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Maintaining Body Alignment: Positioning

Clients cannot always move independently and reposition themselves in bed. In


such instances, caregivers must use proper turning and positioning techniques in
order to achieve the following outcomes:
Increase client comfort
Prevent contractures
Prevent decubiti (pressure sores)
Make portions of the clients body accessible for procedures
Help clients access their environment
Clients who cannot move independently must be repositioned every 2 hours.
Repositioning must be done more often for clients who are:
Uncomfortable or incontinent
Patients who have fragile skin
Poor circulation
Decreased sensation
Poor nutritional status
Impaired mental status
Caregivers need to be aware of Three Essential Concepts when positioning
clients:
1. Pressure
2. Friction
3. Skin shear
A pressure site is any skin surface area on which the client is lying or sitting. The
force of the pressure can compromise circulation and lead to skin breakdown and
ulceration. Tissue areas over bony prominences are more likely to experience
impaired skin integrity. It is important to always inspect the skin and tissue areas
under increased pressure for signs of irritation
Friction is caused when the skin is dragged across a rough surface such as bed
sheets or stretcher surfaces. Friction causes heat, which damages the skin and may
lead to decreased skin integrity with resultant infection and/or skin breakdown.
Skin shear is the result of dragging skin across a hard surface. The force of
resistance to being dragged tears the deep layers of skin which can lead to skin
ulceration.
Here are the following guidelines that caregivers should follow for clients
in bed:
Limit the number of pillows under the head in order to avoid neck flexion.
Arms should be abducted from the body and straight with slight flexion.
Hands should rest comfortably in a flat position with fingers open.
The knees and hips should be aligned; use sandbags or pillows to prevent
external hip rotation.
Avoid flexing the knees by the use of pillows placed behind the knees.
Ankles should be flexed at 90 degrees; use pillows or footboard if necessary.
To maintain proper positioning for a client seated in a chair;
Be sure the head is straight without bending the neck or head dangling.
The trunk should be upright without bending or curving.
Arms and hands are to be supported on armrests or the tabletop; avoid
dangling the arms.
The hands should be in a flat position with the fingers open.
Hips and knees should be flexed.
The feet are to be flat on the floor or footrest with the ankles at a 90 degree
angle.

If the legs are supported on leg rests and are straight, keep the ankles flexed
at a 90 degree angle.
Assisting clients to comfortable therapeutic positions requires much skill. Often the
client is unable to assist in repositioning; in such cases, it is best to use two or more
staff members to reposition the client in order to prevent injury.
Maintaining Proper Position: Assistive Devices (Specialized equipment used
for client positioning)
Bed board Plywood board placed under entire mattress; improves spinal
alignment by providing support
Footboard Board placed at end of bed to provide support for feet to
maintain dorsiflexion
Hand-wrist splint Individually contoured for each client; maintains thumb
adduction and opposition to fingers
Pillow Available in various thicknesses; provides support; elevates body
parts
Restraint Variety of types available (jacket or vest, wrist belt, ankle belt,
waist belt); provides immobilization
Side rails Bars attached to the sides of the bed. Assist with mobility and
prevents falls.
Trochanter roll Folded blanket placed under clients buttocks and rolled
inward toward client to place thigh in a neutral position; used when client is
supine to avoid external rotation of hips and legs.
Traction Used for immobilization and to promote healing of fractures
Trapeze bar Triangular device hanging from above-bed bar that is secured to bed
frame; used by clients with upper extremity function to assist in repositioning and
transferring.
Hand-wrist splints can facilitate extension of the wrist hand-fingers, prevent
contracture, and reduce spasticity. The goal for splint use is to maintain a functional
hand for the client.
Clients must be taught the correct way to put on the device, as incorrect use of a
splint or brace can cause joint damage, stiffness, or pain.
Falls are common types of injuries in hospitals and long-term care facilities.
Side rails, which are placed on the sides of beds and stretchers to prevent falls,
can be raised, lowered, and locked into place.
For clients who are at risk for falls, the following should be checked:
Side rails should always be used; however, they should not give caregivers a
sense of security.
Beds must still be place in the lowest position to reduce the force of a
possible fall, should one occur.
Clients identified as being at-risk for falls should be closely monitored.
Some clients resist the use of side rails because they feel their independence
is altered.
It is important that the caregiver teach clients and families the purpose of
side rails, focusing on safety promotion. Note that some health care agencies
require signed notification consenting to the use of raised side rails.
Restraints are protective devices used to limit physical activity or to immobilize a
client or body part. Restraints are used for the following purposes:
To protect the client from falls
To protect a body part
To prevent the client from interfering with therapies (i.e., pulling out tubes or
catheters)

