Assessment Before Moving and Handling

Original Editors - Naomi O'Reilly and Vidya Acharya

Top Contributors - Naomi O'Reilly, Ewa Jaraczewska, Jess Bell, Tarina van der Stockt, Kim Jackson and Carina Therese Magtibay      

Introduction

Moving and handling people is a core activity for most rehabilitation professionals. Patients who have difficulty moving may require assistance, ranging from verbal encouragement to using electric hoisting equipment. Every moving and handling situation has a degree of risk for the patient and the rehabilitation professional.

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 moving and handling is also vital to providing a safe environment.

This article will explore the factors that directly impact the patient and assist the healthcare professional in ensuring a patient's safety during moving and handling tasks.

Physical Status	Cardiovascular Status	Respiratory Status	Emotional Status	Medical Status	Communication	Cognitive Status	Sensory Status	Other
Height	Heart Rate	Respiratory Rate	Resistive	Diagnosis	Language	Memory	Sensation	Time of Day
BMI	Blood Pressure	Oxygen Saturation	Unpredictable	Medication	Speech	Judgment	Hearing	Environment
Range of Motion		Breathing Pattern	Unco-operative	Assistive Devices	Hearing	Concentration	Vision
Strength			Depression	Fatigue	Vision	Decision making	Touch
Balance			Agression		Culture	Impulsivity	Pressure
Coordination			Confusion			Ability to Follow Instructions	Body Awareness
Tone			Agitated				Pain
Skin Integrity

Communication

Figure. 1 Communication Barriers

Communication is a: "Two-way process of reaching mutual understanding, in which participants not only exchange information, news, ideas and feelings but also create and share meaning." We can transfer information using verbal communication, such as speech and listening; non-verbal communication, including body language, eye contact, gestures and expressions; and visual communication, such as diagrams, illustrations and charts. Effective clinical communication skills can improve health outcomes and are important to high-quality healthcare.

Communication can impact a healthcare professional's interactions with their patients in various ways. Poor communication can lead to adverse patient outcomes and reduced compliance with treatment. Conversely, effective communication leads to productive health changes and higher satisfaction among patients.

The communication cycle can be affected by a number of factors.

For Patients:

• Language barriers
• Cultural barriers
• Physical and cognitive impairments, including hearing or vision loss
• Environmental factors, including a noisy environment or a lack of privacy
• Effect of medication
• Emotional state, i.e. anxiety, pain and physical discomfort

For Healthcare Professionals:

• Time Management
• Inability to build rapport with patients
• High patient load
• Emotional state, i.e. stress and anxiety
• Knowledge insecurity, lack of specialised training

Before any moving and handling task, it is vital to assess whether your patient has any problem expressing themselves or understanding your requests. You must identify each patient's specific communication needs, including access to interpreters or assistive technology. Where you have specific concerns about communication, a referral to speech and language therapy or psychology may be warranted to better understand the patient's communication difficulties and their causes.

For more information on communication types, please see Modes of Communication.

Cognitive Status

We must consider cognitive status when determining if a patient can safely participate in moving and handling interventions. It is important to explore whether the patient has trouble concentrating, understanding instructions, and performing tasks in the correct order or if they are missing out or forgetting elements of the task.

A cognitive status assessment is a quick and simple method to determine a patient's level of orientation at the time of the initial assessment and during manual handling tasks. It provides some basic information on their ability to answer questions and possibly follow instructions.

Assessing orientation can be accomplished by the following:

• 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?"
• Administering a Mini-Mental State Examination:
  • Used primarily to screen for cognitive impairment in older adults, estimate the severity of cognitive impairment at a given point in time, and assess a number of subsets of cognitive status including attention, language, memory, orientation, and visuospatial proficiency.
  • A Mini Mental State Score of 0 - 17 represents severe cognitive impairment. It may impact participation in rehabilitation activities.

