Body Mechanics / Body Transfer
Video
Body mechanics is a broad term used to denote an effort coordinated by the muscles, bones and nervous system. It can either be good or bad and can be directly related to the occurrence of back pains.
Jobs of health care team members require pushing, pulling, carrying and lifting during patient care activities. Prolonged performance of these actions and utilization of incorrect muscles in completing a task can cause severe musculoskeletal strains and fatigue thereby increasing the risk of injuring the patients as well. To avoid these problems, proper body mechanics should be consciously used in performing a physical activity.
Correct body mechanics is the utilization of proper body movement and a result of the coordination of musculoskeletal and nervous systems in maintaining balance, posture, body alignment during activity performance. The scope of body mechanics involves the knowledge on how certain muscles are utilized and explanations of its exploitation.
Purpose
Reasons on the utilization of body mechanics are mainly to prevent and avoid:
Musculoskeletal strain
Injuries to staff members
Injuries to clients
Extreme fatigue
Musculoskeletal system is the second largest body system; it includes the bones, joints, and skeletal muscles, as well as their supporting structures. Disease, surgery, and trauma often affect one or more parts of this system, yet its assessment is often overlooked by nurses. This chapter does not include diagnostic testing related to arthritis or specific tests for osteoporosis. Descriptions of those tests are found in Chapters 21 and 51 under discussions of those diseases.
ANATOMY AND PHYSIOLOGY REVIEW Skeletal System
The skeletal system consists of 206 bones and multiple joints. The growth and development of these structures occur during childhood and adolescence and are not discussed in this text.
i BONES Types
Bones may be classified by their shape. Long bones, such as the femur, are cylindric with rounded ends; they often bear weight. Short bones, such as the phalanges, are small and bear little or no weight. Flat bones, such as the scapula, protect vital organs and often contain blood-forming cells. Bones that have unique shapes are known as irregular bones (e.g., the carpal bones in the wrist). The sesamoid bone is the least common type and develops within a tendon; the patella is a typical example.
I Structure
As shown in Figure 50-1, the outer layer of bone, or cortex, is composed of dense, compact bone tissue. The inner layer, in the medulla, contains spongy, cancellous tissue. Almost every bone has both tissue types but in varying quantities. The long bone typically has a shaft, or diaphysis, and two knoblike ends, or epiphyses.
The structural unit of the cortical, compact bone is the haversian system, as detailed in Figure 50-1. The haversian system is a complex canal network containing microscopic blood vessels, which supply nutrients and oxygen to bone, and lacunae, which are small cavities that house osteocytes (bone cells). The canals run longitudinally within the hard, cortical bone tissue.
The softer, cancellous tissue contains large spaces, or tra-beculae, which are filled with red and yellow marrow. Hematopoiesis (production of blood cells) occurs in the red marrow. The yellow marrow contains fat cells, which can be dislodged and enter the bloodstream to cause fat embolism syndrome (
Bone also contains a matrix (also called osteoid) consisting chiefly of collagen, mucopolysaccharides, and lipids. Deposits of inorganic calcium salts (carbonate and phosphate) in the matrix provide the hardness of bone.
Bone is a very vascular tissue; its estimated total blood flow is between 200 and 400 mL/min. Each bone has a principal nutrient artery, which enters near the middle of the shaft and branches into ascending and descending vessels. These vessels supply the cortex, the marrow, and the haversian system. Sympathetic and afferent (sensory) fibers constitute the sparse nerve supply to bone. Dilation of blood vessels is controlled by the sympathetic nerves. The afferent fibers transmit the pain experienced by clients who have primary lesions of the bone.
■ Growth and Metabolism
After puberty, bone reaches its maturity and maximal growth. Bone is a dynamic tissue, however, that undergoes a continuous process of formation and resorption, or destruction, at equal rates until the age of 35 years. In later years, bone resorption accelerates, decreasing bone mass and predisposing clients to injury. (See Chapter 51 for a discussion of the effects of aging on bone metabolism.)
Bone growth and metabolism are affected by numerous minerals and hormones, including the following:
» Calcium
• Phosphorus
• Calcitonin
• Vitamin D
• Parathyroid hormone (PTH)
• Growth hormone
Glucocorticoids
• Estrogens and androgens
• Thyroxine
• Insulin
1 JOINTS
I Types
There are three types of joints in the body:
■ Synarthrodial, or completely immovable, joints (e.g., in the cranium)
Amphiarthrodial, or slightly movable, joints (e.g., in the pelvis) • Diarthrodial (synovial), or freely movable, joints (e.g.,
the elbow and knee)
Although any of these joints can be affected by disease or injury, the diarthrodial joints are most commonly involved.
