PROPER DRAPING, BED

POSITIONING AND
TURNING
OUTLINE
•Principles of Positioning
•Introduction to Immobilization
•Guidelines to Bed Positioning and Turning
•Bed Positioning & Preventive Positioning
•Draping
PRINCIPLES OF
POSITIONING
PRINCIPLES OF POSITIONING
• Positioning
• Arrangement of parts in
relation to one another
• Technique in placing the
patient safely,
comfortably, and
effectively in preparation
for any procedure
PRINCIPLES OF POSITIONING
•Positioning
• Must be considered BEFORE, DURING, and at
the CONLUSION of treatment and when a
patient is to be considered to be at rest for an
extended period
PRINCIPLES OF POSITIONING
•Rationale of Positioning
• Prevention of soft-tissue injury, pressure, and
joint contracture
• Provide patient comfort
• Provide support and stability for the trunk and
extremities
• Provide access and exposure to areas to be
treated
PRINCIPLES OF POSITIONING
•Rationale of Positioning
• Promote efficient function of patient’s body
systems
• Relieves excessive, prolonged pressure on soft
tissue, bony prominences, and circulatory, and
neurologic structures
IMMOBILIZATION
EFFECTS OF IMMOBILIZATION
•Takes a variety of forms
• Bed rest
• Casting of a body part
• Non-weight bearing status of a lower extremity
EFFECTS OF IMMOBILIZATION
•Deconditioning
• Reduced functional capacity of body system or
systems
• Warrants treatment as a separate entity from
the disease itself
• Affects multiple systems of the body
EFFECTS OF IMMOBILIZATION
•Integumentary System
• Pressure Sores/ Bed Sores/
Decubitus Ulcers
• Bony Prominences are
prone to injuries
EFFECTS OF IMMOBILIZATION
• Musculoskeletal System
• Contracture Formation
• Adaptive shortening of muscle or
other soft tissues that crosses a joint
resulting in LOM
• Shortening or tightening of the skin,
muscle, fascia, or joint capsule that
prevents normal movement or
flexibility of the involved structure
EFFECTS OF IMMOBILIZATION
•Musculoskeletal System
• Decrease in Muscle
Strength & Size
• Loss of strength at about:
• 1-3% per day
• 10-15% per week
• 50% in 3-5 weeks
• Shrink to about 50% of its
original size in 2 months
EFFECTS OF IMMOBILIZATION
•Musculoskeletal System
• Immobilization Osteoporosis
• Decreased bone mass per unit volume (Bone
Density)
• Increased risk of fractures
EFFECTS OF IMMOBILIZATION
•Cardiovascular System
• Postural/ Orthostatic Hypotension
• Impaired ability of the circulatory system to adjust
to the upright position
• Adaptation to upright position completely lost after
3 weeks
• Reduced Cardiac Efficiency
EFFECTS OF IMMOBILIZATION
•Cardiovascular System
• Redistribution of Body
Fluids
• Thrombus Formation
• Emobolus
• Edema Formation
PHYSICAL THERAPY FOR IMMOBILIZATION
•Positioning
•Wound Management
•Cardiovascular training
•Exercises
GUIDELINES TO
POSITIONING &
TURNING
 GUIDELINES FOR POSITIONING AND TURNING
•Equipment for Positioning of Patients
Bed Pillows
Bed board Bolsters or rolls
Mattress Linens or draw sheet
Foot board Rubber sheet
Side rails Canvass or safety strap/
Overhead trapeze restraints
Positioning frames and powered Sliding board
rotating frames Embow or heel protector
Heel elevator
GUIDELINES TO PROPER POSITIONING &
TURNING
•Introduce yourself to the patient and
confirm the patient’s identity
•Inform the patient of the planned treatment
and obtain consent from the patient
•Specifically describe how the patient is to be
positioned and provide assistance if required
GUIDELINES TO PROPER POSITIONING &
TURNING
•Ensure sufficient linens, pillows, equipment
needed for the treatment are available in the
cubicle or treatment area
•Patient must be lifted rather than dragged
•In anew position, check the patient’s skin
after 5-10 minutes
GUIDELINES TO PROPER POSITIONING &
TURNING
•Inspect skin for color and integrity
