Assessment Before Moving and Handling

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Introduction

Moving and handling of people is a part of everyday working life, and a core activity for most rehabilitation professionals. Many rehabilitation techniques and interventions frequently rely on handling and moving patients. Every situation that involves the handling of a patient presents varying levels of risk to both the patient and the rehabilitation professional. Patients who have difficulty to move independently may require assistance, ranging from verbal encouragement to the use of electric hoisting equipment. Decisions about the most appropriate rehabilitation techniques and interventions are made following an individual patient risk assessment in accordance with professional guidelines for moving and handling. While adequate training is a key element of safe moving and handling, having a clear understanding of the range of factors that can impact on moving and handling are also key to providing a safe environment.

This page will explore the factors that have a direct impact on the patient. The ability to think critically and interpret patient cognition, behaviours and physiologic changes is essential to ensure safety when moving and handling a patient. The skills of observational and physical assessment are powerful tools for detecting both subtle and obvious changes in a patient’s health and form a key part of the process throughout moving and handling patients.

Communication

Figure.1 Communication Barriers

Communication is a "two-way process of reaching mutual understanding, in which participants not only exchange (encode-decode) information, news, ideas and feelings but also create and share meaning. Transferring of information can take the form of verbal communication such as speech and listening or non-verbal communication including body language, eye contact, gestures and expressions. Effective clinical communication skills can improve health outcomes and are considered an important aspect of high-quality healthcare.

Communication can impact on your interaction with patients in a variety of ways with poor communication shown to lead to adverse patient outcomes and reduced compliance to treatment, while conversely effective communication leads to productive health changes and higher satisfaction among patients.. Language barriers, physical impairments including hearing or vision loss, cognitive impairment, the physical environment and even a person's emotional state can all affect the communication cycle. In healthcare specifically, there can be barriers for the patients as well as communication barriers for the healthcare professional. Environmental factors have been identified as being a key barrier to therapist-patient communication i.e. a noisy environment or lack of privacy may result in a patient not communicating precisely what they need to. Patient barriers may include language barriers, cultural barriers, medication effects, anxiety, pain and physical discomfort. For healthcare professionals, other identified communication barriers include time management and an inability to build rapport with patients, as well as high patient loads, stress and anxiety. Similarly. healthcare professionals may not be able to communicate effectively if they do not feel confident in their clinical diagnosis or their treatment plan.

Cognitive Status

Cognitive status is crucial in determining if a patient can safely participate in assessment, positioning, transferring and mobilising a patient. A simple method of quickly assessing a patients cognitive status is by determining their orientation at the time of initial assessment and during any manual handling tasks. A patient's level of orientation can convey a lot about their cognitive status, and provide some basic information on their ability to answer questions and possibly follow instructions. Assessing orientation can be accomplished by asking the patient a series of standard questions:*Person - "Can you tell me your name and date of birth?"

• Place - "Can you tell me where you are right now?" or "Can you tell me what city we are in?"
• Time/Date - "Can you tell me today's date?" or "What day of the week is it?" or "What year is it?"
• Situation - "Can you tell me what brought you to the hospital or health centre?" or "What surgery did you have?"

There are many other outcome measures that can be used to assess cognition relevant to the specific environment you work in or specific populations you work with, which can provide insight as to the patient's appropriateness for participation in any rehabilitation activities. The mini-mental state examination is one such example which is used primarily to screen for cognitive impairment in older adults, and estimate the severity of cognitive impairment at a given point in time, and assesses a number of subsets of cognitive status including attention, language, memory, orientation, and visuospatial proficiency. A Mini Mental State Score of 0 - 17 is interpreted as severe cognitive impairment, which may impact participation in rehabilitation activities.

Emotional Status

Emotions are physical and instinctive, instantly prompting bodily reactions to threat, reward, and everything in between. There is shown to be a link between patients’ emotional status and outcomes in orthopaedic areas such as spine, trauma, sports medicine, joint reconstruction and upper extremity surgery, with patients with lower emotional health having a greater risk of less functional improvement after surgery.

Confusion, Agitation, Aggression, Depression, Cooperation

The Richmond Agitation-Sedation Scale (RASS) is one such instrument designed to assess the level of alertness and agitated behaviour in critically-ill patients, A RASS Score between -1 and +1 generally indicate that the patient possess a level of alertness that will allow them to participate in rehabilitation with a minimal risk of adverse effects.

Vision

Eye disease or visual impairment are common problems found across all age groups, genders and ethnicities. Vision loss can have a significant impact on the lives of those who experience it and the health consequences associated with vision loss extend well beyond the eye and visual system. Vision loss has been shown to affect quality of life (QOL), independence, and mobility and has been linked to falls, injury , and worsened status in domains spanning mental health, cognition, social function, employment, and educational attainment.

