8 Lab 05: Transfers

• Diagnosis: This includes the diagnosis that brought her to the hospital (the reason for her admission) as well as any other co-existing illnesses (co-morbidities) that she may have, such as diabetes, HTN or any number of conditions that is currently being treated for.
• PMH: Past Medical History.  This will list the types of illnesses, surgeries, medical events has the patient had over their lifetime.  Some of these will not impact her present situation at all, while others will directly impact her care.  For example, we noted that orthopnea  is a condition that will prevent the patient from being able to lie supine.  If you read that a patient has this diagnosis in her PMH or (more likely) has a diagnosis in which orthopnea is often concomitant, (occurring at the same time) you will know not to lie the patient flat.   For now, appreciate that a patient’s PMH may be very helpful in determining how they will perform a transfer. 
• Specific precautions:Quite often, a diagnosis will have a given restriction or precaution: For example, following cardiac surgery, there will be lifting restrictions as well as those related to strict avoidance of the Valsalva maneuver.  Sometimes the precautions are related to a patient’s co-morbidities or conditions listed in their PMH. 
  • VITAL SIGNS: It is very important, prior to meeting your patient, to be clear on what vital signs you will need to be monitoring. Typically, for a “medical” patient or a patient who has had any time of recent surgery, we monitor their pain, their heart rate and theirblood pressure. If they have a respiratory impairment, we will also be monitoring their oxygen saturation as well as respiratory rate.
  • SEQUENCE: Typically, after our patient interview –when we ask questions about pain and other concerns –we will thencheck the related vital signs. Yes, before we do any treatment.This is so we have a baseline of their vital signs so we can, later in the treatment, once again check their vital signs and compare it to their baseline. Now we know what impact our treatment has on their vital signs. This is very important as it will allow us to make informed clinical decisionsabout our treatments.
• TRANSFERPRECAUTIONS: The patient’s WEIGHT BEARING STATUS. For patients who have had an injury or a surgical procedure to a LE, their surgeon/doctor will have given them limitations on how much of their body weight they are permitted to put on the involved LE.For example, if the patient just fractured their right ankle and they are now in a cast or other form of ankle immobilization, the surgeon will not want them to bear any weight on that right ankle. The term for this is “Non-Weight Bearing” or simply, NWB’gRLE.If the patient’s ankle was beginning to heal and the patient needed to, at times, rest their foot on the floor, but not put any weight on it, the surgeon might progress allow her to just have her toe on the floor (Toe-Touch weight bearing: TTWB’g) or perhaps allow her to rest her entire foot flat on the floor, but without any weight on it: (Foot Flat Weight Bearing: FFWB’g).

  If the patient broke their hip (fractured their femur) and the doctor repaired the fracture by putting the broken parts together by using ‘hardware’ (maybe some screws, pins orthe use of both)…and ORIF…the patient may only be allowed to put some of their weight on the RLE when they walk. This would mean that are “Partial Weight Bearing” –or PWB’g.

  Let’s say the patient’s fracture is now healed, the surgeon might upgrade the weight bearing status to allow the patient to put as much weight on the LE as they can comfortably tolerate. This is called Weight Bearing as Tolerated: WBAT. To be clear, this weight bearing status does not mean “Put all the weight on this leg you can possible bear; embrace the pain; get tough; don’t be a whimp” —rather, it is a very thoughtful weight bearing status. The patient should only be bearing as much weight as they comfortably can –if they do more than that, pain will develop and that can do two things:

1. 1. 1. Lead to a “Limp” – We refer to that as an antalgic gait pattern. This is harmful to the involved extremity as well as the uninvolved extremity.
      2. Damage the fracture site, repair site or injured site.

• Transfer status: During the physical therapy examination and evaluation, the physical therapist will have performed bed mobility and transfers.  If they did not, they will NOT ask you to perform these activities with the patient. Only AFTER they have evaluated the patient’s performance on these skills and written their status in the medical record (physical therapy plan of care: PT POC) will you be asked to complete these skills with the patient.A patient’s ‘level of status’ or ‘level of ability’ regarding transfers, bed mobility and gait are as follows:
  • Independent:   The patient can perform a transfer without any type of verbal or manual assistance. 
  • Modified independent: The patient uses adaptive or assistive equipment to perform a task independently (e.g., a transfer board, bed rail, grab bars, or furniture); the patient may have safety or timeliness issues.
  • Assisted:   The patient requires assistance from another person to perform the activity safely in an acceptable time frame; physical assistance, oral or tactile cues, directions, or instructions may be used.
    • Standby (supervision) assistance: The patient requires verbal or tactile cues, directions, or instructions from another person positioned close to, but not touching, the person to perform the activity safely and in an acceptable time frame; the assistant may provide protection in case the patient’s safety is threatened
    • Contact guarding: The caregiver is positioned close to the patient with his or her hands on the patient or a safety belt; it is very likely the patient will require protection during the performance of the activity.
    • Minimal assistance: The patient performs 75% or more of the activity; assistance is required to complete the activity
    • Moderate assistance: The patient performs 50% to 74% of the activity; assistance is required to complete the activity
    • Maximal assistance: The patient performs 25% to 49% of the activity; assistance is required to complete the activity
    • Dependent: The patient requires total physical assistance from one or more persons to accomplish the activity safely; special equipment or devices may be used

[Image of a female patient with pt staff] 

Explain, Demo, Instruct 

Teach-back, Answer questions, Perform skill 

BED MOBILITY:

We are routinely teaching bed mobility, be it to our patient’s who are in a hospital bed or are in an outpatient clinic learning how to safely get in and out of bed with their newly injured back (hip, knee, etc.).  The principles of bed mobility will apply to virtually every type of patient.

1. Plan ahead to raise bed or squat down
2. Before assisting patient with bed mobility, have wide base of support with staggered stance
3. Face patient
4. Instruct patient to move on the count of 3
5. Shift weight from front leg to back leg when assisting patient

SIT TO STAND and STAND to SIT:

Perhaps our most common transfers. Done correctly, no one will ever appreciate how much goes into making it a safe skill.  Done incorrectly, the patient will know immediately that you did not teach them correctly.  They will be at increased risk for an injury and we are at increased risk for losing our credibility with our patient (AKA: Their trust). 

BASF Break the Chain: Appily Ever After