSYCHOSOCIAL CHANGES

Assessment can identify effects of prolonged immobilisation on the patient’s psychosocial dimension. People who have a tendency towards depression or mood swings are at greater risk of developing psychosocial effects during bed rest or immobilisation. There are many nursing interventions to meet the patient’s psychosocial needs.

The nurse should anticipate changes in the patient’s psychosocial status. The nurse can provide routine and informal socialisation. Nursing activities can be planned so that the patient can talk and interact with staff. If possible, the patient should be placed in a room with others who are mobile and interactive. If a private room is required, staff members should be asked to visit throughout the shift to provide meaningful interaction.

The nurse also provides stimuli to maintain orientation. A daily newspaper helps the patient keep track of events and time. Bedside chats at appropriate moments orient the patient to nursing activities, meals and visiting hours. Diversional activities such as reading, music, television and DVDs can be used to provide stimulation and help pass the time.

Patients should also be involved in their care whenever possible. For example, the nurse should encourage the patient to help determine care routines. The patient should provide as much self-care as possible. Hygiene and grooming articles should be kept within easy reach. Patients should be encouraged to wear their glasses or artificial teeth and to shave or apply makeup, if this is their normal routine. These are activities through which people maintain their body image. Maintenance of body image can help improve the patient’s outlook.

In institutional healthcare settings, nursing care should be scheduled to minimise interruptions to sleep. For example, the nurse may administer medications and assess vital signs at the time when the patient is turned or receives special skin care.

The nurse should also observe the patient’s failure to cope with restricted mobility. If the nursing care plan is not improving coping patterns, an advanced practice nurse, counsellor, social worker, spiritual adviser or other consultant may be needed. Their recommendations should be incorporated into the care plan.

DEVELOPMENTAL CHANGES

Nursing care should provide mental and physical stimulation, particularly for a young child. Play activities can be incorporated into the care plan. Completing games and puzzles, for example, helps a child develop fine motor skills, and reading helps the child develop cognitively. An immobilised child should be placed with children of the same age who are not immobilised, unless a contagious disease is present. Nursing activities, such as dressing changes, cast care and care of traction, can be designed to require the child’s participation. The nurse must recognise significant changes from normal behavioural patterns. If these continue, the nurse should consult a clinical nurse, counsellor or other healthcare professional whose specialty is children.

Restricted mobility of older patients presents unique nursing problems. Older patients who are frail or have chronic illnesses may have an increased risk of the psychosocial hazards of immobility. Having a calendar and a clock with a large dial, conversing about current events and family members and encouraging visits from significant others may reduce the risk of social isolation.

Nursing care should encourage older patients to perform as many ADLs as independently as possible. Time should be made to assist patients to walk, encourage exercise if the patient is able and encourage patients to ambulate from bed to the chair as much as possible. This should include removing any unnecessary tethers such as oxygen, bladder catheters and intravenous catheters, creating hospital norms that patients are expected to walk regularly if they are able, and requesting physiotherapy consultation when assistance may be helpful (Covinsky and others, 2011).

POSITIONING TECHNIQUES

Patients with impaired nervous, skeletal or muscular system functioning and increased weakness and fatiguability often require help from the nurse to attain proper body alignment while in bed or sitting. Several positioning devices are available for maintaining good body alignment for patients (summarised in Table 33-5).

TABLE 33-5 DEVICES USED FOR PROPER POSITIONING

Pillows are a positioning aid that may or may not be readily available. Before using a pillow, the nurse should determine whether it is the proper size. A thick pillow under the patient’s head increases cervical flexion. A thin pillow under body prominences may be inadequate to protect skin and tissue from damage caused by pressure. When additional pillows are unavailable, or if they are an improper size, the nurse can use folded sheets, blankets or towels as positioning aids. The 30-degree lateral position is recommended for patients at risk of pressure ulcer development.

A footboard is placed perpendicular to the mattress, parallel to and touching the plantar surfaces of the patient’s feet. The footboard prevents footdrop by maintaining the feet in dorsiflexion. After placing it on the bed, the nurse needs to determine that it is correctly placed, with the patient’s feet placed firmly against the board. Another common technique is the use of high-top tennis shoes or an ankle–foot orthotic to help maintain dorsiflexion.

A trochanter roll prevents external rotation of the hips when the patient is in a supine position. To form a trochanter roll, a cotton bath blanket is folded lengthwise to a width that will extend from the greater trochanter of the femur to the lower border of the popliteal space (see Figure 33-17). The blanket is placed under the buttocks and then rolled counterclockwise until the thigh is in neutral position or in inward rotation. When correct alignment of the hip is achieved, the patella faces directly upwards. Sandbags are sand-filled plastic tubes or bags that can be shaped to body contours. Sandbags can be used in place of or in addition to trochanter rolls. They immobilise an extremity or maintain body alignment.

FIGURE 33-17 Trochanter roll.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. A hand roll maintains the hand, thumb and fingers in a functional position. The nurse evaluates the hand roll to make sure that the hand is indeed in a functional position. Hand rolls are most often used for patients whose arms are paralysed or who are unconscious. Rolled washcloths should not be used as hand rolls, since they do not keep the thumb well abducted, especially in patients who have a spastic paralysis.

Hand–wrist splints are individually moulded for the patient to maintain proper alignment of the thumb (slight adduction) and the wrist (slight dorsiflexion). These splints should be used only by the patient for whom the splint was made.

The trapeze bar is a triangular device that descends from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair or to perform upper-arm exercises (see Figure 33-18). It is a useful device for helping to increase independence, maintain upper body strength and decrease the shearing action from sliding across or up and down in bed.

FIGURE 33-18 Patient using a trapeze bar, with nurse supporting.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Although each procedure for positioning has specific guidelines, there are some universal steps the nurse should follow for patients who require positioning assistance (Skill 33-2). Following the guidelines reduces the risk of injury to the musculoskeletal system when the patient is sitting or lying. When joints are unsupported, their alignment is impaired. Likewise, if joints are not positioned in a slightly flexed position, their mobility is decreased. During positioning, the nurse also assesses for pressure points. When actual or potential pressure areas exist, nursing interventions involve removal of the pressure, thus decreasing the risk of development of pressure ulcers and further trauma to the musculoskeletal system. In these patients the 30-degree lateral position should be used when possible.

