u20Positioning Clients

PYRAMID TERMS

body mechanics The coordinated efforts of the musculoskel-etal and nervous systems to maintain balance, posture,and body alignment during lifting, bending, and moving toperform activities safely.

ergonomic principles The anatomical, physiological, psycho-logical, and mechanical principles affecting the efficient andsafe use of an individual’s energy.

Fowler’s position The client is supine and the head of thebed is elevated to 45 to 60 degrees.

high Fowler’s position The client is supine and the head ofthe bed is elevated to 90 degrees.

lateral (side-lying) position The client is lying on the sideand the head and shoulders are aligned with the hipsand the spine and are parallel to the edge of the mattress.The head, neck, and upper arm are supported by a pillow.The lower shoulder is pulled forward slightly and, alongwith the elbow, flexed at 90 degrees. The legs are flexedor extended. A pillow is placed to support the back.

lithotomy position The client is lying on the back withthe hips and knees flexed at right angles and the feet instirrups.

prone position The client is lying on the abdomen with headturned to the side.

reverse Trendelenburg’s position The bed is tilted so thatthe client’s foot of the bed is down.

semi-Fowler’s position (low Fowler’s) The client is supineand the head of the bed is elevated about 30 degrees.

Sims’ position The client is lying on the side with the bodyturned prone at 45 degrees. The lower leg is extended, withthe upper leg flexed at the hip and knee to a 45- to90-degree angle.

supine position The client is lying on the back. The head andshoulders usually are elevated slightly (depending on theclient’s condition) with a small pillow. The arms and legsare extended, and the legs are slightly abducted.

Trendelenburg’s position The bed is tilted so that theclient’s head of the bed is down. This position is contraindi-cated in clients with head injuries, increased intracranialpressure, spinal cord injuries, and certain respiratory andcardiac disorders.

THE PYRAMID TO SUCCESS

Nursing responsibility includes positioning clientssafely and appropriately to provide safety and com-fort. Knowledge regarding the client position requiredfor a certain procedure or condition is expected. Thenurse has the responsibility to reduce the likelihoodand prevent the development of complications relat-ed to an existing condition, prescribed treatment, ormedical or surgical procedure. The nurse must reviewthe physician’s prescriptions after treatments or proce-dures and take note of instructions regarding position-ing and mobility (Figs. 20-1 and 20-2). The nursemust also be aware of various body pressure pointswhen clients are positioned in the lying or sitting posi-tion (Fig. 20-3).

CLIENT NEEDS

Safe and Effective Care Environment

Establishing prioritiesEnsuring environmental and personal safetyEnsuring home safetyPositioning the client appropriately and safelyPreventing accidents and injuriesProviding protective measuresUsing equipment safelyUsing ergonomic principles and body mechanics when

moving a client

Health Promotion and Maintenance

Information regarding the need for prescribed therapiesPerforming the techniques of physical assessment

Psychosocial Integrity

Assisting the client to use coping mechanismsKeeping the family informed of client progressProviding support to the client

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Physiological Integrity

Assessing the mobility and immobility level of the clientPreventing the complications of immobilityProviding comfort measures for rest and sleepProviding nutrition and oral intake

Providing personal hygiene as neededUsing assistive devices

I. GUIDELINES FOR POSITIONING

A. Client safety and comfort1. Position client in a safe and appropriate manner

to provide safety and comfort.2. Select a position that will prevent the development

of complications related to an existing condition,prescribed treatment, or medical or surgicalprocedure.

B. Ergonomic principles related to body mechanics(Box 20-1)

Always review the physician’s prescription, espe-cially after treatments or procedures, and take noteof instructions regarding positioning and mobility.

II. POSITIONS TO ENSURE SAFETYAND COMFORT

A. Integumentary system1. Autograft: After surgery, the site is immobilized

usually for 3 to 7 days to provide the time neededfor the graft to adhere and attach to thewoundbed.

Lateral (side-lying) position

Semiprone (Sims’ or forward side-lying) position

Supine positionProne position. The client’s arms and shoulders may

be positioned in internal or external rotation.

s FIGURE 20-2 Common client positions. (From Harkreader, H., Hogan, M., & Thobaben, M. [2007]. Fundamentals of nursing: Caring andclinical judgment [3rd ed.]. St. Louis: Saunders.)

Trendelenburg’s

Fowler’s

Semi-Fowler’s

Reverse Trendelenburg’s

Flat

s FIGURE 20-1 Common bed positions. (Potter, P., & Perry, A.[2009]. Fundamentals of nursing [7th ed.]. St. Louis: Mosby.)

s226 UNIT IV Fundamental Skills

2. Burns of the face and head: Elevate the head ofthe bed to prevent or reduce facial, head, andtracheal edema.

3. Circumferential burns of the extremities: Elevatethe extremities above the level of the heart toprevent or reduce dependent edema.

