Patient Positions for Nurses. Self Learn session 7

These learning notes about nursing positions are for nursing students and can be used in the home, community and the hospital settings with minor modifications to suit the patient’s individual condition and need. Patients who cannot move themselves must be moved two to four hourly, again depending on the patient’s condition. This is to prevent skin breakdown (formation of pressure sores / decubitus ulcers).

Bed sores or pressure sores have been given names. These include decubitus sore, pressure ulcer, bedsore, ischial tuberosity ulcer, bed rest injury, bedrest injury, chronic ulceration, pressure ulceration, decubitus ulceration. All these terms mean about the same thing – patient injury while lying helpless in bed.

Picture 1. Shows a conscious client sitting up comfortably. This type of sitting facility is not suitable for the paralyzed or unconscious patient.

Most institutions have a “no lift policy” so please use the slippery slide sheet or a pat slide for the appropriate movement of a patient. For moving non-weight bearing patients out of bed you must use a hoist. Please check that the hoist’s safe working load is appropriate. No employer will be responsible for any injury to you or any other employee if you did not follow the institution’s policies and procedures.

When positioning a patient it is helpful to be able to focus on key parts. The key parts are the skin, head and neck, arms and shoulders, hips, buttocks, knees and extremities. For the acutely ill patient position should be comfortable and safe. If you, are working in the Operating Theatre you will also need to consider accessibility to the area to be operated on.

Picture 2: Lifting and moving patients up the bed was standard of care then. Now it is disallowed in most facilities.

Skin . All nurses caring for patients must examine the skin of all patients, even healthy ones, and help patients prevent injury. Pressure sores cost the health service billions of dollars. Lesions, bruises, pressure, friction and dry skin lead to many skin problems.

Head and neck . Pillows and head rests should be used strategically. Use “donoughts” if the patient is in the the supine or Trendeleberg position to protect bony prominences on the back of the head.

When a patient is in bed, evaluate the patients’ pressure areas. Check the eyes, ears, and nose. Ensure that these areas aren’t being pinched or obstructed. In female patients, insure that their hair is placed properly, make sure they aren’t wearing hair clips or twists.

Arms and shoulders . The general guideline is to keep the arms at a 90 degree angle to the rest of the body. Some studies suggest that you should never have abduction greater than 60 degrees. These suggest that if you abduct more than 60 degrees you can cause brachial plexus injuries. There are times when you may have to move the patient’s arms to 90 degrees, but as a practical rule, the less severe the angle, the better off the patient will be.

Pad arms and legs for safety and comfort. Do not allow the arms, shoulders or legs to hang over the edge of the bed.

Hips . The key goal to remember with hip placement, whether the patient is in a vertical, prone, Trendelenburg or reverse Trendelenburg position, is to maintain proper alignment. During orthopaedic procedures, the hips are prone to lumbar plexus damage if they are put under excessive strain. Keeping the hips aligned takes a lot of pressure off both the lower back and the hip joints themselves. When caring for patients please do the following:

Always lift both the patient’s legs together, rather than one at a time.

Always use hip supports so that the hips do not flex, this is particularly important when the patient is in the operating theatre.

Always insure that the clients legs are straight and are not twisted in some uncomfortable position.

Use positioning aids wherever possible. A nurse is the patient’s advocate. You may need to initiate action to get positioning devices.

Buttocks . In many instances buttocks bear most of the weight of the body, they remain in contact with bed sheet and the buttocks are the first indicators of poor quality of nursing care; this can cause pressure sores and other complications. Avoid this by placing padding underneath the buttocks and frequent turning.

Knees and lower extremities . Always keep the client’s knees flexed wherever possible. Surgical socks, soft bolsters, pillows can be helpful for maintaining circulation and reduce pressure on the lower extremities.

SUPINE POSITION

This is ordinarily called lying on back, flat with a pillow under the head. The position of the patient should be in the middle of the bed, about three inches below the head of the bed.