Emotional Status

Emotions are physical and instinctive and can result in immediate bodily reactions. The following signs and symptoms can indicate changes in a patient's emotional status:

• Confusion, agitation or depression
• Euphoria or tearfulness
• Inappropriate behaviour (verbal and/or physical)
• Lack of cooperation during the assessment

When faced with any of these situations, the rehabilitation professional should:

• Liaise with relevant members of the multidisciplinary team to ensure a more comprehensive assessment that can determine if any specific factors are impacting emotional status, and/or
• Utilise outcome measures like the Richmond Agitation-Sedation Scale (RASS) - the RASS is designed to assess the level of alertness and agitated behaviour in critically-ill patients
  • A RASS Score between -1 and +1 generally indicates that the patient is sufficiently alert to participate in rehabilitation with minimal risk of adverse effects

Assessing Emotional Status - Suggestions of Questions to Ask about a Person with Cognitive Impairment is a useful tool to support your assessment of cognitive status.

Sensory Status

Vision

The health consequences of vision loss extend beyond the eye and visual system. Vision loss has been shown to affect quality of life, independence, and mobility. It has been linked to falls, injury and worsened status in domains from mental health to cognition, social function, employment, and education.

Assessing vision is a key part of the assessment before moving or handling a patient. You might ask the following questions as part of your assessment:

• 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?
  • e.g. eyedrops for glaucoma
• Do you see the television clearly at home? Can you describe what is in this picture?
• Are you able to read newspaper print? Medicine labels? Can you please read the following paragraph...

The following resources can assist with vision assessments by healthcare professionals:

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

Hearing

Hearing loss is associated with altered balance and an increased risk of falls, particularly for older people. Some emerging evidence suggests that hearing aids may improve postural control in individuals with hearing loss, potentially reducing fall risk, although further research is needed.

Hearing should be assessed during the subjective assessment. Basic questions to ask (verbally, written or signed) as part of your moving and handling assessment are:

• Do you wear hearing aids?
• Are your hearing aids in and switched on?

If a patient does not use hearing aids, healthcare professionals should consider whether they may be beneficial. However, it is important to recognise that during the assessment, difficulties in concentration or attention may present similarly to hearing loss in some individuals.

Vital Signs

Vital signs are measurements of the body's most basic functions, which can detect or monitor medical problems. Typically vital signs monitored by rehabilitation professionals provide information on the cardiovascular and respiratory status and include the following:

• Pulse and Heart Rate
• Blood Pressure
• Respiratory Rate
• Oxygen Saturation

These vital signs can be measured to establish goals and assess a patient's response to activity. Clinical indicators that highlight the need to assess vital signs include dyspnoea, hypertension, fatigue, syncope, chest pain, irregular heart rate, cyanosis, intermittent claudication, nausea, diaphoresis, and pedal oedema.

Cardiovascular Status

Pulses and Heart Rate

Pulse rate or heart rate is the number of times the heart beats per minute. Pulse refers to the wave of blood in an artery, which is created by the contraction of the left ventricle during a cardiac cycle.

Peripheral pulses can be felt in the periphery of the body by palpating an artery over a bony prominence. Examples in the upper extremity are the radial pulse, ulnar pulse and brachial pulse. Examples in the lower extremity are the posterior tibialis pulse, dorsalis pedis pulse and femoral pulse. Clinicians can also measure the carotid pulse in the neck.

The radial pulse is most frequently used in clinical practice. It can be palpated proximal to the wrist joint, on the radial aspect of the forearm.

