How to Safely Transport a Client INTRODUCTION Medical problems and/or physical limitations can and often do restrict a client s ability to ambulate and move, and transporting clients is a primary responsibility of Certified Nursing Assistants (CNAs) and Health Aides. Transporting a client can be required when providing personal care, as a preventive technique to avoid development of pressure ulcers, to change linen when someone cannot get out of bed, or to help a client move from a bed to a wheelchair/chair or back again. These situations are a common part of the day-to-day practice of CNAs and transporting a client requires special techniques, considerable skill, and practice. Note: Transportation is typically used to mean going a considerable distance. But in this module transportation is used to refer to any situation in which you are assisting a client to move, regardless of how far or how extensive the move might be. STATEMENT OF PURPOSE This module will provide CNAs and Health Aides with the information they need to safely and efficiently transport clients. TRANSPORTING CLIENTS: BASIC PRINCIPLES
Before you begin any type of client transportation, consider the following points. 1. Situation assessment: How far and for how long is the client being transported? What resources are available? Have you done this type of transportation assistance before? How much time will you need? 2. Client capabilities: How much assistance will the client need during the transport? Can he/she provide help or will all the moving be done by the CNA? Does the client have any medical problems, physical limitations, or psychological issues that limit her/his ability to ambulate and move, or make moving unsafe? Examples of client issues that affect transportation are listed in Table 1 at the end of this section. This list provides common examples and it is not all inclusive. 3. Fall risk: Transporting a client may not require moving long distances; it may not even involve getting the client out of bed or up from a chair. But most situations in which you are providing transportation assistance does involve the potential for a fall, even a slight fall. You should always know a client s fall risk. 4. Consider measuring blood pressure and pulse before you begin. This may not always be necessary, but if you are
working with a client for the first time or if the client is or may be at risk for falling, measuring these vitals signs before moving a client is a good idea. A change in position, especially from lying to sitting or from sitting to standing, can cause orthostatic hypotension and possibly syncope. 5. Maintain good body alignment of the client during the move. 6. Safety first. In many situations in which you are transporting a client he/she is weak, has difficulty ambulating, or cannot assist with the process. Because even a small fall can have serious consequences safety should be your first priority when transporting a client. 7. Always use Standard Precautions. Identify the client before you begin, and always explain to the client exactly what you are going to do. Table 1: Client Issues and Transporting Age Arthritis Balance disorders Confusion Dementia Diabetic neuropathy Gait disorders Inner ear disorder Muscular weakness
Neurological disorders Obesity Recent surgical procedure Stroke Use of an assistive device, eg, cane or walker Visual impairment Example: The physician has ordered that the client be moved from the bed to a chair, three times a day. The distance to be traveled is obviously very short; five feet. The client is a 66 year-old sedentary male who is obese (He weighs 145 kg) and has diabetic peripheral neuropathy. He recently had a stroke and his left side is considerably weaker then his right. The physical therapist s assessment rated the client s strength poor on his unaffected side and very poor on his affected side. So even without the effects of the stroke the client is not strong and prior to the stroke his body weight and muscular weakness made ambulating difficulty. This is the third day the client has been in the hospital and the first time he will be out of bed. The distance and the time involved in this move are very short. Obviously this client will not be able to move unassisted from the bed to the chair and this move will require more than one person and perhaps some special equipment. In addition, this client has a relatively high risk for falling. CLIENT FALLS
A fall is defined as an unplanned descent to the floor, with or without injury, and transporting a client is very often a situation in which a client fall is possible. Falls are very common in both in the community and in health care facilities. Approximately one-third of all older adults living in the community will fall at least once a year, and falls are the most common adverse event in hospitals: 3%-20% of all clients will fall at least once during hospitalization. Facts you should know about client falls include: The majority of falls are unwitnessed. Falls often happen when the client is being transferred from the bed to a chair. Most falls do not cause injuries, but the injuries that do occur tend to be serious: bleeding, dislocations, fractures, and lacerations. Hip fractures suffered after falls are an especially serious. Approximately 25% of all clients who suffer a hip fracture after a fall die within a year and approximately 50% of these must be discharged to a long-term care facility and never return home.
