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Zorluk: Çok zorBasic Care and Comfort

An assigned client has left-sided hemiplegia resulting from a recent cerebrovascular accident. The healthcare provider prescribes out-of-bed activity to a chair for all meals. Arrange the following nursing actions for a safe bed-to-wheelchair transfer in the correct chronological order. (Place the initial action at the top and the final action at the bottom.)

  1. 1Position the wheelchair at a 45-degree angle to the bed on the client's right side and engage the wheel locks.
  2. 2Assist the client to a dangling position at the edge of the bed and assess for signs of orthostatic hypotension.
  3. 3Securely fasten a transfer gait belt around the client's waist over their clothing.
  4. 4Face the client, widen your base of support, and brace the client's left knee with your own knee.
  5. 5Instruct the client to push down against the mattress with their right hand and stand on the count of three.
  6. 6Pivot with the client toward the chair and instruct them to grasp the far armrest before gently lowering into the seat.

Cevap

The correct chronological sequence prioritizes environmental safety first, followed by physiological adaptation (dangling), equipment application (gait belt), biomechanical stabilization (bracing the weak leg), standing utilizing the strong side, and finally pivoting to safely complete the transfer.
Executing a safe transfer for a client with hemiplegia requires a highly systematic approach based on biomechanical principles. The sequence must begin with securing the environment by placing the chair on the client's strong (right) side. Next, physiological safety is ensured by having the client dangle to prevent orthostatic hypotension. Once seated safely, the gait belt is applied to provide the nurse with a safe handling point. Before standing, the nurse must physically brace the weak (left) leg to prevent it from buckling under the client's weight. The client then actively participates by pushing up with their strong (right) arm. Finally, a controlled pivot leads the client to the chair, where they reach for the armrest to guide a safe descent.

Adım Adım Çözüm

1
Prepare the wheelchair on the client's right side and lock brakes.
The environment is secure and oriented for a strong-side transfer.
Clients with hemiplegia must always transfer toward their unaffected side to utilize their intact muscle strength and coordination.
2
Assist the client to dangle and assess for dizziness.
The client adapts to the upright posture safely.
Moving a client from supine to standing too quickly risks orthostatic hypotension, which could cause a sudden fall during the transfer.
3
Apply a gait belt securely around the waist.
A safe handling interface is established.
A gait belt provides a center-of-gravity hold, preventing the nurse from lifting the client by their flaccid or weak arms.
4
Brace the client's left knee.
The hemiplegic leg is externally stabilized.
The affected leg lacks the motor control to support body weight independently and will collapse unless physically blocked by the nurse's knee.
5
Have the client push off the bed with their right hand to stand.
The client reaches a standing position.
Pushing off a solid surface (the mattress) with the unaffected arm maximizes the client's functional ability and reduces the physical load on the nurse.
6
Pivot toward the chair and have the client reach for the armrest.
The transfer is completed safely.
Pivoting as a single unit maintains alignment, and grasping the armrest provides necessary support to control the sitting motion.

Anahtar Kavram

Safe mobility and transfer techniques for clients with hemiplegia require utilizing the unaffected side for weight-bearing and spatial orientation, while physically supporting the affected side.
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Konular

Basic Care and Comfort

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