Bed Mobility, Positioning, and Transfers (Part 1 and 2) Flashcards
what two movements are involved during mobility and transfers?
both therapist and the patient’s body areas
if therapist movement and patient movement are not in sync, what could happen?
injury to therapist or patient
what kinds of things does transferring and mobilizing include?
minimal strain to patient/therapist
creating environment to use patient strength and ability to transfer with therapist help as small as possible
consideration for safety
emphasis on patient education and promoting functional independence
what is the center of mass (COM)?
point along a segment at which the mass of the segment is distributed equally on each side
what happens if the patient is in motion or has additional weight applied to one of the body areas?
the patient’s COM should be reassessed accordingly for safety
if a patient is standing in anatomical position with a right leg cast, which side will the patient COM be altered?
toward right side
if a patient is standing in anatomical position on crutches and has a right leg amputation, which side will the patient COM be altered?
toward left side
what is the definition of force?
mass x acceleration
what is an example of internal force?
muscle force
what is an example of external force?
gravity, additional weight, etc.
when do clinicians apply force?
mobilizing patients in/out bed, wheelchair, etc.
when transferring, what kinds of forces are present?
a combination of linear and angular (circumduction)
what needs to be overcome in order to transfer safe and efficiently?
internal forces and external forces
what MMT grade would a patient have if they are struggling to counteract gravity?
less than 3
the therapist should be aware of the muscle strength in patient’s different body segment in order to determine what two things?
whether they can withstand the pull of gravity or need assistance
whether assistance of one person is enough or if you need a second person to transfer
what is the definition of line of gravity (LOG)?
direction in which the force of gravity acts on body’s COM
what is the line of action?
direction of force exerted from pull/push
when is the force efficiency applied to the line of action the greatest?
when the force is perpendicularly applied
what is the definition of a force couple?
two difference forces that act to move an object around the fulcrum
how can using a force couple improve transfers?
possibility to make the transfer easier such that they require less force by the therapist
if a patient uses incorrect method during sit-to-stand transfer, what can we do to educate them in efficiently using force couples?
if they have LE weakness, they will try to use their arms as a force couple. the therapist do a knee block to stabilize thee patient, the the patient uses their arms to push up = successful sit to stand
what is the base of support (BOS)?
contact area of an object over the surface it is supported on (extremely important for therapist during transfer)
why does BOS matter during transfer?
the wider the BOS, the better the stability one has
if you have a wider BOS during transfer, what does this help ensure?
that the COM remains within BOS to create more efficiency and lesser force required to complete a transfer
what are the benefits to the therapist for maintaining a wider BOS?
less work on muscles of low back
less risk of injury to low back
better ability to maneuver a patient’s body
if you maintain a narrow BOS during transfer, how does your body compensate?
flexing trunk forward = greater chance of injury
if you want your patient to work on stability, what would you want to do to their BOS?
narrow it
when do most patients fall/what causes this?
COM leaves BOS
you have greater mobility when the BOS is _______.
narrower
what position puts the least amount of stress on the clinician’s back during transfer?
pelvic neutral position
what is dynamic trunk stability?
maintaining trunk stability while it is moving through ROM via activation of core muscles of the back
how is dynamic trunk stability best achieved?
pelvic neutral position (lumbo-sacral complex is in neutral)
how can you place yourself in pelvic neutral position?
“activating transversus abdominus immediately prior to mobility task and maintaining contraction throughout mobility” (straight from PPT)
what is controlled mobility?
when LOG moves outside of the BOS, a coordinated action of muscles is required to facilitate this movement without the loss of balance
what are some examples of controlled mobility?
walking, small range body movement in sitting/standing
what is uncontrolled mobility?
if the LOG moves too far beyond the BOS where muscle action cannot control the movement of the body and unable to bring the LOG back within BOS
what is an example of uncontrolled mobility?
falling
what are some principles to keep in mind during transfers?
large BOS for caregiver
patient’s supporting surface (wheelchair) is locked and stable
caregiver is as close as possible to patient so that LOG does not move too far forward (assist in balance maintenance)
securing patient’s body with use of gait belt
when should you perform a knee block?
when the lower extremity is weak and the patient is not able to stand on their own (force coupling is needed)
the knee block creates a “fake extension” moment
in a seated position, what are the anti-gravity muscles of the LE?
quads, glutes, plantarflexors
if anti-gravity muscles are weakened in a seated position, will the patient be able to perform sit to stand?
highly unlikely because they cannot counter the force of gravity
what is an option to use when a patient’s anti-gravity muscles are weak in a seated position?