Falls can cause anxiety, depression, lack of confidence in the ability to ambulate, and a fear of falling. Falls increase the length of hospitalization and they increase health care costs. There are standardized and validated assessment tools that are used to evaluate a client s risk of falling. Certified Nursing Assistants would not use these assessment tools, but a CNA should be able to perform a basic assessment of the risk of falling. Table 2 illustrates the process of determining a client s risk of falling. Table 2: Assessing a Client s Risk of Falling 1. Physical issues and limitations: Does the client have a medical condition or a physical limitation that would increase his/her risk of falling? Examples would be balance disorders, muscular weakness, and stroke. 2. Mental status: Does the client have a psychiatric disorder that would increase her/his risk of falling? Examples would be confusion, dementia, and memory problems. 3. Medications: Is the client receiving medications that might make him/her more likely to fall? Refer to the medications in Table 3. 4. Environmental issues: Environmental issues are less likely to contribute to a fall in the healthcare facility setting. However, common sense dictates that prior to transporting a client the
environment should be checked for anything that could increase the risk of a fall, eg, poor lighting, a bedside commode or a wheelchair that is not locked, or a wet floor. 5. History of falls: A previous fall is considered to be a risk factor for further falls. 6. Ambulatory status: Can the client walk without assistance or does he/she typically need help? Does the client use a cane or a walker? What is the client's gait like? Is it normal, weak, or unsteady? 7. Ask the client: Many clients know their ambulation/mobility limits, and they can provide valuable information about what is and is not safe for them. Table 3: Medications that Increase the Risk of Falling Analgesics, especially opioid analgesics such as codeine, oxycodone, and morphine Antihistamines, eg, diphenhydramine Anti-depressants, eg, Paxil, Prozac, Zoloft Anti-hypertensives Antipsychotics, eg, Seroquel, Risperdal, Zyprexa Anxiolytics, eg, Buspar, Klonopin, Valium, Xanax Drugs used to treat diabetes (Hypoglycemia can cause a fall) Drugs used to treat urinary frequency, eg, Detrol, Ditropan Hypnotics and soporifics, eg, Ambien TRANSPORTING CLIENTS: TECHNIQUES FOR SPECIFIC SITUATIONS
This module will discuss the following client transportation situations. Assisting a client who is using a cane, crutches, or a walker Assisting a client to a sitting position Helping a client to ambulate Helping a client to stand up Logrolling Moving a client from a bed to a chair Moving a client up in bed Using a slide board to transfer a client Using a transfer belt Transporting a client can be quick, simple and done without help. It can also take a lot of time, special equipment, and several people. But regardless of what the client needs and the situation requires, the key for safely transporting someone is planning: assess the situation, assess the client, and determine the fall risk. Consider this example. Situation: The client is lying down and you need to help her sit on the edge of the edge of the bed; this has been ordered so that the client s ability to tolerate an upright position can be determined. This will essentially only require the client to change positions Client assessment: The client is 55-years-old and she does not have pre-existing medical or psychiatric issues that would affect her ability to do this task. She is of average height but she weighs 245 pounds.
Yesterday she had shoulder surgery, she returned from the operating room late in the early evening, and she hasn t yet changed positions. The operation was uneventful and there were no complications Fall risk: The client has received several doses of oxycodone, a relatively powerful narcotic analgesic but aside from that she has no obvious risk factors for falling. However, when asked she does say that she feels a little weak from the operation and a little dizzy from the oxycodone. Analysis: The move itself is very simple; you will help the client sit up and move to the edge of the bed. However, she had surgery within the past 24 hours and she has not changed positions since returning from the operating room. In addition she has received several doses of oxycodone, she reports feeling weak and dizzy, and she is relatively heavy. A fall is more likely than not, and she could fall to the floor or onto the just-repaired shoulder. Making the move: Wash your hands and if you decide it is necessary, put on disposable gloves. Identify the client and explain what you are going to do. Measure the client s blood pressure and pulse. Make sure the bed is locked. Help the client move close to the edge of the bed and turn onto her side. The side rails should be down and you should be positioned so that you can prevent the client from falling out of bed: in
some cases you will need someone else in front of the client. In this situation it is prudent for another CNA to be present, and your colleague should be behind the client in case she falls backwards after she sits up. The best position for the other CNA is to kneel on the bed so that his/her hands can easily reach and support the client s shoulders if need be. The bed should be raised so that it is level with your hips and the head of the bed should be slowly brought up to 45 degrees. Ask the patent if she can tolerate having her head elevated this far. If she tells you she feels dizzy or lightheaded, lower the head of the bed and notify your supervisor. If she can tolerate this, help the client put her legs over the edge of the bed (they should be supported if necessary) and elevate the head of the bed as much as possible. Place one hand on the client s hip and your other hand on her unaffected shoulder and then slowly pull her to an upright position; she can provide some assistance. Do not let go after she is sitting up. Maintain contact until you are sure she is stable. If the bed has split side rails position one of them so she can hold on to it. Lower the bed so that the client s feet are touching the floor. Stay with the client for the prescribed amount of time.
