4.2 Positioning and Ambulating the Adult Patient

One of the basic procedures that nursing personnel perform most frequently is that of changing the patient's position. Any position, even the most comfortable one, will become unbearable after a period of time. Whereas the healthy person has the ability to move at will, the sick person's movements may be limited by disease, injury, or helplessness. It is often the responsibility of the practical nurse to position the patient and change his position frequently. Once the patient is able to ambulate, certain precautions must be taken to ensure the patient's safety.

Reasons for Changing the Position of a Patient

The following are reasons for changing a patient's position.

Changing positions improves gastrointestinal function and improves respiratory function by allowing for greater lung expansion and relieving pressure on the diaphragm.

When one lies in bed for long periods of time, muscles become atonic and atrophy. Prevention of deformities allows the patient to ambulate when his activity level is advanced.

Basic Principles in Positioning Patients

"Up ad lib."
"Up as desired."
"OOB" (out of bed).

Turning the Adult Patient

  1. General Principles for Turning the Adult Patient.

Sometimes the physician will specify how often to turn a patient.

  1. Prone
  2. Supine
  3. Left Sim's
  4. Right Sim's

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igure 4-1 Prone position.

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Figure 4-2 Supine position.

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Figure 4-3 Sim's position

One example of a schedule for turning would be:

10 a.m Prone position
12 p.m. Left Sim's position
2 p.m Supine position
4 p.m. Right Sim's position
6 p.m. Prone position

Notice that in the preceding sequence, the patient is required to make only a quarter turn rather than a half turn each time the position is changed.  If the patient experiences pain while turning, a quarter turn will be less painful than a half turn.

Certain conditions may make it impossible to turn the patient.

In these cases, you need to rub the back by lifting the patient slightly off the bed and massaging with your hand held flat.

NOTE: For the initial development of skin breakdown, a patient does not have to lie on his back for long periods of time, especially if moisture and sheet wrinkles are present.
  1. Logrolling (see figure 4-4).

Description.


Figure 4-4 Logrolling

Technique.

  1. Wash your hands.
  2. Approach and identify the patient (by checking the identification band) and explain the procedure (using simple terms and pointing out the benefits).
  3. Provide privacy.
  4. Position the bed.
  1. Fold the patient's arms across his chest.
  2. Place your arms under the patient so that a major portion of the patient's weight is centered between your arms. The arm of one nurse should support the patient's head and neck.
  3. On the count of three, move the patient to the side of the bed, rocking backward on your heels and keeping the patient's body in correct alignment.
  4. Raise the side rail on that side of the bed.
  5. Move to the other side of the bed.
  6. Place a pillow under the patient's head and another between his legs.
  7. Position the patient's near arm toward you.
  8. Grasp the far side of the patient's body with your hands evenly distributed from the shoulder to the thigh.
  9. On the count of three, roll the patient to a lateral position, rocking backward onto your heels.
  10. Place pillows in front of and behind the patient's trunk to support his alignment in the lateral position.
  11. Provide for the patient's comfort and safety.
  1. Report and record as appropriate.

Maintaining  Proper Body Alignment with the Patient on His Back

Patients who must lie on their backs much of the time should be kept as comfortable as possible to prevent body deformities. The paraplegic and quadriplegic may not be able to tell you if their position is uncomfortable. You must be especially attentive in this case to prevent possible problems from malalignment.

Pillows can be used to support the patient's head, neck, arms, and hands and a footboard used to support the feet.