SKILL 33-2 Positioning patients in bed

DELEGATION CONSIDERATIONS

The task of moving and positioning patients in bed can be delegated to assistants. A risk assessment should be conducted on all patients requiring assistance with positioning. A ‘no lift’ policy has been implemented in most facilities. Equipment such as lifting machines should be used whenever repositioning poses a risk to the patient and to the staff.

EQUIPMENT

• Slide sheets

• Pillows

• Other support devices as necessary (e.g. hand splints, sandbags, wedge pillows, trochanter rolls)

• Lifting devices if required

STEPS				RATIONALE
1. Assess patient’s body alignment and comfort level while patient is lying down.				Provides baseline data for later comparisons. Determines ways to improve position and alignment.
2. Assess for risk factors that may contribute to complications of immobility:				Increased risk factors require patient to be repositioned more frequently.
	• Paralysis: hemiparesis resulting from stroke; decreased sensation			Paralysis impairs movement; muscle tone changes; sensation is affected. Because of difficulty in moving and poor awareness of involved body part, patient is unable to protect and position body part for self.
	• Impaired mobility: traction or arthritis or other contributing disease processes			Traction or arthritic changes of affected extremity result in decreased range of joint motion.
	• Impaired circulation			Decreased circulation predisposes patient to pressure injury.
	• Age: very young, older adults			Premature and young infants require frequent turning because their skin is fragile. Normal physiological changes associated with ageing predispose older adults to greater risks of developing complications of immobility.
	• Patient’s level of consciousness			Determines need for special aids or devices. Patients with altered levels of consciousness may not understand instructions and may be unable to help.
3. Assess patient’s physical ability to help with moving and positioning.				Enables nurse to use patient’s mobility and strength. Determines need for additional help. Ensures patient and nurse safety.
4. Explain procedure to patient.				Helps to decrease anxiety and increase cooperation.
5. Adjust the bed height to between mid-thigh and hip height.				Raises level of work towards nurse’s centre of gravity.
6. Remove all pillows and devices used in previous position.				Reduces interference from bedding during positioning procedure.
7. Get extra help as needed.				Provides for patient and nurse safety.
8. Position patient in bed.
	A. Patient-assisted bed slide (one nurse):
		(1)Place patient supine with head of bed flat.		Enables nurse to assess body alignment. Reduces gravity’s pull on patient’s upper body.
		(2)Remove pillow from under head and shoulders and place pillow at head of bed.		Prevents striking patient’s head against head of bed.
		(3)Ask or assist the patient to fold his or her arms across the chest.
		(4)Fold a slide sheet in half and tuck under the patient’s shoulders and hips with the fold facing towards the patient’s feet.		Slide sheets reduce friction and reduce the force required to move the patient.
		(5)Ask or assist the patient to roll to the side to pull the slide sheet into position.
		(6)Have the patient roll back to supine position and bend their knees.
		(7)Stand at the end of the bed and support the patient’s feet.
		(8)Ask the patient to extend the legs while holding the feet against the mattress. The patient will push himself or herself up the bed.		Where possible, patients should be encouraged to move themselves.
	B. Bed slide (two nurses):
		(1)Place patient supine with head of bed flat.		Enables nurse to assess body alignment. Reduces gravity’s pull on patient’s upper body.
		(2)Remove pillow from under head and shoulders and place pillow at head of bed.		Prevents striking patient’s head against head of bed.
		(3)Ask or assist the patient to fold his or her arms across the chest.
		(4)Tuck two slide sheets (on top of each other) under the length of the patient’s body.		Slide sheets reduce friction and reduce the force required to move the patient.
		(5)Ask or assist the patient to cross their legs (i.e. if rolling to the left, cross right over left). Roll the patient to the side and pull the slide sheet into position over the mattress.
		(6)Roll the patient back to a supine position.
		(7)Stand at the top end of the bed corners and gather the ends of the top slide sheet with palms down.		Face in the direction of movement to prevent spinal twisting.
		(8)In a controlled manner and with arms straight, both nurses should lunge backwards on the count of three, transferring weight from the front foot to the back foot, moving the patient towards the head of the bed.		Assuming a broad stance increases stability and balance. Use of large muscle groups and shifting weight reduces the force needed to move load.
		(9)Tuck the slide sheets under the patient and pull them out from beneath the patient. Replace pillows and position the patient to a position of comfort and safety.
	C. Position patient in supported semi-Fowler’s position (see illustration):
		(1)Elevate head of bed 45–60 degrees.		Increases comfort, improves ventilation and increases patient’s opportunity to socialise or relax.
		(2)Rest head against mattress or on small pillow.		Prevents flexion contractures of cervical vertebrae.
		(3)Use pillows to support arms and hand if patient does not have voluntary control or use of hands and arms.		Prevents shoulder dislocation from effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling and prevents flexion contractures of arms and wrists.
		(4)Position pillow at lower back.		Supports lumbar vertebrae and decreases flexion of vertebrae.
		(5)Place small pillow or roll under thigh.		Prevents hyperextension of knee and occlusion of popliteal artery from pressure from bodyweight.
		(6)Place small pillow or roll under ankles.		Prevents prolonged pressure of mattress on heels.
Step 8C Supported semi-Fowler’s position.
Critical decision point: To keep feet in proper alignment, place footboard at bottom of patient’s feet.
	D. Position hemiplegic patient in supported semi-Fowler’s position:
		(1)Elevate head of bed 45–60 degrees.		Increases comfort, improves ventilation and increases patient’s opportunity to relax.
		(2)Position patient in sitting position as straight as possible, with support for affected shoulder.		Counteracts tendency to slump towards affected side. Improves ventilation and cardiac output; decreases intracranial pressure. Improves patient’s ability to swallow and helps to prevent aspiration of food, liquids and gastric secretions.
		(3)Position head on small pillow with chin slightly forwards. If patient is totally unable to control head movement, hyperextension of the neck must be avoided.		Prevents hyperextension of neck. Too many pillows under head may cause or worsen neck flexion contracture.
		(4)Provide support for involved arm and hand on overbed table in front of patient. If transfer is to wheelchair, arms of chair can provide support. Place arm away from patient’s side and support elbow with pillow.		Paralysed muscles do not automatically resist pull of gravity as they do normally. As a result, shoulder subluxation, pain and oedema may occur.
			a. Position flaccid hand in normal resting position with wrist slightly extended, arches of hand maintained and fingers partially flexed; may use section of rubber ball cut in half; clasp patient’s hands together.	Maintains hand in functional position. Prevents contractures.
			b. Position spastic hand with wrist in neutral position or slightly extended; fingers should be extended with palm down or may be left in relaxed position with palm up.	Maintains hand in functional position. Inhibits flexor spasticity.
		(5)Flex knees and hips by using pillow or folded blanket under knees.		Ensures proper alignment. Flexion prevents prolonged hyperextension, which could impair joint mobility.
		(6)Support feet in dorsiflexion with firm pillow or footboard.		Prevents footdrop. Stimulation of ball of foot by hard surface has tendency to increase muscle tone in patient with extensor spasticity of lower extremity.
	E. Position patient in supine position:
		(1)Place patient on back with head of bed flat.		Necessary for placing patient in supine position.
		(2)Place small rolled towel under lumbar area of back.		Provides support for lumbar spine.
