When assisting a patient to stand up from being seated How should their feet be positioned?

Many residents in an assistive living facility have some sore of functional mobility limitations.  Some have difficulty moving around in bed, and others may have trouble transferring from sitting to standing or walking without assistance.

One of the challenges of working with and caring for assistive living facility residents is ensuring that safety is maintained at all times.  Helping a resident transfer from a sitting position to a standing position can be very difficult.  The act of moving from a seated position seems simple enough; just raise your body up from the chair.  But there are some things that caregivers at assistive living facilities can do to assist residents when rising from a chair.

Here are a few tips to help a resident safely move to a standing position from sitting.

• Stand directly in front of the person who needs assistance rising from sitting.
• Place a gait belt or transfer belt around the resident’s waist.
• Instruct and  help the person move forward on the chair so their bottom is close to the front edge of the chair.
• Make sure the person rising has both feet flat on the floor and directly under their  knees.
• Keep your spine in an upright position, and bend your knees.
• Hold the gait belt with both arms on the resident’s side.
• Instruct the resident to use both arms to help rise from the chair.
• Instruct the person to bend slightly forward at the waist.  A good phrase to  say is, “Place your nose over toes.”
• Assist the resident to rise up, and maintain contact with the resident’s waist while rising.

Once you have effectively assisted the resident in rising from sitting, make sure the assistive device that they typically use is within reach, and be certain the person is standing with good balance before removing your hands and the gait belt from the person.

The act of rising from a chair seems like a simple task, but when a person has a limitation with functional mobility, it can be a real challenge. By following some simple tips when helping a resident of an assistive living facility rise to stand from sitting, you can be sure to maintain a safety for both you and the resident.

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If the person you care for can stand for short periods, you should have been shown the safest method to do this. In this film we see John and two people assisting him to stand from sitting in a wheelchair. Notice how he adjusts his balance before sitting again and the position of the carer’s hands when they are assisting him.

Therapist:

“Joanne we are going to help John to stand up from his wheelchair.” “So first of all we just check the brakes are on the wheelchair.” “Is your brake on?”

Joanne:

“Yes”

Therapist:

“Mine isn’t so I’ll put this one on.” “And also John, we need to make sure your feet are in the right position.” “So get your feet under your knees, around about a shoulder distance apart.” “So when you stand up you feel balanced on your feet.” “Also, having your heels down so you can push down through your heels as you’re standing up.” “Now John is going to assist a little bit by pushing away with his good arm.” “And we are going to help him get forward so he can get his weight forward over his legs.” “Now we’ve got our arms quite far down his back.” “Up in to standing.” “We’ll just give John a second or two to get his balance.” “Can you bring your weight forward a little more John if you can?” “Try and bring your tummy forward.” “While he’s standing, if we can support him with our hands on his chest at the front and round about his shoulder blade level at the back.” “Avoiding his shoulders, especially his weaker arm.” “We don’t want to grab his arms at all in case we cause any injury.” “Do you feel reasonably balanced there John?”

John:

“No.” “I feel like I’m falling backwards.”

Therapist:

“You’re falling backwards?” “Can you bring your weight forward a wee bit more?” “How’s that, a little bit better?”

John:

“Not bad, that’s better.”

Therapist:

“OK, so your weight’s well forward over your feet.” “To get that balanced feeling isn’t it?”

John:

“Aye”

Therapist:

“Yep”

Therapist:

“So John we’re going to sit down again nice and slowly.” “So if you can feel for the arm of the chair with your left hand.” “Bend in the middle.” “Slowly, slowly down.” “Well done.” “Just make sure your arm is OK.” “Right and again going down Joanne, we had our hands in the same position.” “On his chest at the front and his shoulder blade at the back so we could guide that sitting down.” “He wasn’t falling backwards.” “He was keeping his weight forward as he sat down.”

Here are some points to consider when helping someone from sitting to standing.

• Check the wheelchair brakes are on.
• Check feet position. The person should stand with their feet about a shoulder width apart to help with balance.
• Keep weight forward. Leading with the head over the knees will help to keep the person’s weight forward as they move their weight over the feet. Ask the person to use their unaffected hand to push up from the chair.
• Avoid pulling the arms. Place your hands on the upper chest and the shoulder blade.
• Is the person balanced? If they feel unsafe or unsteady, ask them to make small adjustments aiming to keep their weight evenly over both feet. Some people may push over to one side of the body or like John they may feel they are falling back.
• Keep all movements controlled.

Other points to consider when moving and handling at home.