If the patient's trunk must lie flatter than the neck and head:

Common Positions Utilized for the Adult Patient

Placing the Adult Patient in the Supine Position

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  1. (Collect equipment.
  1. Wash your hands.
  2. Approach and identify the patient (by checking the identification band) and explain the procedure (using simple terms and pointing out the benefits).
  3. Provide privacy throughout the procedure.
  4. Position the bed.
  1. Place the bed in a flat or level position at working height, unless contraindicated.
  2. Lower the side rails on the proximal side (as necessary).
  1. Move the patient from a lateral (side) position to a supine position.
  1. For the patient on his side, remove supportive pillows.
  2. Fold top bedding back to the hips, being careful to avoid any undue exposure of the patient's body.
  3. With one hand on the patient's shoulder and one on the hip, roll his body in one piece (like a log) over onto his back.
  1. Align the patient's body in good position.
  1. Head, neck, and spine are in a straight line.
  2. Arms are at the patient's sides (parallel to the body) with hands prone.
  3. Legs are parallel to his body.
  4. Hips, knees, and feet should be in good alignment.
  1. Support the body parts in good alignment for comfort.

(a) Place a pillow under the head and shoulders to prevent strain on neck muscles and hyperextension and flexion of the neck.

(b) Support the small of the back with a folded bath towel or small pillow.

(c) Put a footboard at the foot of the bed and place the feet flat against it (at right angles to the legs) to prevent plantar flexion ("foot drop").

(d) Arrange a sandbag along the outer portion of the right foot to keep the foot upright.

(e) Make a trochanter roll and arrange it along the right hip and thigh to keep the hip joint from rotating outward.

(f) Place a pillow under each forearm so the arm is at least six inches from the body.

(9) Provide for the patient's comfort and safety.

(a) Replace the bedding neatly and raise the side rails, if used.

(b) Place the call light within reach.

(c) Position the bedside stand or overbed table so that the patient will be within easy reach of drinking water and personal items.

(d) Leave the bed in the low position.

(10) Report significant nursing observations to the charge nurse.

b. Placing the Adult Patient in the Fowler's and Semi-Fowler's Position (see figures 4-5 and 4-6).

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Figure 4-5 Fowler's position.

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Figure 4-6 Semi-Fowler's position

(1) Collect equipment.

(a) Pillows.

(b) Positioning aids as indicated.

(2) Wash your hands.

(3) Approach and identify the patient (checking the ID band) and explain the procedure (in simple terms and pointing out benefits).

(4) Provide for privacy throughout the procedure.

(5) Be sure the patient is in a supine position with his head near the top of the bed.

(6) Elevate the head of the bed.

(a) Elevate 60 to 90 degrees for the Fowler's position.

(b) Elevate 45 to 60 degrees for the semi-Fowler's position.

(7) Raise the knee gatch (knee rest) of the bed approximately 15 degrees unless contraindicated.

(8) Use a footboard to maintain the feet at right angles to the legs.

(9) Use pillows for support as needed.

(a) Behind the shoulders and head to prevent flexion and hyperextension of the neck.

(b) Behind the lower back to prevent posterior convexity of the lumbar spine region.

(c) Under the thighs to prevent hyperextension of the knees.

(10) Place the patient in good body alignment.

(a) Head, neck, and back are straight.

(b) The weight of the body is supported where the hips are flexed in the sitting position.

(c) Feet are straight.

(d) Toes are pointing up.

(11) Provide for the patient's comfort and safety.

(a) Replace bedding neatly.

(b) Raise and secure the side rails.

(c) Place the call light within reach.

(d) Position the bedside stand or overbed table so that the patient will be within easy reach of drinking water and personal items.

(e) Leave the bed in a low position.

(12) Report significant nursing observations to the charge nurse.

c. Prone Position.

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(1) Collect the equipment.

(a) Pillows.

(b) Positioning aids as indicated.

(2) Wash your hands.

(3) Approach and identify the patient and explain the procedure.

(4) Provide for privacy.

(5) Adjust the bed.

(a) Lower the headrest and knee rest so that the bed is in a flat position.

(b) Raise the bed to working height.

(c) Lower the side rails on the side where you are working.

(d) Fold the top bedding down to the level of the patient's hips, but avoid undue exposure of the patient's body, which may cause embarrassment.