1 Structure and Function
The diarthrodial, or synovial, joint is the most common type of joint in the body. Synovial joints are so named because they are the only type lined with synovium, a membrane that secretes synovial fluid for lubrication and shock absorption. As illustrated in Figure 50-2, the synovium lines the internal portion of the joint capsule but does notnormally extend onto the surface of the cartilage at the spongy bone ends. Articular cartilage consists of a collagen fiber matrix impregnated with a complex ground substance. Bursae, small sacs located at joints to prevent friction, are also lined with synovial membrane.
Synovial joints are subtyped by their anatomic structures. Ball-and-socket joints (shoulder, hip) permit movement in any direction. Hinge joints (elbow) allow motion in one plane, flexion, and extension. The knee is often classified as a hinge joint, but it rotates slightly, as well as flexes and extends. It is best described as a condylar type of synovial joint
I Types
There are three types of joints in the body:
■ Synarthrodial, or completely immovable, joints (e.g., in the cranium)
Amphiarthrodial, or slightly movable, joints (e.g., in the pelvis) • Diarthrodial (synovial), or freely movable, joints (e.g.,
the elbow and knee)
Although any of these joints can be affected by disease or injury, the diarthrodial joints are most commonly involved.
1 Structure and Function
The diarthrodial, or synovial, joint is the most common type of joint in the body. Synovial joints are so named because they are the only type lined with synovium, a membrane that secretes synovial fluid for lubrication and shock absorption. As illustrated in Figure 50-2, the synovium lines the internal portion of the joint capsule but does not normally extend onto the surface of the cartilage at the spongy bone ends. Articular cartilage consists of a collagen fiber matrix impregnated with a complex ground substance. Bursae, small sacs located at joints to prevent friction, are also lined with synovial membrane.
Synovial joints are subtyped by their anatomic structures. Ball-and-socket joints (shoulder, hip) permit movement in any direction. Hinge joints (elbow) allow motion in one plane, flexion, and extension. The knee is often classified as a hinge joint, but it rotates slightly, as well as flexes and extends. It is best described as a condylar type of synovial joint.
Muscular System
There are three types of muscle in the body: smooth muscle, cardiac muscle, and skeletal muscle. Smooth, or nonstriated, involuntary muscle is responsible for contractions of organs and blood vessels and is controlled by the autonomic nervous system. Cardiac muscle, or the myocardium, is also controlled by the autonomic nervous system. The smooth and cardiac muscles are discussed with the body systems to which they belong in the assessment chapters.
■ Structure
In contrast to smooth and cardiac muscle, skeletal muscle is voluntarily controlled by the central and peripheral nervous systems. The junction of a peripheral motor nerve and the muscle cells that it supplies is sometimes referred to as a motor end plate. Muscle fibers are held in place by connective tissue in bundles, or fasciculi. The entire muscle is surrounded by dense, fibrous tissue (fascia) containing the muscle’s blood, lymph, and nerve supply.
1 Function
The primary function of skeletal muscle is movement of the body and its parts. When bones, joints, and supporting structures are adversely affected by injury or disease, the adjacent muscle tissue is often involved, limiting mobility. During theaging process, muscle fibers decrease in size and number, even in well-conditioned people. This senile atrophy is compounded when muscles are not regularly exercised, and they deteriorate from disuse.
I DEMOGRAPHIC DATA
Young men are at the greatest risk for trauma related to motor vehicle crashes. Older adults are at the greatest risk for falls that result in fractures and soft-tissue injury (see Chapter 5).
Supporting Structures
In addition to the articular cartilage of joints, several types of cartilage occur in other areas. Costal cartilage connects the sternum to the rib cage. Hyaline cartilage is in the septum of the nose, larynx, and trachea. The external ear and epiglottis contain yellow cartilage. In all areas, the tissue is flexible and elastic and can withstand enormous tension.
Other important supporting structures that are susceptible to injury include tendons (bands of tough, fibrous tissue that attach muscles to bones) and ligaments, which attach bones to other bones at joints.
Musculoskeletal Changes Associated with Aging
As one ages, bone density often decreases, causing postural changes and predisposing a person to fractures. Synovial joint cartilage degenerates as a result of the repeated use of joints, especially weight-bearing joints such as the hips and knees. The result is often degenerative joint disease. Muscle tissue atrophy occurs, but its rate may be slowed by increased activity and exercise. Collectively, these changes cause decreased coordination, gait changes, and predisposition to falls with injury. Chart 50-1 lists the major anatomic and physiologic changes and suggested nursing interventions.
