CHAPTER 16 Positioning Clients

Positions to Ensure Safety and Comfort Integumentary system Autograft

After surgery, the site is immobilized usually for 3 to 7 days, or as prescribed, to provide the time needed for the graft to adhere and attach to the wound bed.

Positions to Ensure Safety and Comfort Integumentary system Skin graft

Elevate and immobilize the graft site to prevent movement and shearing of the graft and disruption of tissue; avoid weight-bearing.

Position to Ensure Safety and Comfort Cardiovascular System Venous insufficiency and leg ulcers

Leg elevation usually is prescribed.

Positions to Ensure Safety and Comfort Cardiovascular system Abdominal aneurysm resection

a. After surgery, limit elevation of the head of the bed to 45 degrees to avoid flexion of the graft. b. The client may be turned from side to side.

Prone position

lying on abdomen, facing downward (head may be turned to one side)

The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure? 1. Bed rest in high-Fowler's position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees

4. Bed rest with head elevation no greater than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the primary health care provider's (PHCPs) preference and on whether a vascular closure device was used), and the client may turn from side to side. The head is elevated no more than 30 degrees (although some PHCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.

Foot Boots

Foot boots are made of rigid plastic or heavy foam and keep the foot flexed at the proper angle. They should be removed 2 or 3 times a day to assess skin integrity and joint mobility by providing range of motion.

Hand Rolls

Hand rolls maintain the fingers in a slightly flexed and functional position and keep the thumb slightly adducted in opposition to the fingers.

Positions to Ensure Safety and Comfort Respiratory system Chronic obstructive pulmonary disease (COPD)

In advanced disease, place the client in a sitting position, leaning forward, with the client's arms over several pillows or an overbed table; this position will assist the client to breathe easier.

Positions to Ensure Safety and Comfort Respiratory System Laryngectomy (radical neck dissection)

Place the client in a semi-Fowler's or Fowler's position to maintain a patent airway and minimize edema.

Positions to Ensure Safety and Comfort Respiratory System Bronchoscopy postprocedure

Place the client in a semi-Fowler's position to prevent choking or aspiration resulting from an impaired ability to swallow.

Positions to Ensure Safety and Comfort Gastrointestinal system Rectal enema and irrigations

Place the client in the left Sims' position to allow the solution to flow by gravity in the natural direction of the colon.

Positions to Ensure Safety and Comfort Reproductive system Perineal and vaginal procedures

Place the client in the lithotomy position.

Position to Ensure Safety and Comfort Neurological system Spinal Injury

a. Immobilize the client on a spinal backboard with the head in a neutral position, to prevent incomplete injury from becoming complete. b. Prevent head flexion, rotation, or extension; the head is immobilized with a firm, padded cervical collar. c. Logroll the client; no part of the body should be twisted or turned, nor should the client be allowed to assume a sitting position.

Position to Ensure Safety and Comfort Sensory system Retinal detachment

a. If the detachment is large, bed rest and bilateral eye patching may be prescribed to minimize eye movement and prevent extension of the detachment. b. Restrictions in activity and positioning after repair of the detachment depends on the PHCP's preference and the surgical procedure performed.

Position to Ensure Safety and Comfort Cardiovascular System Cardiac Catheterization

a. If the femoral vessel was accessed for the procedure, the client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on PHCP preference and if a vascular closure device was used); the client may turn from side to side. b. The affected extremity is kept straight and the head is elevated no more than 30 degrees (some PHCPs prefer a lower head position or the flat position) until hemostasis is adequately achieved.

Position to Ensure Safety and Comfort Neurological system Ischemic Strokes (brain attack)

a. The head of the bed is usually kept flat. b. Maintain the head in a midline, neutral position to facilitate venous drainage from the head. c. Avoid extreme hip and neck flexion; extreme hip flexion may increase intrathoracic pressure, whereas extreme neck flexion prohibits venous drainage from the brain.

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1. "I should sleep on my left side." 2. "I should sleep on my right side." 3. "I should sleep with my head flat." 4. "I should not wear my glasses at any time."

