Transferring a Dependent Patient from Bed to Chair (Two Nurses)

ACTION RATIONALE
1. Explain the procedure to the This facilitates cooperation of the
patient. patient.
2. Perform hand hygiene. Hand hygiene deters the spread of
microorganisms.
3. Move equipment as This ensures patient safety and
necessary to make room for facilitates transfer. It provides for
the chair. privacy and warmth.
4. Move the patient to the near This requires less effort to move the
side of the bed and cross the patient. Locked wheels will prevent
patient’s arms across the the bed from moving if the patient
chest if possible. Lock the leans against it.
wheels of the bed.
5. Position the chair next to the Positioning the chair next to the
bed near the upper end and bed facilitates easier movement
with the back of the chair into the chair.
parallel to the head of the
bed. ( if wheelchair, remove
the armrest closer to the bed
if possible.) Lock the wheels
if appropriate.
6. Adjust the bed into a This facilitates transfer with minimal
comfortable level for nurses muscle strain on the nurse.
or at the level of the armrest
if one is present on the chair.
7. Prepare to lift the patient
from the bed to the chair:
a. The first nurse should Two people lifting the patient
stand behind the chair. distributes weight and the
Slip the arms under decreases the effort needed for
the patient’s axillae transfer.
and grasp the
patient’s wrist
securely.
b. The second nurse
should face the
wheelchair and
support the patient’s
knees by placing the
arms under them.
c. On a predetermined
signal, both nurses
flex their hips and
knees and
 simultaneously lift the
patient gently to the
chair.
8. Adjust the patient’s position This maintains proper body
using pillows where alignment and provides for comfort
necessary. Cover the patient and safety.
and use restraint if
necessary. Position the call
bell so it is available for use.
9. Perform hand hygiene. Hand hygiene deters the spread of
microorganisms.
10. Documents the patient’s This provides accurate
tolerance of the procedure and documentation and ensures
length of time in the chair. continuity of care.

WOUNDS
A wound is a break or disruption in the normal integrity of the skin and
tissues. That disruption may range small cut on a finger to a 3rd degree
burn covering almost all of the body. Wounds may result from mechanical
forces (such as surgical incision) or physical injury (such as burn).

Wounds Classification
Wounds are classified in many different ways. For example, wounds may
classified as intentional or unintentional, open or closed, and acute or
chronic. Wounds may also classified as partial thickness, full thickness, or
complex

Intentional wounds
It is the result of planned invasive therapy or treatment. Examples of
intentional wounds include those that result from surgery, intravenous
therapy, and lumbar puncture. The wound edges are clean, and bleeding
is usually controlled.

Unintentional Wounds
It occur from unexpected trauma, such as from accidents, forcible injury
and burns. Wound edges are usually jagged, multiple trauma is common,
and bleeding is uncontrolled. This factors create a high risk for infection
and longer healing time.

Open and closed Wounds

An open wounds occurs from intentional or unintentional trauma. The skin
surface is broken, providing a portal of entry for microorganisms. Bleeding,
tissue damage, and increased risk for infection and delayed healing may
accompany open wounds.
A closed wound results from a blow, force, or strain caused by trauma
such as a fall, an assault, or a motor vehicle crash. The skin surface is not
broken, but some tissue is damaged, and internal injury and hemorrhage
may occur.

Acute and chronic Wounds

Acute wounds, such as surgical incision, usually heal within days to
weeks. The wound edges are approximated and the risk of is lessened.
Chronic wounds, in contrast, do not progress through the normal
sequence of repair. The wound edges are often not approximated, the risk
of infection is increased, and the normal healing time is delayed. Chronic
wounds include deep pressure ulcers and peripheral vascular arterial or
venous ulcers.

Cleaning a Wound and Applying a Sterile Dressing

EQUIPMENT
Sterile gloves
Gauze dressing or squares
Sterile dressing set or suture set (contains scissors and forceps)
Cleaning solution
Clean disposable gloves
Sterile basin (optional)
Sterile drape (optional)
Plastic bag for soiled dressings
Waterproof pad
Bath blanket
Tape or ties
Surgi-pads or ABDs
Additional dressing supplies as needed or ordered (antiseptic ointments,
extra dressing)
Acetone or adhesive remover (optional)
Sterile normal saline
ACTION
1. Explain the procedure to the
patient.
2. Gather equipment.
3. Perform hand hygiene.
4. Check physician’s order for
dressing change. Note
whether drain is present.
5. Close door or curtain. Use
bath blanket as needed when
exposing area to be
redressed. Position
waterproof pad under patient
if desired.
6. Assist patient to comfortable
position that provides easy
access to wound area.
7. Placed opened, cuffed plastic
bag near working area.
8. Loosen tape an dressing.
Use adhesive remover if
necessary. If tape is soiled,
don gloves.
9. Don cleaning disposal
gloves, and remove soiled
dressings carefully in a clean
to less clean direction. Do not
reach over wound. Check
position of drains before
removing dressing. If
dressing is adhering to skin
surface, It may be moistened
by pouring a small amount of
sterile saline onto it. Keep
soiled side of dressing away
from patient’s view.
10. Assess amount, type, and
odor of drainage.
11. Discard dressings in plastic
disposal bag. Pull off glove
inside out and drop it in bag.
12. Using aseptic technique.
Open sterile dressings and
supplies on work area.
RATIONALE
An explanation encourages patient
cooperation and reduces
apprehension.
Preparation provides for organized
approach to ask.
Hand hygiene deters the spread of
microorganisms.
The order clarifies type of dressing.
Doing so provides for privacy and
warmth.
Proper positioning provides for
comfort.
Soiled dressing may be placed in
disposal bag without contaminating
outside surface of the bag.
It is easier to loosen tape before
putting on gloves.
Using clean gloves protects the
nurse when handling contaminated
dressings. Cautious removal of
dressing is more comfortable for
patient and ensures that drain is not
removed if one is present. Sterile
saline provides for easier removal
of dressing.
Wound healing process or
presence of infection should be
documented.
Proper disposal of dressings
prevents spread of microorganisms
by contaminated dressings.
Supplies are within easy reach, and