What should the nurse do to quickly assess a patients tolerance to a change in position when transferring the patient from a bed to a wheelchair?

This article focuses on the cardiovascular adjustments that take place when an individual makes a change in his/her position, particularly when moving from the supine to the standing position (orthostasis). Some individuals may experience a drop in their blood pressure on assuming the standing position, which may lead to dizziness and/or fainting (orthostatic intolerance). Dangling, which is often an intermediary stage of assisting people into the sitting position with their legs hanging over the side of the bed, before moving them into the standing position, is therefore used to ensure that patients are moved safely. This can help to prevent notable reductions in blood pressure. Nurses, therefore, need to be aware of the cardiovascular changes and compensatory mechanisms that take place during orthostasis, in order to be able to make decisions not just about whether their patient can be moved out of bed, but so that it can be done safely without any of the adverse effects of orthostatic intolerance. Those at greatest risk of developing such adverse effects include those with diabetes mellitus, cardiovascular disease and also those with an age-related vagal dysfunction. Some pharmacological agents may also be implicated in contributing to orthostatic intolerance in some individuals. Recommendations for practice include ensuring that dangling the patient is incorporated as part of the procedure of slowly assisting patients out of bed, encouraging leg and foot movement and continually assessing the patient during the procedure. Should any patient show any sign of not tolerating the position change, the procedure should be halted and the patient assisted back into the supine position.

Table of Contents Show

Assisting Patient to the Sitting Position
Ambulating a Patient

Chapter 3. Safe Patient Handling, Positioning, and Transfers

To prevent and minimize MSI injuries related to patient handling activities, a risk assessment must be done to determine a patient’s ability to move, the need for assistance, and the most appropriate means of assistance (Provincial Health Services Authority [PHSA], 2010). There are four important areas to assess:

The patient
The environment
The health care provider
The organization of the work

Checklist 24 outlines what to assess and how to assess a patient prior to positioning, ambulation, and transfers.

Checklist 24: Risk Assessment


The assessment process should not override clinical judgment and patient-specific needs as determined by the health care team. An assessment should be performed before each handling procedure. Seek additional help if a procedure requires two or more persons. Use assistive devices (gait belts, slider boards, pillows, etc.) to perform the procedure safely. Assess the patient’s ability to tolerate the movement. Acute pain, shortness of breath, and inability to follow direction will place the health care provider and patient at risk for an injury. Always consider the principles of proper body mechanics prior to any procedure, such as raising the head of bed and tucking elbows in to help prevent injuries. Avoid lifting shoulders when positioning a patient. Never lift a patient; always use a weight shift to perform the procedure. When positioning a patient using a sheet, place palms of hands up. A palms-down technique increases risk for injury. Vision and hearing loss and language barriers may increase risk for injury.

1. Assess your patient.	There are three areas to assess: 1. Is the patient cooperative and able to follow directions? Ask patient to squeeze your hands. Is the behaviour predictable (non-aggressive, fearful, or fatigued)? Is the patient able to follow directions with cues? If yes, proceed to next question. If no, use a mechanical lift for transfers and/or assistive devices for repositioning in bed if patient has some abilities. 2. Can the patient bear weight? Ask patient to lift buttocks off the bed (also known as “bridging”) and hold the position for 5 seconds. The health care provider may give cues on how to lift buttocks off the bed. Bridging hips strength test After bridging, ask the patient to perform a straight leg raise by lifting one leg up off the bed and holding it for 5 seconds while the other leg is kept bent. Repeat with the opposite leg. Leg lift strength test If yes, proceed to next question. If no, use an appropriate moving technique, such as a mechanical lift and/or assistive device, to transfer a non-weight-bearing patient. 3. Can the patient sit up on the side of the bed without support? Can the patient sit forward on a chair or the edge of the bed without support? Sit unassisted on the bed If yes, decide on the amount of assist required (minimum, moderate, or maximum) according to your agency policy. If no, use a mechanical lift for transfers and/or an assistive device for repositioning if patient has some movement abilities.
2. Assess your environment.	Is there adequate space? Is available equipment in proper working order? Have all hazards been removed?
3. Assess yourself and readiness to perform procedures.	Complete all required training according to health agency regulations. Wear non-slip footwear. Maintain a neutral spine; do not twist or side bend, and use proper body mechanics when moving or positioning patients. Designate a leader if working in a team to mobilize or position a patient. Always use proper weight-shift techniques (side to side, front to back, and up and down).
4. Assess your work organization.	Ensure adequate number of caregivers. Ensure there is enough time to perform the procedure. Take rest breaks and vary activities to promote optimal back health. If patient is complex or bariatric, consult additional resources, seek assistance, and use assistive devices.
Data source: Interior Health, 2012; National Institute of Occupational Safety and Health, 2010; PHSA, 2010; WorkSafeBC, 2010

To help you assess and make decisions about moving a patient, refer to these two useful tools.