		(3)Place pillow under upper shoulders, neck or head.		Maintains correct alignment and prevents flexion contractures of cervical lumbar spine.
		(4)Place trochanter rolls or sandbags parallel to lateral surface of patient’s thighs.		Reduces external rotation of hip.
		(5)Place small pillow or roll under ankle to elevate heels.		Reduces pressure on heels, helping to prevent pressure sores.
		(6)Support feet in dorsiflexion with firm pillow or footboard.		Prevents footdrop.
		(7)Place pillows under pronated forearms, keeping upper arms parallel to patient’s body (see illustrations).		Reduces internal rotation of shoulder and prevents extension of elbows. Maintains correct body alignment.
Step 8E(7) Supine position with supporting pillows.
		(8)Place hand rolls in patient’s hands. Consider physical therapy referral for use of hand splints.		Reduces extension of fingers and abduction of thumb. Maintains thumb slightly adducted and in opposition to fingers.
	F. Position hemiplegic patient in supine position:
		(1)Place head of bed flat.		Necessary for positioning in supine position.
		(2)Place folded towel or small pillow under shoulder or affected side.		Decreases possibility of pain, joint contracture and subluxation. Maintains mobility in muscles around shoulder to permit normal movement patterns.
		(3)Keep affected arm away from body with elbow extended and palm up. (Alternative is to place arm out to side, with elbow bent and hand towards head of bed.)		Maintains mobility in arm, joints and shoulder to permit normal movement patterns. (Alternative position counteracts limitation of ability of arm to rotate outwards at shoulder (external rotation). External rotation must be present to raise arm overhead without pain.)
		(4)Place folded towel under hip of involved side.		Diminishes effect of spasticity in entire leg by controlling hip position. Slight flexion breaks up abnormal extension pattern of leg. Extensor spasticity is most severe when patient is supine.
		(5)Support feet with soft pillows at right-angle to leg, and keep heels off bed or use heel protectors.		Maintains foot in dorsiflexion and prevents footdrop. Pillows prevent stimulation to ball of foot by hard surface, which has tendency to increase muscle tone in patient with extensor spasticity extremity.
	G. Position patient in prone position:
		(1)Roll patient over arm positioned close to body, with elbow straight and hand under hip. Position on abdomen in centre of bed.		Positions patient correctly so alignment can be maintained.
		(2)Turn patient’s head to one side and support head with small pillow (see illustration).		Reduces flexion or hyperextension of cervical vertebrae.
		(3)Place small pillow under patient’s abdomen below level of diaphragm (see illustration).		Reduces pressure on breasts of some female patients and decreases hyperextension of lumbar vertebrae and strain on lower back. Improves breathing by reducing mattress pressure on diaphragm.
		(4)Support arms in flexed position level at shoulders.		Maintains proper body alignment. Support reduces risk of joint dislocation.
		(5)Support lower legs with pillow to elevate toes (see illustration).		Reduces external rotation of legs and mattress pressure on toes.
Step 8G(2 & 3) Placement of pillows under head and abdomen.				Step 8G(5) Placement of pillows to support lower legs.
	H. Position hemiplegic patient in prone position:
		(1)Move patient towards unaffected side.		Ensures proper patient alignment in centre of bed when patient is rolled onto abdomen.
		(2)Roll patient onto side.
		(3)Place pillow on patient’s abdomen.		Prevents sagging of abdomen when patient is rolled over; decreases hyperextension of lumbar vertebrae and strain on lower back.
		(4)Roll patient onto abdomen by positioning involved arm close to patient’s body, with elbow straight and hand under hip. Roll patient carefully over arm.		Prevents injury to affected side.
		(5)Turn head towards involved side.		Promotes development of neck and trunk extension, which is necessary for standing and walking.
		(6)Position involved arm out to side, with elbow bent, hand towards head of bed and fingers extended (if possible).		Counteracts limitation of arm’s ability to rotate outwards at shoulder (external rotation). External rotation must be present to raise arm over head without pain.
		(7)Flex knees slightly by placing pillow under legs from knees to ankles.		Flexion prevents prolonged hyperextension, which could impair joint mobility.
		(8)Keep feet at right-angle to legs by using pillow high enough to keep toes off mattress.		Maintains feet in dorsiflexion.
	I. Position patient in lateral (side-lying) position:
		(1)Lower head of bed completely or as low as patient can tolerate.		Provides position of comfort for patient and removes pressure from bony prominence on back.
		(2)Position patient supine towards side of bed.		Provides room for patient to turn to side.
Critical decision point: Patients at risk of pressure ulcer development require the 30-degree lateral position.
		(3)Roll patient onto side towards nurse by flexing patient’s knees and placing one hand on patient’s hip and one hand on patient’s shoulder.		Client is positioned so leverage on hip makes turning easy. Rolling patient towards nurse lessens trauma to tissues.
		(4)Place pillow under patient’s head and neck.		Maintains alignment. Reduces lateral neck flexion. Decreases strain on sternocleidomastoid muscle.
		(5)Bring shoulder blade forward.		Prevents patient’s weight from resting directly on shoulder joint.
		(6)Position both arms in slightly flexed position. Upper arm is supported by pillow level with shoulder; other arm, by mattress.		Decreases internal rotation and adduction of shoulder. Supporting both arms in slightly flexed position protects joint. Ventilation is improved because chest is able to expand more easily.
		(7)Place tuck-back pillow behind patient’s back. (Make by folding pillow lengthwise. Smooth area is slightly tucked under patient’s back.)		Provides support to maintain patient on side.
		(8)Place pillow under semiflexed upper leg level at hip from groin to foot (see illustrations).		Flexion prevents hyperextension of leg. Maintains leg in correct alignment. Prevents pressure on bony prominence.
		(9)Place sandbag parallel to plantar surface of dependent foot.		Maintains dorsiflexion of foot. Prevents footdrop.
Step 8I(8) Side-lying patient with pillows in place.
	J. Position patient in Sims’ (semiprone) position:
		(1)Lower head of bed completely.		Provides for proper body alignment while patient is lying down.
		(2)Place patient in supine position.		Prepares patient for position.
		(3)Position patient in lateral position, lying partially on abdomen.		Patient is rolled only partially on abdomen.
		(4)Place small pillow under patient’s head.		Maintains proper alignment and prevents lateral neck flexion.
		(5)Place pillow under flexed upper arm, supporting arm level with shoulder.		Prevents internal rotation of shoulder. Maintains alignment.
		(6)Place pillow under flexed upper legs, supporting leg level with hip.		Prevents internal rotation of hip and adduction of leg. Flexion prevents hyperextension of leg. Reduces mattress pressure on knees and ankles.
		(7)Place sandbags parallel to plantar surface of foot (see illustration).		Step 8J(7) Sims’ (semiprone) position with pillows and sandbag in place.
9. Perform hand hygiene.				Reduces transmission of infection.
10. Lower bed and raise side rails.				Provides for patient safety.
11. Observe patient’s body alignment, position and level of comfort.				Determines effectiveness of positioning. Additional supports (e.g. pillows, bath blankets) may be added or removed to promote comfort and correct body alignment.
12. Assess for areas of erythema or breakdown involving skin.				Provides ongoing observation regarding patient’s skin and musculoskeletal systems. Indicates complications of immobility or improper positioning of body part.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record each position change, including amount of assistance needed and patient’s response and tolerance. • Record and report any signs of pressure injury in areas such as over bony prominences.	• For patients who need positioning at home, teach family the importance of body mechanics for themselves and the patient. • Teach family about the signs of skin breakdown and the importance of safety during positioning for patients with decreased sensation.