Principles of body mechanics
· Maintain a stable center of gravity – This posture evenly distributes the weight in the body.
1. Keep a low center of gravity.
2. A lower center of gravity means greater balance.
3. Flex the hips and knees while keeping the trunk erect as an alternative of bending on the waist.
· A wide base of support is maintained – This provides lateral stability and helps in lowering the center of gravity.
1. Wider base of support means greater stability.
2. Spread the feet apart to a comfortable distance.
3. Flex the knees to move the center of gravity to the base of support.
· Proper body alignment
1. Body alignment refers to the arrangement of joints, tendons, ligaments, and muscles while in a standing, sitting or lying positions.
2. A line of gravity passing through its base for support maintains equilibrium.
3. Equal activity balance in upper and lower body parts reduces risk of back injury.
4. A stronger muscle group means a greater amount of work can be safely executed with it.
5. Keep the back straight in performing any activity.
Body balance is achieved when these principles are implemented. Always remember, when the body is improperly balanced, the center of gravity is displaced, the base of support is narrowed and the body is not correctly aligned.
Pushing
Stand close to the object.
Place feet in a walking position (one is in front of the other)
With hands placed on the object, flex elbows and lean into the object.
Place the weight from the flexor to the extensor portions of the leg.
Apply pressure using leg muscles.
1. Alternate rest period is advisable to prevent fatigue.
Pulling
1. Stand close to the object.
2. Place feet in a walking position (one is in front of the other)
3. Hold object and flex elbows and lean away from the object.
4. Shift weight from the extensor to the flexor portions of the leg.
5. Avoid sudden, jerky movements.
6. Alternate rest period is advisable to prevent fatigue.
Lifting and Carrying
1. Assume a squat position facing the object or client.
2. Grasp the object and tighten the abdominal muscles.
3. Use the stronger leg muscles in lifting.
4. In carrying, hold the object at waist height and near the body.
5. Keep the upper trunk erect.
6. It is easier to pull, roll, push, turn, lever and pivot that it is to lift something.
CHECKLIST FOR MOVING AND LIFTING
MOVING TO THE SIDE OF THE BED
Stand facing patient at the side of the bed.
A. Assume a broad stance, one leg forward of the other with knees and hips flexed, bring arms to the level of the bed.
one arm under shoulders and neck pf patient and another arm under small of patient’s back.
C. Shift body weight from front to back foot, rock backward to a crouch position, bringing patients towards his side. Nurse’s hips come downwards as he rocks backwards. Patient should be pulled.
HELPING THE PATIENT TURN ON HIS SIDE
1. Stand at the side of the bed towards which patient is to be turned. Place patient’s far arm across his chest and far leg over near leg, near arm is lateral to and away from his body.
2. Stand opposite to the patient’s waist and face side of the bed with one foot a step in front of the other.
3. Place one hand on patient’s far shoulder and one hand on his far hip.
4. Shift weight from forwarded leg to rear leg, patient is turned towards the nurse hips come downward.
5. Patient is stopped by nurse’s elbows, which come to rest on mattress at the edge of the bed.
RAISING SHOULDERS OF THE HELPLESS PATIENT
1. Stand at side of the side of the bed and face patient head.
2. Assume a wide stance with foot next to bed behind the other foot.
3. Pass arm over the patient’s near shoulders and rest hand between patient’s shoulder blades.
4. Rock backward, shift weight from forwarded foot to rear foot, hips coming straight down.
RAISING THE SHOULDERS OF TH SEMI HELPLESS PATIENT
1. Stand at one side of the bed facing the head of the patient. Foot next to bed is to rear and the other foot forward. Provide wide base of support.
2. Bend knees to bring arm next to bed down to a level with a surface of the bed.
3. With elbow on the patient‘s bed grasps the nurse’s arm in the same manner.
4. Rock forward, shift weight from forwarded foot to rear foot to bring hips downward. Elbow remains on bed, which serves as fulcrum.
MOVING THE HELPLESS PATIENT UP IN BED
1. Stand at the side of the bed and face the far corner of the foot of the bed.
2. Flex knees so that arms are leveled with the bed. Put arm under patient, one arm under patient’s head and shoulders, one hand under small of his back.
3. Rock forward. Shift weight from forwarded foot to rear foot, hips coming downward. Patient will slide diagonally across the bed towards the head and side of the bed.
4. Repeat from tuck and legs of patient.
5. Go to the other side of the bed and repeat number 1 – 3. Continue this process until patient is satisfactorily positioned.
