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MUSCULOSKELETAL SYSTEM
ASSISTIVE DEVICES
• An assistive device is an object or piece of equipment
designed to help a patient with activities of daily
living, such as a walker, cane, gait belt, or
mechanical lift.
• Assistive devices are required if a person is unable to
safely move from one location to another, these also
allow the healthcare worker to transfer and move
patients in a way that reduces risk for injury to
themselves and patients.
• Transfers are commonly done to help assess mobility
or to progress mobility in an inpatient or community
setting.
USE OF TRANSFER DEVICES
HOIST LIFT
Hoist Lift or Patient Lift is an assistive device that is used
to transfer persons with mobility impairments that does
not allow them to stand or assist with moving, it is used to
move patients who cannot bear weight between a bed
and a wheelchair or other similar places.
TYPES OF HOIST LIFT
→ Mobile Lift, Stationary Lift, Ceiling Hoist, Sit To Stand
Lift
TYPES OF SLINGS
→ Universal Sling, Toilet Sling, Comfort Sling, Bariatric
Sling
OBJECTIVES
• Assist in the safe transfer of patients with mobility
issues.
• Provides better quality of care including activities
such as bathing, toileting, and repositioning, without
the need for excessive physical effort or manual
lifting.
• Minimizing the risk of musculoskeletal injuries by
reducing the physical strain associated with
manually lifting or transferring patients.
ASSESSMENT
• Assess patients weight and height, medical
conditions, behavior and compliance, and medical
attachments.
• Identify the task — for example transfer from floor to
bed, bed to toilet
• Consider the type of hoist, mobile versus gantry or
ceiling system.
• Consider sling choice according to level of the
person's function and disability
INDICATIONS
• Limited mobility
• Orthopedic or neuromuscular impairments such as
Multiple Sclerosis, stroke, or Spinal cord injury.
CONTRAINDICATION
• Contraindicated for those who have been assessed
by a qualified healthcare professional and deemed
incapable of safe use of the Patient Lift for transfers.
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EQUIPMENT
o Hoist lift frame - this frame helps in transferring
patients while providing support when moving
patients.
o Sling - provides assistance to elevate patients when
changing position.
NURSING CONSIDERATIONS
(PRIORITY: Skin integrity; risk for skin tears/sores)
• Work as close to the patient as possible to avoid
stress of leaning and potential back injury to the
healthcare provider.
• Do not push, pull, or lift weight while:
- off-balance or leaning forward
- twisting and/or reaching
- entrapped in a confined space
• Determine number of caregivers needed: Most lifts
require two or more caregivers to safely operate the
lift and handle the patient.
PATIENT SAFETY
• Maintain patient safety.
• Patient lift should be avoided if the patient is agitated,
resistant or combative.
• Do not leave the patient in the hoist any longer than
necessary.
• Never hoist the patient alone.
• Do not use hoist for transporting patients, they are
only for transferring. (e.g. bed to chair, toilet to
wheelchair, or positioning)
EVALUATION
• Patient was transferred with no incident and injury
involved in the environment and among staff.
• Educated patient regarding hoist lift intervention.
Patient eager to cooperate and verbalized
understanding.
• Patient assisted on transfer without difficulty.
• Patient post-transfer effects monitored with no signs
of skin irritation and lesions.
SLIDING SHEET
A sliding sheet is a patient handling aid, used in hospitals,
clinics and care homes. When used correctly, the slide
sheet is designed to prevent back injuries for the nurses
and caregivers
OBJECTIVES
• Minimize risk of injury to the patient.
• Minimize risk of injury to the staff.
• Wide accessibility and versatility.
ASSESSMENT
• Assess the patient for sliding up the bed; check their
mobility care plan and consult a doctor
• Determine how many staff will be required for the
task and ascertain the equipment that will be needed
• Assess the patient’s ability to participate in the
procedure.
• Assess if there is any problem in the patient’s body
that might further complicate during the use of slide
sheet
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• Perform a visual check of the slide sheet before
single use
• Look for any physical hazards on the floor or
surroundings that can trip you over
• Ensure that the patient feels safe and comfortable
INDICATIONS
• Moving a patient up and down the bed
• Turning a patient in bed
• Swivel a patient around while sitting
EQUIPMENT
→ BASE SHEET: base sheet has a non-slip surface on
the underneath the base sheet, which helps to keep
it centered on the mattress.
→ DRAW SHEET: Draw sheets were made to be used on
top of a base sheet.
TYPES OF DRAW SHEETS
2 DIRECTION
→ ideal for people who only require a little bit of
assistance while they're moving around in bed.
→ this type of sheet allows an individual to move from
