NUR 111: SKILL 9-2: MOVING AND POSITIONING PATIENT SIN BED

Brief Introduction: Correctly positioning patients is crucial for maintaining body alignment and comfort; preventing injury to the musculoskeletal and integumentary systems; and providing sensory, motor, and cognitive stimulation. A patient with impaired mobility, decreased sensation, impaired circulation, or lack of voluntary muscle control can develop damage to the musculoskeletal and integumentary system while lying down.

Brief Introduction – Cont’d You must minimize this risk by maintaining unrestricted circulation and correct body alignment while moving, turning or positioning a patient. The term body alignment refers to the condition of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures. Body alignment means that the body is in line with the pull of gravity and contributes to body balance.

ASSESSMENT: 1. Assess patient’s ROM – body alignment, and comfort level while patient is lying down. 2. Assess for risk factors that contribute to complications of immobility. A. Sensation: Decreased from cerebrovascular accident (CVA), paralysis, neuropathy. B. Impaired mobility: Traction, arthritis, hip fracture, joint surgery, or other contributing disease process. C. Impaired circulation: Arterial insufficiency D. Age: Very young, very old

ASSESSMENT – CONT’D 3. Assess patient’s level of consciousness. 4. Assess condition of the patient’s skin, especially over the bony prominences. 5. Assess patient’s physical ability to help with moving and positioning. This may be affected by age, level of consciousness, disease process, strength, ROM, and coordination 6. Assess for the presence of incisions, drainage tubes, and equipment (e.g., traction). Empty drainage bags before positioning. 7. Assess motivation of patient and ability of the family caregiver to participate in moving & positioning. 8. Check health care provider’s order before positioning the patient.

PLANNING: 1. Identify expected outcomes Patient retains ROM Patient’s skin shows no evidence of breakdown. Patient’s comfort level increases Patient’s level of independence in completing activities of daily living (ADLs) increases 2. Raise level of bed to comfortable working height. 3. Remove all pillows and devices used in previous position. 4. Get extra help as needed. 5. Explain the procedure to the patient

IMPLEMENTATION 1. Perform hand hygiene 2. Close door to room or bedside curtains 3. Help patient move up in bed A. Can the patient assist? 1. Fully able to assist, nurse assistance is not needed; nurse stands by to assist. 2. Partially able to assist; patient can assist using positioning cues or aides (e.g., draw-sheet or friction-reduction device).

IMPLEMENTATION – CONT’D 4. Help patient move up in bed using a draw-sheet (two to three nurses assist): A. Place patient supine with head of bed flat. Place height of bed appropriate for all staff. A nurse stands on each side of the bed. B. Remove pillow from under head and shoulders and place it at head of the bed. C. Turn patient side to side to place draw-sheet under them, extending from shoulders to thighs. D. Return patient to a supine position. E. Fan-fold draw-sheet on both sides, with each nurse grasping firmly near the patient. F. Place feet apart with forward-backward stance. Flex knees and hips. On the count of three, shift weight from the front to the back leg and move the patient and the draw-sheet to the desired position in the bed.

IMPLEMENTATION – CONT’D 5. Help the patient move up in bed using a friction-reducing device. A. Position patient as in Steps 4 a-c. B. Place friction-reducing device under draw-sheet by having the patient turn side to side. C. Move patient up in the bed by having two nurses grasp the draw- sheet, and one nurse holds onto the friction-reduction device. Follow steps 4e and f, moving patient up in the bed.

