Learning Objectives
By the end of this section, you will be able to:
- Recognize safety techniques when transferring, lifting, and ambulating patients
- Identify proper usage for various assistive devices
- Develop key aspects for patient education related to transfers
The nurse’s assessment of the patient’s mobility, strength, balance, and ADL status is critical to assisting the patient with transfer needs. The most common patient transfers completed by nurses are from a bed to a stretcher, from a bed to a wheelchair, and from a wheelchair to a bed (Bergman & De Jesus, 2022). Patient transfers that are poorly managed are associated with higher fall rates, morbidity, and mortality (Bergman & De Jesus, 2022).
While there are many methods to transfer patients, the methods used must be safe for the patient and the nurse. One of the most common injuries reported by the worldwide healthcare workforce is musculoskeletal injuries. Nurses make up 37 percent of those injuries, and healthcare assistants make up 46 percent of those injuries (Albanese et al., 2022). Often these are the result of improper lifting, inadequate assistance or equipment, and lack of preparation for the transfer. The following section will discuss safe techniques to move patients including the use of transfer equipment.
Safety with Transferring, Lifting, and Ambulating Patients
Transferring a patient is moving a patient from one place to another. For example, patients may be moved from bed to chair, bed to stretcher, or stretcher to wheelchair. Safety is a top priority when transferring patients. This can be achieved using best practice standards and tailoring techniques based on the patient’s unique needs. There are several factors to consider including:
- Is the patient physically able to transfer?
- Does the nurse have the proper equipment and have they been trained to use it?
- Has the nurse clearly communicated the steps with the patient?
Link to Learning
The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) developed Safe Patient Handling Programs to reduce musculoskeletal injuries in healthcare workers during patient transfer.
Falls can have serious consequences, especially for older adults, leading to declines in quality of life and functional performance. The Centers for Medicare and Medicaid Services focus on preventable falls. Hospitals that have a high number of preventable falls are financially penalized or receive incomplete reimbursement from the patient’s insurance. Modifiable risk factors are scrutinized to determine if the fall could have been prevented with the use of assisted devices, changes in medications, or standardized safety measures. When assessing a patient using a standardized tool, modifiable risk factors for falls should be documented with interventions in place, especially before attempting to transfer a patient (Kiyoshi-Teo et al., 2019).
Patient Conversations
How to Answer Patient Questions about Assistive Devices
Scenario: Carlton is visiting his brother, Sam, at the hospital and observes the different equipment available for Sam and his roommate, Perry. Sam is in the hospital for a cellulitis infection in his right lower extremity and Perry, a total care patient who has dimentia, was diagnosed with a urinary tract infection but is nearly recovered. Natasha is the registered nurse who is caring for both patients.
Patient’s brother: Excuse me, Natasha. I don’t mean to bother you, but I was wondering if you could answer some of my questions.
Nurse: Sure, Carlton, ask away.
Patient’s brother: My brother will be discharged soon but he still has a lot of weakness in his right leg. How will he manage at home?
Nurse: Physical therapy has been working with him and has given Sam crutches to take home. He’s practiced using them and is partial weight-bearing, meaning he can put some weight on his right leg to help keep himself supported and stabilized.
Patient’s brother: That’s great. I didn’t realize that physical therapy was involved. Can I ask you another question?
Nurse: Of course!
Patient’s brother: I see that Perry cannot get out of bed and needs to use that big contraption where he hangs. How does that work?
Nurse: Yes, that is the Hoyer lift. A pad that is specialized for the Hoyer lift is placed underneath Perry. The nurses and patient care assistants can get the pad underneath him by rolling Perry from side to side. Once the pad is underneath Perry, there are designated hooks and loops that will securely hold him when he is lifted up. The Hoyer can fit under the bed so it’s easy to move the patient from the bed to the wheelchair. It’s safe for Perry and helps us transfer him without compromising our backs.
Patient’s brother: That’s so interesting. It’s great to have equipment in place to keep you and Perry safe.
Weight-Bearing Transfer
A person is weight-bearing if they can put force or body weight on a specific limb. There are several types of weight-bearing grades (Table 9.5). If a patient can bear weight, nurses should encourage their help with transfers. The nurse should stand by for safety.
| Weight-Bearing Grade | Description |
|---|---|
| Full weight-bearing | The leg can tolerate the entire body weight, and can ambulate. |
| Weight-bearing as tolerated | Dependent on the circumstance, the patient can support 50 percent to 100 percent of entire body weight on the leg. |
| Partial weight-bearing | A small amount of weight can be tolerated on the leg. The patient needs an assistive device to ambulate, such as a cane or crutches. |
| Touch-down weight-bearing | The patient can use their toes of the affected leg to touch the ground for balance, but cannot support any weight on the leg. |
| Non-weight-bearing | The leg cannot touch the floor or support any body weight. |
For patients who can partially bear weight, nurses should use the stand-and-pivot technique, preferably using a gait or transfer belt or standing lift assist. A stand and pivot is a technique for patients, who can partially weight-bear, by moving from sitting to standing and then just turning with one leg to sitting again (Figure 9.15). A gait belt is a strap that is a few inches wide made of nylon, canvas, or leather. It is placed around a patient’s waist to help nurses assist with transfers. In addition, the patient should transfer toward their stronger side if they have partial weight-bearing capabilities.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Transferring a Patient from the Bed to a Chair
See the competency checklist for Transferring a Patient from the Bed to a Chair. You can find the checklists on the Student resources tab of your book page on openstax.org.
