Safety; Basic Body Mechanics;

Moving & Positioning

Prepared by A. Deans-Clarke
Health Specialist MPhil, BSc.
Patient Safety:
 “Technically the biggest ‘safety system’ in
healthcare is the minds and hearts of the
workers who keep intercepting the flaws in
the system and prevent patients from being
hurt. They are the safety net, not the cause
of injury”.

Don Berwick
Patient Safety #1
 A client’s health and wellness depend
upon safety. Safety is the number 1
priority in all aspects of care.

 Nurses need to be aware of safety. The

hospital setting is complex, potentially
dangerous & unfamiliar to clients.
Ensuring Client safety:
 Reduces length of stay & cost of treatment

 Reduces frequency of treatment

 Reduces potential for law suits

 Reduces the number of work-related injuries

to personnel
Institute of Medicine Report,
1999
 Estimated 48,000-98,000 deaths per year from
medical errors.

 Adverse events ranked as the 8th leading cause

of death, ahead of MVA’s, breast cancer and
AIDS

 Extrapolating from the U.S. data, adverse

events would account for 4,000-10,000 deaths
per year in Canada.
Impetus for action: Threefold
1. Health system has a moral imperative to
ensure the safety of patients

2. Adverse events have a tremendous cost to

the system in extended hospital stays &
additional medical procedures

3. Adverse events expose health organizations

to legal liability
A safe environment is one in which
basic needs are met, physical
hazards are reduced or eliminated,
transmission of organisms is reduced
and sanitary measures are carried
out.
Falls
 Fall risk, especially in the elderly, is
growing. In hospitalized patients, 4-12
falls occur per 1,000 bed days, ranking
them among the 10 most common
claims presented to insurance agencies
Nursing Management,
September 2002

 30% of people 65 yrs and older (in the

community) fall at least once each year.
Focus Assessment:
 To ensure patient safety – the nurse
should conduct a focus assessment
during every nurse-patient encounter
which includes:

 A visual scan of the environment for potential

hazards
 A quick appraisal of patient related factors
Strategies to help reduce falls:
Physical environment
 Appropriate furniture and lighting

 Call bell easily accessible/personal items within reach

 Traffic areas free from obstruction

 Secure/remove loose carpets or runners

 Eliminate clutter

 Grab bars in appropriate areas in washroom

 Handrails in the halls

 Keep bed in a low position – lock bed/wheelchairs/stretcher

 Identify clients at risk for falls.

 If a client experienced falls at home, they will likely continue to be at risk for falls in the hospital
setting. Place them close to nsg station.
Strategies to help reduce falls:
(Communication/Assessment)
 Orient client to physical surroundings

 Explain use of call bell

 Assess client’s risk for falling

 Alert all personnel to the client’s risk for falling

 Instruct client and family to seek assistance when getting up

 Maintain client’s toileting schedule

 Observe/assess client frequently

 Encourage family participation in client’s care

Body Mechanics
 The coordinated efforts of the musculoskeletal & nervous
system to maintain balance, posture & body alignment
during lifting, bending, moving & performing ADL’s.

 Knowledge & practice of proper body mechanics protect

the client and nurse from injury to their musculoskeletal
systems.

 Correct body alignment reduces strain on

musculoskeletal structures, maintains muscle tone, &
contributes to balance.
Body Mechanics (cont.)
 Body balance is achieved when a wide base
of support exists, the center of gravity falls
within the base of support & a vertical line
can be drawn from the center of gravity
through the base of support.

 When lifting an object, come close to the

object, enlarge the base of support & lower
the center of gravity.
Body Mechanics (cont.)
 Proper body mechanics facilitates movement
without muscle strain & excessive use of
muscle energy.

