7.2 Transfers & Ambulation

Transfers & Ambulation

Safe transfers and ambulation are critical duties for CNAs to promote mobility and prevent injury to both the resident and the caregiver. The Utah Nurse Assistant Registry (UNAR) emphasizes strict safety protocols, particularly regarding the use of gait belts, mechanical lifts, and emergency fall management.

Ergonomics & Body Mechanics

Before initiating any transfer or ambulation, the CNA must employ proper body mechanics to prevent personal musculoskeletal injury.

• Maintain a wide base of support: Place feet shoulder-width apart.
• Bend at the knees and hips: Never bend at the waist or curve your spine.
• Use your legs: The large gluteal and quadricep muscles in your legs should do the lifting, not your back.
• Keep the load close: Hold the resident close to your body to center gravity.
• Avoid twisting: Pivot your feet instead of twisting your torso when changing directions.

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The Gait Belt (Transfer Belt)

A gait belt (also known as a transfer belt) is a safety device wrapped around a resident's waist, providing a secure handhold for the CNA during transfers and ambulation.

• Application: Wrap the belt around the resident's waist over their clothing—never on bare skin. Ensure it is snug but comfortable. A general rule of thumb is that you should be able to slide only two fingers flat between the belt and the resident.
• Buckle Placement: Place the metal teeth of the buckle in the front. Thread the belt through the side with teeth first, then through the other side to secure it. Tuck any excess strap to prevent tripping.
• Contraindications: Do not place a gait belt over a resident's breasts, colostomy bag, feeding tube (G-tube), pacemaker, surgical incisions, or if the resident has a severe abdominal aneurysm. In these cases, consult the nurse for alternative transfer plans.
• Grip Technique: Always grasp the gait belt using an underhand grip (palms facing up). An overhand grip (palms facing down) is weak and can slip if the resident loses balance.

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Wheelchair Safety & Stand-Pivot Transfers

When transferring a resident from a bed to a wheelchair, safety checks must be executed systematically.

Critical Brakes Check

Exam Alert: The single most common failure on the manual skills test is forgetting to lock the brakes on both the bed and the wheelchair before beginning a transfer. Leaving brakes unlocked is a major safety violation that results in an automatic skill failure.

Executing a Stand-Pivot Transfer

1. Setup: Position the wheelchair on the resident's stronger side (if they have unilateral weakness, e.g., from a stroke). Angle the wheelchair at 45 degrees (or parallel) to the bed.
2. Preparation: Assist the resident to dangle their legs on the side of the bed. Ensure their feet are flat on the floor and they are wearing non-skid footwear (socks or shoes). Apply the gait belt.
3. Execution: Stand in front of the resident, bracing their knees with your own knees to prevent buckling. Grasp the gait belt with an underhand grip on both sides. On the count of three, assist them to a standing position. Have them pause to check for dizziness (orthostatic hypotension).
4. The Pivot: Guide the resident to pivot their feet until they feel the wheelchair seat against the back of their legs. Instruct them to reach back for the armrests and gently lower themselves into the chair.

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Assist Levels Defined

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Cane & Walker Safety

Devices like canes and walkers are designed to redistribute weight and improve stability. The CNA must ensure these devices are used correctly:

Cane Use Guidelines

• Cane Placement: The resident must hold the cane on their stronger side (unaffected side). This improves balance and mimics natural gait.
• Walking Pattern (Gait):
  1. Move the cane forward about 6-10 inches.
  2. Step forward with the weaker leg (affected leg) to align with the cane.
  3. Step forward with the stronger leg past the cane.
• CNA Positioning: Stand slightly behind and to the weaker side of the resident when assisting.

Walker Use Guidelines

• Walker Placement: The resident stands inside the frame of the walker.
• Walking Pattern:
  1. Move the walker forward 6-10 inches, ensuring all four rubber tips touch the ground simultaneously.
  2. Step forward into the walker with the weaker leg first.
  3. Bring the stronger leg forward to meet the weaker leg.
• Safety Rule: Never allow a resident to pull on the walker frame to stand up from a bed or chair. The walker is lightweight and will tip over. Instruct the resident to push up from the mattress or chair armrests first, then place their hands on the walker once stable.

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Emergency Fall Management

If a resident begins to lose their balance and fall during ambulation, the CNA must never try to hold the resident up or stop the fall. Attempting to catch a falling resident can result in severe spinal injuries to the CNA and worse fractures for the resident.

Step-by-Step Controlled Fall Procedure

1. Widen Your Base: Step behind the resident and widen your stance.
2. Pull the Resident Close: Pull the resident's torso close to your body to support and control their center of gravity.
3. Use Your Leg as a Slide: Wrap your arms around the resident's waist (or grasp the gait belt) and allow them to slide slowly down your leg to the floor.
4. Protect the Head: Guide them downward while protecting their head from hitting furniture or the floor.
5. Call for the Nurse: Once the resident is on the floor, do not move them or attempt to help them stand. Stay with them, keep them calm, and call the nurse immediately. The nurse must assess the resident for spinal injury, fractures, or head trauma before they can be moved.

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Teaching Focus: Transfer Coaching

When teaching a resident or family caregiver, narrate each safety step before you move: lock both bed and wheelchair brakes, place the chair on the strong side, apply the gait belt over clothing with a two-finger fit, and use an underhand grip. Cue the resident to push up from the mattress or armrests—not from a walker—then pause standing to check for dizziness before the pivot. For cane walking, teach "cane on the strong side, weak leg steps to the cane, strong leg steps past." For walkers, teach advancing the frame, then weak leg, then strong leg, with all four tips on the floor before each step.