•Use pillows, rolled towels, or bolsters/
wedges to support body parts and to avoid
pressure
•Sheets, blankets, or bed linen should not be
tucked tightly at the foot of the bed
GUIDELINES TO PROPER POSITIONING &
TURNING
•Whenever possible, the patient should
participate actively
•Patient must be repositioned at least every 2
hours
•When turning a patient, check if assistance
from another person is required
GUIDELINES TO PROPER POSITIONING &
TURNING
•Assess the area before turning a patient
from one position to another
•Make sure patient is secure during turning
and when placed in a new position
•Observe proper body mechanics
PROPER TURNING TECHNIQUE
BED POSITIONING &
PREVENTIVE
POSITIONING
WHEELCHAIR-BOUND PATIENTS
• Reposition self every 10 to 15
minutes
• Use a wedged cushion for patients
with tendency to slide forward
• For patients with good UE strength,
perform wheelchair push-up to
alleviate pressure on ischial
tuberosities
• Leaning side to side
SUPINE POSITION
•Avoid excessive neck and upper back flexion
& shoulder abduction/protraction (rounded
shoulders)
•Avoid prolonged positioning of Knee & Hip
Flexion
•Iliopsoas & Hamstring contractures
•Avoid Hyperextension of the knee
SUPINE POSITION
SUPINE POSITION
•Patient’s UE may be elevated by pillows or
positioned in whatever way the patient
would deem comfortable
•If there is a flaccid UE, the hand should be
placed higher than the elbow
•Maintain Hip in Neutral Position → towards
IR
SUPINE POSITION
PRONE POSITION
•Place a small pillow under the patient’s
forehead or position the head on the left or
right
• Mat with cut-out for the head → maintains
neck in neutral of slight flexion
PRONE POSITION
PRONE POSITION
•A rolled towel under each anterior shoulder
area
•Small pillow or rolled towel under the
anterior aspect of the ankles → should not
maintained for prolonged periods
•Place towel rolls under distal thigh
•Patient’s UE may be positioned for comfort
PRONE POSITION
SIDE-LYING POSITION
•Positioned initially in the center of the bed
with the head, trunk, and pelvis aligned
•Patient’s LE are flexed at the hip and knee
•Uppermost LE should be supported by 1 or 2
pillows, slight forward than the lowermost
extremity
•A small towel roll can be placed proximal to
the lower lateral malleolus
SIDE-LYING POSITION
•The lower extremity provides the stability to
the pelvis and trunk
•Support patient’s head with 1-2 pillows
•Prevent rolling forward and backward
SIDE-LYING POSITION
SIDE-LYING POSITION
•Protect the lowermost greater trochanter
•If the patient will not be able to maintain
position → Safety Straps
•Lowermost UE can be positioned to promote
patient comfort and stability
•Prevent pressure ulcers over G. trochanter
and shoulder
SITTING POSITION
•Seated on a chair with adequate support
and stability for the trunk
•Support the LE with foot on a footstool or
footrests of a wheelchair, or flat on the floor
•Distal posterior thigh should be free of
pressure
SITTING POSITION
SITTING POSITION
•When patient is leaning forward → pillow
support over the anterior trunk
•When patient leaning backward → one or
more pillows behind the patient
•Patient’s UE should be supported
 SUMMARY FOR POSITIONING
• A patient who is immobilized must not be positioned
for >30 min with the ff positions:
• Excessive spine rotation and bending
• Bilateral or unilateral Scapular Abduction or Forward
head position
• Compression of thorax or chest
• Plantarflexion
• Hip or knee flexion. Knee hyperextension
• GH joint Abduction and Internal Rotation
• Flexion of elbow, wrist, and fingers
• Hip adduction or IR/ER
SUMMARY FOR POSITIONING
•Prolonged positions promote excessive stress
or strain to various structures and may
promote the development of a soft-tissue
contracture or patient discomfort