MOVING THE SEMI HELPLESS PATIENT UP IN BED
1. Patient flexes knees, bringing heels up to his buttocks.
2. Stand at the side of the bed, turn slightly towards patient’s head. One foot is stepped in front of the other foot closer to bed. Feet are directed towards the head of the bed.
3. Place one arm under patient’s shoulders, one arm under thighs. Flex knees to bring arms to the level of the surface of the bed.
4. Patient places chin on his chest and pushes with his feet. Nurse shifts weight from rear foot to forwarded foot. Patient grasps the head of the bed with his hands to pull on his own weight.
HELPING THE SEMI HELPLESS: PATIENT RAISE HIS BUTTOCKS
Patient flexes knees and brings heels towards the buttocks.
1. Nurse faces the side of the bed and stands opposite to the patient’s buttocks. Assume a board stance.
2. Flex knees to bring arms to the level of the bed, place one hand under sacral area of the patient. The elbow is resting firmly on the 3 bed.
3. As the patient raises his hips, the nurse comes to a crouching position by bending his knees while his arms act as a lever to help support the patient’s buttocks. Nurse’s hips come straight down. While supporting patient in this position, free hand can place bedpan under the patient’s sacral area.
ASSISTING THE PATIENT TO A SITING POSITION ON THE SIDE OF THE BED
1. Patient is turned to the side towards the edge of the bed.
2. The nurse ensures that the patient does not fall out of the bed by raising the head of the bed.
3. Face the far bottom corner of the bed, support the shoulders of the patient with one arm and the other arm helps patient extend lower legs over the side of the bed top the rear of the other foot.
4. Bring patient to a natural sitting position on the bed; support the patient’s shoulders and legs over the side of the bed. Pivot body to lower legs of the patient. Patient’s legs are swung downward. Nurse’s weight is shifted form front to rear leg.
ASSISTING THE PATIENT TO GET OF BED AND INTO A CHAIR
1. The patient assumes a suiting position on the edge of the bed, put on shoes/slipper and gown.
2. Place the chair at the side of the bed with back towards foot of the bed.
3. Stand facing patient with foot closer to the chair and a step in front of the other to give the nurse a wide base of support.
4. Place patient’s hands on the nurses shoulders and the nurse grasps patient’s waist.
5. Patient steps on the floor and the nurse flexes her knees, forwarded knee is against the patient knee. This provides patient’s knees bending involuntarily.
6. Turn with the patient while maintaining a wide base of support. Bend knees as the patient sits on chair.
CHECKLIST FOR OCCUPIED BED
1. Do the medical handwashing.
2. Gather equipments at bed side and arrange according to use. Explain procedure to patient and screen.
3. Loosen the linens starting at the foot part, then to the sides and around. Remove pillows unless contraindicated.
4. Place clean top sheet over dirty top sheet wider hem, wrong side out at the head part of bed. Spread, then remove the dirty linen without exposing the patient.
5. Turn patient towards one side of the bed.
6. Work on the unoccupied side of the bed. Roll dirty linens toward the patient (except rubber sheet).
7. Place bottom sheet following the principles, tuck head part miter corner tuck. Roll used rubber sheet towards you. Replace with a new one.
8. Place draw sheep over rubber sheet. Tuck together.
9. Turn patient towards made bed.
10. Work on the other side. Remove dirty linens.
11. Spread clean linens, tuck head part of the bottom sheet, miter at side, tuck all together. Do the same with rubber sheet and draw sheet.
12. Turn patient to the center of the bed.
13. Arrange top sheet, fold head part up to the patient’s chest.
14. Make a toe pleat.
15. Tuck foot part, miter corner.
16. Time limit, check features of a good bed and proper body mechanics.
CHECKLIST FOR CLOSED BED
1. Do the medical handwashing.
2. Gather and prepare equipments. Put linens properly and in the chair in the order of their use.
3. Flupp mattress and put on mattress cover
4. Place bottom sheet (folded crosswise, then to quarters lengthwise, then 1/8, narrow hem out, wrong side out) at the edge of the mattress at the foot part of the bed.
5. Open and unfold bottom sheet following the principles and tuck head part then to the side; miter the corner, stretch and tuck the sides.
6. Place rubber sheet (folded crosswise and quarters wrong side out) at the center of the bed. Tuck.
7. Place draw sheet (folded crosswise and quarters wrong side out) on top rubber sheet. Tuck.
8. Place top sheet (folded crosswise, quarters, then 1/8 right side out, wider hem out) at the edge of mattress at head part of the bed.