IMPLEMENTATION – CONT’D 6. Position patient in one of the following positions using correct body alignment. Protect pressure areas. Begin with patient lying in a supine and move up in the bed following either step 4 or 5. A. Position patient in supported semi-Fowler’s or Fowler’s position. 1. with patient lying supine, elevate head of the bed 45 to 60 degrees if not contraindicated. 2. Rest head against mattress or on small pillow. 3. Use pillows to support arms and hands if the patient does not have voluntary control or use of hands and arms. 4. Position small pillow at lower back. 5. Place small pillow or roll under thigh 6. Support calves with pillows

IMPLEMENTATION – CONT’D B. Position hemiplegic patient in supported semi-Fowler’s or Fowler’s position: 1. Position patient in supine position. Elevate head of bed 45 to 60 degrees. 2. Position patient in Fowler’s position as straight as possible. 3. Position head on small pillow with chin slightly forward. If patient is totally unable to control head movement, avoid hyperextension of the neck. 4. Provide support for involved arm and hand by placing arm away from patient’s side and supporting elbow with pillow. 5. Place rolled blanket (trochanter roll) firmly alongside patient’s legs. 6. Support feet in dorsiflexion with therapeutic boots or splints.

IMPLEMENTATION – CONT’D C. Position patient in supported supine position 1. Place patient supine with head of the bed flat. 2. Place small rolled towel under lumbar area of back – provides support for lumbar spine. 3. Place pillow under upper shoulders, neck and head. 4. Place trochanter rolls or sandbags parallel to lateral surface of the patient’s thighs. 5. Place patient’s feet in therapeutic boots or splints. 6. Place pillows under the pronated forearms, keeping upper arms parallel to patient’s body. 7. Place hand rolls in patient’s hands. Consider physical therapy referral for use of hand splints.

TROCHANTER ROLL

IMPLEMENTATION – CONT’D D. Position hemiplegic patient in supine position: 1. Place head of the bed flat. 2. Place folded towel or small pillow under shoulder or affected side. 3. Keep affected arm away from the body with elbows extended and palm up. Position the affected hand in one of the recommended positions for flaccid or spastic hand. (Alternative is to place arm out to the side, with the elbow bent and hand towards the head of the bed). 4. Place folded towel under the hip of the involved side. 5. Flex affected knee to 30 degrees by supporting it on a pillow or folded blanket. 6. Support feet with soft pillows at right angle to the leg

IMPLEMENTATION – CONT’D E. Position patient in prone position, using two nurses: 1. With head of bed flat and one nurse standing on each side of the bed, roll the patient to one side, while placing arm on side to be turned alongside of body. For patients with hemiplegia, move toward unaffected side. 2. Roll patient over arm positioned close to the body, with elbow straight and hand under the hip. Position on the abdomen in center of the bed. 3. Turn patient’s head to one side and support head with small pillow. 4. Place small pillow under the patient’s abdomen below the level of the diaphragm – this reduces pressure on breasts of some female patients and decreases hyperextension of lumbar vertebrae and strain on lower back. Improves breathing by reducing mattress pressure on the diaphragm. 5. Support arms in flexed position level at shoulders 6. Support lower legs with pillows to elevate toes – this prevents foot-drop. Reduces external rotation of legs. Reduces mattress pressure on toes.

IMPLEMENTATION – CONT’D F. Position hemiplegic patient in prone position using two nurses: 1. Move patient toward unaffected side. 2. While rolling patient onto side, place pillow on patient’s abdomen. 3. With one nurse standing on each side of the bed, roll the patient onto their abdomen by positioning involved arm close to the patient’s body, with elbow straight and hand under hip. Roll patient carefully over arm. 4. Turn head toward involved side. 5. Position involved arm out to side with elbow bent, hand toward head of bed, and fingers extended (if possible). 6. Flex knees slightly by placing pillow under legs from knees to ankles. 7. Keep feet at right angle to legs by using pillow high enough to keep toes off the mattress.

IMPLENTATION – CONT’D G. Position patient in 30-degree lateral (side-lying) position (one nurse): 1. Lower head of the bed completely or as low as patient can tolerate. 2. Lower side rail and position patient on side of the bed opposite direction toward which patient is to be turned. Move upper trunk, supporting shoulders first; then move lower trunk, supporting hips. 3. Raise side rail and go to opposite side of the bed. 4. Flex patient’s knee that will not be next to the mattress. Keep foot on the mattress. Place one hand on the patient’s upper bent leg near the hip, and place other hand on the patient’s shoulder. 5. Roll the patient onto side toward you. 6. Place pillow under patient’s head and neck. 7. Place hands under patient’s dependent shoulder and bring shoulder blade forward – this prevents patient’s weight from resting directly on shoulder joint.