•Observe areas of pressure
•Use aids to reduce soft-tissue stress,
support, or stabilize a joint or segment,
relieve pressure, or immobilize the segment
PRECAUTIONS FOR POSITIONING
•Avoid presence of clothing or linen folds
beneath the patient
•Observe skin color over bony prominences
before, during, and after the treatment
PRECAUTIONS FOR POSITIONING
•Avoid positioning the patients extremities
beyond the support surface
•avoid excessive prolonged pressure on soft
tissue, circulatory, and neurological
structures
PRECAUTIONS FOR POSITIONING
• Be particularly careful when positioning a
patient who is
• Older
• Confused or mentally incompetent
• very young
• Comatose or paralyzed
• Agitated
• known to have an impaired cardiopulmonary
system
PREVENTIVE POSITIONING
•Specific positions must be avoided for
certain patients
•Their diagnosis or condition predisposes
them to complications related to short term
or prolonged positioning
PREVENTIVE POSITIONING
•Amputation
• Transfemoral
• Transtibial
• May sit no more than 40
minutes of each hour
• Periodic prone lying is
recommended
PREVENTIVE POSITIONING
•Hemiplegia
• Avoid position of Synergy
• UE
• LE
• Normal Alignment of patient’s head and trunk
should be maintained
PREVENTIVE POSITIONING
•Arthritis
• Swollen joints tend to assume the open-packed
position (flexed)
• Promotes flexion contractures
• Frequent gentle exercises of the involved joints
is necessary unless in acute inflammatory stage
PREVENTIVE POSITIONING
•Split Thickness Burns and Grafted Burn
Areas
• Avoid positions of comfort
• Frequent gentle exercises of the involved joints
is necessary
PREVENTIVE POSITIONING
•Orthopedic Surgical Conditions
• Total Knee Replacement
• Position knee in extension and hip neutral position
• Active assisted exercises, active range of motion
exercises, and getting out of bed ASAP
• Total Hip Replacement
• Restrict the motion of the affected limb
DRAPING
DRAPING
•Manner of arranging the covering with
sheets or towels in order to expose the part
being examined, treated or cleaned
•Exposing only body parts that are needed
for the treatment
•Maintain appropriate/ comfortable body
temperature
RATIONALE FOR DRAPING
•Provides modesty for the patient
•Helps the patient maintain an appropriate
body temperature
•It provides access and exposure to areas to
be treated while protecting other areas
•It protects the patient’s skin or clothing from
being soiled or damaged
GUIDELINES IN DRAPING
•Introduce yourself and determine patient’s
identity
•Inform the patient of the planned treatment,
obtain the consent of the patient
•If the patient is wearing street clothes
indicate specific articles or clothing to be
removed or request permission to remove
them is assistance is necessary
GUIDELINES IN DRAPING
•Provide safe and secure storage for the
patient’s personal items
•Specifically describe how you want the
patient to apply linen items, a gown, a robe,
or exercise clothing to cover or drape the
body
•Provide privacy while the patient is disrobing
and dressing
GUIDELINES IN DRAPING
•Instruct the patient to inform you when he
or she is positioned and draped
•Confirm that the patient is clothed or draped
before entering the cubicle
GUIDELINES IN DRAPING
•A the conclusion of the treatment:
• Instruct the patient to remove draping items
and put in his or her own clothing
• Provide assistance if required or provide privacy
while the patient is dressing
• Provide linen or towel so the patient can
remove perspiration, massage lotion, etc.
GUIDELINES IN DRAPING
•A the conclusion of the treatment:
• Return personal items to the patient
• Disposed of used lined in the proper container
• Prepare the cubicle or treatment area for future
use
PASSIVE RANGE OF MOTION
EXERCISES
DEFINITION:

