Chapter 19

Safely Transferring the Person

Objectives

• Define the key terms and key abbreviations in this chapter.

• Explain how to prevent work-related injuries during transfers.

• Identify the delegation information needed before transferring the person.

• Describe 5 functional status levels for transfers.

• Identify comfort and safety measures for transferring the person.

• Explain wheelchair and stretcher safety.

• Perform the procedures described in this chapter.

• Explain how to promote PRIDE in the person, the family, and yourself.

Key Terms

lateral transfer When a person moves between 2 horizontal surfaces

pivot To turn one’s body from a set standing position

transfer How a person moves to and from surfaces—bed, chair, wheelchair, toilet, or standing position

Key Abbreviations

ADL	Activities of daily living
ID	Identification

Patients and residents are moved to and from beds, chairs, wheelchairs, shower chairs, commodes, toilets, and stretchers. A transfer is how a person moves to and from surfaces—bed, chair, wheelchair, toilet, or standing position. The amount of help needed and the method used vary with the person’s abilities. You will assist with transfers often.

The safety measures for preventing work-related injuries and for moving persons apply to transfers (Chapters 17 and 18). So do the rules for body mechanics (Chapter 17). Protect yourself and the person from injury. Use your body and transfer devices and equipment correctly.

See Focus on Communication: Safely Transferring the Person.

See Teamwork and Time Management: Safely Transferring the Person, p. 282.

See Delegation Guidelines: Safely Transferring the Person, p. 282.

See Promoting Safety and Comfort: Safely Transferring the Person, p. 282.

Focus on Communication

Safely Transferring the Person

Transfers can be painful for older persons and after an injury or surgery. Ask about the person’s comfort. You can say:

• “Please tell me if you feel pain or discomfort.”

• “Tell me to stop if you feel pain.”

Before any transfer, explain the procedure. Tell the person what you and your co-workers will do. Also explain what the person needs to do. Give step-by-step instructions during the procedure.

The procedures in this chapter explain how to transfer the person on the “count of 3.” You and the person or you and your co-workers move at the same time. For example:

I will help you transfer to the chair. I will count “1, 2, 3.” When I say “3,” push on the mattress with your hands and stand. I will steady you with the transfer belt as you stand. You will turn so your legs touch the seat’s edge. Grab the chair’s armrests. I will help you sit.

Teamwork and Time Management

Safely Transferring the Person

Some agencies have “lift teams.” These teams perform most transfer procedures. They use assist equipment and do not manually lift patients and residents unless necessary.

The nurse advises the lift team of scheduled procedures. The team is called by beeper, pager, wireless phone, or other device for unscheduled transfers.

Do not assume that the lift team will transfer your assigned patients and residents. Follow agency policy for checking or adding to the lift team’s schedule. Do not neglect or omit a procedure because the agency has a lift team. If the person is on the schedule, always check to make sure that the procedure was done. Unscheduled or unexpected events can cause delays. Thank the team for the work they do. Their work protects patients, residents, and you from injury.

Delegation Guidelines

Safely Transferring the Person

Many tasks involve transferring persons. Before doing so, you need this information from the nurse and the care plan.

• What procedure to use.

• The person’s height and weight.

• The person’s functional status (Box 19-1). Functional status is the person’s ability to perform the activities of daily living (ADL) required to meet basic needs and required for health and well-being.

Box 19-1

Functional Status—Transfers

Level 0: Independent. The person can stand and walk without help.

Level 1: Supervision. Staff supervise the person during transfers. Staff encourage or remind the person what to do. Staff may need to put assist devices in place. Examples include a wheelchair, walker or cane (Chapter 30), and a transfer belt (Chapter 14), stand-assist device (Fig. 19-1), and sliding board (Fig. 19-2).

FIGURE 19-1 Stand-assist bed attachment.

FIGURE 19-2 Sliding board for transfers to and from surfaces.