• If the person needs support, keep as close as possible. If you are carrying a heavy object keep the weight as close to your body as possible with you back straight but not rigid.
• Think about how and where you are going to hold the person. If you grab too firmly they may tense up and be more difficult to move. The person needs to feel supported but not restricted.
• If you have to bend, start to bend from the knees keeping your back as straight as possible but not rigid. This will restrict your ability to move smoothly.
• Lead with your head and look towards the direction you are going to move to. If possible get the person to do the same. If they have their head down they may not be in a balanced position when you start to move.
• Consider the persons eyesight and sensation. If they cannot see well or cannot  feel when objects are close by they will need extra guidance to locate where they are in relation to where they are going.
• Never pull the person towards you. This position may put both of you off balance and increase risk of injury.
• Never allow the person to hold you around your neck when moving. Instead the person should hold on to your waist , shoulders or arm if they require less support.
• Do not attempt to lift heavy objects above shoulder height.
• Do not over reach for heavy items. This makes your body position top heavy and unstable.
• Use the furniture to help you. Push up from the chair arms or if the bed  is adjustable raise the height to make it easier to get into a standing position.
• If you have been supplied with moving and handling equipment use it. If you are unsure of the technique of how to use it safely or if circumstances have changed and you need advice contact the hospital ( only if still an inpatient ) or local authority social services. You are entitled to a carer needs assessment. If your circumstances have changed it may not be safe for you to continue moving and handling on your own. Alternative help or equipment may be needed.
• There may be training courses locally run by voluntary organisations such as the The Carers Trust specifically for moving and handling. Basic moving and handling courses are also offered by St.Andrews First Aid centers across Scotland.

Chapter 3. Safe Patient Handling, Positioning, and Transfers

Immobility in hospitalized patients is known to cause functional decline and complications affecting the respiratory, cardiovascular, gastrointestinal, integumentary, musculoskeletal, and renal systems (Kalisch, Lee, & Dabney, 2013). For surgical patients, early ambulation is the most significant factor in preventing complications (Sanguinetti, Wild, & Fain, 2014). Lack of mobility and ambulation can be especially devastating to the older adult when the aging process causes a more rapid decline in function (Graf, 2006). Ambulation provides not only improved physical function, but also improved emotional and social well-being (Kalisch et al., 2013).

Prior to assisting a patient to ambulate, it is important to perform a patient risk assessment to determine how much assistance will be required. An assessment can evaluate a patient’s muscle strength, activity tolerance, and ability to move, as well as the need to use assistive devices or find additional help. The amount of assistance will depend on the patient’s condition, length of stay and procedure, and any previous mobility restrictions.

Assisting Patient to the Sitting Position

Patients who have been immobile for a long period of time may experience vertigo, a sensation of dizziness, and orthostatic hypotension, a form of low blood pressure that occurs when changing position from lying down to sitting, making the patient feel dizzy, faint, or lightheaded (Potter, Perry, Ross-Kerr, & Wood, 2010). For this reason, always begin the ambulation process by sitting the patient on the side of the bed for a few minutes with legs dangling. Checklist 27 outlines the steps to positioning the patient on the side of a bed prior to ambulation (Perry, et al., 2014).

Checklist 27: Assisting a Patient to a Sitting Position

Perform hand hygiene. Check room for additional precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Listen and attend to patient cues. Ensure patient’s privacy and dignity. Assess ABCCS/suction/oxygen/safety. Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal. Follow the principles of proper body mechanics with all patient-handling procedures
1. Check physician’s order to ambulate and supplies for ambulation if required, and perform an assessment of patient’s strength and abilities. Check physician orders for any restrictions related to ambulation due to medical treatment or surgical procedure.	Supplies (proper footwear, gait belt, or assistive devices) must be gathered prior to ambulation. Do not leave patient sitting on the side of the bed unsupervised as this poses a safety risk.
2. Explain what will happen and let the patient know how they can help.	This step provides the patient with an opportunity to ask questions and help with the positioning.
3. Lower bed and ensure brakes are applied.	This prepares the work environment.
4. Stand facing the head of the bed at a 45-degree angle with your feet apart, with one foot in front of the other. Stand next to the waist of the patient.	Proper positioning helps prevent back injuries and provides support and balance.
5. Have patient turn onto side, facing toward the caregiver. Assist patient to move close to the edge of the bed.	This step prepares the patient to be moved. Positioning patient on the side of the bed
6. Place one hand behind patient’s shoulders, supporting the neck and vertebrae.	This provides support for the patient.
7. On the count of three, instruct the patient to use their elbows to push up on the bed and then grasp the side rails, as you support the shoulders as the patient sits up. Shift weight from the front foot to the back foot.	Do not allow the patient to place their arms around your shoulders. This action can lead to serious back injuries.
8. At the same time as you’re shifting your weight, gently grasp the patient’s outer thighs with your other hand and help the patient slide their feet off the bed to dangle or touch the floor.	This step helps the patient sit up and move legs off the bed at the same time. Assisting patient into a sitting position
9. Bend your knees and keep back straight and neutral.	Use of proper body mechanics helps prevent injury when handling patients.
10. On the count of three, gently raise the patient to sitting position. Ask patient to push against bed with the arm closest to the bed, at the same time as you shift your weight from the front foot to the back foot.	This allows the patient to help with the process and prevents injury to the health care provider. Assist into a sitting position
11. Assess patient for orthostatic hypotension or vertigo.	If patient is not dizzy or lightheaded, the patient is safe to ambulate. If patient becomes dizzy or faint, lay patient back down on bed.
12. Continue with mobilization procedures as required.	Mobilization helps prevent complications and improves physical function in hospitalized patients.
Data source: ATI, 2015b; Interior Health, 2013; Perry et al., 2014; PHSA, 2010

