Section 5.3: Safe Transfers, Positioning, & Ambulation

Section 5.3: Safe Transfers, Positioning, & Ambulation

Pre-Transfer and Mobility Assessments

Safe transfers and ambulation require systematic planning to prevent falls, which are a major cause of injury in Iowa nursing facilities. Before moving a resident, the CNA must review the care plan to identify the resident's weight-bearing status, cognitive abilities, and any specific assistive devices required (e.g., cane, walker, brace). The CNA must also perform a brief environmental safety check: ensure the pathway is free of clutter, verify that the resident is wearing non-skid footwear (shoes or socks with rubber grips), and ensure that all equipment is in working order.

Operating Wheelchairs Safely

When transferring a resident to or from a wheelchair, the CNA must follow strict safety protocols:

• Lock the Brakes: The most common transfer accident occurs when the wheelchair rolls away. Both wheelchair brakes must be locked securely before the transfer begins.
• Manage the Footrests: The footrests must be folded up and swung out of the way. Leaving the footrests in place creates a severe tripping hazard for the resident and the CNA.
• Positioning the Chair: Place the wheelchair at a 45-degree angle to the bed, positioning it on the resident’s stronger side. This allows the resident to lead with their strong leg and arm during the transfer, maximizing their independence and stability.

Correct Application of a Gait Belt

A transfer belt, or gait belt, is a vital safety tool used to assist residents during transfers and ambulation. It must be applied correctly to prevent injury:

1. Explain the Procedure: Inform the resident that you are applying the belt for their safety.
2. Apply Over Clothing: Never place a gait belt against bare skin, as it can cause skin tears or bruising.
3. Snug Fit: Wrap the belt around the resident's waist. Thread the strap through the metal teeth first, then through the outer loop. The belt must be snug enough that it does not slide up the torso, but loose enough to allow the CNA to insert two fingers flat between the belt and the resident.
4. Buckle Placement: Position the buckle slightly off-center (to either side of the spine or abdomen) to prevent discomfort and avoid pressure on the spine or surgical incisions.
5. Underhand Grip: When assisting the resident, the CNA must grip the belt using an underhand grip (palms facing up). An overhand grip can easily slip and does not provide adequate leverage.

Step-by-Step Bed-to-Wheelchair Transfer

1. Assist the resident to a sitting position on the side of the bed (dangling). Allow them to sit for a minute to prevent orthostatic hypotension (dizziness caused by sudden changes in position). Ensure their feet are flat on the floor.
2. Apply the gait belt.
3. Stand directly in front of the resident, blocking their feet with your feet and bracing their knees with your knees to prevent buckling.
4. Grasp the gait belt on both sides using an underhand grip.
5. Instruct the resident to place their hands on your shoulders (never around your neck, which could injure your spine).
6. On the count of three, rock backward and straighten your legs, assisting the resident to a standing position.
7. Pivot the resident so that their back is toward the wheelchair. Instruct them to reach back for the armrests.
8. Gently lower the resident into the chair, bending your knees and keeping your back straight. Position their feet on the footrests.

Resident Positioning in Bed

Repositioning bedbound residents is crucial for preventing pressure injuries (bedsores), contractures, and respiratory complications. Under Iowa Administrative Code rules, residents must be repositioned at least every two hours (or more frequently if indicated in the care plan). The CNA must master these standard positioning terms:

Pillow Placement for the Lateral Position

To position a resident in the lateral (side-lying) position correctly, the CNA must place pillows under the following areas to prevent bone-on-bone friction and protect skin integrity:

• Under the head and neck.
• Behind the back to support the spine and prevent the resident from rolling backward.
• Between the knees and ankles to prevent pressure injuries on bony prominences (ensure the knees are flexed and the upper leg is aligned with the hip).
• Under the upper arm to keep the arm from dragging and support the shoulder.

Assisting with Ambulation and Managing Falls

When walking (ambulating) a resident:

• Positioning: Stand slightly behind and to the weaker side of the resident, holding the gait belt with an underhand grip. Your other hand is placed lightly on the resident's shoulder for stability.
• Assistive Devices: Canes are held on the resident's strong side. The resident moves the cane first, then the weak leg, and finally the strong leg. Walkers are pushed forward 6 to 10 inches before the resident steps into it.
• Responding to a Fall: If a resident begins to lose their balance and fall, do not attempt to prevent the fall by catching them. Trying to hold up a falling resident can result in severe back injuries to the CNA and head injuries to the resident.
  • Controlled Descent: Immediately widen your stance, pull the resident’s torso close to your body, and allow them to gently slide down your leg to the floor. Protect their head from striking any objects.
  • Post-Fall Protocol: Once the resident is on the floor, do not move them. Stay with the resident, keep them calm, and call for the nurse immediately. The nurse must assess the resident for injuries (such as fractures or head trauma) before they can be moved.

Common Exam Traps

• Trap 1: Placing the wheelchair on the weak side. Always place it on the strong side.
• Trap 2: Using an overhand grip on the gait belt. Always use an underhand grip.
• Trap 3: Trying to catch a falling resident. Slide them down.
• Trap 4: Moving a resident after a fall before the nurse's assessment.