• Rate:
  • A normal resting heart rate in adults is between 60 and 100 beats per minute
    • tachycardia = heart rate above 100 beats per minute
    • bradycardia = heart rate below 60 beats per minute
• Rhythm:
  • During an assessment we need to determine if the pulse is regular, irregular or irregularly irregular
    • sinus arrhythmia = pulse rate changes with respiration - i.e. pulse rate becomes faster during inspiration and slows down during expiration
    • an irregularly irregular pattern often indicates atrial flutter or atrial fibrillation
• Volume:
  • We can also consider the volume of the pulse
    • tissue perfusion indicates the health of the tissue, and is measured by "the volume of blood that flows through a unit quantity of the tissue". A low-volume pulse can suggest inadequate tissue perfusion.
    • When taken manually, the volume/strength of the pulse can be described using a 0-4+ scale (please note, some authors discuss a 0-3+ scale):
      • 0 = no palpable pulse; 1 + = faint, but detectable pulse; 2 + = pulse slightly diminished compared to normal; 3 + = normal pulse; and 4 + = a bounding pulse.
• Symmetry:
  • It is important to check for symmetry of the pulses
    • asymmetrical pulses can occur in aortic dissection, aortic coarctation, Takayasu arteritis, and subclavian steal syndrome
• Amplitude and Rate of Increase:
  • Low amplitude and low rate of increase can occur in conditions such as aortic stenosis
  • High amplitude and rapid rise might suggest aortic regurgitation, mitral regurgitation, and hypertrophic cardiomyopathy

If the heart rate increases or decreases significantly beyond what is considered optimal for that patient, and the patient experiences shortness of breath, chest pain, or faints, then the activity should be stopped at that time.

Action: Stop the activity, return the patient to rest, and monitor heart rate until it stabilises.

Please note, the optimal heart rate may differ among populations and, for patients with specific conditions, may be determined by the medical team. Interdisciplinary communication is, therefore, key.

Blood Pressure

Blood pressure (BP) 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:

• Systolic Pressure
  • Describes the maximum pressure in the large arteries when the heart contracts to pump blood around the body
  • Measured when the heart beats
• Diastolic Pressure
  • Describes the lowest pressure within the large arteries when the heart relaxes between beats
  • Measured between heart beats

Blood pressure is usually assessed with auscultation and a mercury-tube sphygmomanometer. The sphygmomanometer is measured in millimetres of mercury. Blood pressure is expressed in terms of the systolic pressure over diastolic pressure, e.g. 120/60. Semiautomated and automated devices that use the oscillometry method, which detects the amplitude of blood pressure oscillations on the arterial wall, are now frequently used in clinical practice. The brachial artery is the most common site to measure blood pressure.

Blood pressure response to exercise in healthy individuals:

• Initial rise in systolic blood pressure, followed by a linear increase as the intensity of exercise increases
• Diastolic blood pressure tends to remain stable or only slightly increase at higher levels of exercise intensity
  

In a clinical setting, recent changes in blood pressure are most relevant when determining if it is safe to continue with mobilisation. An acute increase or decrease in blood pressure of at least 20% indicates haemodynamic instability and is likely to delay mobilisation.

There are two important things to consider:

• An excessive rise in systolic or diastolic blood pressure during mobilisation, especially if prolonged, may restrict mobility progress.
• Failure of systolic blood pressure to increase or a sustained fall in blood pressure during mobilisation may reflect orthostatic intolerance or an inability of the patient’s cardiovascular system to meet the increased demands of the imposed task.

Action: stop mobilisation or modify the task to a less demanding level where blood pressure can be maintained at appropriate levels.

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
Hypertension: Stage 2	140 - 179	90 - 109
Hypertension: Critical	>180	>110

Respiratory Status

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

Respiratory Rate

Respiratory rate (RR) is the number of breaths per minute. Each breath = the movement of air in and out of the lungs.

The average respiratory rate in adults is around 12 to 20 breaths per minute. The respiratory rate in children can be higher than in adults, but it varies depending on their age. You can find out more about respiratory rates for different age groups here.

Evidence suggests that respiratory rate is one of the first vital signs to change when the body has a problem. It is, therefore, key to closely monitor respiration during rehabilitation interventions, focusing on aspects like respiratory rate, depth of breathing and breathing pattern.

