November 2002

10 Tips for Safe Mobility in the Bariatric Population

By Michael Dionne, PT

Michael Dionne, PT, (with a patient) advises that clients of size should avoid side lying postures if their mobility status is not known because sliding may occur.

A systematic safe progression is the key to managing patients of size. The consequences of misguided techniques can be catastrophic.

Applying mobilizing forces toward a therapeutic goal for a very dependent patient of significant size requires step-by-step considerations to achieve maximal safety. During debut mobilization efforts, a patient’s ability to contribute to the task may be minimal or unknown. For this reason, safe dependent sequencing should be utilized until the patient physically demonstrates otherwise. Nontherapeutic staff should use a mechanical conveyance and adhere to the lift-free environments or lifting policy designated in their facilities.

1. First, reduce skin shear and frictional burn while simultaneously reducing resistance that caregivers will have to physically overcome during the mobilization effort. Preparation may include maximizing inflation of the air-mattress overlay or placement of a Gortex sheet, silicone transfer sheets, transfer mattress, or even plastic bags (home environment) between the patient’s undersurface and bed usually accomplished via log roll activ
ity.
2. Flat spin the patient with the transfer sheet so friction occurs between the sheet and the bed rather than between the patient’s skin and the bed until you accomplish a perpendicular supine posture. Pad the leading edge of the bed to avoid any potential bed trauma to the patient’s posterior thigh surface. Avoid side lying postures in patients where their mobility status is unknown because it is very difficult to prevent or stop a slide from occurring in the first dependent effort.
3. Deflate the air-mattress overlay. It is very important to deflate the air mattress to determine the true deck height and preset safe orthopedic alignment for final positioning. Note: most mattresses have decreased density at the bed’s edge compared to the center of the bed.
4. Use a footstool to pre-position the patient’s thigh so that it is level and the knee joint aligns with the hip joint. Even on beds demonstrating a very low deck height of 14 inches, footstool placement to level the thigh in preparation to trunk elevation is key. This is perhaps the most often missed technique on debut mobilization of the dependent patient of size. If the thigh is downsloping, weight bearing occurs on the posterior aspect of the thigh on the leading edge of the bed surface. During trunk elevation, the patient may begin the slide toward the floor. Once that tragic slide begins, the caregiver is powerless to stop it. If the thigh is level, the patient’s line of gravity is easily returned to the center of the bed with trunk lowering. The only way to stop the slide is through pre-positioning. Until the caregiver knows that the patient has dynamic sitting balance, he or she has no business moving that patient manually toward sitting at the edge of the bed in the presence of a downward sloping thigh.
5. Once the thigh is level, the caregiver can elevate the patient’s trunk toward sitting posture. Try to have overhead rigging with a grab bar available for patient participation.
6. When directing your visual field away from the patient’s lower body, try to maintain physical contact with the patient’s knee especially during the trunk elevation phase of supine to sit. This constant proprioceptive input will allow you to sense any slide that may occur while you are reassuring the patient or monitoring telemetry during the task. Should the patient begin to slide, you would simply lower her trunk to a supine posture, thereby stopping the slide as her line of gravity returns to central location on the bed.
7. Log rolling the patient of size for peri-care, transfer product application, or wound care can be a labor-intensive task in itself. The resistance can be greatly reduced through incorporating an air mattress overlay with rotation function as a device to augment log roll postures. I have also applied a stirrup and pulley system to overhead traction equipment to allow the patient to assist in elevating his leg upward with his own upper extremities. This technique can greatly reduce the nursing workload and, at the same time, it puts responsibility back onto the patients, so they feel less dependent. This is another way to empower the patient during the rehab process.
8. Product selection in an expandable support surface can greatly reduce back injury for staff as they can roll the patient to the far side of a wider bed. On a narrow bed the same staff would be expected to not roll the patient, but perform a compensatory slide of the patient in space as the bed lacks adequate width for a full logroll.
9. With the latest move toward plastic gait belts to reduce infection control vectors, facilities should maintain a practical number of long gait belts of 60 inches for the population of significant size. Too often, clinicians find themselves doubling up gait belts, which may be unsafe. If you have to double up a gait belt, try to have both buckles located as proximal as possible to your grip so you can monitor stability of the buckle.
10. Avoid penetration of gait belt buckles into skin folds, which may result in skin trauma.

Michael Dionne, PT, provides specialized safety programming for the health care industry and is the founder of www.bariatricrehab.com in Gainesville, Ga. He has provided clinical education for the management of the patient of significant size for the past 10 years. The 10 Tips for Safe Mobility in the Bariatric Population derives from his program: Dionne’s Bariatric Ergonomics© Transfers and Mobility of the Obese Patient. He may be reached at Choice Physical Therapy Inc at (770) 532-4327 or via email at: mdionne@bariatricrehab.com.

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