This is one of the simpler client transportation situations and after doing it several times you won t have to think about each step. But this example illustrates the risk involved in even short, easy moves. This client could faint or lose her balance and fall forward, backward, or onto the surgically repaired shoulder. How easily do you think you could catch someone who weighs 245 pounds? This example also illustrates how much planning you need to do to perform client transportation safely and efficiently. Assisting a Client Who is Using a Cane, Crutches, or a Walker Canes, crutches, and walkers are called assistive devices. Canes and walkers are often needed permanently. Crutches are usually, but not always, only needed for a short period of time to help patients ambulate while he/she recovers from an injury. However some clients do depend on crutches for day-to-day ambulation. Assistive devices provide support, balance, and take pressure off an affected leg. Physical therapists provide the initial instruction to clients on the proper use of assistive devices. You may need to help someone who is using an assistive device so you should know how they are used. Assisting a client who uses a cane: Make sure the top of the cane is at the level of the client s wrist when she/he is standing. Instruct the client to hold the cane in the hand opposite the affected leg: this
seems counter-intuitive but the cane provides the most support when used this way. Move the cane and the affected leg forward at the same time. The cane should be placed at the same distance from the body as the affected leg: do not put it too far forward. The client should stand straight and should not lean noticeably to one side on the cane. Once the cane and the affected leg are solidly placed, shift the weight to the cane and move the unaffected leg forward. Going up and down stairs while using a cane can feel tricky at first but with practice and patience it is not difficult Going up stairs the unaffected leg moves first, all of the client s weight is transferred to the unaffected leg, and then the cane and the affected leg are brought up. To go down stairs the sequence is reversed. The affected leg is moved down and then the cane and the unaffected leg are placed on the stair Assisting a client who uses crutches: The crutches should be adjusted so that the tops are one-two inches below the armpits. The handgrips should be level with the hips. When the crutches are in the right position the client s arms should be slightly bent. Start walking by balancing on the unaffected leg, leaning forward slightly, and putting the crutches on the floor about one foot ahead; this distance can be increased after the client has some practice. This
transition can feel unsteady at first and first-time crutch users should be closely supervised as balancing on one leg can be difficult. Clients may be allowed to place some weight on the affected leg but unless this is specifically allowed it should be discouraged. After the crutches have been placed forward instruct the client to place her/his weight on the handgrips of the crutches. Make sure that no weight is placed on the armpits; doing so can damage the blood vessels and nerves in that area. The client s weight is transferred to the hand grips and she/he swings the body forward, landing on the unaffected leg. Short movements are best. Using crutches to get up from a chair is relatively simple. Instruct the client to put both crutches together on the unaffected side. Place the affected leg forward and then push up using the hand grips and the seat of the chair. If the client needs to sit down, he/she should back up until the edge of the chair is touching the legs. Put both crutches on the affected side. Hold onto the hand grips, bend the legs and reach down and grab the chair. To go up stairs place the unaffected leg on the stair, stand up, plant the crutches and then repeat. To go down, first place the crutches on the stair, put the weight on the crutches, and then put the unaffected leg down. Going up and down stairs while using crutches can be difficult and unsafe if the client is weak or has poor balance. A hand
rail makes the process easier but some clients should be instructed to always have assistance. Assisting a client who uses a walker: Walkers are the most stable of the assistive devices, and clients who use a walker will typically only need assistance when they are standing up or sitting down. Ambulating with a walker is done in the same way as ambulating with a cane or crutches. The client places the walker a short distance out form her/his body, uses the walker for support, and then moves forward. Assisting a Client to a Sitting Position This is one of the most basic techniques of transporting a client. It is used prior to helping someone out of bed, helping someone up from an examining table, and in many other situations. Wash your hands, identify the patient, and explain what you are going to do. Measure the client s blood pressure and pulse if needed. Make sure the bed is locked. Help the client move close to the edge of the bed and turn onto her side. The side rails should be down and you should be positioned so that you can prevent the client from falling out of bed. In some situations you will need someone else in front of the client and very often, someone else to the rear of the client in case he/she falls backwards after sitting up. If you are worried that the client may fall backward, the best position for the other CNA is to