side to side while they're in bed, but they won't be
able to slide down in the bed or move up and down.
4 DIRECTION
→ allows the patient to sit on top of the base sheet,
which allows the immobile individual to move.
→ from the perspective of the care provider, using a 4
direction sheet makes it easier to position the person
lying down, as well as turn them over and move
them around on the bed.
MID-LENGTH
→ This type of draw sheet is when the individual laying
down is looking for low friction underneath your
hips, shoulders, and head
FULL-LENGTH
→ This type of draw sheet is ideal when the individual
that's laying down is looking for reduced friction
across the entire body.
NURSING CONSIDERATION
o Assess the patient's overall condition and any
potential risks before using a slide sheet.
o As much as possible, two healthcare providers are
needed to use a slide sheet; one standing on either
side of the bed.
o Check that the slide sheet is in good condition and is
not thin, worn or dirty.
o Consider any environmental factors that may impact
safety, such as the stability of the bed or surface.
o Ensure that the slide sheet is positioned correctly
and that there is adequate support for the patient
during the movement.
o Ensure tubes and attachments are properly placed
prior to the procedure to prevent accidental removal.
o Never leave slide sheets under a person
unsupervised as this could create a risk of a fall.
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o Continuously monitor the patient's comfort level and
well-being during and after the use of slide sheets.
EVALUATION
1. The patient should feel more comfortable during the
repositioning process due to reduced friction and
smooth movement.
2. The risk of skin damage, pressure ulcers, or shear
injuries is reduced as the slide sheet minimizes
friction between the patient's skin and the
supporting surface.
3. Healthcare providers will experience less physical
strain and exertion during patient repositioning.
4. Patients may experience improved mobility as
healthcare providers can more easily assist with
turning, transferring, or repositioning.
USE OF AMBULATORY ASSISTIVE DEVICES (AAD)
CANES
Canes are assistive devices used to help a patient
ambulate.
OBJECTIVES
• Provide balance and support in standing and walking.
• Take some pressure off one leg.
• Improve sensory feedback for safety and security
when walking.
ASSESSMENT
• Assess the patient's upper body strength, ability to
bear weight and to walk, and the need for assistance.
• Review the patient's record for conditions that may
affect ambulation.
• Perform a pain assessment before the time for the
activity.
• If the patient reports pain, administer the prescribed
medication in sufficient time to allow for the full
effect of the analgesic.
• Take vital signs and assess the patient for dizziness
or lightheadedness with position changes.
• Assess the patient's knowledge regarding the use of
a cane.
• Before a patient uses a cane for the first time, the
cane must be adjusted to the patient's height:
a) The top of the cane should be even with the
greater trochanter OR when the patient holds
the arms at their side, the top of the cane should
be even with the wrist crease closest to the
hand.
b) While gripping the cane, the elbow should be
flexed at a 15- 30 degree angle.
INDICATION
Patients with:
1) Minor problems with balance or stability,
2) Injury or disease resulting in decreased ability to
bear weight through one of their lower extremities,
and;
3) Weakness or instability in any part of their leg (hip,
knee, or ankle).
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EQUIPMENT
→ Cane (appropriate type)
→ Gait belt (if needed)
TYPES OF CANE
→ “C” Cane, Functional Grip Cane, Offset Handle,
Quad Cane, Hemi-walker, Folding Walking Cane
NURSING CONSIDERATIONS
o Complete risk assessment for safer patient
handling.
o Complete Quick Priority Assessment (QPA)
including safety.
o Ensure that the cane is the appropriate height for the
individual.
o Teach the person how to use the cane correctly,
emphasizing proper weight distribution and balance
while walking.
o Encourage the individual to wear appropriate
footwear with good traction.
o Encourage the use of padded handgrips or gloves to
enhance comfort and reduce the risk of friction-
related injuries.
o Inspect rubber ends after being outside and remove
any gravel.
o Ensure tubes and attachments are properly placed
prior to the procedure to prevent accidental
removal.
o Emphasize the importance of maintaining proper
hygiene and keeping the cane clean.
EVALUATION
The patient:
• is able to ambulate safely and is free from falls or
injury;
• demonstrates proper use of the cane;
• exhibits muscle strength, joint mobility, and
independence; and
• experiences no injury related to cane use.
WALKER
Walker are used for clients have weakness in their lower
extremities and need more support.
OBJECTIVES
• Provide stability and support
• To help stabilize patients with poor balance and
mobility or lower extremity impairment.