To reduce the risk of injury to others


Traction may be used to maintain alignment, especially following injury or surgery.
There are several traction techniques, including manual, skin, and skeletal.

POSITIONING A CLIENT IN BED


Equipment
Hospital bed with side rails
Turn sheet or draw sheet
Pillows or foam wedges
Hand cones
Foot board
High-top tennis shoes
ACTION
1. Inform client of reason for the move
and how to assist (if able).
2. Elevate bed to highest position.
3. Using two caregivers, place turn (or
draw) sheet under clients back and
head.
FOWLERS
4. Place bed in a 15 to 30 angle for
low-Fowlers position, 45 to 60 angle
for Fowlers position, or 70 to 90 angle
for high-Fowlers position.
5. Place pillows at small of back, under
ankles, under the arms, and under head
of client.

6. Slightly elevate the gatch of the lower


portion of the bed.

RATIONALE
1. Reduces anxiety; helps increase
comprehension and cooperation;
promotes client autonomy.
2. Avoids strain on caregivers back
muscles.
3. Decreases shearing, which can lead to
formation of pressure ulcers.
POSITION
4. The height of the head of the bed is
determined by physicians order, client
preference, client tolerance, or clients
activity (e.g., eating).
5. Promotes client comfort. Pillows under
ankles elevate heels to help prevent
pressure ulcer formation.
Pillows under the arms can assist with
lung expansion.
6. Assists in maintaining correct client
positioning.

7. Assess client for comfort.


7. Comfort is subjective.
8. Lower height of bed and elevate side
8. Promotes client safety.
rails.
SUPINE/DORSAL RECUMBENT POSITION
9. Repeat steps 13.
10. Place bed in a flat position.
11. Place small pillows at the slender
11. Adds to client comfort; relieves
part of the back, under head, and under
pressure on heels.
ankles.
12. Assess clients comfort level.
12. Comfort is subjective.
13. Lower height of bed and elevate side 13. Promotes client safety.
rails.
SIDE-LYING POSITION
14. Repeat steps 13.
15. Logroll client to side.
15. Places client on side for the proper
positioning; reduces flexion of neck and
spine.

16. Place a small pillow under clients


head. Place pillow or foam wedges
behind clients back.
Place a pillow between clients legs. Put
a pillow tucked by the clients abdomen.

16. Pillows at back and abdomen help


maintain side-lying positioning. Small
pillow under head is for comfort. Pillow
between legs is for back alignment,
comfort, and pressure relief. Pillow at
abdomen supports upper arm, thus
protecting the upper arm-shoulder joint
positioning.
17. Removes pressure on upper armshoulder joint, promoting comfort.