9. Open and unfold top sheet following the principles and tuck at the foot part of the bed, miter corner.
10. Fold top sheet
11. Do the same on the other side of the bed.
12. Make a toe pleat.
13. Put on pillow cover and put pillow on the head part.
14. Place loose part of top sheet at the center of bed.
15. Place bed cover – Folded wrong side out, wider hem, out then quarters. Place at head part of the bed. Tuck at foot part.
Body mechanics involve pushing, stooping, carrying, and lifting correctly. Included in this clinical skill is knowledge and the correct performance of various client transfer techniques using team approaches as well as diverse supportive equipment. This skill reviews the proper techniques of general body mechanics as well as some specialized lifting skills from bed to stretcher and from bed to chair and wheelchair and the use of the bed transfer board and a hydraulic lift. Specific tips for client and staff safety will be highlighted, as well as the promotion of client independence and self-help behaviour as an intervention to reduce the risk of client and nurse injury. There are also warm-up exercises that nurses can perform to help avoid injury (see Figure 2-2-3). Use of proper body mechanics maximizes the effectiveness of the efforts of the musculoskeletal and neurological systems and reduces the body’s exposure to strain or injury during movement. Proper body mechanics are as important to the nurse as to the client. The purpose of proper body mechanics is prevention of strain and injury to the muscles, joints, and tendons.
Range of motion reflects the extent to which a joint can move. The ranges vary with each joint and are affected by several factors, including age, physical condition, and heredity. Parameters for range of motion are outlined in tables
The clinical application of body mechanics is described later in the implementation section of this chapter.
PHYSIOLOGY OF MOBILITY
Mobility is regulated by the coordinated effort of the musculoskeletal and neurological systems. The major functions of the musculoskeletal system are to maintain body alignment and to facilitate mobility. The musculoskeletal system consists of a framework of bones, muscles, joints, tendons, ligaments, bursae, and cartilage.
The Musculoskeletal System
The musculoskeletal system (comprised of bones, cartilage, joints, tendons, ligaments, bursa, and muscles) serves several functions as described in Table 34-1. Bone is the foundation of the musculoskeletal system.
Mobility and weight-bearing capacity are directly related to the bone’s size and shape. Joints work with muscles to provide motion and flexibility. Skeletal muscles overlying the joint exert opposing forces and, therefore, cause movement.
Muscles are basically machines that convert energy into mechanical work. Contractility is the common property among the three types of muscles: smooth, cardiac, and skeletal. Skeletal muscle fibers are innervated by somatic nerves, and, therefore are generally under voluntary control.
The muscles work in cooperation with the nervous system to maintain body alignment and cause movement. Muscles act in pairs to perform work. One muscle of the pair produces movement in a single direction. The other muscle of the pair produces movement in the opposite direction. When one muscle of the pair is contracted, the other is relaxed. The opposing actions of contraction and relaxation make motion possible. The position of the tendons upon the bones and the articulation of the bones make possible types of motion such as flexion, extension, circumduction, rotation, and gliding. Muscles that maintain body alignment work together to stabilize surrounding body parts and to support the body’s weight. Posture is maintained primarily by the muscles in the back, neck, trunk, and lower extremities.
Nervous System
Muscle contraction is controlled by the central nervous system (CNS) and is influenced by the transport of nutrients and oxygen and by the removal of waste products.
An intact CNS is essential for coordinated movement to occur. Nerve impulses stimulate the muscles to contract.
The myoneuronal junction is the point at which nerve endings come into contact with muscle cells. The afferent pathway conveys information from sensory receptors to the CNS; these neurons conduct impulses throughout the body. The CNS processes the sensory input and determines a response. The efferent pathway transmits the desired response to skeletal muscles via the somatic nervous system. If the nerve impulses are interrupted, the muscle is paralyzed and cannot contract.
Proprioception
Proprioception is the awareness of posture, movement, and changes in equilibrium and the knowledge of posi tion, weight, and resistance of objects in relation to the body. Nerve endings in muscles, tendons, and joints (proprioceptors) continuously provide input to the brain, which, in turn, regulates smooth coordinated involuntary movement.
Postural Reflexes
Postural tonus is maintained by postural or righting reflexes. Table 34-2 describes the major reflexes involved in maintaining posture.
EXERCISE
Exercise is any physical activity involving muscles that elevates the heart rate above resting levels. Exercise reduces joint pain and stiffness, and increases flexibility, muscle strength, and endurance. It also helps with weight reduction and contributes to an improved sense of well-being (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 1997). Americans have become less active in recent years (Bray, 1998).