4. Skin graft: Elevate and immobilize the graftsite to prevent movement and shearing of the

graft and disruption of tissue; avoid weight-bearing.

B. Reproductive system1. Mastectomy

a. Position the client with the head of the bedelevated at least 30 degrees (semi-Fowler’sposition), with the affected arm elevated ona pillow to promote lymphatic fluid returnafter the removal of axillary lymph nodes.

b. Turn the client only to the back and unaffectedside.

2. Perineal and vaginal procedures: Place the clientin the lithotomy position (Fig. 20-4).

C. Endocrine system1. Hypophysectomy: Elevate the head of the bed to

prevent increased intracranial pressure.

s FIGURE 20-3 Pressure points in lying and sitting position. (From Elkin, M., Perry, A., & Potter, P. [2007] Nursing interventions and clinicalskills [4th ed.]. St. Louis: Mosby.)

tBox 20-1 Body Mechanics (ErgonomicPrinciples) for Health Care Workers

When planning to move a client, arrange for adequatehelp. 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.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 trans-

ferring a client onto a stretcher, a slide board is moreappropriate.

Set (tighten) abdominal and gluteal muscles in prepara-tion for the move.

Person with the heaviest load coordinates efforts of teaminvolved by counting to three.

Modified from Potter, P., & Perry, A. (2009). Fundamentals of nursing

(7th ed.). St. Louis: Mosby.

s FIGURE 20-4 Lithotomy position for examination. (From Potter, P.,& Perry, A. [2009]. Fundamentals of nursing [7th ed.]. St. Louis:Mosby.)

s227CHAPTER 20 Positioning Clients

2. Thyroidectomya. Place the client in the semi-Fowler’s to Fowler’s

position to reduce swelling and edema in theneck area.

b. Sandbags or pillows may be used to supportthe client’s head or neck.

D. Gastrointestinal system1. Hemorrhoidectomy: Assist the client to a lateral

(side-lying) position to prevent pain andbleeding.

2. Gastroesophageal reflux disease: Reverse Tren-delenburg’s position may be prescribed topromote gastric emptying and prevent esopha-geal reflux.

3. Liver biopsy (see Priority Nursing Actions)

PRIORITY NURSING ACTIONS!

Actions to Take for a Client Undergoing a LiverBiopsy1. Explain the procedure to the client.2. Ensure that an informed consent has been obtained.3. Position the client supine, with the right side of the

upper abdomen exposed; the client’s right arm israised and extended behind the head and over theleft shoulder.

4. Remain with the client during the procedure.5. After the procedure, assist the client into a right lat-

eral (side-lying) position and place a small pillow orfolded towel under the puncture site.

6. Monitor vital signs closely after the procedure andmonitor for signs of bleeding.

7. Document appropriate information about the proce-dure, client’s tolerance, and postprocedure assess-ment findings.For the client undergoing a liver biopsy (or any inva-

sive procedure), the procedure is explained to the clientand an informed consent is obtained. The client is posi-tioned supine, with the right side of the upper abdomenexposed (liver is located on the right side), and the rightarm is raised and extended behind the head and overthe left shoulder. This position provides for maximalexposure of the right intercostal spaces. The nurseremains with the client during the procedure to provideemotional support and comfort. After the procedure, theclient is assisted into a right lateral (side-lying) positionand a small pillow or folded towel is placed under thepuncture site for at least 3 hours to provide pressure tothe site and prevent bleeding. Vital signs are monitoredclosely after the procedure and the client is monitoredfor signs of bleeding. The nurse documents appropriateinformation about the procedure, the client’s tolerance,and postprocedure assessment findings.

Reference: Pagana, K., & Pagana, T. (2009). Mosby’s diagnostic

and laboratory test reference (9th ed. pp. 604–605). St. Louis:

Mosby.

a. During the procedure, do the following:(1) Position the client supine, with the right

side of the upper abdomen exposed.(2) The client’s right arm is raised and

extended behind the head and over theleft shoulder.

(3) The liver is located on the right side; thisposition provides for maximal exposureof the right intercostal spaces.

b. After the procedure, do the following:(1) Assist the client into a right lateral

(side-lying) position.(2) Place a small pillow or folded towel

under the puncture site for at least 3hours to provide pressure to the site andprevent bleeding.