Assessing vision forms a key part of your assessment prior to performing any moving or handling of a patient, regardless of which environment you are in. Basic questions as part of moving and handling assessment should include;

• When did you last have a vision test?
• Do you wear glasses? If so are your glasses up to date?
• What do you wear your glasses for? e.g. reading / distance / everything [bifocals/varifocals]?
• Have you got your glasses with you?
• Do you have any eye conditions? If so, are you using any prescribed treatment? (eg eyedrops for glaucoma)
• Check distance vision by asking the patient can they see the television clearly at home or show them a picture and ask them to tell you what it is.
• Check near vision by asking the patient can they normally see to read newspaper print, or medicine labels or you can ask them to read something.

The following resource, "Look out! Bedside Vision Check for Falls Prevention" by the Royal College of Physicians provides a detailed plan with visual resources for completing a bedside vision assessment to reduce the risk of falls during moving and handling activities. While the VISIBLE resource (Vision Screening to Improve Balance & Prevent Falls) created by Health Innovation Network (HIN) South London provides a simple stepped approach to implement vision screening in community settings.

Hearing

Cardiovascular Status

Pulses and Heart Rate

Pulse rate is defined as the wave of blood in the artery created by contraction of the left ventricle during a cardiac cycle. The most common sites of measuring the peripheral pulses are the radial pulse, ulnar pulse, brachial pulse in the upper extremity, and the posterior tibialis or the dorsalis pedis pulse as well as the femoral pulse in the lower extremity. Clinicians also measure the carotid pulse in the neck. In day to day practice, the radial pulse is the most frequently used site for checking the peripheral pulse, where the pulse is palpated on the radial aspect of the forearm, just proximal to the wrist joint.

1. Rate:
   • The normal range used in an adult is between 60 to 100 beats /minute with rates above 100 beats/minute and rates and below 60 beats per minute, referred to as tachycardia and bradycardia, respectively. Changes in the rate of the pulse, along with changes in respiration is called sinus arrhythmia. In sinus arrhythmia, the pulse rate becomes faster during inspiration and slows down during expiration.
2. Rhythm:
   • Assessing whether the rhythm of the pulse is regular or irregular is essential. The pulse could be regular, irregular, or irregularly irregular. Irregularly irregular pattern is more commonly indicative of processes like atrial flutter or atrial fibrillation.
3. Volume:
   • Assessing the volume of the pulse is equally essential. A low volume pulse could be indicative of inadequate tissue perfusion; this can be a crucial indicator of indirect prediction of the systolic blood pressure of the patient.
4. Symmetry:
   • Checking for symmetry of the pulses is important as asymmetrical pulses could be seen in conditions like aortic dissection, aortic coarctation, Takayasu arteritis, and subclavian steal syndrome.
5. Amplitude and Rate of Increase:  
   • Low amplitude and low rate of increase could be seen in conditions like aortic stenosis, besides weak perfusion states. High amplitude and rapid rise can be indicative of conditions like aortic regurgitation, mitral regurgitation, and hypertrophic cardiomyopathy.<ref name=":0">Sapra A, Malik A, Bhandari P. Vital Sign Assessment. InStatPearls [Internet] 2019 Dec 28. StatPearls Publishing.

Blood Pressure

Blood pressure is the force of circulating blood on the walls of the arteries, mainly in large arteries of the systemic circulation. Blood pressure incorporates two measurements:

1. Systolic Pressure
   • Describes the maximum pressure in the large arteries when the heart contracts to propel blood through the body.
   • Measured when the heart beats
2. Diastolic Pressure
   • Describes the lowest pressure within the large arteries when the heart relaxes between beats.
   • Measured between heart beats.

Blood pressure is traditionally assessed using auscultation with a mercury-tube sphygmomanometer measured in millimeters of mercury and expressed in terms of systolic pressure over diastolic pressure e.g. 120/60. However, semiautomated and automated devices that use the oscillometry method, which detects the amplitude of the blood pressure oscillations on the arterial wall, have become widely used in daily clinical practice. The brachial artery is the most common site for BP measurement.

Table.1 Normative Blood Pressure Measurements

Reduce Accuracy	Systolic	Diastolic
Hypotension	<90	<60
Normal	90 - 129	60 - 79
Hypertension; Stage 1	130 - 139	80 - 89
Hyoertension: Stage 2	140 - 179	90 - 109
Hypertension: Critical	>180	>110

Respiratory Status

Work of breathing is the amount of energy or O₂ consumption needed by the respiratory muscles to produce enough ventilation and respiration to meet the metabolic demands of the body.

Respiratory Rate

The respiratory rate, which is the number of breaths per minute, is defined as the one breath to each movement of air in and out of the lungs. The normal breathing rate is about 12 to 20 beats per minute in an average adult. In paediatrics age group, the respiratory rate is dependant on the age of the child.