1. "I should sleep on my left side." Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

Positions to Ensure Safety and Comfort Gastrointestinal system Liver Biopsy

1. Explain the procedure to the client. 2. Ensure that informed consent has been obtained. 3. Position the client supine, with the right side of the upper abdomen exposed; the client's right arm is raised and extended behind the head and over the left shoulder. 4. Remain with the client during the procedure. 5. After the procedure, assist the client into a right lateral (side-lying) position and place a small pillow or folded towel under the puncture site. 6. Monitor vital signs closely after the procedure and monitor for signs of bleeding. 7. Document appropriate information about the procedure, client's tolerance, and postprocedure assessment findings.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1. Left Sims' position 2. Right Sims' position 3. On the left side of the body, with the head of the bed elevated 45 degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees.

1. Left Sims' position Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.

2. Elevate and immobilize the grafted extremity. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized after surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Sims' position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow

2. Lying in bed on the unaffected side Rationale: To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure.

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Head elevated lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated

2. On the nonoperative side with the legs abducted Rationale: Positioning after a total hip replacement depends on the surgical technique used, the method of implantation, the prosthesis, and the primary health care provider's (PHCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or lying on the operative side (unless specifically prescribed by the PHCP) is avoided to prevent displacement of the prosthesis.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3. Bed rest with elevation of the affected extremity Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low-Fowler's 3. High-Fowler's 4. Supine with the head flat

3. High-Fowler's Rationale:During insertion of a nasogastric tube, the client is placed in a sitting or high-Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side and low-Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows

4. Supine, with the residual limb supported with pillows Rationale: The residual limb is usually supported on pillows for the first 24 hours after surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check the primary health care provider's or surgeon's prescriptions regarding positioning after amputation, because there are often differences in preference in terms of positioning after the procedure related to risks associated with hip and knee

Pillows

Pillows provide support, elevate body parts, splint incisional areas, and reduce postoperative pain during activity, coughing, or deep breathing. They should be of the appropriate size for the body part to be positioned.

Positions to Ensure Safety and Comfort Respiratory

Always check the PHCP's prescription regarding positioning for the client who had a thoracotomy, lung wedge resection, lobectomy of the lung, or pneumonectomy.

Positions to Ensure Safety and Comfort Gastrointestinal system Hemorrhoidectomy:

Assist the client to a lateral (side-lying) position to prevent pain and bleeding.

Position to Ensure Safety and Comfort Neurological system Cerebral Aneurysm (A weakness in a blood vessel in the brain that balloons and fills with blood.)

Bed rest is maintained with the head of the bed elevated 30 to 45 degrees to prevent pressure on the aneurysm site.

Positions to Ensure Safety and Comfort Gastrointestinal system Paracentesis

Client is usually positioned in a semi- Fowler's position in bed, or sitting upright on the side of the bed or in a chair with the feet supported; client is assisted to a position of comfort after the procedure.

Position to Ensure Safety and Comfort Cardiovascular System Deep Vein Thrombosis

Deep vein thrombosis a. If the extremity is red, edematous, and painful, traditional heparin sodium therapy may be initiated. Bed rest with leg elevation may also be prescribed for the client. b. Clients receiving low-molecular-weight heparin usually can be out of bed after 24 hours if pain level permits.

Positions to Ensure Safety and Comfort Integumentary system Circumferential burns of the extremities

Elevate the extremities above the level of the heart to prevent or reduce dependent edema.

Position to Ensure Safety and Comfort Neurological system Autonomic dysreflexia (syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above)

Elevate the head of the bed to a high-Fowler's position to assist with adequate ventilation and assist in the prevention of hypertensive stroke.

Positions to Ensure Safety and Comfort Endocrine system Hypophysectomy (removal of the pituitary gland)

Elevate the head of the bed to prevent increased intracranial pressure.

Positions to Ensure Safety and Comfort Integumentary system Burns of the face and head

Elevate the head of the bed to prevent or reduce facial facial, head, and tracheal edema.

Position to Ensure Safety and Comfort Cardiovascular System Varicose Veins

Leg elevation above the heart level usually is prescribed; the client also is advised to minimize prolonged sitting or standing during daily activities.

Supine position

Lying on back, facing upward

Semiprone position (sims' or forward side-lying)

Patient lying face downwards, but with one or both knees flexed to one side

Position to Ensure Safety and Confort Cardiovascular System Heart failure and pulmonary edema

Position the client upright, preferably with the legs dangling over the side of the bed, to decrease venous return and lung congestion.

Position to Ensure Safety and Comfort Sensory system Cataract surgery

Postoperatively, elevate the head of the bed (semi-Fowler's to Fowler's position) and position the client on the back or the nonoperative side to prevent the development of edema at the operative site.