excessive UE force of patient (traps and lat dorsi, extensors)
when you are blocking the knees, where should you apply the force?
perpendicularly to the anterior surface of knee joint (not lateral or to the sides)
what are some examples of good clinician body mechanics during transfers?
maintaining erect posture
head up
wide/diagonal BOS
use large muscle groups
work within your ability
give good verbal command
what all should you test during upper extremity exam?
shoulder elevation
shoulder flexion/extension (if you can)
shoulder abduction/adduction
wrist flexion/extension
finger dexterity/grip strength
what are the goals of positioning a patient?
comfort
prevent skin breakdown
prevent deformity
prevent pressure of peripheral nerves
maintain cardiovascular/pulmonary integrity
provide access to environment
used for specific interventions
in terms of positioning - what is the biggest thing we are trying to prevent in patients that have been bed-ridden for long periods of time?
skin breakdown
what kind of deformities are we trying to prevent with patient positioning?
relaxed foot position is plantar flexed and IR - if here for long periods of time, this can cause toe walking once mobile again
what position is best for patients with limited cardiopulm function?
prone (gives increased chest expansion and promotes diaphragm function)
what are the benefits of bridging?
relieves pressure with pillow or roll above/below area of concern
allows skin to breathe
decreases humidity to reduce breakdown
why would you not want to place a pillow under a patient’s knee replacement?
promotes knee contractures
what are risk areas for pressure ulcers in supine?
occiput of skull
scapula (especially inferior angles)
medial epicondyles of humerus
ischial tuberosity/sacrum
heels (maybe lateral malleolus if ER)
what are risk areas for pressure ulcers in prone?
ear/side of face
chin
anterior surface of shoulders
iliac crests/ASIS
knees/patella
dorsal surface of feet
when would you want to place a patient in a prone position?
major skin breakdown on posterior
COVID/ventilated patients
what are risk areas for pressure ulcers in side lying?
ear/side of face
lateral shoulder/humeral head
hip/greater trochanter
lateral AND medial femoral condyles
lateral AND medial malleolus
what is proper pillow positioning for a patient in supine?
pillow under head
pillow under arm (if having limited UE function)
pillow proximal to knee going to ankle joint, allowing heels to dangle
what is proper pillow positioning for a patient in prone?
pillow underneath head
pillow under stomach (maybe chest if needed)
pillow/wedge under the legs to keep off of floor
shoulders in abduction
what is proper pillow positioning for a patient in side lying?
pillow under head
pillow between knees
one arm hugging a pillow (top arm) or laying to side on hip
bottom arm hugging around head pillow
what is the position called when you are a quarter-turn from prone?
semiprone
what is the position called when you are a quarter-turn from supine?
semisupine
what is long-sitting, fowler?
place patient in a seated position on bed with full LE support
place board/surface underneath feet to promote dorsiflexion (could be used in patients with prolonged bed rest to promote gastroc function)
what is semi-fowler?
trunk is place at approximately 60 degrees in seated position and board is placed on bottom of feet to promote dorsiflexion
what are some reminders/guideline for patient positioning?
patient comfort (only give pillows if we know patient cannot move these extremities on their own - if they have function, we want them to try and move extremities as much as possible)
orthopedic precautions (keep in mind)
whenever possible, ACTIVE PATIENT PARTICIPATION
skin check
lift/roll, no dragging
segment movement-bridging
what guidelines/precautions to take with a dependent patient?
protect skin integrity
must change position at least every 2 hours (more frequent in certain patients)
poor circulation, fragile skin, inability to move
what are some guidelines to follow to ensure good body mechanics during transfers?
clear the clutter in the area
mentally plan and execute the transfer before the actual transfer
factor in patient’s muscle strength and body weight into proposed task
wide BOS
avoid excessive forward movement of spine/maintain neutral spine
maintain partial flexion of hip/knee - COM is lower, gives stability
stay close to patient
activate core muscles
avoid trunk rotation
use staff as needed
what scoring used to be used before GG Codes?
FIM score (functional independence measure)
ranged 1-7 with 7 being best status
was used for determining functional status of patient and change in status with treatment
what defines a GG code of 1:Dependent?
“dependent assist”
patient needs almost total help
ANYTIME two people are needed
ex: one therapist, one person rolling O2 tank
what defines a GG code of 2:max assist?
“maximum/substantial assist”
collectively, therapist is helping with more than 50% of the work
ex: helps with both getting up and sitting down
what defines a GG code of 3:Limited Assist?
“partial or moderate assist”
patient can do more than 50% of the work, therapist helps with the rest
ex: help with getting up, can sit down on their own
what defines a GG code of 4:Supervision?