FIGURE 33-19 Abduction pillow used after total hip replacement.

From Beare PG, Myers JL 1998 Adult health nursing, ed 3. St Louis, Mosby.

TRANSFER TECHNIQUES

Nurses often provide care for immobilised patients whose position must be changed, who must be moved up in bed or who must be transferred from a bed to a chair or from a bed to a stretcher. Use of proper body mechanics enables the nurse to move or transfer patients safely and also minimises risk of injury. Although nurses use many transfer techniques, the following general guidelines should be followed in any transfer procedure:

Moving a completely immobilised patient alone is difficult and dangerous. The nurse who is attempting transfer or moving techniques for the first time should request help to reduce the risk of injury to patient and nurse. It is important to be aware of lifting and transferring policies in different states and healthcare agencies—Victoria, for example, has manual handling principles and the Australian Nursing Federation has a no-lift policy.

TRANSFERRING A PATIENT FROM A BED TO A CHAIR

Transfer of a patient from a bed to a chair by one nurse requires assistance from the patient and should not be attempted with a patient who cannot help (see Skill 33-3). The nurse explains the procedure to the patient before the transfer. The environment is also prepared by moving obstacles out of the way. The chair is placed next to the bed with the chair back in the same plane as the head of the bed. Placement of the chair allows the nurse to pivot with the patient and to transfer the patient’s weight quickly.

SKILL 33-3 Transfer techniques

DELEGATION CONSIDERATIONS

The task of moving and positioning patients in bed can be delegated to assistants. A risk assessment should be conducted on all patients requiring assistance with positioning. A ‘no lift’ policy has been implemented in most facilities. Equipment such as lifting machines should be used whenever repositioning poses a risk to the patient and to the staff.

EQUIPMENT

• Transfer belt (if needed), sling or lap board (as needed), non-skid shoes, bath blankets, pillows, lifting equipment when necessary

• Wheelchair: position chair at 45-degree angle to bed, lock brakes, remove footrests, lock bed brakes

• Stretcher: position at right-angle (90 degrees) to bed, lock brakes on stretcher, lock brakes on bed

• Mechanical/hydraulic lift: use frame, canvas strips or chains, and hammock or canvas strips