• Reduce the risk of falls
• To improve ability to walk
• To improve muscle and strength in client’s legs
ASSESSMENT
• Assess the client’s overall mobility and for a walker.
• Assess the length of time in bed and the amount and
type of activity the client was able to tolerate.
• Evaluates the client’s ability to understand and
follow instructions for using the walker.
• Determine the appropriate height adjustment for the
walker based on the client’s height and comfort.
INDICATION
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• Weakness or instability in lower extremities
• Impaired balance
• Elderly individuals at risk of falls
• Post- surgery or injury recovery
• Chronic conditions affecting mobility
CONTRAINDICATION
• Inadequate upper body strength
• Severe cognitive impairment
• Certain medical conditions that may require further
evaluation
• No medical recommendation to stand up for the
patient
EQUIPMENT
→ Walker, Rubber Tips or Glide Tips for stability,
Nonskid Shoes, Gait Belt
TYPES OF WALKER
TWO-WHEELED WALKER
→ This is used for providing mobility assistance and
stability for client with mild to moderate balance or
mobilized issues.
STANDARD WALKER
→ Used for providing stability and support for clients
with balance issues or weakness in lower extremity,
aiding in mobility and fall prevention
FOUR-WHEELED WALKER (ROLLATOR)
→ Used for client with mobility issues.
→ It provides support, stability and the option to sit if
needed.
NURSING CONSIDERATIONS
o Choose the appropriate type of walker based on the
patient's needs.
o Ensure proper height adjustment to match the user's
height and promote an upright posture. (It should be
at the hip level of the patient using it. Patient’s arm
should rest on the handgrip and should exhibit 20 to
30 degrees of flexion at the elbows. The patient
should wear sturdy and well-lifting shoes.)
o Evaluate the condition of the walker regularly to
address any maintenance or safety concerns.
(Check the rubber tips on all assistive devices
frequently. They can become worn quickly. Worn
rubber tips can lead to instability and falls.)
Tips: When teaching a client to stand up prior to using a
walker, have him use the armrest on the chair, not the
walker, for support. The walker is less stable, and client
could pull it over.
EVALUATION
• Assess if the client is able to demonstrate safe
and independent ambulation with the assistance
of walker.
• Assess if the client feels confident and safe while
using the assistive device.
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DOCUMENTATION
• Document the type of device the client is using, the
level of understanding the use of the device, how far
the client is able to walk using the device, and the
client’s response to the activity.
CRUTCHES
This type of walking aid allows the patient to move
independently, transferring their body weight from
their legs to the upper body and is often used by people
who cannot use their legs to support their weight (from
short-term injuries to lifelong disabilities).
OBJECTIVES
• To limit the weight-bearing on the injured leg and
improve the range of motion and self-care ability.
ASSESSMENT
• Review the patient’s record and nursing plan of care
to determine the reason for using crutches and
instructions for weight bearing.
• Check for specific instructions from physical
therapy.
• Perform a pain assessment before the time for the
activity. If the patient reports pain, administer the
prescribed medication in sufficient time to allow for
the full effect of the analgesic.
• Determine the patient’s knowledge regarding the use
of crutches and assess the patient’s ability to
balance on the crutches.
• Assess for muscle strength in the legs and arms.
Determine the appropriate gait for the patient to use.
determined by the patient's condition and medical
management of that condition.
EVALUATION
• Make sure the chair is steady before you try to stand.
• Move forward to the edge of the chair so your good
foot is flat on the floor. Slide your injured leg forward
and follow the weight bearing order.
• Hold the crutches by the handgrips in one hand. Hold
the armrest of the chair (or chair seat) with the other
hand.
• Stand up, taking weight through your good leg.
Transfer the crutches under your arms after you get
your balance.
NURSING CONSIDERATIONS
o Make sure the patient's crutches have rubber tips,
padded shoulder pieces and hand grips. These
should be checked regularly, kept in good condition,
and replaced as needed.
o It’s important to use the crutches correctly. If the
patient feels any numbness or tingling below their
armpits or in their upper arms, they’re probably not
using the crutches correctly.
o The patient should never stand on their injured leg
unless your doctor says they can. Always follow the
doctor’s order about the weight-bearing status of the
patient’s injured leg.
o The patient should always wear good supportive
shoes or bare feet rather than slippers.
o Remove loose mats and rugs, electric cords, and
cables—these could cause the patient to trip or slip.