 Improper body mechanics can lead to injury

for both the nurse & the patient, especially
back injury when lifting.
“In 1990, Canadian hospitals reported 30,487
time loss injuries. Fifty-three percent were
sustained by nurses. Almost half (of the
injuries) were back injuries. Back injury is now
recognized as one of the major reasons for ill-
health retirement from nursing. Not only is it
the most frequent injury sustained by nurses, it
is the most debilitating”
Action
When planning to move a client,
arrange for adequate help. Use
mechanical aids if help is
unavailable.
Encourage client to assist as much
as possible.
Keep back, neck, pelvis and feet
aligned. Avoid twisting.
Flex knees; keep feet wide apart.
Position self close to client (or object stability. The force is minimized. 10
being lifted).
Rationale
Two workers lifting together divide
the workload by 50%.
This promotes the client’s abilities &
strength while minimizing workload.
Reduces risk of injury to lumbar
vertebrae & muscle groups. Twisting
increases risk of injury.
A broad base of support increases
lbs at waist height close to the body
is equal to 100 lbs at arms’ length.
Action
Use arms and legs (not back)
Slide client toward yourself using a
pull sheet.
Set (tighten) abdominal & gluteal
muscles in preparation for move.
Person with the heaviest load
coordinates efforts of team involved
by counting to three.
Rationale
The leg muscles are stronger, larger
muscles capable of greater work
without injury.
Sliding requires less effort than
lifting. Pull sheet minimizes
shearing forces, which can damage
client’s skin.
Preparing muscles for the load
minimizes strain.
Simultaneous lifting minimizes the
load by any one lifter.
Moving & Positioning
Mobility – persons ability to move about freely.

Immobility – person unable to move about freely, all body

systems at risk for impairment.

 Frequent movement improves muscle tone, respiration,

circulation & digestion.
 Proper positioning at rest also prevents strain on muscles,
prevents pressure sores (decubitus ulcers within 24 hours)
& joint contractures (abnormal condition of a joint,
characterized by flexion & fixation & caused by atrophy &
shortening of muscle fibers or by loss of normal elasticity of
the skin).
Moving & Positioning (cont.)
 Pressure Sores – tissues are
compressed, decreased bld supply to
area, therefore, decreased oxygen to
tissue & cells die.
Correct Positioning
 Is crucial for maintaining body alignment and comfort,
preventing injury to the musculoskeletal system, and providing
sensory, motor, and cognitive stimulation.

 It is important to maintain proper body alignment for the

patient at all times, this includes when turning or positioning the
patient.

 Aim – least possible stress on patient’s joints & skin. Maintain

body parts in correct alignment so they remain functional and
unstressed.

 Patients who are immobile need to be repositioned q 2 hrs.

Application of proper body mechanics
“By applying the nursing process and using the
critical thinking approach, the nurse can
develop individualized care plans for clients
with mobility impairments or risk for
immobility. A care plan is designed to
improve the client’s functional status,
promote self care, maintain psychological well
being, and reduce the hazards of immobility.”
(Potter and Perry, 2006)
Moving & Positioning: Nursing Process
 Assessment
 Comfort level & alignment while lying down
 Risk factors - Ability to move, paralysis
 Level of consciousness
 Physical ability/motivation
 Presence of tubes, incisions, equipment

 Nursing Diagnosis
 Defining characteristics from the assessment
 Activity intolerance
 Impaired physical mobility
 Impaired skin integrity
refer to Perry and Potter
Nursing Process (cont.)
 Planning
 Know expected outcomes – good alignment, increased comfort

 Raise bed to comfortable working height

 Remove pillows & devices

 Obtain extra help if needed

 Explain procedure to client

 Implementation
 Wash hands

 Close door/curtain

 Put bed in flat position

 Move immobile patient up in bed

 Realign patient in correct body alignment (pillows etc.)