The U.S. Surgeon General’s Report on Physical Health and Activity (Centers for Disease Control and Prevention, 1999) lists the following facts about exercise:
• People who are usually inactive can improve their health and well-being by becoming even moderately active on a regular basis.
• Physical activity need not be strenuous to achieve health benefits.
• Greater health benefits can be achieved by increasing the amount (duration, frequency, or intensity) of physical activity.
Vigorous exercise stimulates an increased production of endorphins, which promote a sense of wellbeing.However, it is important to caution people not to overdo the exercise, especially when first starting a new regimen. The following may be signs of too much exercise: unusual or persistent fatigue, increased weakness, decreased range of motion, joint swelling, or continuing pain (pain that lasts more than 1 hour after exercising) (National Institute of Arthritis and Musculoskeletal System, 1997). Instruct clients, especially those with sedentary lifestyles, to consult their nurse practitioner or physician before beginning an exercise program.
Types of Exercise
There are several types of exercise that promote physical and psychologic health; see Table 34-3.
MOVING WITH HELP
At various stages in your life with ALS, transfers — moving you from one surface to another — may require no assistance, the assistance of one other person, the assistance of several people or the use of special equipment.
The degree of your weakness at each stage of ALS will determine the type of transfer necessary and the number of people or type of equipment required to perform the transfer. It’s imperative that your safety and the safety of your caregiver be the top priority in this process.
The instructions in this chapter are addressed more to your caregiver than to you, as the person with ALS, for self-evident reasons. Nonetheless, you’ll want to be aware of these techniques so you’ll understand the procedures, direct the transfers in some cases and anticipate the movements in the process.
(By the way, for simplicity’s sake, this chapter often refers to the person with ALS as “he,” but of course the same information applies whether you’re a man or a woman.)
Transfer techniques should be taught to your primary caregivers by a physical or occupational therapist. The therapist will assist you and your caregivers in deciding upon the most appropriate transfer methods. Any time you’re having trouble with transfers, your health care team can answer questions and help with techniques and equipment.
Keep in mind that all transfers take some practice. With experience, your caregiver soon will be able to do them with ease.
SPECIAL NOTE:
Caregivers: The following descriptions are general guidelines. Review them with your health care team to be sure they apply to the person you’re caring for. Transfer needs can vary among individuals, and for safety’s sake you should let a PT or OT show you how to transfer your loved one.
INSTRUCTIONS FOR CAREGIVERS
Sliding Board Transfer
The sliding board transfer requires the use of a transfer belt or gait belt and a sliding board or transfer board. Your OT or PT can help you find this equipment. Use the sliding transfer when moving the person with ALS to or from a bed or chair into the wheelchair.
Position the wheelchair and lock it parallel to or at a slight angle to the bed.
When you’re transferring the person with ALS from the bed to the wheelchair, you should remove the armrest on the side you’re transferring to. He should lean slightly and you should place the sliding board well under the buttocks, with the other end of the board over the wheelchair seat. Be careful not to pinch him between the board and the bed.
Stand in front of your loved one to block his knees. Grasp his transfer belt at the back and perform the transfer by a series of leaning and sliding movements until he’s moved down the board into the chair.
When he’s on the chair, remove the board and release him when he’s sitting in a position he can maintain.
You can reverse this procedure when transferring him to a bed.
Standing Pivot Transfer Without Assistance
Here’s a way of transferring someone from the wheelchair to the bed without a sliding board.
The person with ALS moves to the edge of the locked wheelchair and, using the arms of the chair, pushes to a standing position.
He or she pivots by moving the feet in small increments, and then reaches for the bed. Note: Reaching for the bed before pivoting may lead to a loss of balance.
The person sits by lowering himself to the bed.
Standing Pivot Transfer With Assistance
The person with ALS should assist as much as possible when being helped to the standing position. In this way you don’t actually lift, but only help him into the upright position. This requires the use of good body mechanics and a transfer belt.
Remove the footrests from the wheelchair; then the person being transferred places his feet on the floor directly under the knees. He slides forward to the edge of the locked wheelchair.
Place your feet and knees to the outside of his feet and knees. He then places his hands on the armrests in preparation to assist in pushing to the standing position.
With your knees bent, grasp the person’s transfer belt at the back and initiate a forward rocking motion.
Give the command to “stand” and straighten your knees to assist him to a standing position. Continue to grasp the transfer belt as he pivots toward the bed. A transfer pivot disc is often helpful in this process.
He lowers himself to the bed, but don’t release him until he’s in a position he can maintain.