INDICATIONS
• Has lost the use of a limb (it is either injured or
amputated).
• Is having problems with balance and impaired
strength.

TYPES OF CRUTCHES
AXILLARY CRUTCHES (underarm crutches)
→ are the most common type of crutch.
→ They are usually used for short-term injuries to
support patients who have temporary restrictions
on ambulation-as in recovering from ankle or knee
injuries.
→ easiest to use, but can cause user to slouch/armpit
injury

FOREARM CRUTCHES (lofstrand or elbow crutches)

→ often used by people with long term disabilities.
→ encourage the user to use good posture, and
experience less back and neck problems, yet hard
to use for beginners.

GUTTER CRUTCHES (adjustable arthritic crutches)

→ are used for people who need additional support,
such as people with arthritis or other chronic pain
conditions.

WEIGHT BEARING - is the amount of weight borne on a

lower extremity during standing or ambulation. It is
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ELECTROENCEPHALOGRAM
o An electroencephalogram (EEG) is a test that
measures electrical activity in the brain using small,
metal discs (electrodes) attached to the scalp.
o The procedure is painless and non-invasive, and it
helps diagnose and monitor various brain-related
conditions.
WHY DO WE CARE ABOUT BRAIN WAVES?
→ The patterns and frequencies of these brain waves
reflect different states of brain activity, like sleep,
wakefulness, concentration, and even certain
emotions.
→ By analyzing these patterns, doctors can gain
valuable insights into various brain functions and
diagnose various neurological disorders.
TYPES OF BRAIN WAVES
ALPHA WAVES (8-13Hz)
→ Indicates a calm and relaxed state
BETA WAVES (13-35Hz)
→ Associated with a strongly engaged mind
DELTA WAVES (0.5-4Hz)
→ Occurs in deep sleep
THETA WAVES (4-8Hz)
→ When a person is in a state of mental creativity
GAMMA WAVES (35+Hz)
→ associated with higher mental activity such as
perception, problem-solving, and consciousness
OBJECTIVES
• Identify the indications of the EEG.
• Describe the technique of electroencephalogram.
• Outline the clinical significance of EEG.
• Review the role of the interprofessional team in
evaluating and performing electroencephalogram.
PURPOSE
• To assess changes in mental status and
consciousness.
• To assess the degree of daytime sleepiness by
analyzing sleep patterns.
• To determine and classify the different sleep stages
(including REM & non-REM stages)
• To differentiate between epileptic seizures and
other non- epileptic events that may mimic seizures
during sleep
• To detect abnormal brain activity during sleep
(including patterns indicative of seizures or other
neurological disorders that may occur during sleep).
ASSESSMENT
1) Before assisting a patient into an
electroencephalography (EEG), conducting a
thorough assessment to ensure the patient's safety
and the accuracy of the test results is a must.
• Medical History: Review the patient's medical
history to identify any underlying conditions or
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medications that may affect the EEG results. It
is important to disclose any history of seizures,
brain injuries, or neurological disorders.
• Medications: Some medications can
influence EEG results, so it is important to be
informed about any medications being taken.
Certain drugs, such as sedatives or anti-
seizure medications, may need to be
temporarily discontinued before the test.
PREPARATION FOR ELECTRODES
o Inform the patient about the need for clean and dry
hair for optimal electrode contact. If necessary,
assist the patient in washing their hair before the
procedure.
o Sleep and Rest: In some cases, the patient may be
asked to have a good night's sleep before the EEG.
Sleep deprivation or excessive fatigue can affect the
EEG results, so it is important to follow any specific
instructions given.
o Communication Ability: Make sure the patient can
communicate properly. Understanding the patient's
capacity to follow instructions and respond to stimuli
is critical during an EEG.
o Consent: Informed consent is necessary before
performing an EEG. Explain the procedure, its
purpose, and any potential risks or discomforts
involved. The patient or their legal guardian should
have a clear understanding and provide consent for
the test.
INDICATIONS
• To classify the type of seizure and localize the onset
of seizures
• Sodium amobarbital or Wada test to determine the
hemisphere dominance for language and memory
• Management of status epilepticus and inducing
therapeutic coma
• Patients with altered mental status from various
etiologies like toxic metabolic encephalopathies
• Encephalopathic patients with unexplained
etiologies to assess the degree of encephalopathy
EQUIPMENTS
→ Electrode Wire Harness, Conductive paste, EEG
caps, Adapter, Skin prep Gel
NURSING CONSIDERATION
PRE-PROCEDURE:
o Patient education: Explain the purpose and
procedure of BEG, potential discomforts, and
importance of cooperation. Discuss any
medications or allergies and potential interactions.
o Informed consent: Ensure informed consent is
obtained after addressing any questions or
concerns.
o Medications: Manage medications per physician
orders, considering potential interactions with EEG
results (e.g., anticonvulsants).
o Fasting: Follow physician instructions regarding
fasting requirements, especially for specific EEG
tests.
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o Hair preparation: Instruct patients to avoid hair
products like oils, gels, or sprays that may interfere SIR ELMER NOTES:
with electrode placement. o 2-4 persons when lifting
o Comfort and safety: Ensure a comfortable and safe o PRIORITY: safety (and skin integrity)
environment, adjusting bedding and positioning as
needed. 3 MANNERS IN LIFTING PATIENT
1) Systematic
DURING PROCEDURE: 2) Synchronized
o Electrode placement: Assist with electrode 3) Balance (well balanced)
placement, ensuring proper adherence and avoiding
sensitive areas. NSG. CON FOR CRUTCHES
o Monitoring: Monitor vital signs and patient comfort → Height and Weight of the patient
throughout the procedure. Be alert for any signs of
discomfort or anxiety. ELECTROENCEPHALOGRAM (EEG)
o Patient instructions: Remind the patient to remain → Measures brain activity (as well as seizure/epilepsy)
still and follow instructions regarding eye
movements, breathing, or mental tasks. ALPHA 8-13 Hz calm, relaxed, sitting
o Communication: Maintain clear communication with strongly engaged mind,
the EEG technician and physician regarding any BETA 13-35 Hz
problem solving
observations or concerns. DELTA 0.5-4 Hz deep sleep (slowest)
mental creativity, yoga,
POST-PROCEDURE PROTOCOL: THETA 4-8 Hz
meditating
o Electrode removal: Gently remove electrodes and higher mental activity,
clean the scalp according to GAMMA 35+ Hz
accidents
o Documentation: Document the procedure, patient
responses, observations, and any relevant 5 TYPES OF EEG
information. o ROUTINE EEG – quickest, convenient, 20-30 min,
outpatient
EVALUATION o PROLONGED EEG – more comprehensive data set,
• Monitor patient vital signs or complications detect abnormalities, 1-2 hrs
• Assess patient consciousness and responsiveness o AMBULATORY EEG – recording done at home, 24 hrs
• Check the patient for distress to 3 days
• Document behavioral changes of the patient o VIDEO EEG – in patient, in hospital video and record,
• Ensure Patient Comfort usually takes a number of days
o SLEEP EEG – during sleep/nighttime