• Rate:
  • Tachypnoea: respiratory rate is more than 20 breaths per minute
    • Physiological causes: exercise, emotional changes, pregnancy etc
    • Pathological causes: pain, pneumonia, pulmonary embolism, and asthma etc
  • Bradypnoea: respiratory rate is less than 12 breaths per minute
    • Causes include: worsening of underlying respiratory conditions, resulting in respiratory failure; central nervous system depressants such as alcohol, narcotics, benzodiazepines etc
  • Apnoea: "complete cessation of airflow to the lungs for a total of 15 seconds"
    • Causes include: cardiopulmonary arrest, airway obstruction, overdose of narcotics and benzodiazepines.

• Depth of Breathing:
  • Hyperpnoea: increase in the depth of breathing
  • Hyperventilation: increase in both the rate and depth of breathing
  • Hypoventilation: decrease in the rate and depth of ventilation
• Also look at which muscles the patient is using - i.e. accessory muscles (e.g. sternocleidomastoid) and abdominal muscles - and check for the symmetry in the chest wall movements
• Also remember that an inability to speak in full sentences or an increased effort to speak can indicate discomfort when breathing.

Breathing Pattern

Many conditions can influence an individual's breathing pattern:

• Biot’s Respiration: periods where breathing rate and depth are increased, followed by periods where there is no breathing / apnoea
• Cheyne-Stokes Respiration: periods where depth of ventilation increases, followed by periods of no breathing / apnoea
• Kussmaul’s Breathing: breathing rate is regular, but depth of ventilation increases
• Orthopnoea: an individual has breathlessness in lying, but it improves when they sit up or stand
• Paradoxical Ventilation: inward movement of the abdominal or chest wall on inspiration and outward movement on expiration. Occurs with: diaphragmatic paralysis, muscle fatigue, chest wall trauma

Oxygen Saturation

Oxygen saturation is a crucial measure of how well the lungs are working. It is an essential vital sign to check when assessing and monitoring a patient for positioning, transferring or mobilising. Oxygen saturation refers to the percentage of oxygen circulating in an individual's blood.

"There is no set standard of oxygen saturation where hypoxemia occurs." However, it is usually accepted that a resting oxygen saturation of less than 95% is "abnormal". During exercise, there is a temporary decrease in saturation level, but the saturation level rises quickly as the respiratory rate increases.

Pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen in a person’s blood. Most pulse oximeters are accurate to within 2-4% of the actual blood oxygen saturation level (SaO₂). This means that a pulse oximeter reading (SpO₂) may be anywhere from 2-4% higher or lower than the SaO₂. For example, an SpO₂ of 92% can be an SaO₂ of 88-96% depending on the accuracy of the pulse oximeter. However, it has been found that pulse oximetry readings are less accurate when arterial oxygen saturation (i.e. SaO₂) is below 90%.

Factors that can affect the accuracy of pulse oximetry:

• Cold hands
• Poor circulation or low perfusion state
• Wearing artificial nails
• Wearing nail polish (especially darker colours like black, blue or purple)
• Very low oxygen saturation (i.e. <80%)
• Skin pigment - accuracy reduces in individuals with darker skin pigmentation
• Skin thickness
• Anaemia
• Motion artefact - excessive motion or shaking of the probe
• Intravascular dyes
• Smoking

Ways to increase the accuracy of pulse oximetry:

• Warm up skin
• Apply topical vasodilator
• Place patient's hand below the level of the heart
• Probe location (e.g. ear vs finger)
• Probe type - transmission vs reflectance probe
• Probe size - paediatric vs adult

Environment

You must consider the area or environment in which you will complete movement and handling tasks. In particular, look at how this space could make the task unsafe. An environmental assessment identifies any problems and offers solutions to environmental hazards.

Questions to consider during the assessment before moving and handling include:

• Are there any space constraints?
• Is the floor slippery or uneven?
• Is there sufficient lighting?
• Are there any trip hazards?
• Does the patient have any attachments?