Video 3.2

Ambulating a Patient

Ambulation is defined as moving a patient from one place to another (Potter et al., 2010). Once a patient is assessed as safe to ambulate, determine if assistance from additional health care providers or assistive devices is required. Checklist 28 reviews the steps to ambulating a patient with and without a gait belt.

Checklist 28: Ambulating a Patient

Perform hand hygiene. Check room for additional precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Listen and attend to patient cues. Ensure patient’s privacy and dignity. Assess ABCCS/suction/oxygen/safety. Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal. Bring in required assistive devices and proper footwear.
1. Ensure patient does not feel dizzy or lightheaded and is tolerating the upright position. Instruct the patient to sit on the side of the bed first, prior to ambulation. Ensure proper footwear is on patient, and let patient know how far you will be ambulating. Proper footwear is non-slip or slip resistant footwear. Socks are not considered proper footwear. Check physician’s orders for any activity restrictions related to treatment or surgical procedures.	Proper footwear is essential to prevent accidental falls. Footwear
2. Apply gait belt snugly around the patient’s waist if required.	Assessment and instructions prior to ambulation Gait belts are applied over clothing. Apply gait belt over clothing Gait belt should be snug, not tight
3. Assist patient by standing in front of the patient, grasping each side of the gait belt, keeping back straight and knees bent.	The patient should be cooperative and predictable, able to bear weight on own legs and to have good trunk control. Apply gait belt if required for additional support.
4. While holding the belt, gently rock back and forth three times. On the third time, pull patient into a standing position.	This action provides momentum to help patient into a standing position. Rock back and forth to provide momentum Pulled to a standing position
5. Once patient is standing and feels stable, move to the unaffected side and grasp the gait belt in the middle of the back. With the other hand, hold the patient’s hand closest to you. If the patient does not require a gait belt, place hand closest to the patient around the upper arm and hold the patient’s hand with your other hand.	Standing to the side of the patient provides assistance without blocking the patient. Assisting ambulation with a gait belt
6. Before stepping away from the bed, ask the patient if they feel dizzy or lightheaded. If they do, sit patient back down on the bed. If patient feels stable, begin walking, matching your steps to the patient’s. Instruct patient to look ahead and lift each foot off the ground.	Always perform a risk assessment prior to ambulation. Walk only as far as the patient can tolerate without feeling dizzy or weak. Ask patient how they feel during ambulation.
7. To help a patient back to bed, have patient stand with back of knees touching the bed. Grasp the gait belt and help patient into a sitting position, keeping your back straight and knees bent.	Allowing a patient to rest after ambulation helps prevent fatigue.
8. When patient is finished ambulating, remove gait belt and settle patient into bed or a chair.	This provides a safe place for the patient to rest. Remove gait belt
9. When patient returns to bed, place the bed in lowest position, raise side rails as required, and ensure call bell is within reach. Perform hand hygiene.	Placing bed and side rails in a safe position reduces the likelihood of injury to patient. Proper placement of call bell facilitates patient’s ability to ask for assistance. Bed in the lowest position, call bell in reach, and side rail up Hand hygiene reduces the spread of microorganisms.
10. Document patient’s ability to tolerate ambulation and type of assistance required.	This provides a baseline of patient’s abilities and promotes clear communication between health care providers.
Data source: ATI, 2015b; Interior Health, 2013; Perry et al., 2014; PHSA, 2010

Video 3.3

Video 3.4

Watch the video How to Ambulate with a Cane by Kim Morris of Thompson Rivers University.

Video 3.5

Watch a video How to Ambulate With Crutches by Kim Morris, Thompson Rivers University.

1. A 90-year-old male patient is required to ambulate. He had a total hip arthroplasty and is post-operative day 3 (POD 3). What risk factors should be considered prior to ambulating an elderly patient who has been immobile after hip surgery?
2. Does ambulation require a physician’s order?
3. What should you do if a patient feels dizzy or lightheaded before ambulation?