→ Take patient’s history

→ When was the last seizure, how long, … etc.
→ Medication (levetiracetam)

WHAT IF WITH WOUND/BUMPS ON HEAD?

→ continue if wound is dry
→ if with pain = NO EEG

OIL/CONDITIONER = may affect results

REMOVE earrings and clips = conductive

AFTER EEG
→ ask how patient feels
→ check vital signs
→ if with DOB, check o2 sat, give oxygen if needed

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HOIST LIFT PROCEDURE
STEPS RATIONALE
1. Introduce yourself to the patient and explain the Communication provides rapport and empowers the
procedure. client.
Assessment is crucial in determining the size and type of
2. Assess the patient’s condition. Check the patient’s
sling to be used. Checking the patient’s weight is crucial
weight and mobility challenges.
so that it is within the maximum capacity of the hoist.
Two healthcare providers will give an efficient and safe
3. Survey the environment. Ensure that there is a safe
assistive transfer: one controlling the lift and the other
path for transfer. Ensure that there are at least 2
assisting the patient with sling and position. Patient and
healthcare providers for the procedure.
healthcare provider safety is a priority.
4. Verify and prepare proper equipment. Determine the Appropriateness and availability of equipment makes the
use and type of lift. procedure readily to be used on a case to case basis.
5. Check the hoist lift and the sling. Ensure hoist lift is
Enhancing safety protocols by checking equipment's
properly charged and test controls before use. Ensure
functionality helps promote safe use.
sling is intact, hook attachments, strap supports in
good condition and appropriately sized.
6. Position the bed at a good working height. Helps the provider to place the sling with ease.
Correct lift height provides ease of transfer to the patient.
7. Position lift and receiving surface at correct height.
Full open position of base legs ensures lift stability.
Move lift base legs near the patient and in a full open
Locking the wheels keeps the lift in place and refrain it from
position. Lock lift in place.
moving.
8. Carefully roll the patient away from the lift with one
Helps with sling placement.
healthcare provider supporting back from other side.

9. Place the sling on the patient's back. Fold the far end
Ensures sling is centered and under the back.
of the sling and insert it beneath the patient.
10. Carefully roll the patient away towards the opposite
side and open the folded sling. Carefully return the Helps with sling placement.
patient to a supine position.
11. Lower sling bar at a good working level and attach sling Lowering the sling bar makes attachment of clips easier
straps to the sling bar. while the patient is in bed.
12. Match clips to each side. Make sure straps are not
Ensure balance of the sling. Provides comfort towards the
twisted. Ensure support in the patient's head and back
patient.
if necessary.
13. Examine all the hooks in each attachment point are
locked and will not unhook. Ensure that strap latches Ensures safety during the transferring process.
are securely fastened and that the hoist lift is stable.
14. Ensure that there is always at least one healthcare
provider that is checking the patient’s condition Ensures safety during the transferring process.
during the transfer. Clearly communicate with the Communicating fosters trust and reduces anxiety towards
patient throughout the process while explaining each the patient.
step.
15. Gradually lift the patient using the controls. Make Provides a controlled smooth lift to the patient, minimizing
sure the patient has been lifted high enough so their discomfort and avoiding sudden movements which could
feet don’t drag along the surface lead to injury.
16. Move the patient towards the desired location Ensure a safe and efficient transfer.
Remove the hooks in each attachment. Unlatch the strap.
17. Gently lower the patient using the controls.
Carefully remove the sling from the patient’s back.
18. Monitor the patient for any signs of discomfort or
Provides a controlled descent.
distress during the lift. Document the procedure.