4. Paracentesis: Client is usually positioned in asemi-Fowler’s position in bed, or sitting uprighton the side of the bed or in a chair with the feetsupported; client is assisted to a position ofcomfort following the procedure.

5. Nasogastric tubea. Insertion

(1) Position the client in a high Fowler’sposition with the head tilted forward.

(2) This position will assist to close the tra-chea and open the esophagus.

b. Irrigations and tube feedings(1) Elevate the head of the bed 30 to 45

degrees (semi-Fowler’s to Fowler’s posi-tion) to prevent aspiration.

(2) Maintain head elevation for 1 hour afteran intermittent feeding.

(3) The head of the bed should remain ele-vated for continuous feedings.

If the client receiving a continuous tube feedingneeds to be placed in a supine position whenproviding care, such as when giving a bed bath orchanging linens, shut off the feeding to prevent aspi-ration. Remember to turn the feeding back on andcheck the rate of flow when the client is placed backinto the semi-Fowler’s or Fowler’s position.

6. Rectal enema and irrigations: Place the client inthe left Sims’ position to allow the solution toflow by gravity in the natural direction of thecolon.

7. Sengstaken-Blakemore and Minnesota tubesa. Not commonly used because they are uncom-

fortable for the client and can cause compli-cations, but their use may be necessarywhen other interventions are not feasible.

b. If prescribed, maintain elevation of the headof the bed to enhance lung expansion andreduce portal blood flow, permitting effectiveesophagogastric balloon tamponade.

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E. Respiratory system1. Chronic obstructive pulmonary disease: In

advanced disease, place the client in a sittingposition, leaning forward, with the client’s armsover several pillows or an overbed table; thisposition will assist the client to breathe easier.

2. Laryngectomy (radical neck dissection): Placethe client in a semi-Fowler’s or Fowler’s posi-tion to maintain a patent airway and minimizeedema.

3. Bronchoscopy postprocedure: Place the client ina semi-Fowler’s position to prevent choking oraspiration resulting from an impaired ability toswallow.

4. Postural drainage: The lung segment to bedrained should be in the uppermost position;Trendelenburg’s position may be used.

5. Thoracentesisa. During the procedure, to facilitate removal of

fluid from the pleural space, position the cli-ent sitting on the edge of the bed and leaningover the bedside table with the feet supportedon a stool, or lying in bed on the unaffectedside with the head of the bed elevated about45 degrees (Fowler’s position).

b. After the procedure, assist the client to a posi-tion of comfort.

Always check the physician’s prescription regard-ing positioning for the client who had a thoracotomy,lung wedge resection, lobectomy of the lung, orpneumonectomy.

F. Cardiovascular system1. Abdominal aneurysm resection

a. After surgery, limit elevation of the head ofthe bed to 45 degrees (Fowler’s position) toavoid flexion of the graft.

b. The client may be turned from side to side.2. Amputation of the lower extremity

a. During the first 24 hours after amputation,elevate the foot of the bed (the stump is sup-ported with pillows but not elevated becauseof the risk of flexion contractures) to reduceedema.

b. Consult with the physician and, if prescribed,position the client in a prone position twice aday for a 20- to 30-minute period to stretchmuscles and prevent flexion contractures of thehip.

3. Arterial vascular grafting of an extremitya. To promote graft patency after the procedure,

bedrest usually ismaintained for approximately24 hours and the affected extremity is keptstraight.

b. Limit movement and avoid flexion of the hipand knee.

4. Cardiac catheterizationa. If the femoral artery was accessed for the pro-

cedure, the client is maintained on bedrestfor 4 to 6 hours (time for bedrest may varydepending on physician preference and if avascular closure device was used); the clientmay turn from side to side.

b. The affected extremity is kept straight andthe head is elevated no more than 30 degrees(some physicians prefer the flat position)until hemostasis is adequately achieved.

5. Congestive heart failure and pulmonary edema:Position the client upright, preferably with thelegs dangling over the side of the bed, todecrease venous return and lung congestion.

Most often, clients with respiratory and cardiacdisorders should be positioned with the head of thebed elevated.

6. Peripheral arterial diseasea. Obtain the physician’s prescription for

positioning.b. Because swelling can prevent arterial blood

flow, clients may be advised to elevate theirfeet at rest, but they should not raise their legsabove the level of the heart because extremeelevation slows arterial blood flow; some cli-ents may be advised to maintain a slightlydependent position to promote perfusion.

7. Deep vein thrombosisa. If the extremity is red, edematous, and pain-

ful, and if traditional heparin sodium therapymay be initiated, bedrest with leg elevationmay be prescribed for the client.

b. Clients receiving low-molecular-weight hepa-rin usually can be out of bed after 24 hours ifpain level permits.