kneel on the bed so that his/her hands can easily reach and support the client s shoulders. The bed should be raised so that it is level with your hips and the head of the bed should be slowly brought up to 45 degrees. Ask the client if this is tolerable. If the client reports feeling feels dizzy or lightheaded, lower the head of the bed and notify your supervisor. If she/she can tolerate this, help the client put his/her legs over the edge of the bed (they should be supported if necessary) and elevate the head of the bed as much as possible. Place one hand on the client s hip and your other hand on the shoulder and slowly pull until the client is upright. Do not let go after the client is sitting up. Maintain contact until you are sure the client is stable. If the bed has split side rails position one of them for support. Lower the bed so that the client s feet are touching the floor. Stay with the client for the prescribed amount of time. Helping a Client to Ambulate Ambulating is defined here as getting out of bed or up from a chair or a wheelchair and then walking. There are different ways of helping a client to ambulate; the step-bystep process that you use will depend on the situation and the client s needs. The client may need to use an assistive device, a transfer
belt/gait belt may be needed, or perhaps he/she will only need you to hold onto an elbow for support. But regardless of what the situation requires, use these principles when you are helping a client to ambulate. (Note: These principles can be applied to almost all situations in which you are transporting a client). 1. Assess the client s fall risk and any client issues that may affect transporting. If this is your first time working with this client, the first time the client has ambulated after being on bed rest, or you have identified a fall risk, measure blood pressure and pulse before you begin. 2. Plan the route. Make sure the path is clear. 3. Make sure you have assistance if you need it. Ambulating some clients can require several people in order to do it safely. 4. As always, wash your hands, identify the client, and explain what you are going to do. 5. Lock the bed or lock the wheelchair. 6. After the client is standing up, ask if she/has feels dizzy or lightheaded. You should also observe the client closely to see if he/she is unsteady. If the client fells dizzy or lightheaded or
appears unsteady do not continue. Return the client to bed or the chair and notify your supervisor. 7. Walk slightly behind the client. This will put you in the best position in case of a fall. Consider using a transfer belt. 8. Help the client to ambulate for the prescribed amount of time, but do not continue if she/he is not tolerating it or you feel this situation is unsafe. Safety if the first priority, not completing the task. You should also be prepared to support a client if she/he falls. If you are by yourself and the client begins to fall, move your legs apart to establish a base of support. Extend one leg forward between the client s legs, hold him/her under the arms, and guide the client s body so that it slides down your leg. Lower the client gently and slowly to the floor. Helping a Client to Stand Up Helping a client to stand up is usually preceded by helping someone to a sitting position and it is often followed by ambulating or moving to a chair or a wheelchair. Wash your hands, identify the client, and explain what you are going to do. Lock the wheels of the bed or the wheelchair. Begin by facing the client and establishing a firm base of support. If needed, apply a
transfer belt. Instruct the client to slide forward to the edge of the bed, chair, or wheelchair. Once in this position ask the client to lean move his/her legs apart to shoulder width and then lean forward slightly so that his/her weight is centered over the feet and legs. Coordinate the move with the client and use whatever level of support is needed: One or two arms in the armpits or the transfer belt. Once the client is standing up, ask her/him if she feels dizzy or lightheaded. You should also observe the client closely to see if he/she is unsteady. If the client feels dizzy or lightheaded or appears unsteady do not continue. Return the client to bed or the chair and notify your supervisor. Logrolling Logrolling is used when a client cannot get out of bed but a position change is necessary. Logrolling is used to help a client change positions and avoid pressure on areas that are susceptible to pressure ulcers; if you need to provide perineal care; if the client needs to use a bedpan; to perform a skin inspection, or; to change the sheets. Wash your hands, identify the client and explain what you are going to do. Lock the bed and raise it to a height that is comfortable for you: the same height as your hips is usually best. Make sure both side rails are up.