Level 2: Limited Assistance. The person is highly involved in the transfer. Staff provide no weight-bearing help. Staff guide but do not lift the person’s arms or legs. Staff may encourage or cue the person. Staff may need to put assist devices in place. The devices listed in Level 1 may be used.

Level 3: Extensive Assistance. The person needs help to transfer. The person can bear some weight. Weight-bearing help is needed. A stand-assist lift or mechanical lift (see p. 295) is used for transfers.

Level 4: Total Dependence. The person cannot help with the transfer. Staff transfer the person using a mechanical lift.

Modified from Centers for Medicare & Medicaid Services: CMS’s RAI version 3.0 manual, Section G: Functional Status, October 2014.

• The person’s physical abilities. Can the person sit up, stand up, or walk without help? Does the person have strength in his or her arms and legs?

• If the person has a weak side. If yes, which side?

• If the person has problems that increase the risk of injury. Dizziness, confusion, hearing or vision problems, recent surgery, and fragile skin are examples.

• The person’s ability to follow directions.

• If behavior problems are likely. Combative, agitated, uncooperative, and unpredictable behaviors are examples.

• The amount of assistance needed.

• The number of staff needed to complete the task safely.

• Any doctor’s orders for transferring the person.

• What equipment to use.

Promoting Safety and Comfort

Safely Transferring the Person

Safety

Many older persons have fragile bones and joints. To prevent injuries:

• Follow the rules of body mechanics and the safety measures for preventing work-related injuries (Chapter 17).

• Always have help to transfer the person.

• Use transfer equipment and devices as directed by the nurse and the care plan.

• Transfer the person carefully.

• Keep the person in good alignment.

Decide how to transfer the person before starting the procedure. Ask needed staff to help before you begin. Arrange the room to allow enough space for a safe transfer. Correctly place the chair, wheelchair, or other device. Also plan how to protect drainage tubes or containers connected to the person.

Raise or lower the bed to a safe and comfortable level for the transfer. If the person will stand, the feet must be flat on the floor. For lateral transfers the bed is at a safe working height for staff.

Comfort

To promote mental comfort when transferring the person:

• Explain what you are going to do and how the person can help.

• Screen and cover the person to protect the right to privacy.

• Reassure the person that mechanical lifts (p. 295) are safe.

To promote physical comfort:

• Keep the person in good alignment.

• Do not pull on any part of a person’s body.

• Raise the head of the bed as soon as possible. Lying flat for long periods can cause discomfort and trouble breathing.

• Use pillows and other positioning devices as directed by the nurse and the care plan.

Wheelchair and Stretcher Safety

Wheelchairs are useful for people who cannot walk or who have severe problems walking (Fig. 19-3). Wheelchairs are moved by:

• The person using the hand rims or his or her feet.

• The person using hand, chin, mouth, or other controls on a motorized wheelchair.

• Another person using the hand grips/push handles.

Stretchers are used to transport persons to other areas. They are used for persons who:

• Cannot sit up

• Must stay in a lying position

• Are seriously ill

The stretcher is covered with a folded flat sheet, fitted stretcher sheet, or bath blanket. A pillow and extra blankets are on hand. If the nurse allows, raise the head of the stretcher to a Fowler’s or semi-Fowler’s position (Chapter 17). This increases the person’s comfort.

Follow the safety measures in Box 19-2 (p. 284) when using wheelchairs and stretchers. The person can fall from the wheelchair or stretcher. Or the person can fall during transfers to and from the wheelchair or stretcher.

Box 19-2

Wheelchair and Stretcher Safety

Wheelchair Safety

Maintenance

• Check the wheel locks (brakes). Make sure you can lock and unlock them.

• Check for flat or loose tires. A wheel lock will not work on a flat or loose tire.

• Make sure wheel spokes are intact. Damaged, broken, or loose spokes can interfere with moving the wheelchair or locking the wheels.

