7 Lab 05: Body Mechanics, Bed Positioning, Transfers, and Wheelchair Mobility
BASIC BODY MECHANICS, BED POSITIONING, TRANSFERS AND WHEELCHAIR MOBILITY
By now you are beginning to experience how each lab unit builds on the previous unit. As we look at the objectives for our transfer unit (below in red), we can see that, to accomplish any of those objectives, we need to be integrating objectives from our prior units.
Unit Objectives
THE STUDENT WILL SAFELY AND EFFECTIVELY IMPLEMENT INTERVENTIONS FOR BASIC BODY MECHANICS, BED POSITIONING, TRANSFERS AND WHEELCHAIR MOBILITY FOR COMMON PATIENT/CLIENT CONDITIONS.
- DESCRIBE proper body techniques used in basic transfer activities.
- DEMONSTRATE safe and effective basic transfers as per a patient’s plan of care established by the physical therapist.
- INSTRUCT AND ASSIST another person to perform various transfer techniques with effective communication.
- ADJUST the position of a person who is recumbent with or without the assistance of another person in preparation for the transfer.
- DEMONSTRATE how to properly guard and protect a person during the performance of a transfer.
- Correctly DESCRIBE the level of assist used to describe transfers.
However, the ‘principles’ and ‘objectives’ we need to integrate to successfully achieve these objectives will include the following:
Can you think of any others?
INFECTION CONTROL:
- Perform proper techniques of hand hygiene for clean situations
- Explain the use of standard precautions and transmission-based precautions and related protocols
- Select appropriate infection control procedures for a given case scenario
- Demonstrate proper procedure when donning and doffing personal protective equipment
BODY MECHANICS:
- Describe proper body mechanics to use for lifting, reaching, pushing, pulling, and carrying objects.
- Explain the importance of gravity, friction, base of support, center of gravity, and line of gravity as factors in good body mechanics.
- Demonstrate proper body mechanics for lifting, reaching, pushing, pulling, and carrying objects
- Instruct another person to use proper body mechanics using effective communication
- Explain specific precautions to use when lifting, reaching, pushing, pulling, and carrying objects
- Describe appropriate positioning of the trunk, head, and extremities with the patient supine, prone, side lying, or sitting
POSITIONING and DRAPING
- Identify areas at risk for skin trauma when positioning a patient supine, prone, side lying, or sitting
- List reasons for using and applying proper patient positioning.
VITAL SIGNS
- COMPARE patient vital signs to normative values for a given case scenario
- Determine a patient’s response to change in position by measuring vital sign before and after the intervention.
- Using role play, respond effectively when a patient’s vital signs indicate the need for emergency intervention.
So, have you thought of what might be missing? Right, the objectives for your knowledge of wheelchairs. If you have thought of others, please share those during our pre-lab discussion!
TIME TO BEGIN: Let’s start at the end.
Below you will find the skills checklist for transfers. Take a moment to familiarize yourself with the skills you will need to perform in order to successfully demonstrate your competency with transfers. Doing so will help you better focus your reading and preparation for lab as well as your understanding of the material. As you go through the checklist, ask yourself:
- What motor skills will I need to perform? (We have video links for you to watch these transfers so you can have a clear image of the skills).
- When performing these skills, what do I need to be thinking about: Before, during and after?
- How might a sequence these activities in a logical manner to ensure patient safety?
- What else do I need to know?
The student will correctly perform the proper techniques in a safe and effective manner in accordance with the following criteria. The student is required to demonstrate competency for all criteria.
- Introduction
- Student introduction provided to instructor.
- Procedure(s) explained in a clear and concise manner to instructor and lab partner
- Explain specific precautions during demonstrations
- .Demonstration:
- Correctly Applies Principles of Body Mechanics to all Transfers
- Demonstration: Wheelchair to mat table Pre-Transfer
- Determine the patient’s mental and physical capacities to perform transfer through patient interview
- Environment is Prepared: Wheelchair is locked and correctly positioned; treatment table is secure; floor is dry and obstacle free.
- Gait belt correctly applied.
- Instructions are provided clearly; any questions raised are addressed pre-transfer
- Demonstration: Wheelchair to mat table Transfer:
- Positioning of self and lab partner correct for transfer.
- Level of assistance provided matches level of assistance for given scenario provided by the instructor
- Transfer is smooth and coordinated with application of correct body mechanics
- Demonstration: Wheelchair to mat table Post-Transfer:
- .Lab partner is positioned safely prior to disengaging from the transfer
- Lab partner is interviewed for any untoward changes
- Demonstration of Mat Transfers:
- Upward movement, patient supine
- Downward movement, patient supine
- Supine to/from sidelying
- Sitting to/from supine
NOW for a CLOSER LOOK
What are Transfers?
Transfers are the safe movement of a patient from one surface or position to another.
What do Transfers require?