Move the client - or have the client move - so that she/he is positioned on the outer third of the bed away from the direction in which he/she will be moving: if the client is going to be logrolling so his/her left side is down, position the client on the right side of the bed. If the client cannot move, place a slide sheet so that it goes from the shoulders to the knees and use the slide sheet to pull the client into place. Place a pillow between the client s legs. The arm that will be under the client after the move has been done should be extended so that it is not pinned against the client s side. Logrolling requires two people. One should be at the client s shoulder and the other at the hips and when you are ready, gently and slowly move the client so that she/he is perpendicular to the bed. When you are logrolling be sure that the body and spine are maintained in a position of alignment. Keep a straight line: do not move the shoulders, then the hips, and then the legs. In order to avoid injury during logrolling, a client should be moved so that all parts of his/her body are rotated together. This is one of the reasons why two CNAs are usually needed for logrolling. If you are logrolling a client for a position change, place pillows next to the back and shoulders to help keep the client in place. Moving a Client from the Bed to a Chair
If you are not sure you can perform this move safely get assistance: this situation can put the client at risk for a fall. Wash your hands, identify the client and explain what you are going to do. Lock the wheels of the bed. Help the client move close to the edge of the bed and turn onto his/her side. The side rails should be down and you should be positioned so that you can prevent the client from falling out of bed. Raise the bed so that it is level with your hips and then slowly elevate the head of the bed to 45 degrees. Ask the client if this is tolerable. If she/he reports feeling dizzy or lightheaded, lower the head of the bed and notify your supervisor. If not, help the client put her/his legs over the edge of the bed (the legs should be supported if necessary) and elevate the head of the bed as much as possible. Place one hand on the client s hip and your other hand on the shoulder and then slowly pull until the client is upright. Do not let go: maintain contact until you are sure he/she is stable. If the client reports feeling dizzy or lightheaded or appears unsteady, lower her/him back down, put the side rails back up and notify your supervisor. If the client can tolerate being upright, lower the bed until his/her feet are touching the ground. Put the client s shoes on. Face the client and establish a firm base of support. If needed, apply a transfer belt.
Instruct the client to slide forward to the edge of the bed. Once in this position, ask the client to move his/her legs apart to should width and then lean forward slightly so that his/her weight is centered over the feet and legs. Use whatever level of support is needed: this could be one or two arms in the client s armpits, your arms around his/her waist, a transfer belt, or the client s hands on your shoulders. Lift up under the arms, by the waist, or with the transfer belt, and once the client is standing ask her/him if she feels dizzy or lightheaded, and observe the client closely to see if he/she is unsteady. If the client fells dizzy or lightheaded or appears unsteady do not continue. Help the client back down and notify your supervisor. When the client is standing you will help her/him pivot and then slowly lower into the chair. The pivoting motion can be slightly awkward, especially if the client is weak, so take your time and give as much support as needed. Moving a Client Up in Bed Moving a client up in the bed should be done using a slide sheet. Slide sheets are single use or re-usable sheets that have very low friction and they are a great help in this procedure. Wash your hands, identify the client, and explain what you are going to do. This procedure requires two people.
Raise the bed to a comfortable working level. If you think that moving the client will be difficult, even with the use of the slide sheet, the top of the bed can be lowered so that the client s head is slightly below his/her feet. If this is needed, place a pillow between the client and the headboard to protect his/her head. Log roll the client and place the slide sheet so that it reaches from the shoulders down past the buttocks. Once the sheet is in place, establish a firm base of support with your legs apart at least shoulder width, grab the slide sheet and then move the client to the desired position. You are sliding, not lifting; use the low friction of the slide sheet to your advantage. Remove the slide sheet. Using a Slide Board Slide boards are a simple and effective ways of transferring clients from a bed to a chair or a wheelchair or back again, or from a chair to a chair. They are often used when the client has very limited or no lower body strength. Wash your hands, identify the client and explain what you are going to do. First make sure that the transferring surfaces are secured, eg, bed locks or wheelchair locks are on, or the chairs the client will be moving between are stable. If the client s bare skin will be against the board,
place a pillow case or something on the board as bare skin against the slide board will negate its advantage of low friction. Place one end of the slide board underneath the client s thigh. If the client has sufficient upper body strength, he she can make the move unassisted: simply use the board to slide from one position to the other. If he/she needs help you can put both hands just underneath the buttocks or apply a transfer belt. Coordinating the move with the client, move him or her sideways. Use a sliding motion, do not lift. Using a Transfer Belt Transfer belts, which are also called gait belts, have been mentioned several times earlier in the module. Transfer belts are a simple and very effective tool that can help you safely perform many transportation situations. Transfer belts are made of heavy cloth, leather, or webbing, they have a buckle that attaches one end of the belt to the other, and they are usually about 1 and one-half to four inches wide. The belt is placed around the client s waist, the buckle is locked, and the belt then provides you with a secure handle that can be used to lift or slide a client. SUMMARY Transporting clients is a common part of the day-to-day practice of CNAs. Transporting clients is not technically difficult, but it does
require special techniques, considerable skill, and practice. Each situation in which you are transporting a client is different and must be individually assessed. However, use the following principles for every client transportation situation. Assess the situation and assess the client Determine the fall risk. Transporting clients often puts them at risk for a fall. Ask for help; it s better to have help and not need it then need help and not have it. Maintain good body alignment of the client during the move. Safety first: do not continue transporting a client - or start transporting - if the situation seems unsafe. Always use Standard Precautions, identify the client before you begin, and always explain to the client exactly what you are going to do.