• Make sure the casters point forward. This keeps the wheelchair balanced and stable.

• Clean the wheelchair according to agency policy.

• Follow the safety measures to prevent equipment accidents (Chapter 13).

Transfers

• Lock (brake) both wheels before you transfer a person to or from the wheelchair.

• Remove the armrests (if removable) when the person transfers to the bed, toilet, commode, tub, or car.

• Swing front rigging out of the way for transfers to and from the wheelchair. Some front riggings detach for transfers.

• Position the person’s feet on the footplates. Make sure feet are on the footplates before moving the chair. The person’s feet must not touch or drag on the floor when the chair is moving.

• Do not let the person stand on the footplates.

• Do not let the footplates fall back onto the person’s legs.

• Provide needed wheelchair accessories—safety belt, pouch, tray, lap-board, cushion.

Transport

• Use good body mechanics (Chapter 17).

• Push the chair forward when transporting the person. Do not pull the chair backward unless going through a doorway or down a steep ramp or incline.

• Follow the care plan and agency policy for the number of staff needed to transport the person. This depends on:

• The person’s weight

• If the person is cooperative

• If the wheelchair is motorized

• Move wheelchairs up and down ramps and curbs safely (Figs. 19-4 and 19-5).

FIGURE 19-4 A, Moving a wheelchair up a ramp. B, Moving a wheelchair down a ramp.

• Going up a ramp: push the wheelchair front-first.

• Going down a ramp: face the back of the wheelchair. Roll it backward looking behind you as you move the wheelchair.

• Going up a curb:

• Position the wheelchair so the front casters are at the curb.

• Tilt the wheelchair back so the front casters are above the curb.

• Push the wheelchair forward until you can set the wheelchair down over the curb.

• Push the rear wheels up over the curb.

• Going down a curb:

• Turn the wheelchair so the rear wheels are at the curb.

• Lower the rear wheels down the curb.

• Lower the front casters down the curb.

• Follow the care plan for keeping the wheels locked when not moving the wheelchair. Locking the wheels prevents the chair from moving if the person wants to move to or from the chair. (Locking the wheelchair may be viewed as a restraint. See Chapter 15.)

Stretcher Safety

• Ask 2 or more co-workers to help you transfer the person to or from the stretcher.

• Lock (brake) the stretcher wheels before the transfer.

• Fasten the safety straps when the person is properly positioned on the stretcher.

• Follow the care plan and agency policy for the number of staff needed to transport the person. As many as 4 staff members may be needed. This depends on:

• The person’s weight

• If the person is cooperative

• Raise the side rails. Keep them up during the transport.

• Do not leave the person alone.

• Make sure the person’s arms, hands, legs, and feet do not dangle through the side rail bars.

• Stand at the head of the stretcher. Your co-worker stands at the foot of the stretcher.

• Move the stretcher feet first (Fig. 19-6, p. 286). This is so the staff member at the head of the stretcher can watch the person’s breathing and color during the transport.

FIGURE 19-6 The stretcher is moved feet first.

• Use good body mechanics during the transfer and transport (Chapter 17).

• Follow the safety measures to prevent equipment accidents (Chapter 13).

Stand and Pivot Transfers

Some persons are able to stand and pivot. Pivot means to turn one’s body from a set standing position. A stand and pivot transfer is used if:

• The person’s legs are strong enough to bear some or all of his or her weight.

• The person is cooperative and can follow directions.

• The person can assist with the transfer.

See Delegation Guidelines: Stand and Pivot Transfers.

See Promoting Safety and Comfort: Stand and Pivot Transfers.

Delegation Guidelines

Stand and Pivot Transfers

Before a transfer, you need this information from the nurse and the care plan.

• What procedure to use.

• The person’s functional status (see Box 19-1).

• The amount of help the person needs.

• What equipment to use—transfer belt, wheelchair, stand-assist device, positioning devices, wheelchair cushion, bed or chair alarm, and so on.