(6) Position the patient in bed.

(a) If there is room between the end of the mattress and the foot of the bed, the patient should be moved down in the bed so that his feet extend over the edge of the mattress.

(b) Remove the footboard if one is present.

(7) Turn the patient onto his side and then onto his stomach.

(a) Roll toward you so you can observe him closely.

(b) Continue to roll until he is on his stomach.

(8) Align the patient in good position.

(a) Head is turned to one side.

(b) Neck and back are in a straight line.

(c) Arms are parallel to the body in a slightly flexed position; or arm on the same side toward which the head is turned can be flexed sharply at the elbow so the hand is near the head.

1 Legs are straight.

2 Feet are extended over the edge of the mattress to avoid hyperextension of the foot; or a pillow is placed under both ankles to prevent plantar flexion (foot drop) as a result of prolonged hyperextension.

(d) Support the patient's body and keep it in good alignment.

1 A small pillow or folded towel under the head may be used to prevent hyperextension and flexion of the neck.

2 A pillow under the abdomen provides comfort and prevents hyperextension of the lower spine.

(e) Provide for the patient's comfort and safety.

1 Replace bedding neatly.

2 Raise and secure the side rails.

3 Place the call light within reach.

4 Position the bedside stand or over-the-bed table within reach so the patient can get drinking water and personal items.

5 Leave the bed in a low position.

(f) Report significant nursing observations to the Charge Nurse.

d. Lateral (see figure 4-7) and Sim's positions.

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Figure 4-7 Lateral position.

(1) Collect equipment.

(a) Pillows.

(b) Positioning aids as indicated.

(2) Wash hands.

(3) Approach and identify the patient by checking identification band.

(4) Explain the procedure and gain patient's cooperation.

(a) Use simple terms.

(b) Point out benefits.

(5) Provide for privacy.

(6) Position the bed.

(a) Lower head and foot of the bed so it is level or flat.

(b) Lower the side rails on the proximal side; the distal side rail must be up.

(7) Turn the patient onto the side.

(a) Obtain assistance, if needed.

(b) Fold the top bedding back to the level of the patient's hips, but avoid undue exposure of the patient's body which may cause embarrassment.

(c) Flex the distal knee and place the distal arm across the chest.

(d) "Log-roll" the patient toward you by placing one hand on the shoulder and the other on the distal hip and pulling without twisting the patient's torso.

(e) Reach behind the patient's back with both hands, placing one on the proximal hip and lift slightly outward and roll the body toward yourself.

(8) Alternative method: turn the patient onto the side away from self.

(a) "Log-roll" the patient's body away from self by putting one hand on the proximal shoulder and the other on the hip and rolling the patient to the distal side.

(b) Lower hands to the distal shoulder and hip and pull them toward self to stabilize the patient in the lateral position.

(9) Align the patient's body in good position.

(a) Ensure the patient is not lying on his/her arm.

(b) Head, neck, and back are in a straight line.

(c) Legs are parallel with knees slightly flexed.

(d) Uppermost arm may be flexed across patient's abdomen or supported on his/her body and hip.

(10) Support the body in good alignment for comfort.

(a) Place a pillow under the patient's head and neck to prevent muscle strain and maintain alignment.

(b) Put a pillow under the uppermost leg so that it is supported from the knee to the foot.

(c) Place another pillow firmly against the patient's abdomen to support the back and hips in better alignment, if necessary.

(d) You may want to use a pillow to support the back.

1 Place a pillow lengthwise along the back.

2 Tuck one edge under the side.

3 Roll the remainder of the pillow under (toward the bed surface).

4 Tuck the pillow firmly against the back.

(e) You may also want to use a pillow to support the knee. 1

Place a pillow between the knees.

2 Bend the upper knee to provide stability.

(11) Provide for the patient's comfort and safety.

(a) Replace the bedding neatly.

(b) Raise and secure the side rails.