The pillow under the patient’s head should extend about two inches below the patient’s shoulders, with the head in the middle of the pillow.

A trochanter roll should be placed along the affected hip or along the both hips if the patient has little control over the legs. A trochanter roll is devised by rolling a bath blanket into a shape about 12-14 inches in length. The roll should be just long enough to reach from above the hip to above the knee. The trochanter roll prevents external rotation of the hip.

Place pillows under the legs to reach from above the back of the knee to the ankle so that the ankles and heels do not rub on the sheets. When patients skin rubs against the sheet, pressure sores are formed and often take a long time to heal.

Position the footboard or place a folded pillow to support the patient’s feet. The ankles should be at 90° angles.

Extend the patient’s arms and place small pillows to reach from the elbow to below the wrist. The hand should be in alignment with the wrist. This positioning will prevent nerve injury due to hyper extension.

SEMI-SUPINE POSITION

This position is sometimes called the coma position. On a bed, the patient lies on his/her side at a 45 degree angle to the patient’s back and the bed.

You may place a pillow behind the patient’s back for support, comfort and warmth.

Make sure the patient’s left shoulder forward is slightly to the forward. Also you may need to Flex the elbow of the left arm and place the lower left arm, palm up, on a pillow. This will insure proper circulation and there will be no pressure on any nerve.

Flex the elbow of the right arm and bring the forearm across the chest with palm down.

Extend both legs. Place right leg a little behind left leg. Support right leg with two pillows folded in half that extend from groin to ankle.

PRONE POSITION

In this position the patient is lying on his stomach with face down (onto the pillow). Make sure that the patient is not suffocated by pillow(s). Ironically, in the ICU, this is the position in which a patient is nursed when he/she is in respiratory distress.

The position of the face is always turned to one side, to prevent suffocation. Legs are straight and extended. Place pillows at strategic points to prevent pressure sores.

A small pillow is placed under the head so that it extends to the patient’s shoulders and five to six inches beyond the face.

Also a small pillow is placed under the abdomen (female patients). This relieves pressure on the back and reduces pressure against a female patient’s breasts. Alternatively the nurse can roll a towel and place it under each shoulder.

Lastly, place a pillow under the arms to reach from the elbow to below the wrists. The shoulders and elbows may be flexed or extended, whichever is more comfortable for your patient. If your patient is unconscious, and on the ventilator, you will have to decide about his/her most comfortable position because you know your patient best.

A pillow is also placed under the lower legs to prevent pressure on the toes. The patient may be moved down in the bed before starting the procedure, so that the feet extend over the end of the mattress. This allows the foot to assume a normal standing position.

SEMI-PRONE POSITION

The objective of this position is to relieve pressure from the hips. Relatively speaking, breathing is easier in the semi-prone position than in the full prone position which is used for patients in respiratory failure. I have stated here, method for the patient lying on the left side. The method can be easily adapted for the right side as well.

First, extend the patient’s left arm and tuck it slightly beneath the patient’s body.

Then place a pillow in front of and at right angles to the patient’s chest.

Follow this by flexing the patient’s right knee and hip. Support with pillows that are parallel to the leg.

Finally, grasp the patient’s left arm from the back of the patient. Turn the patient onto his chest facing away from you. Gently pull his left arm toward you and push on his hip.

To make the patient comfortable extend the right arm upward and toward the head of the bed. Put it on the head pillow with the fingers and palm against the bed. Remember, if your patient is unconscious you are his/her advocate. Then flex the upper arm on a pillow.

Lift up the sheepskin and place a foam block under the sheepskin above the iliac crest (hip bone). Finally, place another foam block under the sheepskin just below the iliac crest. The nurse of care giver should be able to slide his/her hand between the hip and the bed.

RIGHT LATERAL POSITION

In this position the patient is lying on his right side with his right iliac crest bearing the weight of the body. In this position a pillow is placed under the head so it extends five to six inches beyond the patient’s face and down to the shoulders.