Non-Weight-Bearing Transfer
A non-weight-bearing injury is when the affected limb or limbs cannot support any weight. In injury or recovery, patients may have practitioner orders to maintain non-weight-bearing status with a certain limb to aid in healing. Premature weight-bearing can delay recovery and lead to complications. Transfer devices, such as a full body sling lift or slide board, should be utilized as appropriate.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Transferring a Patient from the Bed to a Stretcher
See the competency checklist for Transferring a Patient from the Bed to a Stretcher. You can find the checklists on the Student resources tab of your book page on openstax.org.
Sling Transfer
A sling transfer is a patient transfer from a bed, wheelchair, toilet, or shower using a lift machine and flat piece of material placed under the patient (Figure 9.16). The use of the sling carries the full weight of the patient, reducing the risk of injury for the patient and caregiver. The slings are fitted to the patient to provide neck, head, and shoulder support.
When transferring with a sling, the equipment used to transfer should be appropriate for the sling and applied correctly. Equipment should never be substituted if the correct item is not available. Most facilities and lift manufacturers require two caregivers to safely operate a patient lift. If the lift has wheels, make sure they are locked. Slide the sling under the patient by either having them roll side to side or lean forward. The patient’s arms should be as close to the sides of their body to help keep the weight centralized. During transfer it is important for the nurse to continuously communicate with the patient as they may be fearful or anxious about falling. Each transfer should be carefully planned, as all have varied requirements.
Link to Learning
This video provides step-by step instruction on how to safely operate a Hoyer lift to transfer a patient. A Hoyer lift is a type of sling transfer.
Sliding Board
A sliding board is a piece of equipment that is flat and rigid, used for patients who cannot complete a transfer between two surfaces or if a standing transfer is not safe (Figure 9.17). The board makes a “bridge” between the bed and the other surface, such as a stretcher, and the patient can slide between the two. The nurse should always use a gait/transfer belt for safety and instruct the patient to move slowly and deliberately across the board if they are assisting with the transfer. Skin precautions are essential to prevent sheering and friction.
Various Assistive Devices
Assistive devices can give patients mobility and the ability to transfer from one location to another. Allowing patients to participate in active transfers, if they are able, can help promote functional independence. At home, patients may find ADLs challenging; therefore, the use of assistive devices is vital, especially for older adults, to maintain mobility, remain safe, and enable communication with others. Assistive devices can include self-care devices to accomplish daily tasks, mobility devices that help with moving around and walking, and safety assistive technology that can help with lack of balance, weakened limb function, decreased eyesight, and other sensory issues.
Gait Belt
A gait belt can also be used as a device to assist an unsteady patient with ambulation. The nurse holds the gait belt to steady themselves and the patient as they move around together. Gait belts have been found to reduce the incidence of patient falls as well as physical stress on the nurse (Figure 9.18).
When utilizing a gait belt as an assistive device:
- Ensure the patient is wearing nonslip footwear.
- Place the gait belt snugly over a layer of clothing.
- Ensure two fingers fit between the belt and the patient, ensuring it is not too tight.
- Face the patient with the back straight, knees bent, in a wide stance while preparing to lift the patient from sitting to standing.
- Grab the gait belt on both sides of the patient and straighten your body as the patient rises.
- Stand behind and to the side of the patient when ambulating, and use an underhand grip to grasp the loop on the back of the gait belt.
- Maintain open communication with the patient throughout the procedure, and encourage the patient to promptly report any discomfort or fatigue.
Contraindications in using a gait belt include patients who have abdominal aneurysms, G tubes, hernias, or severe cardiac or respiratory conditions and patients who have had recent chest, back, or abdominal surgery.
Crutches
Devices called crutches are an aid used for standing, walking, and mobility for patients who cannot support the weight of their bodies with their leg, knee, or ankle. The patient’s weight-bearing status will determine how much pressure can be put on the affected limb. There are three types of crutches: axilla, elbow, and gutter.
An axillary (underarm) crutch should be two fingers distant between the axilla and axilla pad of the crutch. The patient’s weight should be focused where their hands grip the crutch and not under their armpits. This is to prevent axillary nerve damage.
Link to Learning
This video provides instruction on how to properly use axillary crutches and includes different gait techniques.