(c) Place the call light within reach.

(d) Position the bedside stand and over-the-bed table so that the patient is within easy reach of drinking water and personal items.

(e) Leave the bed in a low position.

(12) Report significant nursing observations to the charge nurse.

ACTIONS THE PRACTICAL NURSE CAN TAKE TO ALLEVIATE DISCOMFORT AND PROMOTE RELAXATION

POSITIONING THE ADULT TO PROMOTE SLEEP AND RELAXATION

If a patient is restless, having difficulty getting comfortable, or not sleeping well, consider the following steps. As always, be sure you have a physician's order for the patient to be turned when necessary.

  1. Wash your hands.
  2. Approach and identify the patient (by checking the ID band) and explain the procedure (using simple terms and pointing out the benefits).
  3. Perform practical nursing care to promote relaxation.
  1. Position the patient in the preferred position for rest if possible. Follow the physician's order for turning if specified.
  2. Modify the position for support and comfort. Use aids for the patient's positioning as indicated.
  3. Check for the position and function of tubes and drains.
  4. Check the bed linens for comfort.
  1. Tell the patient when you plan to return.
  2. Position the call light and bedside table within easy reach.
NOTE: To keep the call light within the patient's reach, secure it to the bed linen with a safety pin, if necessary.
  1. Provide for quiet in the area when possible.
  1. Avoid interrupting the patient once he falls asleep.
  1. Report and record significant nursing observations.

RATIONALE FOR GETTING THE PATIENT OUT OF BED

PRINCIPLES OF ASSISTING PATIENTS OUT OF BED

  1. Reassure the patient of his personal safety against injury and over-exertion.
  2. If necessary, get additional help to assist you in ambulating the patient.
  3. Support the affected side or extremities of the patient when ambulating or moving.
  4. Do not overtire the patient; increase time up in the chair and ambulation gradually.
  5. Lock all wheelchair or litter wheels before transferring the patient from the bed.
  6. Stabilize the footstool, when it is utilized.
  7. Place a signal cord or call-light button within easy reach of the patient while he is up.
  8. Check on the patient frequently.

STEPS IN PREPARING TO AMBULATE THE PATIENT

a. Review the patient's medical record for an authorizing physician's order.

b. Review the patient's nursing care plan for information regarding the following:

(1) Physical limitations.

(2) Mechanical equipment being utilized; that is, IV infusion pumps, chest drainage set, urinary drainage sets. (3) Distance patient is to ambulate.

(4) Length of time patient is to be out of bed.

(5) Frequency patient is to get out of bed.

c. Review the Nurse's Notes to identify the patient's previous tolerance of the activity specified.

d. Explain the rationale for getting out of bed to the patient.

e. Pre-medicate for pain prior to getting out of bed, if necessary.

f. Ensure that the patient is appropriately clothed, including footwear.

STAGES IN ASSISTING THE PATIENT TO AMBULATE

a. Assist the patient to sit on the side of the bed (dangling).

b. Assist the patient to stand.

c. Assist the patient to move to a chair, or to ambulate.

MANAGEMENT OF THE FALLING PATIENT

a. The Patient Who Collapses.

(1) Assume a broad stance with one foot slightly forward, grasp the patient's body firmly at the waist or under the axilla, and allow him to slide down against your leg.

(2) Ease the patient slowly to the floor using your body as an incline.

(3) Lower your body along with the patient, if necessary.

(4) Utilize proper body mechanics.

b. The Patient Who Loses Balance.

(1) Attempt to stabilize the patient by bracing him against you.

(2) Guide the patient to the bedside or chair, if possible. (3) If a fall begins to occur, guide him slowly toward the floor.

Closing

The physiological and psychological benefits of repositioning, being out of bed, and sitting up or ambulating should not be under-emphasized. Basic nursing care activity such as this, although not always pleasant for the patient, does make a significant difference in the recovery and return to health of the patient.