STEPS			RATIONALE
1. Assess the patient for the following: • Muscle strength • Joint mobility • Presence of paralysis or paresis • Orthostatic hypotension • Activity tolerance • Level of consciousness • Level of comfort • Ability to follow instructions			Provides information relative to patient’s abilities, physical status, ability to comprehend, and the number of people needed to provide safe transferral.
2. Identify patients at greatest risk of problems with transferral.			Provides information relative to patients who may require intervention beyond the care provider (e.g. physiotherapy department).
3. Explain procedure to patient.			Promotes cooperation, encourages assistance and enhances understanding of procedure.
4. Close door or curtain.			Maintains privacy.
5. Perform hand hygiene.			Reduces transfer of microorganisms.
6. Transfer patient.
	A. Assisting patient into sitting position on side of bed:
		(1)With patient in supine position, raise head of bed 30 degrees.	Decreases amount of work needed by patient and nurse to raise patient to sitting position.
		(2)Where possible, patients should be encouraged to move themselves into position or assist as much as possible.
		(3)Turn patient to side, facing nurse on side of bed on which patient will be sitting (see illustration).	Prepares patient to move to side of bed and protects patient from falling.
		(4)Stand opposite patient’s hips. Turn diagonally so that nurse faces patient and far corner of foot of bed.	Places nurse’s centre of gravity nearer patient. Reduces twisting of nurse’s body because nurse is facing direction of movement.
		(5)Place feet apart with foot closer to head of bed in front of other foot.	Increases balance and allows nurse to transfer weight as patient is brought to sitting position on side of bed.
		(6)Place arm nearer head of bed under patient’s shoulder, supporting head and neck.	Maintains alignment of head and neck as nurse brings patient to sitting position.
		(7)Place other arm over patient’s thighs (see illustration).	Supports hip and prevents patient from falling backwards during procedure.
		(8)Move patient’s lower legs and feet over side of bed. Pivot towards rear leg, allowing patient’s upper legs to swing downwards.	Decreases friction and resistance. Weight of patient’s legs when off bed provides gravity to lower legs, and weight of legs helps pull upper body into sitting position.
		(9)At same time, shift weight to rear leg and elevate patient (see illustration).	Allows nurse to transfer weight in direction of motion.
Step 6A(3) Patient lying on side, facing nurse.	Step 6A(7) Placement of nurse’s arms to support patient.		Step 6A(9) Nurse shifting weight to rear leg to elevate patient safely.
		(10)Remain in front of patient until patient regains balance.	Reduces risk of falling.
	B. Transfer patient from bed to chair:
		(1)Adjust the bed slightly higher than the chair. Assist patient to sitting position on side of bed. Have chair in position at 45-degree angle to bed and ensure brakes are on.	Positions chair within easy access for transfer.
		(2)Apply transfer belt or other transfer aids, if needed.	Transfer belt allows nurse to maintain stability of patient during transfer and reduces risk of falling. Patient’s arm should be in sling if flaccid paralysis is present.
Critical decision point: If patient has immobile lower leg (i.e. cast, paralysis), transfer towards the stronger leg.
		(3)Ensure that patient has stable, non-skid shoes. Weightbearing, or stronger, leg is placed forwards, with weaker foot back.	Non-skid soles decrease risk of slipping during transfer. Always have patients wear shoes during transfer; bare feet increase risk of falls. Patient will stand on weightbearing, or stronger, leg.
		(4)Spread feet apart.	Ensures balance with wide base of support.
		(5)Flex hips and knees, aligning feet and knees with patient’s feet (see illustration).	Flexion of knees and hips lowers nurse’s centre of gravity to object to be raised; aligning knees with patient’s allows for stabilisation of knees when patient stands.
		(6)Grasp transfer belt from underneath, if used, or reach through patient’s axillae and place hands on patient’s scapulae.	Transferring patient with hands on scapulae reduces pressure on axillae and maintains patient stability. Patients with upper-extremity paralysis or paresis should never be lifted by or under arms. Transfer belt is grasped at each side to provide movement of patient at centre of gravity.
		(7)Rock patient up to standing position on count of three while straightening hips and legs and keeping knees slightly flexed (see illustration). Patient is instructed to use hands to push up if possible.	Rocking motion gives patient’s body momentum and requires less muscular effort to transfer patient.
		(8)Maintain stability of patient’s weak or paralysed leg with knee.	Ability to stand can often be maintained in paralysed or weak limb with support of knee to stabilise.
		(9)Pivot on foot further from chair.	Maintains support of patient while allowing adequate space for patient to move.
		(10)Instruct patient to use armrests on chair for support and ease themselves into chair (see illustration).	Increases patient stability.
		(11)Flex hips and knees while lowering patient into chair (see illustration).	Prevents injury to nurse from poor body mechanics.
		(12)Assess patient for proper alignment for sitting position. Provide support for paralysed extremities. Lap board or sling will support flaccid arm. Stabilise leg with bath blanket or pillow.	Prevents injury to patient from poor body alignment.
Step 6B(5) Position of flexed hips and knees.	Step 6B(7) Rock patient up to standing position.		Step 6B(10) Patient uses armrests for support while being lowered.	Step 6B(11) Flexion of hips and knees to lower patient.
	(13)Praise patient’s progress, effort, performance.		Continued support and encouragement provide incentive for patient perseverance.
C. Use mechanical/hydraulic lift to transfer patient from bed to chair (two nurses):
		(1)Bring lift to bedside. Before using lift, be thoroughly familiar with its operation.
		(2)Position chair near bed and allow adequate space to manoeuvre hoist.	Prepares environment for safe use of lift and subsequent transfer.
		(3)Raise bed to safe working height with mattress flat. Lower side rails.	Allows nurse to use proper body mechanics.
Critical decision point: Assess all tubes, making sure that they will not be inadvertently pulled, tangled or strained during transfer.
		(4)Roll patient laterally towards one nurse.	Positions patient for use of lift sling.
		(5)Place sling evenly under patient’s back (follow manufacturer’s guidelines for correct positioning of the sling) and then roll patient to opposite side to position sling.	Place sling under patient’s centre of gravity and greatest portion of bodyweight.
		(6)Roll patient supine on sling and position hoist over patient. Lower boom and attach sling to frame with the head end attached first. Raise patient’s knees and feed the leg sections of the sling under the thighs and attach to frame.	Sling should extend from shoulders to knees to support patient’s bodyweight equally.
		(7)Elevate head of bed.	Positions patient in sitting position.
		(8)Ask or assist patient to fold their arms over the chest.	To prevent injury during transfer.
		(9)Pump hydraulic handle using long, slow, even strokes, or activate electronic hoist until patient is raised off bed ensuring the head is supported (see illustration).
		(10)Use steering handle to pull lift from bed and manoeuvre to chair.	Moves patient from bed to chair.
		(11)Slowly lower patient into chair (see illustration).
		(12)Detach sling from frame and remove hoist. Pull leg straps to the side, tilt patient forward to slide out the sling.	Safely guides patient into back of chair as seat descends.
		(13)Reposition the patient to a position of comfort and safety.
7. Perform hand hygiene.
8. With each transfer, assess patient’s tolerance and level of tiredness.
9. With each transfer, evaluate patient’s alignment.
Step 6C(9) Using mechanical lift to raise patient off bed.			Step 6C(11) Lowering patient into chair.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record each transfer and position change, including amount of assistance needed and patient’s response. • Record and report any signs of pressure injury over areas such as bony prominences.	• Teach family the importance of body mechanics for safety of themselves and the patient.

A safe transfer is the first priority. The nurse who is doubtful about personal strength or the patient’s ability to help should request assistance. Often a hydraulic lift can be used to transfer patients (see Skill 33-3). The patient should sit and dangle the feet over the side of the bed for a minute before standing. The patient should then stand at the side of the bed for another minute, so that the patient can quickly be lowered back into bed in case of dizziness or fainting.

When moving an immobilised patient from a bed to a wheelchair, both nurses must use proper body mechanics. If a patient has an immobile lower extremity from a cast or paralysis, the transfer should be towards the unaffected leg. A lifting device should be used.

TRANSFERRING A PATIENT FROM A BED TO A STRETCHER

An immobilised patient who must be transferred from a bed to a stretcher or from a bed to another bed requires the use of a transfer board and slide sheet beneath the patient (Figure 33-20). In this technique, nurses need to be on opposite sides of the bed and holding on to the slide sheet when transferring the patient to the stretcher. The stretcher and the bed are placed side by side so that the patient can be transferred quickly and easily using the slide sheet. As with all procedures, safety is the priority. Safety is increased if the team works together in a coordinated way. Therefore one person should assume the leadership role.

