Nursing, LVNs and Patients

 Recently research has motivated organizational leaders in health care facilities to recognize the value of fostering a safety culture within our institutions. Healthcare employees and patients benefit when policies encourage the development of safe patient handing committees. It is recommended that these committees or teams be comprised of interdisciplinary members to help fully assess facility needs.

 Team members may recommend the use of safety cards, palm cards and safety handling algorithms. The team may research specific safe patient handling equipment and schedule training for direct patient care staff. Safe work environments exists when the use of patient transfer equipment and team work is routine and all injuries and accidents are promptly reported.

 Nurses and other direct patient care providers need to be aware of the types of injuries that have occurred in their facility and the frequency of those injuries. Remember, the best tool of all is your brain. Plan your patient care activities with the concepts of biomechanics, body mechanics and ergonomics in mind. Recognize your limitations, take responsibility for protecting yourself and your patient. Help develop a safety culture in your workplace and appreciate that you can have a long and healthy career.

Patients putting Nurses at Risk

Patient transfers are common tasks and present a variety of hazards for direct patient caregivers. In this example, we see a nurse involved in the task of lifting a patient from the floor. Note the bend, twisted position of the torso which places the lower back at risk for injury. The tendons in the right shoulder are at risk for strain and the left knee is hyperextended. In this example, the same situation; the nurse is being helped by her staff members or by the Institution's lift team. The full body sling is probably the most common lifting aid device. They may or may not be motorized and they may be mounted on a portable base or on overhead tracks. No members of the team performing the task of lifting the patient are at risk for jury and more importantly, the patient is not at risk.

Here, the nurse is repositioning a patient in a bed that has not been raised to help her perform the task. Not only is she placing her lower back at risk, this manoeuvre places the patient at risk for injury. Now the nurse has enlisted the aid of a team member. The bed is raised and they are using a friction reducing sliding device to help reposition the patient. There is no risk of injury to anyone involved in this task. Current bed technologies have innovative designs to reduce the amount of slippage down to the foot of the bed experienced by patients when raising the head of the bed. Some beds can even convert into chairs and other beds use air bladders incorporated into the mattress surface to help aid in rotation and patient movement.

Daily activities of direct patient care require many repetitive actions that can place any part of the body at risk but the primary hazard depicted in these scenes involves the hand and the wrist. Successful preventive action for such conditions as carpel tunnel syndrome are exercise and attention to ergonomics. Some devices designed to support the wrist may help limit movement and help reduce pain. In contrast to injuries occurring through immediate trauma or over time because or repetitive motions or the hazards of holding static positions for lengthy periods of time.

Kim, LVN: As I was holding her leg, my lower right muscle in my back, it started burning. It felt like it was burning and by the time I finished the delivery I literally had to walk sort of leaning over because it hurt so bad.

Amy, LVN: Three to four years ago I noticed that in my work day as I was bending over and helping with this 20 to 30 minute feeding, I would have pain running down my shoulder and into my lower back and numbness out to my fingers.

Although internal loading is usually associated with repetitive stress, cumulative trauma can occur while maintaining a static position. Due to individual human frailties, factors such as the weight of the load or the length of time a position is held are situational.
 Here's a routine patient transfer from a wheelchair to a bed. This has developed into hazardous situation due to poor body mechanics, the improper height of the bed, the lack of a gait transfer belt and the precarious reliance on the patient to help accomplish the task. The use of improper body mechanics has placed the nurse at risk for injury to the lower back, the shoulder and the knee. However, the proper use of body mechanics by the nurse in this situation will do very little to assure the safety of the patient.

 Now the bed is at a proper height and the nurse has provided a sliding board, allowing the patient to take a more active and safer role in performing the task. While substantially reducing the manual lifting required of the nurse to move the patient. Direct patient care involving these high risk activities can be safely achieved but all too often the help or equipment needed to ensure the safety of both the nurse and the patient is simply unavailable. The majority of healthcare safety studies have focused on patient safety and only recently has a focus shifted to consider the safety of the health care professional. Today, only a handful of states have passed safe patient handling legislation that requires hospitals and other health care facilities to provide policies or programs to reduce work related injuries. States that do have regulation addressing safe patient handing have begun with research and support from large organizations such as OSHA or NIOSH.