• It is exercise in which movement is

performed by an external force in
the available pain free range of
motion. The external force may be
from the therapist, family member,
or the patient or equipment.
PASSIVE ROM EXERCISES ARE CHARACTERIZED BY:

1.No muscular activation by the

patient
2.Performed within the available
ROM
3.Applied by some external force
4.No pain
IMPORTANCE OF PASSIVE ROM EXERCISES

Passive ROM exercises are very

important if the patient has to stay in
bed or in a wheelchair. ROM exercises
help keep joints and muscles as
healthy as possible. Without these
exercises, blood flow and flexibility
(moving and bending) of the joints
can decrease. Passive ROM exercises
help keep joint areas flexible
INDICATIONS

• when voluntary movements are

impossible as when the subject is
comatose, or when paralysis of the
part.
• When Active movement may disrupt
the healing process, as when there is
acute inflammation of the joint or the
surrounding tissue.
• When active movement is too painful
to perform, as after surgery and injury
for 2 to 6 days according to the
condition.
 AIMS OF PASSIVE ROM EXERCISE

Passive exercises are largely preventive in nature and

are
used to:
1. Maintain range of motion.
2. Maintain joint and connective tissue mobility.
3. Minimizes the effects of and the formation of contractures.
4. Enhances synovial movement.
5. Maintain mechanical elasticity of muscles.
6. Assist circulation and vascular dynamics.
7. Help maintain the patient’s awareness of movement.
POINTS TO REMEMBER

Passive ROM exercises will NOT:

• Build up muscles or make them
stronger.
• Prevent muscle atrophy.
• Increase strength or endurance.
• Assist in circulation to the extent that
active, voluntary muscle contraction
will.
RANGE OF MOTION:

• Range of motion is the term that is used

to describe the amount of movement that
occur at each joint. Every joint in the
body has a "normal" range of motion.
Joints maintain their normal range of
motion by being moved. It is therefore
very important to move all joints every
day.
CAUSES OF DECREASED RANGE OF MOTION

▪ Prolonged immobilization or bed rest.

▪ Trauma to soft tissues, bones or other
joint structures.
▪ Muscle weakness.
▪ Surgeries.
▪ Joint disease.
▪ Neuromuscular disease.
▪ Pain.
EFFECT OF IMMOBILIZATION AND DECREASES
MOBILITY
Immobilization leads to decrease loading and stress on
joints and soft tissues resulting in

• Joint stiffness and adhesion.

• Atrophy and weakness of the skeletal muscle.
• Decrease tensile strength of tendons and
ligaments.
• Degeneration of articular surface.
• Adaptive shortening of the muscle and soft
tissues.
• Osteoporotic changes of the bone
 CYCLE OF IMMOBILITY

Decreased loading

Limitation of
Decreased ability
Adaptive shortening mobility
to perform A.D.L
and function

Pain from disuse

Weakness and adaptive Substitution
shortening
All these complications lead to decrease ability of to
perform the activities of daily living
 APPLICATION OF PASSIVE EXERCISES
Technical Principles
• Before performing passive exercises, some of the technical
principles should be remembered

1. Place the patient in proper comfortable position with

proper body alignment and stabilization to perform the
exercise.
2. The therapist should be in a proper position and
effective stance.
3. Free the region from restrictive closes, linen, splints,
and dressings.
4. Drape and cover the patient as necessary.
5. Utilize the proper hand holds or grasps by the therapist.
6. Perform the exercise slowly, smoothly with rhythm within
the available pain free range of motion without any force
behind the range.
7. Do all ROM exercises smoothly and gently. Never force, jerk,
or over-stretch a muscle. This can hurt the muscle or joint
instead of helping.
8. Stop ROM exercises if the person feels pain. The exercises
should never cause pain or go beyond the normal
movement of that joint.
9. Repeat the exercise 5 to 10 repetitions according to the
patient condition and response
 ISOMETRIC EXERCISES (CONT)

i.e.
• Eccentric cont. = max. tension
• Isometric cont. = intermediate tension.
• Isotonic cont. ( concentric) = minimum tension.
i.e. to start a stregthening program:
• Start by isotonic (concentric) harden by isometric then harden
by eccentric .
• If no contraction start by static then follow the same
progression.
 RULES AND PRINCIPLES OF ISOMETRIC EXS.

1. Strength will increase if an isometric contraction is sustained

against resistance for at least 6 seconds. Isometric resistance
exs. will not improve m. endurance as effectively as dynamic
exs.
2. During isometric training it is suffiscient to use an exercise
load ( resistance) up to 60-80% of th m. force-devloping
capacity in order to gain strength.
3. Since there is no joint mov. , strength will devlop only at th
position in which the ex. is performed.
4. To develop strength throughout the ROM, resistance must
be applied when the jt. is in several positions.
RULES AND PRINCIPLES OF ISOMETRIC EXS.(CONT.)

4.The length of a m. at the time of a contraction

directly affects the amount of tension that can be
produced at a specific point in the ROM.→ the
amount of resistance will vary at different points
in the range.

