CENTRO ESCOLAR UNIVERSITY

Manila * Makati * Malolos

SCHOOL OF NURSING

PROCEDURE CHECKLIST WITH RATING FORM

Therapeutic Positioning

Name of Student Score

Year/Section/Group/Number

Rate the student's performance by checking the appropriate box using the following criteria:

5 - Excellent (Carries out procedures efficiently, systematically and independently/Personality trait is observed at all times)
4 - Very Satisfactory (Carries out procedures efficiently and systematically but requires minimal guidance and supervision/Personality trait is
observed at all times)
3 - Satisfactory (Carries out the procedures efficiently and systematically but requires moderate guidance and supervision/Personality trait is
observed at all times)
2 - Fair (Carries out the procedures efficiently and systematically but requires close guidance and supervision/Personality trait is observed at
all times)
1 - Poor (Carries out the procedures inefficiently, unsystematically even under close guidance and supervision/Personality trait is observed at
all times)
0 - Not done

Criteria 5 4 3 2 1 0
ASSESSMENT
1. Assesses the client's ability to move independently.
2. Assesses the client's flexibility.
3. Assess the client's age, medical diagnosis, cognitive status, skin integrity,
nutritional status, continence, altered sensation, as well as the overall
condition of the musculoskeletal system.
4. Assesses for presence of tubes, incisions, and equipment.
5. Assesses the physician's orders for specific restrictions regarding client
positioning.
PLANNING
6. Gathers all necessary equipment:
6.1 Pillows
6.2 Rolled blankets or towels
6.3 Footboard and heel protectors
6.4 Trochanter rolls
6.5 Hand rolls
6.6 Gloves
7. Raises level of bed to a comfortable working height.
8. Removes all pillows and devices used in previous position.
9. Get extra help as needed
IMPLEMENTATION
10. Performs hand hygiene and put on PPE, if indicated
11. Introduces self to client.
12. Verifies the client using at least two identifiers (i.e. name and birth date or
name and identification number). Compare identifiers with information on
the client’s medical record/client’s identification band.
13. Explains the procedure to the client and encourage to participate as
appropriate.
14. Closes the room door and/or curtains around the bed if possible. Assembles
equipment at bedside.

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 15. Raises level of bed to comfortable working height. Lower the side rail
and assist client in side lying position.
16. Removes all pillows and devices used in previous positions. Plan the
moving technique.

Criteria 5 4 3 2 1 0
17. Obtains any needed supportive devices or assistance.
18. Follows proper body mechanics guidelines.
Placing Client in Supine position
19. Places client on back with head of bed flat and spine in straight alignment.
20. Places pillow under shoulders, neck or head.
21. Places pillows under pronated forearms, keeping upper arms parallel to
client's body.
22. Places hand rolls in client's hands.
23. Places small rolled towel under lumbar area of back.
24. Places trochanter rolls parallel to lateral surface of the client's thighs.
25. Places footboard or firm pillows against bottom of client's feet.
26. Positions feet with toes pointed upwards.
Placing Client In Fowler's Position
27. Places the patient in supine position.
Elevate the head of the bed to an angle of:
27.1 For Fowler's: approximately 45 degrees. The head and trunk are
raised 45° to 60° relative to the bed and the knees may or may not be
flexed.
27.2 For Semi-Fowler's: approximately an angle of less than 45 degrees
(often 20-30 degrees).
27.3 For High-Fowler’s position: the head and trunk are raised 60° to
90°, and most often means the client is sitting upright at a right angle
to the bed.
Placing Client in Orthopneic Position
28. Have the client sits either in bed or on the side of the bed with an over bed
table across his lap.
29. Pad table with pillow and elevate to a height that is comfortable to the
client.
30. Have the client bend with head and arms resting on the table.
Placing Client in Lateral (Side Lying) Position
31. Positions the client on the side with the head supported on a low pillow.
32. Tucks a pillow along the patient's back.
33. Brings the underlying arm forward and flex it onto the pillow used for the
head.
34. Brings the top arm forward, flex it and rest it on a pillow in ront of the
body. Put hand rolls in place if needed.
35. Flexes the top leg and bring it slightly forward.
36. Places the pillow lengthwise under the top leg.
37. Supports the feet at right angles.
Placing Client in Sim's Position
38. Places the patient in a side-lying position using only a single supporting
pillow under the head.
39. Turns the patient far enough onto the abdomen so that the lower arm is
extended behind the back and both knees are slightly flexed. Flex upper
leg farther forward than the lower leg.
40. Turns the head to one side. Be sure the spine is straight.
41. Places a folded towel under each shoulder.

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 42. Places arms flat on the patient's side or flexed at the elbow with the hands
near the patient's head. Place handroll, if needed
43. Positions client's feet beyond the end of the mattress or between the
mattress and footboard. Use a trochanter roll under ankles or pillows under
the legs.
Placing Client on Prone Position
44. Positions the client by turning him or her onto the abdomen.
45. Turns the head to one side. Be sure the spine is straight.
46. Places a folded towel under each shoulder.
47. Places arms flat on the patient's side or flexed at the elbow with the hands
near the patient's head. Places handrolls if needed.

Criteria 5 4 3 2 1 0
48. Positions client's feet beyond the end of the mattress or between the
mattress and footboard. Uses a trochanter roll under ankles or pillows under
the legs.
Placing Client in Knee Chest (genupectoral) Position
49. Places client on a kneeling position on the bed or table. Ask the client to
lean forward with the hips on the air and the chest and arms on the bed or
table. Places a pillow under the patient's head.
50. If a special examination table is available have the patient kneel on the
platform and lean on the table.
51. Drapes the client.
Placing Client in Dorsal Recumbent Position
52. Places client in a back lying position. Client’s head and shoulders are
slightly elevated on a small pillow. And the forearms may be elevated on
pillows or placed at the client’s sides.
53. Raises the patient's knees and separate legs.
54. Remains the feet flat in position on bed
Placing Client in Lithotomy Position
55. Places the client on his back. Flexes both knees simultaneously so that the
feet are brought close to the hips. Separate the thigh and legs apart,
maintaining the flexed position.
56. If on examining table, the hips should be in line with the edge of the table
and feet supported in stirrups.
57. Cover the patient's legs and body.
Placing Client in Trendelenburg Position
58. Place client in supine position with the head of the bed down and the entire
bed frame tilted downward with the head approximately 30 degrees below
horizontal level.
EVALUATION
59. Safe and proper body alignment and movement were achieved for both
client and caregiver.
60. The client is comfortable in the new position as evidenced by verbal and
nonverbal cues.
61. The client's skin and underlying organs and tissues were protected from
pressure, friction, and shear.

Total Score:

Comments/Suggestions:

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 Computation: Total Score divided by 63 (number of items) x 20 (factor) = _________________

*Total points shall be transmuted using the table for 100 pts. Passing cut-off point is 65.

Equivalent Numeric Grade: _______________

Interpretation: __________________________

Evaluator: Conforme:

Clinical Instructor's Student’s Signature Date:

Printed Name & Signature

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