IMPLEMENTATION – CONT’D 8. Position both arms in slightly flexed position. Support upper arm with pillow level with shoulders; other arm, by mattress. 9. Place hands under dependent hip and bring hip slightly forward so angle from hip to mattress is approximately 30 degrees. 10. Place small tuck-back pillow behind patient’s back (Make by folding pillow lengthwise. Smooth area is slightly tucked under patient’s back.) 11. Place pillow under semi-flexed upper leg level at hip from groin to foot. 12. Place sandbags parallel to plantar surface of dependent foot. May use ankle-foot orthotic on feet, if available.

IMPLEMENTATION – CONT’D H. Position patient in Sims (semi-prone) position (one nurse). 1. Lower head of bed completely. 2. Place patient in supine position and position them on side of bed opposite direction toward which they are to be turned. Move upper trunk, supporting shoulders first, followed by moving lower trunk, supporting hips. 3. Move to other side of the bed and turn patient on their side. Position in lateral position, lying partially on abdomen, with dependent shoulder lift out and arm placed at patient’s side.

IMPLEMENTATION – CONT’D (H) 4. Place small pillow under patient’s head. 5. Place pillow under flexed upper arm, supporting arm level with shoulder. 6. Place pillow under flexed upper legs, supporting leg level with hip – prevents internal rotation of hip and adduction of legs. Flexion prevents hyperextension of leg. Reduces mattress pressure on knees and ankles. 7. Place sandbags parallel to plantar surface of foot.

IMPLEMENTATION – CONT’D I. Logroll patient (three nurses) 1. Place small pillow between patient’s knees. 2. Cross patient’s arms on chest. 3. Position two nurses on side toward which patient is to be turned and one nurse on side where pillows are to be placed. 4. Fan-fold draw-sheets alongside of patient that will be turning. – Provides strong handles to grip draw-sheet without slipping. 5. With one nurse grasping draw-sheet at lower hips and shoulders and lower back, roll patient as one unit in a smooth, continuous motion on count of three. 6. Nurse on opposite side of bed places pillows along length of patient for support. 7. Gently lean patient as a unit back toward pillows for support.

WHEN YOU THINK OF A LOGROLL, IT IS NOT THE ONE ON THE LEFT, BUT THE ONE ON THE RIGHT!

EVALUATION: 7. Perform hand hygiene. 1. Assess patient’s body alignment, position, and level of comfort. Patient’s body should be supported by adequate mattress, and vertebral column should be without observable curves. 2. Measure ROM 3. Observe for areas of erythema or breakdown involving skin – provides ongoing observation regarding patient’s skin and musculoskeletal systems. Indicates complications of immobility or improper positioning of body part.

UNEXPECTED OUTCOMES: 1. Joint contractures develop or worsen – Increases frequency of ROM exercises to affected and immobilized areas. 2. Skin shows localized areas of erythema and breakdown – Increases frequency of repositioning. 3. Patient avoids moving – Medicate with analgesia as ordered by health care provider to ensure patient’s comfort before moving. Allow patient medication to take effect before proceeding.

RECORDING & REPORTING: Record procedure and observations (e.g., condition of skin, joint movement, patient’s ability to assist with positioning). Report observations at change of shift and document in nurses’ notes and electronic health record (EHR). Record time and position change of patient throughout shift.

END OF SKILL This is the end of your skill Your book has provided a video for this skill and the link is as follows: http://booksite.Elsevier.com/Perry- Potter/ClinicalSkills/video12.php Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques. 8e – 9.2 Moving and positioning a patient in bed. This is a long skill and in order to pass it, you need to practice it in the skills lab!