FIGURE 33-20 A, Transfer board is placed under a slide sheet beneath the patient. B, Patient is transferred from bed to stretcher using slide sheet and board.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Caution is used when the patient has or is suspected of having spinal cord trauma. If the patient must be moved, a transfer board should be placed under the patient to maintain spinal alignment before transferring the patient to a stretcher (see Figure 33-20). The patient should be prepared for the transfer and asked to help when possible (e.g. by folding arms over the chest). The environment should be free from obstacles, and unnecessary equipment should be removed from the bed.

Restorative care

The goal of restorative care for the patient who is immobile is to maximise functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance. The focus in restorative care is not only on ADLs that relate to physical self-care, but also on instrumental activities of daily living (IADLs). IADLs are activities that are necessary to be independent in society beyond eating, grooming, transferring and toileting, and include such skills as shopping, preparing meals, banking and taking medications.

The nurse uses many of the same interventions as described in the health promotion and acute care sections above, but the emphasis with restorative care is on working collaboratively with patients and their significant others and with other healthcare professionals. The aim is to facilitate the patient’s return to maximal functional ability in both ADLs and IADLs so that quality of life is enhanced.

Intensive specialised therapy such as occupational or physiotherapy is common. The patient, if in an institution, is likely to go to the therapy department 2–3 times a day. The nurse’s role is to work collaboratively with these professionals and reinforce exercises and teaching. For example, after a stroke, a patient is likely to receive gait training from a physiotherapist, speech rehabilitation from a speech therapist and training from an occupational therapist on food preparation or other household chores. The therapy may not be able to restore total functional health, but may help the patient adapt to the mobility limitations or complications.

Restorative care is carried out in a variety of settings for the patient who has mobility limitations. The site of the care depends on the level of care needed, the amount and frequency of care required and the types of care that are available in a geographical area. Extended care refers to a variety of supportive care services that are provided to patients who have lost the ability for some aspect of self-care. The term ‘extended care’ is somewhat misnamed, however, since the timeframe for restorative-care services that a patient requires may range from several weeks to years. After a total knee replacement, for example, it is not unusual for a patient to move from the acute care setting to a restorative care setting such as a nursing home or a rehabilitation facility, or to a rehabilitative unit at the same hospital where acute care was provided. Restorative care may also take place at home. The patient may go from hospital to nursing home to home, or go directly home from a hospital. The patient may receive care in the home from professionals or make outpatient visits to therapists’ offices.

Common restorative interventions focus on regaining mobility. Performing exercises to maintain or regain joint mobility and teaching the use of aids for walking are common restorative nursing interventions. Items frequently used to help adapt to mobility limitations include walkers, walking sticks, wheelchairs, and aids such as toilet seat extenders, reaching sticks, special eating utensils and clothing with Velcro closures.

RANGE-OF-MOTION EXERCISES

To ensure adequate joint mobility, the nurse can teach the patient about active ROM exercises. When the patient does not have voluntary motor control, the nurse institutes passive ROM exercises. Joint mobility is also increased by walking. Occasionally patients need to use aids such as crutches or walkers to help them walk.

Patients with restricted mobility are unable to perform some or all ROM exercises independently. This limitation can be identified in patients in whom one extremity has limited movement or in completely immobilised patients. When caring for patients with actual or potential impaired mobility, the nurse designs interventions directed at maintaining maximum joint mobility. One such nursing intervention is ROM exercises.

To ensure that patients routinely receive these exercises, the nurse should schedule them at specific times, perhaps with another nursing activity, such as during the patient’s hygiene care. This enables the nurse to systematically assess and improve the patient’s ROM. In addition, bathing usually requires that extremities and joints be put through complete ROM. The nurse first assesses the patient’s ability to engage in active ROM exercises and the need for assistance. In general, exercises should be as active as health and mobility allow. Contractures may develop in joints not moved periodically through their full ROM.

Unless contraindicated, the care plan should include moving the patient’s extremities through the fullest ROM possible. Passive ROM exercises should begin as soon as the patient’s ability to move the extremity or joint is lost. Movements are carried out slowly and smoothly, just to the point of resistance, and should not cause pain. The nurse should never force a joint beyond its capacity. Each movement should be repeated at least 5 times during the session.

When performing passive ROM exercises, the nurse stands at the side of the bed closest to the joint being exercised. If an extremity is to be moved or lifted, the nurse places a cupped hand under the joint to support it (Figure 33-21), supports the joint by holding the adjacent distal and proximal areas (Figure 33-22) or supports the joint with one hand and cradles the distal portion of the extremity with the remaining arm (Figure 33-23).

FIGURE 33-21 Using a cupped hand to support a joint.

From Potter PA, Perry AG 2004 Fundamentals of Nursing, ed 6. St Louis, Mosby.

FIGURE 33-22 Supporting the joint by holding the distal and proximal areas adjacent to the joint.

From Potter PA, Perry AG 2004 Fundamentals of Nursing, ed 6. St Louis, Mosby.

FIGURE 33-23 Cradling the distal portion of an extremity.

From Potter PA, Perry AG 2004 Fundamentals of nursing, ed 6. St Louis, Mosby.

The following sections describe movements for major joints in the body. Refer back to Table 33-3 for details of ROM and illustrated motion for each joint.

NECK

ROM is permitted by the flexibility of the cervical vertebrae and the pivotal connection between the head and neck. Unless contraindicated because of spinal surgery, spinal cord trauma or other central nervous system trauma, ROM exercises should be performed by patients with limited neck mobility. When flexion contracture of the neck occurs, the patient’s neck is permanently flexed with the chin close to or actually touching the chest. Ultimately, the patient’s body alignment is altered, the visual field is changed and the level of independent functioning is decreased.

SHOULDER

One feature of the shoulder that sets it apart from other joints in the body is that the strongest muscle controlling it, the deltoid, is in complete elongation in the normal position. No other muscle exerts its full strength when in complete elongation. The goal of action in the shoulder is full ROM. Shoulder movements include flexion, extension, abduction, adduction, internal and external rotation, and circumduction. The full ROM must be maintained or regained to avoid pain.

When caring for a patient with limited shoulder mobility, the nurse may need to design support devices for the shoulder, such as slings when the patient is standing or sitting or pillows when the patient is in bed. Correctly positioning the shoulder prevents pain, joint dislocation and further changes in body alignment.

ELBOW

The elbow functions optimally at an angle of about 90 degrees. An elbow fixed in full extension is disabling and limits the patient’s independence.