“supervision/touch assist”
therapist has to be there just in case, do not feel comfortable leaving patient on their own
may not have to touch patient but you give verbal cueing, may have to give hand as a guide (simple touch)
what defines a GG code of 5:Set-up Assist?
“complete independently but helper needed to set-up environment”
patient is able to perform the task on their own but they need someone’s assistance to set up environment
NO VERBAL CUEING to perform correct sequence
what defines a GG code of 6:Independent?
“complete independent with activity, may use assistive device”
patient is able to stand themselves and sit themselves
may/may not use a transfer board/walker without verbal cueing or someone assisting them
what are the four transitions/activities of bed mobility?
supine to/from sit
rolling
scooting in supine
scooting in sitting
what should you do to prepare for bed mobility?
review patient’s chart
evaluate/reevaluate patient’s mental status, AROM/PROM, strength, assistance level, check vital signs before and after
always explain to the patient what you are trying to do and what is expected of them
ensure the patient is aware of treatment goals
what are some aspects about the environment to keep in mind while preparing for bed mobility?
optimal lighting
patient privacy (modesty)
distractions to patients
soft bed - can be hard to maneuver
your positioning - you should be facing patient
teaching about “1,2,3” count to stay in sync
slow, segmental movement whenever possible
what are some aspects about the equipment to keep in mind when preparing for bed mobility?
adjust bed height to ensure proper body mechanics (therapist ASIC level)
lowering bed rails
raising the head of the bed vs. keeping it low
check wheel locks
what are some precautions to keep in mind while preparing for bed mobility?
lines and tubes must be pre-arranged TOWARD the direction of movement and slackened
uncover the patient as necessary to ensure all lines/tubes are accounted for
roll patient toward you
don’t attempt to stop midway in rising from supine to sit unless specific reason required
avoid shearing forces
establish patient upright stability and medical stability before leaving patient
teach them!
what are the two central point of moving the patient on the bed?
pelvis and shoulders
what are the specifications of placing a patient in “hook lying” position?
hip are flexed at ~50 degrees, knees at ~90 degrees, place heels slightly together
what are some advantageous uses of the hook lying position in bed mobility?
used for pressure relief of lower extremity areas
certain activities such as bridging or rolling to side are initiated here
advantageous position for rolling, LE is shortened (level weight arm shorter)
efficient use of glutes and quads - good position to facilitate contraction
raised LE move towards gravity when rolling so it is easier
what is the description of “bridging”?
lifting buttocks and lower spine off of bed such that hips moves in “neutral” flex/extend
may use arm to push into bed to assist the movement
what are the two purposes of bridging?
pressure relief
scooting in supine
what is the progression of independent supine to side lying performed by patient?
head turned, shoulder abducted
opposite LE flexed at hip/knee, place opposite UE across chest
push from opposite LE, keeping same side shoulder abducted
complete
what are some things to consider when performing dependent supine to side lying?
move segmentally
roll patient toward you by placing hands on posterior pelvic/shoulder girdles
pay attention to the head and neck
watch for arm and lines/tubes
what are some characteristics of supine to long sitting with the trapeze bar?
allows the patient to actively participate
requires adequate UE strength/ROM
use bodyweight for support
how do you perform a dependent supine to sitting transfer?
flex hips/knees and bring feet off EOB
scoop behind knees and posterior shoulders to bring patient to sitting in a simultaneous motion and utilizing counter pressure
which side of the patient do you want to be moving toward when performing bed mobility/transfers?
stronger side
what does SPHM stand for?
Safe Patient Handling and Movement
what does SPHM apply to?
the principles and techniques of minimal lift policies
promotes the use of powered lift equipment and assistive devices
discourages use of manual techniques when a patient requires a maximal lift, or moderate to maximal assistance to perform a transfer
what are the components of SPHM program?
facilities will each have their own policy for “no-lift” policies
lift teams
algorithms for lifting decision making
implementation of mechanical methods of moving patients
patient is graded “dependent” or “total assistance” whenever mechanical lifts are used
what is a “SARA”?
standing and raising aids (pic on slide 5/6 of part 2)
what does TMPH stand for?
traditional manual patient handling
what does TMPH apply to?
the principles and techniques of proper body mechanics and the use of safety belts
includes aspect of teaching proper techniques to help patients transfer themselves
what kinds of things are NOT included in TMPH?
powered equipment (used when patients require maximal lift, or moderate to maximal assistance to perform a transfer)
in TMPH, how is a patient graded with GG codes?
based on the amount of patient participation
what is the definition of a transfer?
movement of person from one surface to another, implying patient participation
what is the purpose of a transfer?