5. Resistance can be applied either manully or

mechnically by having the pt. hold against a
heavy load or push against an immovble object.
 RULES AND PRINCIPLES OF ISOMETRIC EXS.(CONT.)

6. Muscle setting exercises are also a form of isometric exs. but are
not performed against apreciable resistance.
a. Muscle setting exercises will be used to describe gentle static
muscle contractions used to maintain mobility between muscle
fibers and then decrease muscle spasm & pain.
b. Quadriceps settings and gluteal settings are common
examples.
c. They are not performed against resistance and will not increase
appreciably muscle strength.
d. Settings may retard atrophy in the evry early stage of rehab. of
muscle or joint when jt. Immobilization is necessary.
 INDICATIONS OF ISOMETRIC CONTRACTIONS

1. Pain ( sever pain in joints e.g. arthritis);

2. Effusion of the knee.( static cont. of the knee).
3. Weakness of the m.( as 1st step in m. reeducation).
4. Immobilization in plaster cast or back splint.
5. Inflammation of the joint ( static contraction around
the joint) to avoid weakness during theacute stage.
 PRACTICAL POINTS

1. Position: suitable & comfortable.

2. Time of contraction equal time of relaxation( not less
than 6 sec.)
3. Repetition, teach the pt. on the sound limb, then on
the affected limb to be repeated 10 min. every hour.
4. Manual or mechanical ( Velcro weights or elastised
material as Theraband) could be used gradually ,
beginning with high repetitions and low resistance the
reverse.
5. Instruct the pt. not to hold his breath.
CONTRAINDICATIONS TO ISOMETRIC EXS.

1. Hypertension
2. Haert Disease
 ISOMETRIC REGIMENS

• Brief maximal isometric exercise (Hettinger & Muller):

• Single isometric cont. of the muscle to be strengthened
against a fixed resistance.
• Hold for 5 -6 sec. , once a day, 5 – 6 days a week.

• Brief Repetitive Isometric Exs. (BRIME):

• Refinement of the previous study.
• 5 – 10 brief but max. isometric contactions are performed
against max. isometric contactins are performed against
resistance 5 days per week.
ISOMETRIC REGIMENS IN REHABILITATION &
CONDITIONING

• Early studies documented that isometric resistance exs. can

be effective means of improving muscle strength.
• Minimal effects in muscle endurance→ dynamic
( isotonic& isokinetic) exs. are more
effective.
• Multiple angle isometric exs. are necessary to improve
strength throughout the ROM.
• Resistance should be applied at least
every 20° throughout the range.
• 10 sets of 10 repetitions of 10 sec
contraction every 10° in the ROM (
Davies).
REFERENCES
•Fairchild, S.L., (2013). Pierson and Fairchild’s
Principles And Techniques of Patient Care,
5th Edition. Elsevier saunders, 3251 Riverport
Lane, St. Louis, Missouri
THANK YOU!!!
LABORATORY ACTIVITY
• Demonstration
• Group 1 → Supine Position/ Transfemoral
Amputation
• Group 2 → Prone Position/ Transtibial Amputation
• Group 3 → Side-Lying Position/ Hemiplegia
• Group 4 → Sitting Position/Total Knee Replacement
and Total Hip Replacement
• Return Demonstration
LABORATORY
• Please write your name, section and date
on a ¼ yellow paper and write the
following:
1. Patient Rapport, Informed Consent, and Respect,
check for VS
2. Patient Instruction and cueing for the procedure
3. Execution of the technique
4. Proper Body mechanics of PT and Patient
5. Conclusion of the PT session
LABORATORY CASE (POSITIONING AND
TURNING)
• CASE A • CASE B
• A 64 year old woman has • A 34 year old patient
decreased sensation over with hemiplegia on the
the bilateral lower right side. He has no
extremities, suffers sensation over the right
dyspnea when lying UE and LE, and there is
down. There is also (+) pressure ulcer over
edema on both lower the sacrum
legs
LABORATORY CASE (POSITIONING & DRAPING)
• CASE C • CASE D
• A patient with shoulder • A patient with low back
pain over the anterior pain (Right) was
and lateral aspect. was referred to your care.
referred to your care. You opted to use
You opted to use electrical stimulation
modalities for the pain