SPECIAL TRANSFERS
When transferring your loved one with ALS to the toilet, car or bathtub, you should use the same techniques described above, with the following additional considerations:
Toilet
Position the locked wheelchair facing the toilet at a slight angle. After the person with ALS has achieved standing, assist him in partially disrobing. Then help him to sit on the toilet.
Bathtub
Position the locked wheelchair parallel to the tub and remove the footrests and the armrest nearest the tub. The person with ALS moves to the outside edge of the tub bench while you assist in maintaining his balance.
Place one arm around his shoulders and the other arm under the knees. With one movement, pivot him to face forward on the bench while swinging the legs into the tub.
Car
Position the locked wheelchair parallel to the car. Transfer your loved one to the outside edge of the car seat.
Place one arm around his shoulders and the other arm under the knees. With one movement, pivot his legs onto the floorboard of the car.
BODY MECHANICS FOR THE CAREGIVER
As you assume more responsibility for the care of your loved one with ALS, your risk of injury increases. The use of proper body mechanics will minimize this risk. Good body mechanics distributes the stress over several sets of muscles and uses the stronger muscles.
General principles are as follows:
Lifting
Face the person with ALS squarely, with your feet shoulder width apart.
Position yourself as close to him or her as possible. Bend your knees and lift with the legs rather than the back. Keep your head up.
Pushing/Pulling
Keep your feet apart — one foot in front of the other. Shift your weight from your back foot to your front foot. It’s usually safer to push than to pull.
Spotlight on Transfer Tips and Precautions
To prevent back injury to you (the caregiver), bend at the hips and knees, not at the waist, as you prepare to lift someone; then straighten at the hips and knees as you lift.
Keep a wide base of support by spreading your feet apart. If you’re transferring someone from one place to another, stagger your feet in a walking position, and shift your weight from front to back as you lift, while keeping the person as close to you as possible.
To avoid back injury: When turning, pivot on your feet or move them. Don’t twist at the waist. For added back support, consider wearing a safety belt like those used by workers who frequently lift and carry items on the job.
Wear shoes with low heels, flexible nonslip soles and closed backs.
Plan ahead. Know where you’re going and how you’re going to get there, and make sure the person you’re lifting also knows. Move everything out of the way, and make sure the brakes are engaged on any wheeled devices. Transfer him to even, stable surfaces; avoid low or overstuffed chairs and couches.
If he starts to fall, ease him down onto the nearest surface — a chair, bed or even the floor. Don’t stretch to complete the intended transfer. You’re likely to lose your balance, strain your muscles, and injure both yourself and the person you’re transferring.
Tailor your lifting and transferring techniques to the type and degree of weakness in the person with ALS. Needs may change over time as weakness progresses.
Use mechanical devices to help you whenever possible.
If the person you’re transferring is using a wheelchair, be sure to stabilize it by securing the brakes. Remove the footrests and armrest on the side he’s being transferred toward.
Don’t be discouraged if a lift seems cumbersome or too difficult to use at first. Practice makes perfect!
DEPENDENT TRANSFERS
If the person with ALS is unable to assist in the transfer, a dependent transfer will be necessary. There are two major types of dependent transfers: dependent standing pivot and a two-person lift. You may also choose to use a mechanical or hydraulic lift. A physical therapist will assist you in selecting the proper type of transfer and instruct you in how to do it.
Dependent Standing Pivot
When transferring someone from a wheelchair to a bed, place the locked wheelchair parallel to the bed and remove both footrests and the armrest nearest the bed. With the person’s feet on the floor, move him to the edge of the seat by grasping under the knees and pulling forward. Place his feet outside your feet and block his knees.
Reach around the back of the person and grasp the transfer belt while he attempts to hold his arms together in front of the body.
Initiate a rocking motion and then straighten his legs to lift him out of the chair. The lift need be only high enough to clear the wheelchair.
In a swift motion, pivot toward the bed, rotating the person to the proper position for sitting. Lower him to the bed but don’t release him until he’s in a position that can be maintained.
Dependent Two-Person Lift
Position the wheelchair at a slight angle to the bed. Remove both footrests and the armrest nearest the bed. Caregiver #1 (generally the stronger person) should stand next to the chair, within the angle formed by the chair and bed. Caregiver #2 will stand in front of and facing the person you’re transferring.
Have the person cross his arms in front of his chest. Caregiver #1 should reach under the arms and grasp the person’s right wrist with the right hand and his left wrist with the left hand. Caregiver #2, with feet apart and knees bent, should support the legs by placing both hands under the knees.