Nursing Process (cont.)
 Evaluation
 Assess body alignment, comfort
 Ongoing assessment of skin condition
 Use of proper body mechanics (nurse)
Restraints
 Device used to immobilize a client or an extremity

 A temporary means to control behavior

 Restraints are used to:

 Prevent falls & wandering
 Protect from self-injury (pulling out tubes)
 Prevent violence toward others

 Restraints deprive a fundamental right to control

your own body.
CRNNS Position Statement on
Use of Physical Restraints
 “The Registered Nurses’Assoc. of N.S. recognizes the
right of all persons to be treated in a respectful and
dignified manner. Additionally, the CRNNS believes that
all individuals have an inherent right to autonomously
and independently make decisions regarding their health
care. (RNANS, 1997)

 Use of physical restraints may violate these inherent

rights.

 The CRNNS does not endorse the use of physical

restraints.
Cautious Use of Restraints
 While restraint-free care is ideal, there are
times that restraints become necessary to
protect the patient & others from harm.

 Highly agitated, violent individual – Physical/Chemical

restraints
 Intubated patient – pulling out endotracheal tube
 Suicide patient - ? Chemical restraints
Use of Restraints:
 Use only when absolutely necessary.

 Attending physician is responsible for the assessment, ordering

& continuation of restraint.

 Can be instituted on your nsg judgment – must have a doctors

order ASAP.

 Continued use of restraints must be reviewed daily by the RN &

documented on the health record.

 Always explain what you do & why, to reduce anxiety & promote
cooperation.
Goals of Restraint Use
 To avoid the use of restraints whenever possible.

 Encourage alternatives

 Family member to sit with patient

 Geri chair vs. bed
 Non restraint measures – safety belt, wedge pillows, lap tray

 Consider restraints as a temporary measure – decrease likelihood of

injury from restraint use.

 Remove restraints as soon as the patient is no longer at risk for injury.

Complications assoc. with restraints
 Hazards of immobility
 Death
 Pressure sores, pneumonia, constipation, incontinence,
contractures, decreased mobility, decreased muscle strength,
increased dependence
 Altered thought processes
 Humiliation, fear, anger & decreased self-esteem

• Strangulation
• Compromised circulation
• Lacerations, bruising, impaired skin integrity
• Must release restraint every 2 hours for assessment & ROM
Physical Restraints – device that limits a
clients ability to move
 Side rails – stop patient from rolling out, but does not stop them
from climbing out – side rail down when working on that side.

 Jackets & Belts – patient who is confused & climbing over rails
may need a jacket or belt to restrain them to bed. Sleeveless
with cross over ties, allows relative freedom in bed.

 Arm & Leg – Undesirable, limits patients movement, injury to

wrist/ankle from friction rubbing against skin – use extra
padding. Restrain in a slightly flexed position, if too tight could
impair circulation. Never tie to a bed rail.
Physical Restraints (cont.)
 Mitts are used for those confused & pulling at@ edges
of dsgs, tubes, iv’s, wounds. Doesn’t limit arm
movement, soft boxing glove that pads the hand,
remove, wash & exercise.
 Ensure not too tight

 Use quick release tie for all restraints

Chemical Restraints
 Medication

 Patient must be closely observed and assessed

frequently post medication.

 Remains a high risk for injury.

Supporting Documentation
 Rationale for the use of restraints, including a statement
describing the behavior of the patient.

 Previous unsuccessful measures or the reason alternatives

are not feasible.

 Decision to restrain with the type of restraint selected and

date & time of application.

 Observations regarding the placement of the restraint, its

condition and the patient’s condition, including the
frequency of observation (not just at the end of your shift)
Supporting Documentation (cont.)
 Assessment of the need for ongoing
application of restraint.

 Care of the patient which may include

re-positioning, toileting, mobilization
and/or skin care
Civil Actions
 Most civil cases are based on allegations of
negligence.