FOREARM

Most functions of the hand are best carried out with the forearm in moderate pronation. When the forearm is fixed in a position of full supination, the patient’s use of the hand is limited. For optimal functioning, the forearm must be able to rotate from supination to pronation.

WRIST

The primary function of the wrist is to place the hand in slight dorsiflexion, the position of functioning. Full ROM is therefore not as great a priority as maintaining the wrist in a functional position. When the wrist is fixed in even a slightly flexed position, the grasp is weakened. In the immobilised patient the functional position of the wrist can be achieved by using splints.

FINGERS AND THUMB

The ROM in the fingers and thumb enables the patient to perform ADLs and activities requiring fine motor skills, such as carpentry, needlework, drawing and painting. The functional position of the fingers and thumb is slight flexion of the thumb in opposition to the fingers. In patients with restricted mobility, hand rolls help maintain this position.

HIP

Because the lower extremities are concerned chiefly with locomotion and weightbearing, stability of the hip joint may be more important than its mobility. For example, if one hip has no mobility but is fixed in a neutral position and fully extended, it is possible to walk without a significant limp.

However, contractures often fix the hip in positions of deformity. Excessive abduction makes the affected leg appear too short, whereas excessive adduction makes the affected leg appear too long. In either case the patient has limited locomotion and walks with an obvious limp. Internal and external rotation contractures cause an abnormal and unbalanced gait.

KNEE

One of the main functions of the knee is stability, which is achieved by ROM, ligaments and muscles. However, the knees cannot remain stable under weightbearing conditions unless there is adequate quadriceps power to maintain the knee in full extension. ROM exercises should include pulling the knee into full extension.

An immobile knee joint can result in serious disability. The degree of disability depends on the position in which the knee is stiffened. If the knee is fixed in full extension, the person must sit with the leg thrust out in front. When the knee is flexed, the person limps while walking. The greater the flexion, the greater the limp. Complete flexion contractures prevent the person from walking without a walker or crutches.

ANKLE AND FOOT

Ankle ROM is important, as without full ROM there will be gait deviations. The joint must be stable and able to bear weight, or the person will fall. If joint mobility is diminished, the nurse should maintain the joint in a position in which walking can be carried out with a forward rolling motion from the heel onto the forefoot.

When the person relaxes as in sleep or coma, the foot relaxes and assumes a position of plantar flexion. This results from relaxation of the gastrocnemius and soleus muscles, which maintain dorsiflexion. If the foot remains in plantar flexion without support, these two muscles shorten and the dorsiflexion muscles try to compensate by overstretching. As a result, the foot becomes fixed in plantar flexion (footdrop), which impairs the ability to walk. Inversion and eversion must also be avoided to allow the foot to rest flat on the floor. The foot must be flat to allow weightbearing and proper walking.

TOES

Excessive flexion of the toes results in clawing. When this is a permanent deformity, the foot is unable to rest flat on the floor and the patient is unable to walk properly. Flexion contractures are the most common foot deformity associated with reduced joint mobility.

Adequate ROM gives the necessary mobility to carry out ADLs and exercise and to engage in relaxing activities. In addition, adequate ROM in the lower extremities allows walking.

USING AIDS FOR WALKING

Patients who are recovering from a lengthy illness that required bed rest and whose mobility is impaired often require walking aids. These include walking sticks, walkers and crutches; the patient and family may need to be taught how to use these aids.

WALKERS

Walkers are extremely light, movable devices about waist high and made of metal tubing (Figure 33-24). They have four widely placed, sturdy legs. The client holds the handgrips on the upper bars, takes a step, moves the walker forwards and takes another step. There are many variations on this theme.

FIGURE 33-24 Client using a walker.

Image: Dreamstime/Monkey Business Images.

WALKING STICKS

Walking sticks are lightweight, easily movable devices that are about waist high and made of wood or metal. Two common types of walking stick are the single straight-legged walking stick and the four-pronged walking stick. The single straight-legged stick is more common and is used to support and balance a client with decreased leg strength. This stick should be kept on the stronger side of the body. For maximum support when walking, the client places the stick forward 15–25 cm, keeping bodyweight on both legs. The weaker leg is moved forwards to the stick so that bodyweight is divided between the stick and the stronger leg. The stronger leg is then advanced past the stick so that the weaker leg and the bodyweight are supported by the stick and weaker leg. The client must be taught that two points of support, such as both feet or one foot and the stick, are present at all times.

The four-pronged stick provides the most support and is used when there is partial or complete leg paralysis or some hemiplegia (Figure 33-25). The same three steps that are used with the straight-legged stick are taught to the client.

FIGURE 33-25 Four-pronged stick.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

CRUTCHES

Crutches are often needed to increase mobility. The nurse begins crutch instruction with guidelines for safe use (Box 33-7). The use of crutches may be temporary, such as after ligament damage to the knee. However, a client with paralysis of the lower extremities may need crutches permanently. A crutch is a wooden or metal staff. The two types of crutches are the double adjustable Lofstrand, or forearm, crutch (Figure 33-26) and the axillary wooden or metal crutch. The forearm crutch has a handgrip and a metal band that fits around the client’s forearm. The metal band and the handgrip are adjusted to fit the client’s height. The axillary crutch has a padded curved surface at the top, which fits under the axilla. A handgrip in the form of a crossbar is held at the level of the palms to support the body.

BOX 33-7 CLIENT TEACHING FOR CRUTCH SAFETY

OBJECTIVE

• Client will state and demonstrate safe crutch walking.

TEACHING STRATEGIES

• Teach client with axillary crutches about the dangers of pressure on the axillae, which occurs when leaning on the crutches to support bodyweight.

• Explain why client must use crutches that were measured for him or her.

• Show client how to routinely inspect crutch tips. Rubber tips should be securely attached to the crutches. When tips are worn, they should be replaced. Rubber crutch tips increase surface friction and help prevent slipping.

• Explain that the crutch tips should remain dry. Water decreases surface friction and increases the risk of slipping.

• Show client how to inspect the structure of the crutches. Cracks in a wooden crutch decrease its ability to support weight. Bends in aluminium crutches can alter body alignment.

• Provide client with a list of pharmacies or medical supply companies in the community for obtaining repairs, new rubber tips, handgrips and crutch pads.

EVALUATION

• Client states and demonstrates principles of crutch safety.