19. Ensure that the patient is in a comfortable position.
20. Monitor the patient for any signs of discomfort or
distress during the lift. Document the procedure.
Provides comfort to the patient.
Recording the procedure in the document maintains
patient’s mobility status which aids for the continuity of
care and serves as reference for future interventions.

by: 元美安
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MOVING PATIENT UP IN BED PROCEDURE

STEP RATIONALE
1. Make sure an additional health care provider is This procedure requires two health care providers.
available to help with the move.
2. Explain to the patient what will happen and how the Doing this provides the patient with an opportunity to ask
patient can help questions and help with the positioning.
3. Complete risk assessment of patient’s ability to help This step prevents injury to patient and health care
with the positioning. provider
4. Raise bed to safe working height and ensure that
Safe working height is at waist level for the shortest health
brakes are applied. Health care providers stand on
care provider.
each side of the bed.
5. Lay patient supine; place pillow at the head of the bed This step protects the head from accidentally hitting the
and against the headboard. headboard during repositioning.
6. Stand between shoulders and hips of patient, feet
This keeps the heaviest part of the patient closest to the
shoulder width apart. Weight will be shifted from back
center of gravity of the health care provider
foot to front foot.
7. Fan-fold the draw sheet toward the patient with palms This provides a strong grip to move the patient up using
facing up. the draw sheet
8. Ask patient to tilt head toward chest, fold arms across
This step prevents injury from patient and prepares
chest, and bend knees to assist with the movement.
patient for the move.
Let the patient know when the move will happen
9. Tighten your gluteal and abdominal muscles, bend The principles of proper body mechanics help prevent
your knees, and keep back straight and neutral. injury.
10. On the count of three by the lead person, gently slide
(not lift) the patient up the bed, shifting your weight
from the back foot to the front, keeping back straight
with knees slightly bend
11. Replace pillow under head, position patient in bed,
This step promotes comfort and prevents harm to patient.
and cover with sheet
Placing bed and side rails in safe positions reduces the
12. Lower bed, raise side rails as required, and ensure
likelihood of injury to patient. Proper placement of call
call bell is within reach. Perform hand hygiene
bell facilitates patient’s ability to ask for assistance.

by: 元美安
 RLE116GEP
USING CANE PROCEDURE
STEP RATIONALE
1. Review the medical record and nursing plan of care for
conditions that may influence the patient’s ability to This validates the correct patient and correct procedure
move and ambulate.
2. Prepare equipment and perform hand hygiene. Save time, effort, and energy. Prevent the spread of
microorganisms.
3. Identify the patient. Explain the procedure. Tell the
patient to report any feelings of dizziness, weakness, Patient identification validates the correct patient
or shortness of breath while walking. Let the patient procedure. Discussion and explanation will prepare the
know how far you plan to ambulate. patient for what to expect.

4. Assist the patient to put on appropriate socks and

shoes. Proper footwear is essential to prevent accidental falls.

5. Ensure cane height is correct. This manner provides support and balance.
6. Encourage the patient to get to a standing position.
a) Place the cane on the STRONG side and keep
the weak leg slightly extended out.
Ensures they use their strong side for support while
b) The patient will lean forward out of the chair
minimizing strain on the weak leg.
and push down on the cane’s hand grip and
chair’s armrest.
c) The patient will put weight on the strong leg and
stand in position with the cane.
Holding the cane on the stronger side helps to distribute
the patient’s weight away from the involved side and
7. Have the patient hold the cane on his or her
prevents leaning.
STRONGER side, close to the body, while the nurse
Positioning to the side and slightly behind the patient
stands to the WEAK side and slightly behind the
encourages the patient to stand and walk erect.
patient.
It also places the nurse in a safe position if the patient
should lose his or her balance or begin to fall.
8. The patient should place the tip of the cane about 4 Cane position is forward and slightly to the side when
inches from the side of the STRONG foot. ambulating.
9. The patient will move the cane and WEAK side
Moving in this manner provides support and balance.
TOGETHER forward, and then move the STRONG side.
10. Continue with ambulation for the planned distance
and time.
11. Return the patient to the chair based on the patient’s
tolerance and condition.
a) The patient will back up to the chair until they
feel the chair with the back of their legs.
Ensures the patient safely lowers themselves into the chair
b) The patient will then allow the cane to rest on
using the strong leg and arm support, while minimizing
the side of the chair.
strain on the weak leg.
c) Then the patient will place both hands on the
chair’s armrest and place weight on the hands
and bend the strong leg while keeping the weak
leg slightly extended and sit down in the chair.

