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. Pressure2. Friction3. 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 fracturesTrapeze 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 BEDEquipment Hospital bed with side rails Turn sheet or draw sheet Pillows or foam wedges Hand cones Foot board High-top tennis shoes

ACTIONRATIONALE

1. Inform client of reason for the move and how to assist (if able).1. Reduces anxiety; helps increase comprehension and cooperation; promotes client autonomy.

2. Elevate bed to highest position.2. Avoids strain on caregivers back muscles.

3. Using two caregivers, place turn (or draw) sheet under clients back and head.3. Decreases shearing, which can lead to formation of pressure ulcers.

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 high-Fowlers 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. Place pillows at small of back, under ankles, under the arms, and under head of client.

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. Slightly elevate the gatch of the lower portion of the bed.6. Assists in maintaining correct client positioning.

7. Assess client for comfort.7. Comfort is subjective.

8. Lower height of bed and elevate side rails.8. Promotes client safety.

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.11. Adds to client comfort; relieves pressure on heels.

12. Assess clients comfort level.12. Comfort is subjective.

13. Lower height of bed and elevate side rails.13. Promotes client safety.

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. Run your hand under the clients dependent shoulder and move the shoulder slightly forward.17. Removes pressure on upper arm-shoulder joint, promoting comfort.

18. Assess the client for comfort.

19. Lower the bed and elevate the side rails.19. Promotes client safety.

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 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.22. Pillows at head and chest are for comfort. The arms are positioned according to client preference and flexibility. Pillow under chest protects breasts and promotes comfort.

23. Place a small pillow under ankles or allow toes to rest in space between foot of bed and the mattress.23. Relieves pressure on toes.

24. Assess client for comfort.

25. Lower the bed and elevate the side rails.25. Promotes client safety.

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.26. Helps prevent hand flexion contractures.

27. Assess the clients skin frequently (at least every 2 hours) for pressure marks.27. Immobile clients are prone to tissue ischemia with subsequent development of pressure ulcers.

28. Turn client frequently, at least every 2 hours.

28. Promotes blood circulation and prevents skin breakdown.

29. Use a footboard or high-top tennis shoes for clients in Fowlers and supine position. 29. Assists in prevention of foot drop.

30. Prepare a turn schedule for each client. Place sign at head of clients bed.30. Stresses to all nursing personnel the importance of turning client frequently.

INDICATIONS:FOWLERS: Promote comfort Improve respiratory problems Encourage post-operative drainageDORSAL RECUMBENT (SUPINE): Promote comfort NOTE: Head and shoulders are kept flat after procedures involving spinal anestheticsPRONE: Helps prevent contractures of hips and knees Promotes drainage from mouthSIDE-LYING POSITION/LATERAL: Promote comfort Relieves pressure on sacrum and heelsSIMS POSITION Promotes drainage from mouth Prevents aspiration Reduces pressure on sacrum and greater trochanter of hip

SCORE SHEETPOSITIONING A CLIENT IN BEDNAME:DATE:ACTION530

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 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.

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.