1. Rates:
   • Rates higher or lower than expected are termed as tachypnea and bradypnea, respectively. Tachypnea described as a respiratory rate more than 20 beats per minute could occur in physiological conditions like exercise, emotional changes, pregnancy, and pathological conditions like pain, pneumonia, pulmonary embolism, asthma, etc. Bradypnea which is ventilation less than 12 breaths/minute can occur due to worsening of any underlying respiratory condition leading to respiratory failure or due to usage of central nervous system depressants like alcohol, narcotics, benzodiazepines, or metabolic derangements. Apnea is the complete cessation of airflow to the lungs for a total of 15 seconds which may appear in cardiopulmonary arrests, airway obstructions, the overdose of narcotics and benzodiazepines.
2. Depth of Breathing:
   • Hyperpnea is described as an increase in the depth of breathing. Hyperventilation, on the other hand, is described as both an increase in the rate and depth of breathing and hypoventilation describes the decreased rate and depth of ventilation. Depth of breathing involves what muscle groups they are using—for example, the sternocleidomastoid (accessory muscles) and abdominal muscles—the movement of the chest wall in terms of symmetry. The inability to speak in full sentences or increased effort to speak is an indicator of discomfort when breathing.

Oxygen Saturation

Oxygen saturation is a crucial measure of how well the lungs are working, and is considered an essential element to assess and monitor a patient for positioning, transferring or mobilising. The term oxygen saturation refers to the percentage of oxygen circulating in an individuals blood.

Pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen (SpO2) in a person’s blood. Most pulse oximeters are accurate to within 2% to 4% of the actual blood oxygen saturation level, which means that a pulse oximeter reading may be anywhere from 2% to 4% higher or lower than the actual oxygen level in arterial blood, in oarticulalr when oxygen saturation is below 90%. For example, a 92% oxygen saturation on the pulse oximeter can actually be between 88 to 96% depending on the accuracy of the specific pulse oximeter.

Table.2 Factors Affecting the Accuracy of Pulse Oximetry

Reduce Accuracy	Increase Accuracy
Cold Hands	Warm Up Skin
Poor Circulation or Low Perfusion State	Apply Topical Vasodilator
Wearing Artifical Nails	Hand Below Level of Heart
Wearing Nail Polish Especially Darker Colours e.g.black, blue and purple	Probe Location Ear v Finger
Very Low Oxygen Saturation <80%	Probe Type Transmission versus Reflectance Probes
Skin Pigment Reduces with Darker Skin Pigmentation	Probe Size Paediatric versus Adult
Skin Thickness
Anaemia
Motion Artefact Excessive Motion or Shaking of Probe
Intravascular Dyes
Smoking

Breathing Pattern

There are many conditions which are based on the variation in the pattern of breathing. Biot’s respiration is a condition where there are periods of increased rate and depth of breathing, followed by periods of no breathing or apnea. Cheyne-Stokes respiration is a peculiar pattern of breathing where there is an increase in the depth of ventilation followed by periods of no breathing or apnea. Kussmaul’s breathing refers to the increased depth of ventilation, although the rate remains regular. Orthopnea refers to difficulty in respiration occurring on lying horizontal but gets better when the patient sits up or stands. Paradoxical ventilation refers to the inward movement of the abdominal or chest wall during inspiration, and outward movement during expiration, which is seen in cases of diaphragmatic paralysis, muscle fatigue, trauma to the chest wall.

Pain

Determining pain is an important component of any assessment prior to moving a patient. When assessing pain, it is important to recognise the differences between acute and persistent pain and the implications for assessment and management of the patient. Pain is a subjective experience, and self-report of pain is the most reliable indicator of a patient’s experience. Always assess pain at the beginning of any physical assessment to determine the patient’s comfort level and potential need for pain comfort measures prior to moving the patient.

Medication

In the older person in particular, medications are among one of the most common cause of increased falls risk so as rehabilitation professionals it is important to be aware of medications that our patients are taking, as these can impact on on our patients safety during manual handling tasks. While medication management is not the role of most rehabilitation professionals, understanding what the potential impact of some medications can be very valuable. Planning assessment and rehabilitation interventions around medication, where interventions involving manual handling should be timed to coincide with medication peak effectiveness where applicable.

The following classes of drugs in particular can increase risks of falls as they can affect the brain, heart and circulatory system;

1. Drugs Acting on the Central Nervous System e.g. Psychotrophic Drugs
   • Drugs or other substance that affects how the brain works that can cause changes in mood, thoughts, perception, behaviour, levels of alertness, altered reflexes, altered reaction times, altered muscle tone, balance etc.
2. Drugs Acting on the Heart and Circulatory System
   • Drugs that are used to treat different heart disorders (such as congestive heart failure, angina, or arrhythmia) or diseases of the vascular system (e.g., hypertension) can cause hypotension, orthostaic hypotension, syncope, bradycardia, muscle weakness or muscle spasms secondary to hyponatermia
3. Drugs Acting on Glycemic Control
   • Hypoglycemia and hyperglycemia have been correlated with an increased risk for falls in the hospitalised population.