12. Document:
a) Activity and any other pertinent observations;
b) The patient’s ability to use the cane;
c) The patient’s tolerance of the procedure and the Provides information with regards to patients progress to
distance walked; and care and response to therapy.
d) The use of transfer aids and the number of staff
required for transfer.

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GOING UP AND DOWN THE STAIRS USING A CANE

GOING UP GOING DOWN
a) Patient will move the STRONG leg up onto the step a) The patient will move the cane down onto the step
first. with the WEAK leg.
b) Then the patient will move the WEAK leg and cane up b) Then the patient will move the STRONG leg down
onto the step. onto the step.
c) Repeat. c) Repeat.
Moving in this manner provides support and balance.

ASSISTING A PATIENT WITH AMBULATION USING A WALKER

STEP RATIONALE
1. Ensure proper footwear is on the patient, and let the
Proper footwear is essential to prevent accidental falls.
patient know how far you will be ambulating.
The top of the walker should line up with the crease on the
inside of the wrists when one is standing. Elbows should
2. Measure client for walker height.
flex 15-30 degrees when standing inside the walker with
the hands on the hand grips.
3. Explain and demonstrate how to walk with a walker.
Assessment and instructions prior to ambulation.
4. From a sitting position, instruct patient to push up Do not use the walker to pull oneself up. It is not stable
from the chair’s armrest to a standing position. and could result in injury.
Move the walker forward a short distance
The base of the walker provides a broad base of support.
5. Firmly grip both sides of the walker.
Once patient is standing and feels stable, move to the
unaffected side.
Do not step forward if all four feet of the walker are not in
6. Step forward with the injured or weak leg first, taking
contact with the floor.
weight through one’s hands.
Walker - weak leg- strong leg
Keep feet within the walker’s boundaries.
Then step with the stronger leg.
Advise the patient to look forward not down at the floor.
7. To turn: Advise to take small steps, moving the walker Avoid twisting the knee joint when turning. Walking in a
and then the legs. large circle may be necessary.

ASSISTING A PATIENT WITH AMBULATION USING CRUTCHES

STEP RATIONALE
1. Review the medical record and cursing plan of care
Reviewing the medical record and plan of care validates
for conditions that may influence the patient’s ability
the correct patient and correct procedure.
to move and ambulate.
• Assess for tubes, IV lines, incisions, or equipment
Assessment helps identify problem areas to minimize the
that may alter the procedure for ambulation.
risk for injury.
• Assess the patient’s knowledge and previous
experience regarding the use of crutches.
2. Determine that the appropriate size crutch has been obtained: Measure the crutch:
Lying:
• Have the patient lie supine, arms at sides, wearing a shoe on the unaffected foot.
• Using a tape measure, measure from the axilla to the heel of the shoe and add two (2) inches.
• Adjust the crutch shaft to this measurement.
Standing:
• Crutch tip 6” from the foot and at a 45-degree angle.
• Hand grip at the ulnar styloid process or at the level of the greater trochanter.
• Elbow is about 20-30 degrees of flexion.
• Hand grip distance to the top of the crutch, 2-3 finger widths.
3. Perform hand hygiene. Put on PPE, if indicated.
4. Identify the patient. Explain the procedure to the
Patient identification validates the correct patient and
patient. Tell the patient to report any feelings of
correct procedure. Discussion and explanation help allay
dizziness, weakness, or shortness of breath while
anxiety and prepare the patient for what to expect.
walking

