Nursing Procedure 1.1
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
Secure as much additional assistance as needed for safe moves. Many agencies use "lift teams," personnel specially trained to move clients, and some special moving equipment. As a general rule, approved moving, lifting, and transfer equipment should be used if available to support safety and provide an ergonomically safe environment for the nurse/caregiver. NEVER BECOME SO IMPATIENT THAT SAFETY BECOMES JEOPARDIZED WITH ANY TYPE OF MOVE. Check all equipment to be used, including chairs, for adequate function and stability. If physical injury of personnel is sustained because of performance of any work-related activity, follow agency policies regarding follow-up medical attention and completion of incident report forms. This provides for proper care and ensures financial assistance as needed. Avoid excessive pressure and shearing on skin when moving the client by lifting and not dragging the client.
If child is restless, agitated, or confused, secure assistance to prevent injury during the moving process. Consider that some parents may be conflicted about the use of physical assistance to perform procedures. Take the time to provide explanations to parents if additional personnel assistance is necessary.
If client is restless, agitated, or confused or has a condition that causes loss of muscle control, secure assistance to prevent injury during the moving process.
Assess the home environment to determine the need to rearrange furniture and other items and to secure mechanical equipment to ensure the safety of client and family as they move client and perform care.
If special precautions are to be used when moving a client, reinforce the precautions with assistive personnel to ensure they understand the client's care needs.
| Action | Rationale | |
|---|---|---|
| 1 | Perform hand hygiene (see Nursing Procedure 1.2). | Reduces microorganism transfer |
| 2 | Determine factors that indicate need for additional personnel, such as: | Promotes efficiency and enhances safety of client and caregiver |
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| 3 | Apply client’s glasses and hearing aids (if used) if client is able to assist. | Enables client to assist in making a safe move |
| 4 | Explain required movement techniques to assistive personnel, family, and client; instruct and allow client to do as much as possible. | Facilitates coordinated movement and prevents physical injury; promotes independence |
| 5 | Organize equipment so that it is within easy reach, stabilized, and in proper position: | Avoids risks once movement begins; minimizes number of actions needed for the move |
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| 6 | Raise or lower bed and other equipment to a comfortable and suitable height. | Prevents unnecessary use of back muscles when performing tasks |
| 7 | Maintain proper body alignment by using the following principles when handling equipment and when moving, lifting, turning, and positioning client: | |
| Maintains proper body alignment | |
| Provides greater stability | |
| Establishes more stable position; prevents pulling on spine | |
| Promotes use of large muscles of extremities rather than of spine | |
| Prevents improper alignment and inefficient muscle use | |
| Avoids use of spine and back muscles | |
| 8 | Don gloves if contact with body fluids is likely. | Prevents contamination of hands; reduces risk of infection transmission |
| 9 | Secure tubes, drains, traction, and other equipment by whatever means are needed for proper functioning during moving, lifting, turning, and positioning. | Prevents dislodgment of tubes and reflux of contaminants into body |
| 10 | Move client close to edge of bed in one unit or move client to side of bed at any time during procedure, moving one unit of the body at a time from top to bottom or vice versa (i.e., head and shoulders first, trunk and hips second, and legs last). Coordinate move so that everyone exerts greatest effort on count of three; the person carrying the heaviest load should direct the count. | Maintains correct alignment; facilitates comfort; prevents physical injury |
| 11 | Use the following principles to move a heavy object or client: | |
| Reinforces original plan | |
| Allows full use of arm and leg muscles | |
| Facilitates client participation and prevents fall injury | |
| Provides extra leverage | |
| Facilitates use of large muscle groups; prevents injury to arms during move and centers client’s weight | |
| Prevents fatigue and subsequent physical injury | |
| Promotes stability | |
| Prevents injury to vertebrae and back muscles | |
| Avoids pulling against gravity | |
| Allows time to straighten spine and reestablish stability | |
| Avoids vertebral and back injury related to rotating and twisting spine | |
| Avoids twisting of spine and possible muscle strain | |
| 12 | Position props and body parts for appropriate body alignment of client after move is completed: | Maintains body alignment |
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| 13 | After move is completed, provide for comfort and safety of client with the following actions, if applicable: | |
| Prevents falls | |
| Promotes safety | |
| Promotes safety | |
| Supports airway clearance | |
| Reestablishes proper functioning of equipment | |
| Promotes proper body alignment and supports airway, if client is intubated | |
| Provides warmth and privacy | |
| Provides means of communication | |
| Enhances comfort and general satisfaction | |
| 14 | Discard gloves and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