Attachments

Patients often have various attachments in the hospital setting, including electrocardiogram (ECG) leads, arterial and venous lines, central venous catheters, urinary catheters, pulse oximetry, and underwater sealed drains.

Prior to performing a moving or handling task, consult with the nursing staff to find out which attachments can be safely disconnected for the activity. Attachments that provide vital physiological data, like ECG leads and pulse oximeters, must often remain connected for safety, particularly when the patient is moved for the first time.

Care must be exercised during mobilisation to avoid dislodging attachments. It is important to remove or avoid kinks and twists in the lines and watch out that drains (e.g. urinary catheter or chest drains) remain below the level of tube insertion in the body. It is important to check there is no excessive drainage or pressure swing in the water seal level of a drain before and after treatment, as these factors can impact the performance of the drain.

Other Factors

Pain

Pain can be a significant barrier that must be addressed during a moving and handling assessment. To address pain, the healthcare provided should do one or all of the following:

• Assess the pain:
  • When assessing pain, it is important to recognise the difference between acute and persistent pain and the implications for assessing and managing the patient.
  • Pain is a subjective experience, and self-report of pain is the most reliable indicator of a patient’s experience.
  • If a patient has sufficient cognition and communication abilities, pain can be assessed using a standard self-report tool such as a Numeric Pain Rating Scale or Visual Analogue Scale.
  • However, these scales are not suitable for many critical care patients because of sedation or mechanical ventilation. In these instances, several objective measures of pain (see below) have been found to be valid and effective.
  • Always assess pain at the beginning of any physical assessment to determine the patient’s comfort level and the potential need for pain relief prior to moving the patient.

Pain Assessment Tools

Critical Care Pain Observation Tool (CPOT): The CPOT is an 8-point measure that utilises 4 basic behaviours (facial expression, body movement, muscle tension, and ventilator compliance (intubated patients) or vocalisations (extubated patients) to provide an assessment of pain.

Behavioural Pain Scale (BPS): The BPS is intended for use in patients receiving mechanical ventilation. The BPS is a 12-point scale that uses 3 basic behaviours (facial expression, upper extremity movement, and ventilator compliance) to assess pain.

Medication

Rehabilitation professionals should be aware of the patient's medications, as these can impact the patient's safety during manual handling tasks. While medication management is not the role of most rehabilitation professionals, understanding the potential impact of some medications can be very valuable. Assessment and rehabilitation interventions should be timed to coincide with the peak effectiveness of medication.

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

• Drugs Acting on the Central Nervous System, e.g. psychotropic drugs
  • Drugs or other substances that affect the brain can cause changes in mood, thoughts, perception, behaviour, levels of alertness, reflexes, reaction times, muscle tone, balance, etc.
• Drugs Acting on the Heart and Circulatory System
  • Drugs that are used to treat different heart disorders (e.g. congestive heart failure, angina, or arrhythmia) or vascular conditions (e.g. hypertension) can cause hypotension, orthostatic hypotension, syncope, bradycardia, muscle weakness or muscle spasms secondary to hyponatremia.
• Drugs Acting on Glycemic Control
  • Hypoglycemia and hyperglycemia have been associated with an increased risk of falls in hospitalised individuals.

Conclusion

These safety assessments should be considered before and during any moving or handling activity to maximise safety and minimise risk for both the patient and rehabilitation professionals involved. However, it is important to recognise that we do not necessarily have to conduct each assessment during every assessment. Instead, we must carefully consider the patient, their condition and their environment and use our clinical reasoning and judgment to choose the most appropriate assessments to ensure their safety during moving and handling tasks.

Resources

• The Handling of People: A Systems Approach
• Clinical Procedures for Safer Patient Care
• Patient Handling and Mobility Assessments, 2nd Edition
• Guidance on Manual Handling in Physiotherapy (4th edition)
• Guidance for Physiotherapists - Paediatric Manual Handling