Read the Mobility Decision Support Tool PDF, which was provincially developed, to guide decision making about transfers and ambulation.

Watch the Assess Every Time video, which was developed by WorkSafeBC, to review the quick assessment as described in Checklist 24.

A patient requires repositioning in bed. After your assessment, you determine the patient is cooperative and predictable, able to weight bear, but unable to sit up unassisted. What are your two options to reposition the patient?
When assessing your abilities to perform a patient-handling procedure, what five things must you consider?
Vision and hearing impairments, along with language barriers, are risk factors when performing patient-handling procedures. What additional risk factors should be considered?

Chapter 3. Safe Patient Handling, Positioning, and Transfers

Immobility in hospitalized patients is known to cause functional decline and complications affecting the respiratory, cardiovascular, gastrointestinal, integumentary, musculoskeletal, and renal systems (Kalisch, Lee, & Dabney, 2013). For surgical patients, early ambulation is the most significant factor in preventing complications (Sanguinetti, Wild, & Fain, 2014). Lack of mobility and ambulation can be especially devastating to the older adult when the aging process causes a more rapid decline in function (Graf, 2006). Ambulation provides not only improved physical function, but also improved emotional and social well-being (Kalisch et al., 2013).

Prior to assisting a patient to ambulate, it is important to perform a patient risk assessment to determine how much assistance will be required. An assessment can evaluate a patient’s muscle strength, activity tolerance, and ability to move, as well as the need to use assistive devices or find additional help. The amount of assistance will depend on the patient’s condition, length of stay and procedure, and any previous mobility restrictions.

Assisting Patient to the Sitting Position

Patients who have been immobile for a long period of time may experience vertigo, a sensation of dizziness, and orthostatic hypotension, a form of low blood pressure that occurs when changing position from lying down to sitting, making the patient feel dizzy, faint, or lightheaded (Potter, Perry, Ross-Kerr, & Wood, 2010). For this reason, always begin the ambulation process by sitting the patient on the side of the bed for a few minutes with legs dangling. Checklist 27 outlines the steps to positioning the patient on the side of a bed prior to ambulation (Perry, et al., 2014).

Checklist 27: Assisting a Patient to a Sitting Position


Perform hand hygiene. Check room for additional precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Listen and attend to patient cues. Ensure patient’s privacy and dignity. Assess ABCCS/suction/oxygen/safety. Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal. Follow the principles of proper body mechanics with all patient-handling procedures

1. Check physician’s order to ambulate and supplies for ambulation if required, and perform an assessment of patient’s strength and abilities. Check physician orders for any restrictions related to ambulation due to medical treatment or surgical procedure.	Supplies (proper footwear, gait belt, or assistive devices) must be gathered prior to ambulation. Do not leave patient sitting on the side of the bed unsupervised as this poses a safety risk.
2. Explain what will happen and let the patient know how they can help.	This step provides the patient with an opportunity to ask questions and help with the positioning.
3. Lower bed and ensure brakes are applied.	This prepares the work environment.
4. Stand facing the head of the bed at a 45-degree angle with your feet apart, with one foot in front of the other. Stand next to the waist of the patient.	Proper positioning helps prevent back injuries and provides support and balance.
5. Have patient turn onto side, facing toward the caregiver. Assist patient to move close to the edge of the bed.	This step prepares the patient to be moved. Positioning patient on the side of the bed
6. Place one hand behind patient’s shoulders, supporting the neck and vertebrae.	This provides support for the patient.
7. On the count of three, instruct the patient to use their elbows to push up on the bed and then grasp the side rails, as you support the shoulders as the patient sits up. Shift weight from the front foot to the back foot.	Do not allow the patient to place their arms around your shoulders. This action can lead to serious back injuries.
8. At the same time as you’re shifting your weight, gently grasp the patient’s outer thighs with your other hand and help the patient slide their feet off the bed to dangle or touch the floor.	This step helps the patient sit up and move legs off the bed at the same time. Assisting patient into a sitting position
9. Bend your knees and keep back straight and neutral.	Use of proper body mechanics helps prevent injury when handling patients.
10. On the count of three, gently raise the patient to sitting position. Ask patient to push against bed with the arm closest to the bed, at the same time as you shift your weight from the front foot to the back foot.	This allows the patient to help with the process and prevents injury to the health care provider. Assist into a sitting position
11. Assess patient for orthostatic hypotension or vertigo.	If patient is not dizzy or lightheaded, the patient is safe to ambulate. If patient becomes dizzy or faint, lay patient back down on bed.
12. Continue with mobilization procedures as required.	Mobilization helps prevent complications and improves physical function in hospitalized patients.
Data source: ATI, 2015b; Interior Health, 2013; Perry et al., 2014; PHSA, 2010