Knee Pain in Nurses

Another musculoskeletal injuries associated with patient related care is injury to the lower extremities. Particularly the knee. Knee joints are somewhat unstable structures. Subject to articular cartilage deterioration and ligament injury. Articular cartilage covers the ends of the leg bones making the ends slick enabled to easily slide over one and other. It absorbs shock and provides a smooth surface to facilitate motion. The mechanism of injury to the knee is through slips, trips, falls, sustained awkward positions and unexpected forces. There are four essential ligaments that provide support for the knee; the medial collateral ligament (MCL), the lateral collateral ligament (LCL), the anterior cruciate ligament (ACL) in front and the posterior cruciate ligament or PCL in the back of the knee. The MCL and LCL prevent the knee from moving too far in the side to side direction. The ACL and PCL control the front to back motion of the knee joint. The ligaments all taken together are the most important structures controlling the stability of the knee. Menisci, are special types of ligaments located between the femur and the tibia but help stabilize the component of the knee and distribute the force generated from the weight of the body. The menisci are thicker around the outside and this thickness keeps the round femur from rolling on the flat tibia. Without the menisci, the concentration of force into a small area on the articular cartilage can damage the surface and over time lead to degeneration. The mechanism of injury from many ACL ruptures is a sudden deceleration, hyperextension or pivoting motion. Recent research indicates that due to basic anatomical differences, women run a greater risk of suffering an injury to their anterior cruciate ligament than men. And some studies suggests that women's ACLs may be weakened by the effects of the female hormone; estrogen. As we have noted, there are numerous muscles, tendons and ligaments that can be affected during the course of performing a job. While it is not possible to anticipate every potential source of injury being aware of the most common injury sites and the tasks that may lead to injuries and the nature of the injury itself is the first step to creating a safe working environment.

Wrist pain in Nurses

The wrist joint is a complex joint formed between the distal ends of the radius and ulna bones and the eight carpel bones. The wrist connects the forearm to the hand and allows for a good range of motion. Repetitive or forceful or sustained or even awkward use of the hands may however lead to injury.

With the fire code, the heavy door we now had to twist a lever after we punched in a code and this constant twisting after using our hand for other things, this constant twisting of going in and out in the nursery. We started to notice symptoms in other nurses as well as myself. Some of the LVNs were having symptoms in both hands, some in one. One LVN even calculated on a night shift, not day shift but night shift that she was going in and out of the door 100 times in a 12 hour shift. This constant turning and pushing was increasing her symptoms. Several nurses decided to have surgery. I decided rather than have surgery to talk to the nurse manager about perhaps changing the door handles going to the lever system versus the door knob system. It took about six months for the door knob handles to be changed and subsequently for those of us that didn’t have surgery our symptoms diminished.

Of the three nerves that pass from the forearm across the wrist and into the hand, it is the median nerve that is affected by carpal tunnel syndrome or CTS. The median nerve passes through the carpel tunnel and splits into four branches supplying the sensational feeling to the thumb, the index finger, the middle finger and the inter-half of the ring finger. This is where the development of carpal tunnel syndrome occurs. In carpel tunnel syndrome, the nerves, blood supply and tendons that runs through the carpel tunnel get irritated and swell. Any increase in pressure within the carpel tunnel may reduce blood flow to the nerves leading to the loss of nerve function and producing numbness in the affected fingers. Medical conditions such as diabetes, pregnancy, hypothyroidism or tumors or cysts on the wrist may also generate carpel tunnel syndrome.

Shoulders and Neck pain in Nurses

Another type of musculoskeletal injury reported by nurses and other direct patient care workers. Occurs in the shoulders and neck area. The shoulder is the most moveable joint in the body and is inherently unstable. It is easily injured by impact or simple overuse.

Angie, LVN: "It was the kind of pain that I couldn’t ignore anymore and I began to notice that at work every day because I was doing repetitive behaviours at work. I was laying over a rocking chair, helping Moms with breastfeeding or I was leaning over the bed and trying to help Moms in a really quiet static cold and so the leaning forward and extending my arm out every day would cause my shoulder to ache."

The shoulder joint includes three bones; the clavicle or collar bone, the scapula or shoulder blade and the humerus (the upper arm bone). The bones of the shoulder are held together with tendons and ligaments providing additional strength and stability. The rotator cuff is a unique structure in the shoulder that is formed by four tendons. These four tendons attach to four muscles that help keep the shoulder stabilized in the socket or glenoid and help rotate the upper arm inward and outward. If the rotator cuff is torn and is not repaired a type of wear and tear arthritis of the shoulder can develop over time.

 Injuries may occur due to normal use and over extended use of the shoulder during patient handling activities. The mechanism of injury results from the rotator cuff sliding between the humeral head and the acromion as the arm is raised. As the sliding occurs over and over, the rotator cuff tendons will often be pinched. This pinching is called; impingement. Over time, impingement may lead to damage and weakening of the rotator cuff tendons. During the natural human ageing process, shoulder tendons become weaker and blood supplied to the tendons diminishes, this affects the recovery and healing process.