Position your client’s right arm so shoulder and elbow are flexed and palm of hand is facing up. You, the person caring for this patient should be able to see that the hand is nice and pink, and warm.

Place client’s left arm so it is extended; only slightly flexed and rest it on patient’s hip or bring it forward and place it on a pillow. Make sure that the client’s shoulder, elbow, and wrist are at approximately the same height.

Place a pillow between the patient’s legs so that it extends from above the knee to below the ankle. The patient’s hip, knee, and ankle should be at approximately the same height.

A pillow may be placed behind the patient to help maintain the position.

SIM’S POSITION.

A position in which the patient lies on one side with the under arm behind the back and the upper thigh flexed, used to facilitate rectal and vaginal examinations, and also for the administration of enemas and treatments. Also called lateral recumbent position . This position is a variation of lateral position with the patient on the left side, left leg extended and right leg flexed. Sim’s Position is shown in the figure below. Notice the placement of pillow under the head.

Diagram showing SIM’s Position.
Diagram obtained from http://www.mum.org/simsspec.htm

Note the position of legs, chest, and pelvis. The inclination of the pelvis is most significant because the organs of the pelvis drop into the abdomen, making it easy to install medications into the body’s cavities..

FOWLER’S POSITION

In this position the patient is lying, on his/back, on the bed. This position is considered, by many to be the most comfortable. It is ideal for many treatments and is also comfortable for watching TV feeding and is comfortable for patients who have difficulty breathing.

1. Modern beds allow the head of the bed to be elevated at different comfort levels. It is ideal to have two to three pillows under the back and shoulders. The patient’s hips should be at the place where the bend bends when the bed head is rolled up. Place the head of the bed at 30° for semi-Fowler’s, 45° to 60° for Fowler’s, and 90° for high Fowler’s.

2. Flex elbows and place a pillow under each arm to prevent pull on the shoulders.

Picture from: http://www.moondragon.org/images/patientpositionfowlers.jpg

3. Place a pillow under each leg to extend from above the knee and to the ankle, to prevent pressure on heels.

4. It is important to place footboards or pillows to keep feet in position, to prevent footdrop.

ORTHOPNEIC POSITION

In this position the patient is literally sitting up. This position is deal for patients who are hiving difficulty breathing when lying down flat. Patients with heart failure who suffer from orthopneacic dyspnoea will benefit by lying in this position.

The patient can be made comfortable by placing two pillows behind the back and getting the patient to lean forward.

This is a variation of slight variation of the high fowler’s position discussed above. The position of the head of bed remains the same at 90 degrees.

The patient’s above the bed table can be used to help the patient to lean forward. This helps the patient to breathe easily.

Picture was obtained from http://www.moondragon.org/images/patientpositionfowlers.jpg

SITTING POSITION

(See Picture 1)

Nurses and non-nurses are comfortable with this position and we all know what we mean by it. However, when caring for a patient who is partially or wholly paralysed, sitting up is necessary but can be dangerous for the patient. For this reason patients should be made comfortable in a well-constructed, function specific chair. The head and the spine should be erect. The back and buttocks must be up against the back of the chair. The patient’s feet must touch the floor and must be kept warn, not left on the cold floor.

Additional pillows should be used to maintain position and posture. The small of the back is important. The proper curvature of the spine (lordosis) must be maintained at all times. This can be done by placing a small pillow or a rolled up towel in the small of the back. This usually has a supporting and comforting role. Last, but not least, do not permit the back of the patient’s knees to rest against the chair as this will obstruct circulation.

CONCLUSION – POSITIONING

After you have turned and moved the patient into proper body alignment, you can place pillows and other supportive devices to help the patient maintain the position. Directions are given here for the basic positions and their variations.

Last but not least, these notes require you to have a nursing background to be able to fully understand the rationalizations for using the different positions. If you are unsure about any details please contact your lecturer or the institution. Do not risk harm to yourself, the patient, society or the institutions.