 Important to support your judgment/actions

with quality documentation
Promoting Safety
 Measures designed to promote client safety are the
result of individualized assessment findings. Often it
is the conclusion of the nurse that a client’s safety is
at risk, and subsequent nursing interventions are
implemented. Assessment of a client’s safety should
occur in the home, healthcare facility, and
community environment.
(Perry and Potter,
2002)
 Canadian Nurses Association’s (CNA)
online Patient Safety Resource Guide

 www.cna-aiic.ca
Nursing 125 LAB

Safety; Basic Body Mechanics;

Moving & Positioning
Moving the patient: up in bed
Move close to the side of the
bed
Up in bed (1 nurse)
(Patient alert & cooperative)
Up in bed (2 nurses)
(heavy patient or one who
cannot help)
Back straight, knees bent, one foot forward (broad
base of support)
Encourage independence & foster self-esteem.
Patient bends knees, feet firmly on the bed –
grasps side rail @ shoulder level. Nurse positions
hand & arms under patients hips, back straight,
bend knees, feet apart, count to 3. Nurse pulls
patient up in bed & pt pulls arms & pushes feet up
into bed.
Patient bends knees, feet firmly on bed, 1 st nurse
at HOB arms under head & shoulders, face foot of
bed, 2nd nurse under hips facing foot of bed, on
same side – count to 3.
Moving the patient: lifter
Up in bed using the pull sheet/lifter
(2 nurses)
Do not lift, always slide
One nurse on each side of the bed, firmly
grasp the lifter in both hands, ask the patient
to lift their head. Slide the patient up in bed
on the count of 3.
Benefit: 1. movement b/w 2 layers of cloth
has less friction than skin on cloth.
2. Much easier to grasp sheet firmly than it is
to hold a patient’s body.
3. Lifter supports the entire body (except the
head) making it easier to keep the patient
straight.
Moving the patient: lateral
From the back to the side Move the patient to the side of the bed, so
(lateral) position the patient will be in the center when
complete.
Raise rail, move to other side of bed, roll
patient toward you far ankle over near ankle,
far knee over near knee. Place one hand on
client’s hip and one hand on his/her shoulder
and roll pt. onto side toward you. Place
pillow under head & neck, bring shoulder
blade forward, position both arms in slightly
flexed positions (protects joints).
Upper arm supported by pillow.
Place pillow behind patient’s back & pillow
under semi flexed upper leg
Assess need to support feet (footboard, high
top sneakers).
Moving the patient: prone
From the back to the Move to the extreme edge of the bed, raise rail on that
abdomen (prone) side, move to other side.
Pillow for support under abdomen, near arm over head,
turn face away, roll as above, check arm & face, continue
rolling.

Prone - infrequently used because respirations can be

compromised
Good position for pressure sores on hips/buttocks.

Important to turn head to the side, no pillow b/c it hyper

extends the neck – can use small towel, small folded towel
under each shoulder to prevent slumping, flat pillow at
abdomen (esp. women with large breasts)
Arms at either sides or flexed by head, hand rolls, feet in
dorsiflexion – sandbags under ankles.
Tips for positioning the patient
 After turning – use aids i.e. pillows, towels, washcloths,
blankets, sandbags, footboards etc.

 Joints should be slightly flexed b/c prolonged extension creates

undue muscle tension & strain

 Supine
 Low or flat pillow (prevents neck flexion)
 Trochanter role (supports hip joint prevents external rotation)
 Hand roll – used if hands are paralyzed (thumb & fingers flexed around
it)
 High top sneakers, foot board, sandbags (support feet with toes
pointing upward. Prolonged plantar flexion leads to foot drop
(permanent plantar flexion & inability to dorsiflex)
Tips (cont.)
 Side lying
 Even if paralyzed on one side a patient can be placed on
that side. Take care not to pull on the affected
extremity.

 Head on low pillow, pillow along back – supports back &

holds body in position, underlying arm comes forward &
flexed onto pillow used for head, top arm flexed forward
& resting on pillow in front of body, hand rolls if
necessary, flex top leg forward & place on pillow, feet at
right angles with sandbag.