17. Run your hand under the clients


dependent shoulder and move the
shoulder slightly forward.
18. Assess the client for comfort.
19. Lower the bed and elevate the side
19. Promotes client safety.
rails.
PRONE POSITION
20. Repeat steps 13.
21. Assist the client to lie on abdomen.
21. Prepares client to assume prone
position.
22. Place a small pillow under clients
22. Pillows at head and chest are for
head; turn head to side. The clients
comfort. The arms are positioned
arms can be extended near side or
according to client preference and
flexed toward head. Place a small pillow
flexibility. Pillow under chest protects
under chest for female clients and for
breasts and promotes comfort.
clients with barrel chest.
23. Place a small pillow under ankles or
23. Relieves pressure on toes.
allow toes to rest in space between foot
of bed and the mattress.
24. Assess client for comfort.
25. Lower the bed and elevate the side
25. Promotes client safety.
rails.
GENERAL GUIDELINES FOR CLIENT POSITIONING
26. Use a hand cone for positioning the
26. Helps prevent hand flexion
hand if needed. Place the cone in hand,
contractures.
with the wider portion near the little
finger and the narrow portion nearer the
index finger.
27. Assess the clients skin frequently
27. Immobile clients are prone to tissue
(at least every 2 hours) for pressure
ischemia with subsequent development
marks.
of pressure ulcers.
28. Turn client frequently, at least every
28. Promotes blood circulation and
2 hours.
prevents skin breakdown.
29. Use a footboard or high-top tennis
shoes for clients in Fowlers and supine
position.
30. Prepare a turn schedule for each
client. Place sign at head of clients bed.

29. Assists in prevention of foot drop.

30. Stresses to all nursing personnel the


importance of turning client frequently.

INDICATIONS:
FOWLERS:
Promote comfort
Improve respiratory problems
Encourage post-operative drainage
DORSAL RECUMBENT (SUPINE):
Promote comfort

NOTE: Head and shoulders are kept flat after procedures involving spinal
anesthetics
PRONE:
Helps prevent contractures of hips and knees
Promotes drainage from mouth
SIDE-LYING POSITION/LATERAL:
Promote comfort
Relieves pressure on sacrum and heels
SIMS POSITION
Promotes drainage from mouth
Prevents aspiration
Reduces pressure on sacrum and greater trochanter of hip

NAME:

SCORE SHEET
POSITIONING A CLIENT IN BED

DATE:

ACTION
1. Inform client of reason for the move and how to assist (if able).
2. Elevate bed to highest position.
3. Using two caregivers, place turn (or draw) sheet under clients
back and head.
FOWLERS POSITION
4. Place bed in a 15 to 30 angle for low-Fowlers position, 45 to
60 angle for Fowlers position, or 70 to 90 angle for highFowlers position.
5. Place pillows at small of back, under ankles, under the arms,
and under head of client.
6. Slightly elevate the gatch of the lower portion of the bed.
7. Assess client for comfort.
8. Lower height of bed and elevate side rails.
SUPINE/DORSAL RECUMBENT POSITION
9. Repeat steps 13.
10. Place bed in a flat position.
11. Place small pillows at the slender part of the back, under head,
and under ankles.
12. Assess clients comfort level.
13. Lower height of bed and elevate side rails.
SIDE-LYING POSITION

14. Repeat steps 13.


15. Logroll client to side.
16. Place a small pillow under clients head. Place pillow or foam
wedges behind clients back.
Place a pillow between clients legs. Put a pillow tucked by the
clients abdomen.
17. Run your hand under the clients dependent shoulder and
move the shoulder slightly forward.
18. Assess the client for comfort.
19. Lower the bed and elevate the side rails.
PRONE POSITION
20. Repeat steps 13.
21. Assist the client to lie on abdomen.
22. Place a small pillow under clients head; turn head to side. The
clients arms can be extended near side or flexed toward head.
Place a small pillow under chest for female clients and for clients
with barrel chest.
23. Place a small pillow under ankles or allow toes to rest in space
between foot of bed and the mattress.
24. Assess client for comfort.
25. Lower the bed and elevate the side rails.
GENERAL GUIDELINES FOR CLIENT POSITIONING
26. Use a hand cone for positioning the hand if needed. Place the
cone in hand, with the wider portion near the little finger and the
narrow portion nearer the index finger.
27. Assess the clients skin frequently (at least every 2 hours) for
pressure marks.
28. Turn client frequently, at least every 2 hours.
29. Use a footboard or high-top tennis shoes for clients in Fowlers
and supine position.
30. Prepare a turn schedule for each client. Place sign at head of
clients bed.