The integration of the following techniques and principles:
- Proper body mechanics
- Proper patient positioning
- Use of infection control procedures
- Monitoring appropriate vital signs
- Requires communication before, during and after the transfer.
- Thorough and thoughtful PREPARATION of
- The ENVIRONMENT
- The PATIENT and
- The THERAPIST…. LET’S START HERE.
- Thorough and thoughtful PREPARATION of
[Image of a female patient 1]
Your clinical instructor has just asked you to instruct this patient is safe bed mobility techniques and then transfer the patient to their wheelchair. You are so psyched to be given this opportunity. …but where do you start?
You probably know more how to begin then you think. Take a moment to jot down what you need to know about this patient before you would even consider transferring her.
Now let’s see how our lists compare.
- 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 their blood 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 then check 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 decisions about our treatments.
- TRANSFER PRECAUTIONS: 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’g RLE.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:
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- 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.
- Damage the fracture site, repair site or injured site.
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So, this leads to a great question: Will all patient’s have a weight bearing status? The answer is no, only those who have had an ‘event’ related to a LE: Surgery, injury, etc. For your patients with non-orthopedic diagnoses, they will not have a weight bearing precaution.
- 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
You will need to know “what” TYPE OF TRANSFER (s) you will be performing:
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- Stand-Pivot
- Bed transfers
- Wheelchair Transfers
- Mechanical Lift
- Transfer Board
- Patient concerns and/or perspective of readiness:
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- For “this” transfer or bed mobility activity: You will ask questions of your patient to determine their level (to name just a few)
- Fatigue
- Pain.
- Weakness
- Nausea.
- Dizziness.You will also need to assess their cognitive and emotional readiness for the transfer. You will ask questions to determine their level of understanding of what is expected of them (can they ‘teach it back’ to you or are they confused?) as well as their level of anxiety or enthusiasm.
[Image of a female patient with pt staff]
Environmental Preparation:
Now that you have an idea of what you will be doing with the patient, how the patient did with those activities during her prior treatment and what the patient is thinking and feeling about the upcoming skills, we can now make sure the environment is safe and secure for our treatment.
Let’s BEGIN WITH THE END IN MIND”
- Knowing where do we want to END with the patient will let us work backwards to set the area up safely. If I am going to transfer the patient to a wheelchair, is the wheelchair:
- Locked?
- In the correct position?
- Are the leg rests out of the way?
- Are the front caster wheels out of the way?
- Is the seat cushion in the chair (correctly)?
- Is the floor dry and uncluttered?
- Is my pathway to the wheelchair clear?
- Knowing where I am starting from is helpful too😊. I can make sure that the surface the patient is starting from (let’s say hospital bed) is:
- Locked?
- At the correct height?
- Free from clutter?
- Positioned optimally (head part of bed elevated or maybe not…same for foot part of bed)
- Is the room lighting sufficient / appropriate for this patient?
- Is the GAIT BELT secured?
- Transfer board handy if needed?
- Are lines, tubes, alarms or other devices patient may be hooked to secured?
Patient Preparation:
At this point, once we are knowledgeable about the patient’s needs and abilities…once we have step up the environment correctly (including providing our patient with a gait belt or any other device they need) …we can now prepare the patient. …but how…?
COMMUNICATION: Right you are. And here is the procedure we will follow:
- EXPLAIN the procedure in general terms: (This will be a bit of a repeat as you did this when you first met patient and asked for permission to work with them). So, as I mentioned a few moments ago when I entered your room, I would show you how to safely get from the bed to your chair (keep language patient-friendly). After I have asked you all those questions, are you still up for it today? (They will smile and say, “absolutely!”)…to which you smile back and say “Great…here’s how we do it”
- Provide a DEMONSTRATION along with your INSTRUCTIONS. We do not want to assume our amazing instructions will ever be sufficient for our patient. If a picture is ‘worth a thousand words’ then our demonstrations are worth millions of words. Take your time…be clear…feel free to repeat your demo from BOTH SIDES…do not rush. Once you feel the patient is understanding, ask them for a TEACH-BACK (they will tell you how to perform the skill). If you are happy with that, then proceed. If not, do NOT proceed. Take your time and re-explain and demo in maybe a different manner. Answer any questions.
- Perform the activity.
Explain, Demo, Instruct
Teach-back, Answer questions, Perform skill
THE SKILLS:
The “SKILL LIST” below is a list of the bed mobility and transfer activities you will need to be competent performing. Please take your time to review each of these PhysioU videos. Hyperlinks are provided, but you will need to have PhysioU open on your browser. The link will take you directly to the given topic.
Under each video on PhysioU, you will see a bullet point list of the primary areas of importance. Please refer to that list before or after viewing the video. You may decide to CREATE YOUR OWN list for each of the transfers. …just an idea😊!