Forearm (lofstrand, elbow, or Canadian) crutches have a forearm cuff and handgrip. These are often used long term in patients with lower extremity disabilities.
Link to Learning
This forearm crutches demonstration gives proper instruction on how to these crutches.
Gutter crutches are modified forearm crutches and a modified hand grip for patients who may not have mobility and strength in their hands. This type of crutch can be recommended for patients with rheumatoid arthritis. Crutches should be tailored to the patient and fit according to their height.
Link to Learning
This gutter crutches demonstration shows patients ambulating using these crutches.
Nurses can teach patients how to walk with crutches by having them clasp the hand grips, move both crutches forward at the same, swing their “good” limb through, and land with a shorter stride.
Knee walkers (knee scooters or mobility scooters) are used as well to help with lower limb mobility. This wheeled crutch alternative allows the injured foot and/or leg to be elevated on a padded platform. The patient can balance naturally on two legs and can move by pushing with the good leg and steering with the handlebar.
Walker
A walker is an aide that has four points of contact with the ground. Walkers provide a greater base of support, assisting in stability for balance and mobility. There are many types of walkers including standard, two-wheeled, upright, and four-wheeled walkers. Standard four-point walkers (four-point or Zimmer frame) are used with the patient taking one step forward and then the patient moving into the walker (Figure 9.19). Two-wheeled walkers are used the same way except the walker can slide forward instead of the patient needing to pick it up because there are two rear wheels (Figure 9.20a). Four-wheeled walkers have handles to control brakes and may also have a seat, tray, or basket (Figure 9.20b). The patient must remember to lock the brakes when stationary to avoid the risk of a fall. The gutter frame walkers are wheeled and adapted to patients who need more support. Forearm supports fix the elbows at 90 degrees.
Cane
A cane is a singular assistive device that assists in balance when walking or helps compensate for an injury or disability. A cane can either have a single tip or four points that touch the ground, called a quad cane. The quad cane provides a broader base of support. The grip on canes can vary by size and material. Some may be made of foam or plastic, and sizes may vary for arthritic hands. The patient’s elbow bend and wrist height should be taken into consideration when fitting a cane for a patient (Figure 9.21). The elbow should bend at a comfortable angle, approximately 15 degrees, and the top of the cane should line up with the crease on the patient’s wrist. Patients should hold the cane in the opposite hand of the weak or painful limb. The cane should move with the affected leg.
Cultural Context
Culture and Assistive Devices Awareness
Racial and ethnic disparities exist in health care, which include the use of assistive devices among older adults. Assistive devices are meant to extend independence in aging; however, the rate of use of assistive devices among older adults living in Hispanic communities is lower than other populations (Orellano-Colon et al., 2016).
Barriers reported by Hispanic community-living older adults include the following:
Human Barriers
- lack of knowledge about assistive devices including availability, acquisition, or the use of devices for ADL assistance
- safety concerns with many participants fearing that the equipment will break or they may fall
- dislike for assistive devices and a lack of perceived usefulness
- concern of losing functional capacities if assistive devices are used
Assistive Device Barriers
- complexity in the use of assisted devices
- the equipment failed or is unattractive in appearance
Context Barriers
- financial limitations
- lack of access to the physical environment including not having enough space
- institutional systems barriers that prevent access to equipment and services
- social stigma with use of assistive device
There are multifactorial reasons why the use of assistive devices among older people in the Hispanic community is lower than other populations. Social determinants of health, language, and understanding, as well as education, are factors that need to be considered when working with patients of varied cultures.
Unfolding Case Study
Unfolding Case Study #2: Part 5
Refer back to Unfolding Case Study #2: Part 4 to review the patient data.
| Nursing Notes | 1430: Patient educated about importance of maintaining mobility to improve functional status. Patient expressed understanding of teaching and willingness to work with physical therapy to improve strength. Patient reminded to use call light before getting up and fall risk precautions in place. |
| Provider's Orders | Physical therapy consult Orthostatic vital signs daily |
Patient Education Related to Transfers
In transfers and assistance with mobility, patient education is important to maintain safety and ensure a successful process. Be sure to include education about
- the importance of remaining engaged to maintain safety;
- maneuvers during transfer, such as pivoting, and ensure the patient understands directions before proceeding;
- any equipment or assistive devices being used, including safety measures;
- signs and symptoms of any distress during the procedure to report to the nurse; and
- if unable to transfer independently, provide education on calling for assistance and use of call light.
The nurse should always ask permission and inform the patient of all the steps of the transfer or equipment use. Explain all steps in simple and clear terms, gather all the necessary equipment for the transfer, and cue the patient to perform as much as possible. Ensure that the patient has proper alignment of the spine and limbs and is wearing the proper clothing (e.g., nonslip footwear, a nonrestrictive hospital gown). Before transfer, the nurse should institute skin precautions, request additional personnel assistance, if needed, use proper body mechanics, and lock and stabilize equipment.