FIGURE 33-26 Double adjustable Lofstrand, or forearm, crutch.

Image: Shutterstock/RTimages.

It is important that crutches be measured for the appropriate length and that clients be taught to use their crutches safely, to achieve a stable gait, to ascend and descend stairs and to rise from a sitting position.

Measuring for crutches

The axillary crutch is the more common crutch used. Measurements include the client’s height, the angle of elbow flexion and the distance between the crutch pad and the axilla. When crutches are fitted, the length of the crutch should be 5 cm from the axilla to a point 15 cm lateral to the client’s heel (Figure 33-27).

FIGURE 33-27 Measuring crutch length.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

The handgrips should be positioned so that the client’s bodyweight is not supported by the axillae. Pressure on the axillae increases risk to underlying nerves, which could result in partial paralysis of the arm (crutch palsy). Correct position of the handgrips is determined with the client upright, supporting weight by the handgrips with the elbows slightly flexed (20–25 degrees). When the height and placement of the handgrips have been determined, the nurse should again verify that the distance between the crutch pad and the client’s axilla is 3–4 finger-widths (Figure 33-28).

FIGURE 33-28 Verifying correct distance between crutch pad and axilla.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Crutch gait

Crutch gait is assumed by alternately bearing weight on one or both legs and on the crutches. The gait selected by the doctor is determined by assessing the client’s physical and functional abilities and the disease or injury that resulted in the need for crutches. This section summarises the basic crutch stance and the four standard gaits: four-point alternating gait, three-point alternating gait, two-point gait and swing-through gait.

The basic crutch stance is the tripod position, formed when the crutches are placed 15 cm in front of and 15 cm to the side of each foot (Figure 33-29). This position improves the client’s balance by providing a wider base of support. The body alignment of the client in the tripod position includes an erect head and neck, straight vertebrae and extended hips and knees. No weight should be borne by the axillae. The tripod position is assumed before crutch walking.

FIGURE 33-29 Tripod position, basic crutch stance.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Four-point alternating, or four-point, gait gives stability to the client but requires weightbearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times (Figure 33-30A).

FIGURE 33-30 (Read each diagram from bottom to top.) A, Four-point alternating gait. Solid feet and crutch tips show foot and crutch tip moved in each of the four phases. B, Three-point gait with weight borne on unaffected leg. Solid foot and crutch tips show weightbearing in each phase. C, Two-point gait with weight borne partially on each foot and each crutch advancing with opposing leg. Solid areas indicate leg and crutch tips bearing weight.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Three-point alternating, or three-point, gait requires the client to bear all of the weight on one foot. In three-point gait, weight is borne on both crutches and then on the uninvolved leg, and the sequence is repeated (Figure 33-30B). The affected leg does not touch the ground during the early phase of the three-point gait. Gradually the client progresses to touchdown and full weightbearing on the affected leg as the doctor orders.

The two-point gait requires at least partial weightbearing on each foot (Figure 33-30C). The client moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking.

The swing-through gait is often used by paraplegics who wear weight-supporting braces on their legs. With weight placed on the supported legs, the client places the crutches one stride in front and then swings to or through the crutches while they support the client’s weight.

Crutch walking on stairs

When ascending stairs on crutches, the client usually uses a modified three-point gait (Figure 33-31). The client stands at the bottom of the stairs and transfers bodyweight to the crutches. The unaffected leg is advanced between the crutches onto the stairs. The client then shifts weight from the crutches to the unaffected leg. Finally, the client aligns both crutches on the stairs. This sequence is repeated until the client reaches the top of the stairs.

FIGURE 33-31 Ascending stairs. A, Weight is placed on crutches. B, Weight is transferred from crutches to unaffected leg on stairs. C, Crutches are aligned with unaffected leg on stairs.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

To descend the stairs (Figure 33-32), a three-phase sequence is also used. The client transfers bodyweight to the unaffected leg. The crutches are placed on the stairs, and the client transfers bodyweight to the crutches, moving the affected leg forwards. Finally, the unaffected leg is moved to the stairs with the crutches. Again, the client repeats the sequence until reaching the bottom of the stairs.

FIGURE 33-32 Descending stairs. A, Bodyweight is on unaffected leg. B, Bodyweight is transferred to crutches. C, Unaffected leg is aligned on stairs with crutches.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Because in most cases clients will need to use crutches for some time, they should be adequately taught to use crutches on stairs before discharge. This instruction applies to all crutch-dependent clients, not only those who have stairs in their homes.

Sitting in a chair with crutches

As with crutch-walking and crutch-walking up and down stairs, the procedure for sitting in a chair involves phases and requires the client to transfer weight (Figure 33-33). First, the client gets positioned at the centre front of the chair with the posterior aspect of the legs touching the chair. Then the client holds both crutches in the hand opposite the affected leg. If both legs are affected, as with a paraplegic person who wears weight-supporting braces, the crutches are held in the hand on the client’s stronger side. With both crutches in one hand, the client supports bodyweight on the unaffected leg and the crutches. While still holding the crutches, the client grasps the arm of the chair with the remaining hand and lowers the body into the chair. To stand, the procedure is reversed, and the client, when fully erect, should assume the tripod position before beginning to walk.

FIGURE 33-33 Sitting in a chair. A, Both crutches are held by one hand. Client transfers weight to crutches and unaffected leg. B, Client grasps arm of chair with free hand and begins to lower herself into chair. C, Client completely lowers herself into chair.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

EVALUATION

Patient care

To evaluate outcomes and response to nursing care, the nurse measures the effectiveness of all interventions. Patient assessment data are compared with the selected evaluation criteria and expected outcomes, such as the patient’s ability to maintain or improve body alignment, joint mobility, walking, moving or transferring, or the absence of complications of immobility. The effectiveness of patient and family teaching to prevent future risks to mobility are also evaluated (Figure 33-34). Evaluation is cumulative and continuous. The continuous or formative nature of evaluation allows the nurse to determine whether new or revised therapies are required and if new nursing diagnoses have developed.

FIGURE 33-34 Critical thinking model for immobility evaluation phase.

ONLINE RESOURCES

Department of Health and Ageing; physical activity guidelines, www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-active-index.htm

Ministry of Health; physical activity guidelines, www.health.govt.nz/yourhealth-topics/physical-activity

National Health and Medical Research Council; clinical practice guideline for the prevention of venous thromboembolism in patients admitted to Australian hospitals, www.nhmrc.gov.au/guidelines/publications/cp115