An example from PhysioU:
- Front Wheeled Walker: (FWW)
Therapist Position
- Assist patient to scoot forward as needed
- Stand on right side of patient
- Left hand on gait belt/right hand on shoulder to assist patient to stand as needed
Patient Cues
- Scoot forward in chair
- Strong leg under patient
- Right leg extended out in front of patient
- Front wheeled walker placed in front of patient
- Lean trunk forward
- Both hands push off armrest or surface OR one hand on armrest/surface and one hand on walker
- Center of gravity should be over base of support
- Balance self over legs
- Stand to Sit
Therapist Position
- Assist patient to back up to chair as needed
- Stand to one side of patient
- One hand on gait belt/other hand on shoulder to cue patient, as needed, to sit
Patient Cues
- Cue patient to turn completely and back up so right leg touches chair
- One hand or both hands reach for armrest or surface
- Left leg extended out in front of patient
- Lean trunk forward
- Center of gravity should be over base of support
- Slowly sit down
The videos you will soon be watching are very short and very clear. They will be focused on two areas: Bed mobility and Sit to/from stand. Before we look at the SKILLS LIST, just a quick word on both area.
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.
- Plan ahead to raise bed or squat down
- Before assisting patient with bed mobility, have wide base of support with staggered stance
- Face patient
- Instruct patient to move on the count of 3
- 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).
The “SKILL LIST”:
- PREPARATION: Surface height adjustment; Stance and weight shifting
- Move patient towards you
- Rolling: right and left
- Scooting Up in bed
- Up in bed with draw sheet. Down in bed with draw sheet
- Side to side
- SUPINE TO SIT
- SIT TO SUPINE
TRANSFERS:
Here, we will be looking at transfers done for non-weight bearing (NWB’g) and partial weight bearing (PWB’g) as well as general weakness. In lab we will be looking at weight-bearing as tolerated (WBAT)
Regardless of the weight bearing status, we will be using gait belts.
PLEASE VIEW: Preparation and Set-up: Gait Beltt -link
SKILLS LIST CHECKLIST
BWB’g:
- Axillary Crutches
- R LE non-weightbearing
- L LE non-weightbearing
- Front Wheel Walker
- R LE affected
- L LE affected
- Hemi-Walker
- R LE affected
- L LE affected
- Axillary Crutches
- R LE non-weightbearing
- L LE non-weightbearing
- Front Wheel Walker
- R LE affected
- L LE affected
- Hemi-Walker
- R LE affected
- L LE affected
STAND PIVOT:
NWB’g
- R LE non-weightbearing
- L LE non-weightbearing
Partial WB’g: Transfers: PWB’g Stand Pivot:
- B/L LE weak – both guarded
- B/L LE weak – R leg guarded transfer R
- B/L LE weak – L leg guarded transfer L
- R LE weak – transfer R
- R LE weak – transfer L
- L LE weak – transfer R
- L LE weak – Transfer L
APPLICATION ACTIVITY:
So, let’s return to our patient that we have been primarily working with this semester: Our 85 yof patient who is s/p ORIF d/t a fracture of her right femur. We know that she was transferred to a SNF for rehab before she can return to her cottage.
Thus far, we have been practiced in lab:
- Our introduction and explanation prior to treatment
- Our use of infection control practices before, during and after our treatment.
- Our use of correct body mechanic during our treatment activity.
- Our positioning of this patient’s RLE to minimize any chance of skin breakdown or of having her LE edema increase. We also provided patient education regarding the use of ankle exercises to prevent contractures.
Today we will be transferring this patient out of her bed to her wheelchair. Once safely in the wheelchair, we will teach her some basic wheelchair activities as well as some simple exercises. After she is done with that part of the treatment, we are to transfer her back to bed.
In order to prepare you for this lab activity (as you will be performing on your skills checks and your lab practical), let’s practice sequencing the steps involved in this process.
PLEASE SEQUENCE:
Your 85 yof patient who is s/p right hip ORIF is ready for your bed mobility and bed to wheelchair interventions (education and activities). Her RLE is weak (3/5) and edematous. You have shown her some positioning ideas; now time to teach her how to move safely from supine to sit. What do you need to know about the patient first and WHY?
How will you set-up the environment? What are you looking for?
How will you present the information to the patient?What will you be monitoring and when? Regarding your Body mechanics, what principles would most apply? NOW IT IS TIME TO TRANSFER YOUR PATIENT TO HER WHEELCHAIR.What additional information do you need to know and WHY?
How will you set-up the environment first?
How will you present the information to the patient? (You can use ‘your own’ answers from above to answer this question)
What will you be monitoring?
Regarding your Body mechanics, what principles would most apply?
Now that your patient is in the wheelchair, how do you position them? Be specific / clear with your rationale.
Why every little thing matters in our quest for safe patient experiences…
BASF Break the Chain: Appily Ever After