to permit patients to function in different environments or utilize different types of facility equipment
allows integumentary system a chance to replenish and flush surface areas
what is the goal with transfers?
generalizability, help patient reach independence
skills learned from one transfer can be utilized in another transfer (surfaces/equipment/etc)
what should you ALWAYS do before transferring a patient (after asking consent)?
muscle strength testing and ROM
what does repetitive stress typically cause?
job-related injuries
what are some ways to prepare the environment for a transfer?
wash your hands
keep sufficient space in treatment area
routinely evaluate equipment
position equipment for stability, safety, accessibility before patient arrives
wheelchair/chair should be about 45 degrees to bed/mat
use safety belt/draw sheet
ask for help - even from patient
draping for modesty
lines and tubes are accounted for
when is the assistance level of a patient determined?
during the transfer
what are some components to patient communication during a transfer?
be brief, concise (demonstrate first)
simple commands
be sure everyone is clear on when to move (1,2,3)
expectations of everyone should be clear
when should you complete the transfer if you have already committed to it?
if you are more than 50% complete through the transfer
when should you NOT complete the transfer if you have committed to it?
if you have barely moved them and they are in a bad position/patient is dizzy/etc.
what are some situations that may be challenging to transfer a patient?
long leg casts
open reduction/internal fixation (ORIF)/fractures
total hip arthroplasty (THA)
concurrent injuries to UE as well as LE
hemiparesis
UE fractures
when surface heights > 3 inches in difference
what are the post-surgery protocols for a total hip arthroplasty posterior approach?
no adduction past 0 degrees/midline
no IR
no hip flexion > 90 degrees
what are the two possible methods of transferring between two surfaces
seated
pivoting
what are some components of seated transfers?
can be either lateral or in A/P direction
no weight bearing is involved for lower extremities
patient ALWAYS remains seated, so COM is lower
seated transfers are completed when transferring to what kinds of surfaces?
bed
mat
chair/wheelchair
car sear
toilet seat
bath bench
what is a key component of lateral seated transfers?
patient does not have to bear weight on the LE
what kinds of scenarios would a lateral seated transfer be useful?
bilateral LE amputee
hemiplegic
generalized LE weakness with very strong UE
what should be true of the two surfaces when using lateral seated transfers?
the “transferring to” surface should be somewhat lower than the “transferring from” surface”
if you are completing a lateral seated transfer and one of the surfaces in a wheelchair, what should it have?
removable arm rests
when should the transfer board be placed on the patient?
underneath ischial tuberosity
what is the difference in the independent and assisted transfer board usage?
assisted requires the therapist to be standing in front of the patient ready to perform a knee block, may hold onto transfer belt while moving for added assistance
what are some precautions to consider when using a transfer board?
ensure patient has clothing that discourages friction forces between transfer board and patient’s buttocks
powder can be applied on transfer board to reduce friction if needed
make sure patient is not holding through the hole in transfer board
what two aspects of the patient are important during an anterior-posterior seated transfers?
excellent UE strength and adequate extensibility of the hamstrings
what are some components to pivot transfers?
patient must be able to bear weight through LE
movement occurs through patient’s feet
hip/trunk move toward target surface
what occurs during a standing pivot?
patient stands erect, turns, and sits
what occurs during a squat pivot?
patient in partially erect posture, turns, sits
how do you prepare the environment for a pivot transfer?
wheelchair/bed locked
wheelchair 45 degree angle from bed
no clutter between the surfaces
leg rests moved away
arm rests can stay during a stand pivot, but removed during squat pivot on side closest to bed
what are some key ways to prepare the patient (positioning) before performing a pivot transfer?
move patient forward in chair/bed
feet turned away from “transfer to” surface, flat on floor
foot near target surface slightly forward (if one foot has WB restriction, that should be away from target surface)
trunk flexed
arm/hands on arms of therapist, move to arm rests during stand pivot
how should the therapist prepare themselves during pivot transfers?
use transfer belt
mimic position of patient, wide BOS, hands over transfer belt
knee blocking if necessary
if patient does not release the arm rests or if they do not bring COM forward/leaning too far back during pivot transfer, what should you do?
stop transfer and lower patient back to surface
what modification should you make in transfer if the patient is NWB in one leg?
pivot transfer can be done on one foot while holding leg in air
what modification should you make in transfer if the patient is hemiplegic?
can perform pivot transfer with knee block on affected side, stand pivot is other leg is strong
what modification should you make in transfer if the patient has a THA?
pivot transfer can be completed on one foot, then help lower leg to ground, place pillow underneath bottom on wheelchair