Video 3.2

Ambulating a Patient

Ambulation is defined as moving a patient from one place to another (Potter et al., 2010). Once a patient is assessed as safe to ambulate, determine if assistance from additional health care providers or assistive devices is required. Checklist 28 reviews the steps to ambulating a patient with and without a gait belt.

Checklist 28: Ambulating a Patient


Perform hand hygiene. Check room for additional precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Listen and attend to patient cues. Ensure patient’s privacy and dignity. Assess ABCCS/suction/oxygen/safety. Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal. Bring in required assistive devices and proper footwear.

1. Ensure patient does not feel dizzy or lightheaded and is tolerating the upright position. Instruct the patient to sit on the side of the bed first, prior to ambulation. Ensure proper footwear is on patient, and let patient know how far you will be ambulating. Proper footwear is non-slip or slip resistant footwear. Socks are not considered proper footwear. Check physician’s orders for any activity restrictions related to treatment or surgical procedures.	Proper footwear is essential to prevent accidental falls. Footwear
2. Apply gait belt snugly around the patient’s waist if required.	Assessment and instructions prior to ambulation Gait belts are applied over clothing. Apply gait belt over clothing Gait belt should be snug, not tight
3. Assist patient by standing in front of the patient, grasping each side of the gait belt, keeping back straight and knees bent.	The patient should be cooperative and predictable, able to bear weight on own legs and to have good trunk control. Apply gait belt if required for additional support.
4. While holding the belt, gently rock back and forth three times. On the third time, pull patient into a standing position.	This action provides momentum to help patient into a standing position. Rock back and forth to provide momentum Pulled to a standing position
5. Once patient is standing and feels stable, move to the unaffected side and grasp the gait belt in the middle of the back. With the other hand, hold the patient’s hand closest to you. If the patient does not require a gait belt, place hand closest to the patient around the upper arm and hold the patient’s hand with your other hand.	Standing to the side of the patient provides assistance without blocking the patient. Assisting ambulation with a gait belt
6. Before stepping away from the bed, ask the patient if they feel dizzy or lightheaded. If they do, sit patient back down on the bed. If patient feels stable, begin walking, matching your steps to the patient’s. Instruct patient to look ahead and lift each foot off the ground.	Always perform a risk assessment prior to ambulation. Walk only as far as the patient can tolerate without feeling dizzy or weak. Ask patient how they feel during ambulation.
7. To help a patient back to bed, have patient stand with back of knees touching the bed. Grasp the gait belt and help patient into a sitting position, keeping your back straight and knees bent.	Allowing a patient to rest after ambulation helps prevent fatigue.
8. When patient is finished ambulating, remove gait belt and settle patient into bed or a chair.	This provides a safe place for the patient to rest. Remove gait belt
9. When patient returns to bed, place the bed in lowest position, raise side rails as required, and ensure call bell is within reach. Perform hand hygiene.	Placing bed and side rails in a safe position reduces the likelihood of injury to patient. Proper placement of call bell facilitates patient’s ability to ask for assistance. Bed in the lowest position, call bell in reach, and side rail up Hand hygiene reduces the spread of microorganisms.
10. Document patient’s ability to tolerate ambulation and type of assistance required.	This provides a baseline of patient’s abilities and promotes clear communication between health care providers.
Data source: ATI, 2015b; Interior Health, 2013; Perry et al., 2014; PHSA, 2010

Video 3.3

Video 3.4

Watch the video How to Ambulate with a Cane by Kim Morris of Thompson Rivers University.

Video 3.5

Watch a video How to Ambulate With Crutches by Kim Morris, Thompson Rivers University.

A 90-year-old male patient is required to ambulate. He had a total hip arthroplasty and is post-operative day 3 (POD 3). What risk factors should be considered prior to ambulating an elderly patient who has been immobile after hip surgery?
Does ambulation require a physician’s order?
What should you do if a patient feels dizzy or lightheaded before ambulation?