8. Varicose veins: Leg elevation above heart levelusually is prescribed; the client also is advised tominimize prolonged sitting or standing duringdaily activities.

9. Venous insufficiency and leg ulcers: Leg eleva-tion usually is prescribed.

G. Sensory system1. Cataract surgery: Postoperatively, elevate the

head of the bed (semi-Fowler’s to Fowler’s posi-tion) and position the client on the back or thenonoperative side to prevent the developmentof edema at the operative site.

2. Retinal detachmenta. If the detachment is large, bedrest and

bilateral eye patching may be prescribed tominimize eye movement and prevent exten-sion of the detachment.

b. Restrictions in activity and positioning fol-lowing repair of the detachment depends on

s229CHAPTER 20 Positioning Clients

the physician’s preference and the surgicalprocedure performed.

H. Neurological system1. Autonomic dysreflexia: Elevate the head of the

bed to a high Fowler’s position to assist withadequate ventilation and assist in the preventionof hypertensive stroke.

If autonomic dysreflexia occurs, immediatelyplace the client in a high Fowler’s position.

2. Cerebral aneurysm: Bedrest is maintained withthe head of the bed elevated 30 to 45 degrees(semi-Fowler’s to Fowler’s position) to preventpressure on the aneurysm site.

3. Cerebral angiographya. Maintain bedrest for the length of time as

prescribed.b. The extremity into which the contrast

medium was injected is kept straight andimmobilized for about 6 to 8 hours.

4. Brain attack (stroke)a. In clients with hemorrhagic strokes, the head

of the bed is usually elevated to 30 degrees toreduce intracranial pressure and to facilitatevenous drainage.

b. For clients with ischemic strokes, the head ofthe bed is usually kept flat.

c. Maintain the head in a midline, neutral posi-tion to facilitate venous drainage from thehead.

d. Avoid extreme hip and neck flexion; extremehip flexion may increase intrathoracic pres-sure, whereas extreme neck flexion prohibitsvenous drainage from the brain.

5. Craniotomya. The client should not be positioned on the site

that was operated on, especially if the boneflap has been removed, because the brain hasno bony covering on the affected site.

b. Elevate the head of the bed 30 to 45 degrees(semi-Fowler’s to Fowler’s position) andmain-tain the head in a midline, neutral position tofacilitate venous drainage from the head.

c. Avoid extreme hip and neck flexion.6. Laminectomy

a. Logroll the client.b. When the client is out of bed, the client’s

back is kept straight (the client is placed ina straight-backed chair) with the feet restingcomfortably on the floor.

7. Increased intracranial pressurea. Elevate the head of the bed 30 to 45 degrees

(semi-Fowler’s to Fowler’s position) andmaintain the head in a midline, neutralposition to facilitate venous drainage fromthe head.

b. Avoid extreme hip and neck flexion.

Do not place a client with a head injury in a flat orTrendelenburg’s position because of the risk ofincreased intracranial pressure.

8. Lumbar puncturea. During the procedure, assist the client to the

lateral (side-lying) position, with the backbowed at the edge of the examining table,the knees flexed up to the abdomen, andthe neck flexed so that the chin is resting onthe chest.

b. After the procedure, place the client in thesupine position for 4 to 12 hours, asprescribed.

9. Myelogram postprocedurea. The head position varies according to the dye

used.b. The head is usually elevated if an oil-based or

water-soluble contrast agent is used and thehead is usually positioned lower than thetrunk if air contrast is used.

10. Spinal cord injurya. Immobilize the client on a spinal backboard,

with the head in a neutral position, to pre-vent incomplete injury from becomingcomplete.

b. Prevent head flexion, rotation, or extension;the head is immobilized with a firm, paddedcervical collar.

c. Logroll the client; no part of the bodyshould be twisted or turned, nor shouldthe client be allowed to assume a sittingposition.

I. Musculoskeletal system1. Total hip replacement

a. Positioning depends on the surgical tech-niques used, the method of implantation,and the prosthesis.

b. Avoid extreme internal and external rotation.c. Avoid adduction; side-lying on the operative

side is not allowed (unless specifically pre-scribed by the physician).

d. Maintain abduction when the client is in asupine position or positioned on the nonop-erative side.

e. Place a pillow between the client’s legs tomaintain abduction; instruct the client notto cross the legs (Box 20-2).

f. Check the physician’s prescriptions regardingelevation of the head of the bed; flexion usu-ally is limited to 60 degrees during the firstpostoperative week (usually 90 degrees for2 to 3 months thereafter).

2. Devices used to promote proper positioning(see Box 20-2)

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