On command from caregiver #1, raise the person to a height that will ensure that he clears all parts of the wheelchair. In one smooth motion caregiver #1 should step to the side and lower him onto the bed.
MECHANICAL AND HYDRAULIC LIFTS
Lifts provide a method by which one person can transfer a person with ALS. This is especially useful if the person with ALS is larger than you.
There are two types of lifts: mechanical and hydraulic. The hydraulic lift, especially the battery-operated type, is generally considered easier to operate, putting much less stress on the caregiver. Some lifts are made to sit and roll on the floor; another type runs on a ceiling track and may help transport a person from room to room.
There are many types of slings available, including one with a head support. A sling may be lifted by means of chains or web straps.
SPECIAL NOTE: Lift transfers must not be attempted without proper instruction and demonstration. Consult with your PT!
The following demonstrates the use of a hydraulic lift (such as a Hoyer lift) using a sling lifted by means of web straps.
Position the sling under the person by rolling him to one side, positioning the sling, then rolling him to the other side. To avoid pressure on his skin, position the seams away from him.
Check to be sure the valve locking device is closed.
Move the lift into position so the swivel bar hook is over the center of the person’s abdomen. Attach the web straps to the sling by placing the S-shaped hooks through the holes in the sling. Make sure the tips of the hooks point away from the person.
Attach the shortest web strap through the hole for the back and head support part of the sling. This will ensure a sitting position when you raise the person. Finally, attach the top of the web straps to the swivel bar.
Place the base in the widest possible position before raising the person. Raise him slowly by pumping the jack handle, taking care to ensure that a safe sitting position is attained. Move him into position over the seat of the locked wheelchair.
Lower him by pressing the jack handle inward toward the jack. Be sure to lower him slowly and guide the descent by slight pressure to his knees or thighs. This pushes him into the sitting position.
Once your loved one is seated in the wheelchair, close the valve by moving the jack handle away from the jack. Remove the web straps from the sling and move the lift away from the wheelchair.
BED POSITIONING
If the person with ALS is unable to move independently in bed, a bed-positioning program will promote his or her comfort and reduce the risk of skin breakdown.
SPECIAL NOTE: The skin over bony areas is the most susceptible to problems from pressure caused by staying in one position in a bed or wheelchair for many hours. The length of time that a person can tolerate pressure varies. Should skin breakdown occur, it’s important to contact your ALS physician for proper wound management.
Bed positioning will also help to minimize the swelling associated with severe weakness. This swelling or accumulation of fluid under the skin, known as edema, occurs as a result of muscle inactivity and the effects of gravity on the limbs. It occurs most frequently in the hands and feet. Proper elevation of the limbs helps to reduce the swelling and encourages blood flow.
Bed positioning should:
be comfortable for the person with ALS
be changed frequently
keep the person’s head in line with his body, neither too flexed nor too extended
prevent friction or compression between body parts by the use of pillows or other position devices
Spotlight on Recovering From a Fall
For the reader with ALS: Maneuver yourself over to a solid, stable object such as the sofa, a heavy chair or a locked wheelchair.
Get into a kneeling position. Bring your stronger leg in front and place the foot flat on the floor. Push up with your strong leg, using your arms to assist as much as possible.
If a caregiver is available, have him or her assist you to stand or sit.
There are two basic positions for lying in a standard bed — on the back and sidelying. The position should be changed at least every two hours from lying on the right side, to lying on the back, and then to lying on the left side.
If a hospital bed is available, the positioning options increase owing to the flexibility of the bed. If you notice a reddened area that lasts longer than 20 minutes, you should increase the frequency of the turning schedule.
This need varies greatly from one individual to another. Consult with your PT, OT or nurse for specific instructions in bed positioning.
Sidelying
Place a pillow between the knees of the person in bed and wedge another pillow behind the back. Elevate the upper arm on a pillow.
Lying on the Back
Place a pillow under the knees and elevate both arms slightly with pillows.
Turning From the Back to Sidelying
Stand on the side of the bed that the person is to be rolled toward (i.e., if rolling him to the right side, stand on the right side of the bed). Face the bed squarely and grasp the end of the draw sheet farthest from you at shoulder and hip level. Keep your back straight and knees bent.
Lean back and pull the draw sheet to roll the person onto his or her side. Stabilize him at the shoulder with one hand while wedging a pillow behind his back with the other hand.
Bend his knees slightly forward and place a pillow between his legs. Position his head in proper alignment with the body. Elevate his upper arm on a pillow and place the call button within his reach.
To reposition the person on his back, reverse the technique.