• The person’s height and weight.

• The number of staff needed.

• Areas of weakness. For example, if the arms are weak, the person cannot hold on to the mattress for support. If the left side is weak, he or she gets out of bed on the stronger right side. The person uses the right arm to help move.

• What observations to report and record:

• Pulse rate before and after the transfer (Chapter 29)

• Complaints of dizziness, pain, discomfort, difficulty breathing, weakness, or fatigue

• The amount of help needed to transfer the person

• Who helped you with the procedure

• How the person helped with the procedure

• How you positioned the person

• When to report observations.

• What patient or resident concerns to report at once.

Promoting Safety and Comfort

Stand and Pivot Transfers

Safety

The person wears non-skid footwear for stand and pivot transfers. Such footwear protects the person from falls. Slipping and sliding are prevented. Tie shoelaces securely. Otherwise the person can trip and fall.

Long gowns and robes can cause falls. Avoid robes with long ties. The person can trip and fall.

Lock (brake) bed and wheelchair wheels and wheels on other devices. This prevents the bed and the device from moving during the transfer. Otherwise, the person can fall. You also are at risk for injury.

Comfort

After the transfer, position the person in good alignment. Place the call light and other needed items within reach.

Transfer Belts

Transfer belts (gait belts) are discussed in Chapter 14. They are used to:

• Support patients and residents during transfers.

• Re-position persons in chairs and wheelchairs (Chapter 18).

• Assist with ambulation (Chapter 30).

Wider belts have padded handles. They are easier to grip and allow better control should the person fall.

Bed to Chair or Wheelchair Transfers

Safety is important for chair, wheelchair, commode, and shower chair transfers. Help the person out of bed on his or her strong side. If the left side is weak and the right side is strong, get the person out of bed on the right side. In transferring, the strong side moves first. It pulls the weaker side along. Transfers from the weak side are awkward and unsafe.

See Focus on Surveys: Bed to Chair or Wheelchair Transfers.

See Promoting Safety and Comfort: Bed to Chair or Wheelchair Transfers.

See procedure: Transferring the Person to a Chair or Wheelchair.

Focus on Surveys

Bed to Chair or Wheelchair Transfers

Agencies must ensure that nursing assistants can safely perform the skills needed for safe care. Surveyors will observe how nursing assistants function. One skill in their focus is transferring a person from the bed to a wheelchair.

Promoting Safety and Comfort

Bed to Chair or Wheelchair Transfers

Safety

The chair, wheelchair, or other device must support the person’s weight. The number of staff needed depends on the person’s abilities, condition, and size. Sometimes you need a mechanical lift (p. 295).

The person must not put his or her arms around your neck. Otherwise the person can pull you forward or cause you to lose your balance. Neck, back, and other injuries are possible.

If not using a mechanical lift, a transfer belt is used for chair or wheelchair transfers. It is safer for the person and you. Putting your arms around the person and grasping the shoulder blades is another method. It can cause the person discomfort. And it can be stressful for you. Use this method only if instructed to do so by the nurse and the care plan.

Bed and wheelchair wheels are locked for a safe transfer. After the transfer, unlock the wheelchair wheels to position the chair as the person prefers. After positioning the chair, lock the wheels or keep them unlocked according to the care plan. Locked wheels may be viewed as restraints if the person cannot unlock them to move the wheelchair (Chapter 15). However, falls and other injuries are risks if the person tries to stand when the wheels are unlocked.

Comfort

Most wheelchairs and bedside chairs have vinyl seats and backs. Vinyl holds body heat. The person becomes warm and perspires more. If the nurse allows, cover the back and seat with a folded bath blanket. This increases the person’s comfort.

Some people have wheelchair cushions or positioning devices. Ask the nurse how to use and place the devices. Also follow the manufacturer’s instructions.

Transferring the Person to a Chair or Wheelchair