Positions to Ensure Safety and Comfort Gastrointestinal system Gastroesophageal reflux disease

Reverse Trendelenburg's position may be prescribed to promote gastric emptying and prevent esophageal reflux.

Sandbags

Sandbags are soft devices filled with a substance that can be shaped to body contours to provide support. They immobilize extremities and maintain specific body alignment.

Positions to Ensure Safety and Comfort Respiratory System Postural drainage

The lung segment to be drained should be in the uppermost position; Trendelenburg's position may be used.

Side Rails

These bars, positioned along the sides of the length of the bed, ensure client safety and are useful for increasing mobility. They also provide assistance in rolling from side to side or sitting up in bed. Laws regarding the use of side rails vary state to state, and these laws must be followed; some states view side rails as a form of restraint, and therefore, laws and agency policies must be followed.

Bed Boards

These plywood boards are placed under the entire surface area of the mattress and are useful for increasing back support and body alignment. Many of the beds used in health care facilities have the capability of being adjusted to a softness or hardness desired for the mattress to meet the client's needs.

Trochanter Rolls

These rolls prevent external rotation of the legs when the client is in the supine position. To form a roll, use a cotton bath blanket or a sheet folded lengthwise to a width extending from the greater trochanter of the femur to the lower border of the popliteal space.

Hand-Wrist Splints

These splints are individually molded for the client to maintain proper alignment of the thumb in slight adduction and the wrist in slight dorsiflexion.

Trapeze Bar

This bar descends from a securely fastened overhead bar attached to the bed frame. It allows the client to use the upper extremities to raise the trunk off the bed, assists in transfer from the bed to a wheelchair, and helps the client to perform upper arm- strengthening exercises.

Wedge Pillow

This triangular pillow is made of heavy foam and is used to maintain the legs in abduction after total hip replacement surgery.

Position to Ensure Safety and Comfort Neurological system Laminectomy and other vertebral surgery

a. Clients are often out of bed postoperatively with a back brace if prescribed. b. When the client is out of bed, the client's back is kept straight (the client is placed in a straight-backed chair) with the feet resting comfortably on the floor.

Position to Ensure Safety and Comfort Cardiovascular System Amputation of lower extremities

a. During the first 24 hours after amputation, elevate the foot of the bed (the residual limb is supported with pillows but not elevated because of the risk of flexion contractures) to reduce edema. b. Consult with the PHCP and, if prescribed, position the client in a prone position twice a day for a 20- to 30-minute period to stretch muscles and prevent flexion contractures of the hip.

Position to Ensure Safety and Comfort Neurological system Lumbar puncture

a. During the procedure, assist the client to the lateral (side-lying) position, with the back bowed at the edge of the examining table, the knees flexed up to the abdomen, and the neck flexed so that the chin is resting on the chest. b. After the procedure, place the client in the supine position for 4 to 12 hours, as prescribed.

Positions to Ensure Safety and Comfort Respiratory System Thoracentesis

a. During the procedure, to facilitate removal of fluid from the pleural space, position the client sitting on the edge of the bed or examining table and leaning over a bedside table with the feet supported on a stool, or lying on the unaffected side with the client in Fowler's position. b. After the procedure, assist the client to a position of comfort.

Position to Ensure Safety and Comfort Neurological system Increased intracranial pressure

a. Elevate the head of the bed 30 to 45 degrees and maintain the head in a midline, neutral position to facilitate venous drainage from the head. b. Avoid extreme hip and neck flexion. Do not place a client with a head injury in a flat or Trendelenburg's position because of the risk of increased intracranial pressure.

Positions to Ensure Safety and Comfort Gastrointestinal system Nasogastric tube

a. Insertion: Position the client in a high- Fowler's position with the head tilted forward; this position will help close the trachea and open the esophagus. b. Irrigation and tube feedings: Elevate the head of the bed (semi-Fowler's to Fowler's position) to prevent aspiration; head elevation is maintained for 30 minutes to 1 hour (per agency procedure) after an intermittent feeding and should remain elevated for continuous feedings.

Position to Ensure Safety and Comfort Neurological system Cerebral angiography (In cerebral angiography, a catheter (long, thin, flexible tube) is inserted into an artery in the arm or leg. Using the catheter, a technician injects a special dye into the blood vessels that lead to the brain. In cerebral angiography, X-ray images show blood vessel abnormalities in the brain)

a. Maintain bed rest for the length of time as prescribed. b. The extremity into which the contrast medium was injected is kept straight and immobilized for about 6 to 8 hours.

