Sunday, 3 January 2010

TRANSFER FROM BED TO WHEELCHAIR

For the patient with diminished or absent lower-body sensation or one-sided weakness, immobility, or injury, transfer from bed to wheelchair may require partial support to full assistance—initially by at least two persons. Subsequent transfer of the patient with generalized weakness may be performed by one nurse. After transfer, proper positioning helps prevent excessive pressure on bony prominences, which predisposes the patient to skin breakdown.
Equipment
Wheelchair with locks (or sturdy chair) • pajama bottoms (or robe) • shoes or slippers with nonslip soles • optional: transfer board if appropriate. (See Teaching the patient to use a transfer board.)
Implementation
  • Explain the procedure to the patient and demonstrate his role.
  • Use good body mechanics during the transfer to prevent injury.
  • Place the wheelchair parallel to the bed, facing the foot of the bed, and lock its wheels. Raise the wheelchair footrests to avoid interfering with the transfer. Make sure the bed wheels are also locked and the bed is in the lowest position in relation to the floor to prevent an accident.
  • Check pulse rate and blood pressure with the patient supine to obtain a baseline. Then help him put on the pajama bottoms and slippers or shoes with nonslip soles to prevent falls.
  • Raise the head of the bed and allow the patient to rest briefly to adjust to posture changes. Then bring him to the dangling position (see “Progressive ambulation,” page 47). Recheck pulse rate and blood pressure if you suspect cardiovascular instability. Don't proceed until the patient's pulse rate and blood pressure are stabilized to prevent falls.
  • Tell the patient to move toward the edge of the bed and, if possible, to place his feet flat on the floor. Stand in front of the patient, blocking his toes with your feet and his knees with yours to prevent his knees from buckling.
  • Flex your knees slightly, place your arms around the patient's waist, and tell him to place his hands on the edge of the bed. Avoid bending at your waist to prevent back strain.
  • Ask the patient to push himself off the bed and to support as much of his own weight as possible. At the same time, straighten your knees and hips, raising the patient as you straighten your body.
  • Supporting the patient as needed, pivot toward the wheelchair, keeping your knees next to his. Tell the patient to grasp the farthest armrest of the wheelchair with his closest hand.
  • Help the patient lower himself into the wheelchair by flexing your hips and knees, but not your back. Instruct him to reach back and grasp the other wheelchair armrest as he sits to avoid abrupt contact with the seat. Fasten the seat belt to prevent falls and, if necessary, check pulse rate and blood pressure to assess cardiovascular stability. If the pulse rate is 20 beats or more above baseline, stay with the patient and monitor him closely until it returns to normal because he's experiencing orthostatic hypotension.
  • If the patient can't position himself correctly, help him move his buttocks against the back of the chair so that the ischial tuberosities, not the sacrum, provide the base of support.
  • Place the patient's feet flat on the footrests, pointed straight ahead. Then position the knees and hips with the correct amount of flexion and in appropriate alignment. If appropriate, use elevating leg rests to flex the patient's hips at more than 90 degrees; this position relieves pressure on the popliteal space and places more weight on the ischial tuberosities.
  • Position the patient's arms on the wheelchair's armrests with shoulders abducted, elbows slightly flexed, forearms pronated, and wrists and hands in the neutral position. If necessary, support or elevate the patient's hands and forearms with a pillow to prevent dependent edema.
Special considerations
  • If the patient starts to fall during transfer, ease him to the closest surface—bed, floor, or chair. Never stretch to finish the transfer. Doing so can cause loss of balance, falls, muscle strain, and other injuries to you and the patient.
  • If the patient has one-sided weakness, follow the preceding steps, but place the wheelchair on the patient's unaffected side. Instruct the patient to pivot and bear as much weight as possible on the unaffected side. Support the affected side because the patient will tend to lean to this side. Use pillows to support the hemiplegic patient's affected side to prevent slumping in the wheelchair.

Documentation
If necessary, record the time of transfer, the extent of assistance, and note how the patient tolerated the transfer.