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5. Assist the patient to put on appropriate socks and
shoes.
6. Encourage the patient to make use of the stand-assist
device, if available. Assist the patient to stand erect, Stand-assist devices reduce caregiver strain and
face forward in the tripod position. decrease the risk of patient injury. Positioning the
crutches in this manner provides a wide base of support
This means the patient holds the crutches 6- 12 to increase stability and balance.
inches in front of and; 6-12 inches to the side of each
foot at a 45-degree angle
For the FOUR-POINT GAIT:
• Begin in the tripod position.
This movement ensures stability and safety
• Have the patient move the right crutch forward 6-12
inches and then move the left foot forward to the level
So it goes: move R crutch, then move L leg, then move L
of the right crutch.
crutch, and then move the R leg.
• Then have the patient move the left crutch forward 6-12
inches and then move the right foot forward to the level
of the left crutch.
For the THREE-POINT GAIT:
• Begin in the tripod position.
Patient bears weight on the stronger leg.
• Have the patient move the affected leg and both
So it goes: move both crutches and injured leg forward
crutches forward about 6- 12 inches.
together and then move the non-injured leg
• Have the patient move the stronger leg forward to the
level of the crutches.
For the SWING-TO GAIT:
Most rapid gait. Patient bears weight on the unaffected
• Begin in the tripod position.
leg.
• Have patient move both crutches forward 6-12 inches
Swing-to gait provides mobility for patients with weakness
• Have the patient bend and lift the injured leg and swing
or paralysis of the hips or legs.
it at the level of the crutches, supporting his or her body
weight on the crutches.
For the SWING-THROUGH-GAIT:
• Begin in the tripod position. The client stands on the
strong leg, bending the knee of the injured leg. Most rapid gait. Patient bears weight on the unaffected leg
• Moves both crutches forward the same distance,
• Rests his or her weight on the palms, and swings
forward slightly ahead of the crutches.
For the TWO-POINT GAIT:
Patient bears partial weight on both feet.
• Begin in the tripod position.
• Have the patient move the left crutch and the right foot
So it goes: move the R crutch along with the L leg and then
forward about 6-12 inches at the same time.
move the L crutch along with the R leg.
• Have the patient move the right crutch and left leg
forward to the level of the left crutch at the same time
Continued ambulation promotes activity. Adhering to the
7. Continue with ambulation for the planned distance
planned distance and time prevents the patient from
and time.
becoming fatigued.
8. Return the patient to the bed or chair based on the Provides comfort and prevents fatigue.
patient’s tolerance and condition, ensuring that the A call bell reassures the patient that you will attend to
patient is comfortable. Make sure the call bell and his/her needs
other necessary items are within easy reach.
Removing PPE properly reduces the risk for infection
9. Remove PPE, if used. Perform hand hygiene transmission and contamination of other items. Hand
hygiene prevents the spread of microorganisms.
10. Document:
• the patient’s ability to use the crutches
• the patient’s tolerance of the procedure, and the
Provides information about the patient's progress to care
distance walked.
and response to therapy.
• the use of transfer aids and number of staff required for
transfer and other appropriate interventions

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GOING UP AND DOWN THE STAIRS USING CRUTCHES

GOING UP GOING DOWN
a) Stand up straight and use both crutches for body- a) Using the uninjured leg (healthy leg) for body-weight
weight support support with the knee
b) Use the uninjured leg (healthy leg) to step up first b) slightly flexing and then allow both crutches step
c) Using the uninjured leg (healthy leg) as a body-weight down first.
support, bring both crutches and the injured leg (post- c) Then the injured leg (post-surgery leg) step down.
surgery leg) step up together. d) Using both crutches as body-weight support, allow
the uninjured leg (healthy leg) to step down

SITTING DOWN AND GETTING UP FROM A CHAIR WITH CRUTCHES

GOING UP GOING DOWN
a) Step backwards until the back of your good leg touches a) Make sure the chair is steady before you try to stand.
the front of the chair. Keep your injured leg forward b) Move forward to the edge of the chair so your good
b) Keeping your weight on the good leg, take the crutches foot is flat on the floor. Slide your injured leg forward
from under your arms. and follow the weight bearing order.
c) Transfer 1 crutch and hold both crutches by the hand c) Hold the crutches by the handgrips in one hand. Hold
grips in 1 hand. the armrest of the chair with the other hand.
d) Lean forward and bend your good knee. Hold the d) Stand up, taking weight through your good leg.
armrest of the chair (or chair seat) with the other hand. Transfer the crutches under your arms after you get
e) Sit down slowly. Keep your crutches next to the chair. your balance.

ELECTROENCEPHALOGRAM PROCEDURE
STEP RATIONALE
1. Explain procedure to the patient and instruct that no
shock will be applied and that it is a painless To ease the patient’s anxiety and promote cooperation.
procedure
2. Obtain an informed consent To protect the staff and institute from legalities.
3. Withhold medication such as anti-convulsant,
stimulants, tranquilizers and depressants for 24-48 These medications may alter the brain wave’s activities
hours before the procedure.
4. Withhold tea, cola and chocolates before the These particular foods and beverages may stimulate brain
procedure. Smoking should be restricted for 24hrs activity. Smoking produces obvious changes in EEG
before the procedure activity.
5. Wash patient’s hair thoroughly with shampoo and dry
hair completely about 6hr prior to the procedure.
Oil interferes with the conduction of electrical activities
Instruct patient not to apply conditioners or oil after
shampooing
6. If sleep study is ordered, the adult patient should
This is done to induce sleep to the patient during the test.
sleep as little as possible the night before
7. Make the patient lie in a supine position and fasten Lying on their back (supine) showed significantly stronger
electrodes to the scalp activity over the back of the brain.
8. Instruct patient to lie still during procedure. Movement may affect the recording.
9. After the procedure is done record the procedure in
This step protects the head from accidentally hitting the
nurse record with date, time and patient response to
headboard during repositioning.
the procedure

by: 元美安