Positions to Ensure Safety and Comfort Gastrointestinal system Sengstaken-Blakemore and Minnesota tubes (used to stop or slow bleeding from the esophagus and stomach)

a. Not commonly used because they are uncomfortable for the client and can cause complications, but their use may be necessary when other interventions are not feasible. b. If prescribed, maintain elevation of the head of the bed to enhance lung expansion and reduce portal blood flow, permitting effective esophagogastric balloon tamponade.

Position to Ensure Safety and Confort Cardiovascular System Peripheral arterial disease

a. Obtain the PHCP's prescription for positioning. b. Because swelling can prevent arterial blood flow, clients may be advised to elevate their feet at rest, but they should not raise their legs above the level of the heart, because extreme elevation slows arterial blood flow; some clients may be advised to maintain a slightly dependent position to promote perfusion. Dependent position simply means put the legs dangling because when you dangle legs you decrease the return of blood and reduce pulmonary congestion. If you put the legs higher than the level of your heart, you increase return of blood to the heart and therefore increase pulmonary congestion

Positions to Ensure Safety and Comfort Endocrine system Thyroidectomy

a. Place the client in the semi-fowler's to Fowler's position to reduce swelling and edema in the neck area. b. Sandbags or pillows or other stabilization devices may be used to support the client's head or neck. c. Avoid neck extension to decrease tension on the suture line.

Positions to Ensure Safety and Comfort Reproductive system Mastectomy

a. Position the client with the head of the bed elevated at least 30 degrees (semi- Fowler's position), with the affected arm elevated on a pillow to promote lymphatic fluid return after the removal of axillary lymph nodes. b. Turn the client only to the back and unaffected side.

Position to Ensure Safety and Comfort Musculoskeletal system Total hip replacement

a. Positioning depends on the surgical techniques used (anterior or posterior approach), the method of implantation, the prosthesis, and surgeon's preference. b. Avoid extreme internal and external rotation. c. Avoid adduction; in most cases side- lying is permitted as long as an abduction pillow is in place; some surgeons allow turning to only 1 side. d. Maintain abduction when the client is in a supine position or positioned on the nonoperative side. e. Place a wedge (abduction) pillow between the client's legs to maintain abduction; instruct the client not to cross the legs f. Check the PHCP's prescriptions regarding elevation of the head of the bed and hip flexion.

Position to Ensure Safety and Comfort Neurological system Craniotomy

a. The client should not be positioned on the site that was operated on, especially if the bone flap has been removed, because the brain has no bony covering on the affected site. b. Elevate the head of the bed 30 to 45 degrees and maintain the head in a midline, neutral position to facilitate venous drainage from the head. c. Avoid extreme hip and neck flexion.

Position to Ensure Safety and Comfort Neurological system Hemorrhagic Stroke (brain attack)

a. The head of the bed is usually elevated to 30 degrees to reduce intracranial pressure and to facilitate venous drainage. b. Maintain the head in a midline, neutral position to facilitate venous drainage from the head. c. Avoid extreme hip and neck flexion; extreme hip flexion may increase intrathoracic pressure, whereas extreme neck flexion prohibits venous drainage from the brain.

Position to Ensure Safety and Comfort Cardiovascular System Arterial vascular grafting of an extremity

a. To promote graft patency after the procedure, bed rest usually is maintained for approximately 24 hours, and the affected extremity is kept straight. b. Limit movement and avoid flexion of the hip and knee.

Body Mechanics (Ergonomic Principles) for Health Care Workers

▪ When planning to move a client, arrange for adequate help, including the use of mechanical aids. Use mechanical aids if help is unavailable. ▪ Encourage the client to assist as much as possible. ▪ Keep the back, neck and pelvis, and feet aligned. Avoid twisting. ▪ Flex knees and keep feet wide apart. ▪ Raise the client's bed so that the client's weight is at the level of the nurse's center of gravity. ▪ Position self close to the client (or object being lifted). ▪ Use arms and legs (not back). ▪ Slide client toward yourself, using a pull sheet. When transferring a client onto a stretcher, a slide board is more appropriate. ▪ Set (tighten) abdominal and gluteal muscles in preparation for the move. ▪ The person with the heaviest load coordinates efforts of the team involved by counting to 3.