Patient Positioning PDF

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In this guide for patient positioning, learn about the common bed positions such as Fowler’s, dorsal recumbent, supine, prone, lateral, lithotomy, Sims’, Trendelenburg’s, and other surgical positions commonly used. Learn about the different patient positioning guidelines, how to properly position th...

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Patient Positioning: Complete Guide for Nurses What is Patient Positioning? Patient positioning involves properly maintaining a patient’s neutral body alignment by

preventing hyperextension and extreme lateral rotation to prevent complications of immobility and injury. Positioning patients is an essential aspect of nursing practice and a responsibility of the registered nurse. In surgery, specimen collection, or other treatments, proper patient positioning provides optimal exposure of the surgical/treatment site and maintenance of the patient’s dignity by controlling unnecessary exposure. In most settings, positioning patients provide airway management and ventilation, maintaining body alignment, and provide physiologic safety.

Goals of Patient Positioning The ultimate goal of proper patient positioning is to safeguard the patient from injury and physiological complications of immobility. Specifically, patient positioning goals include:  Provide patient comfort and safety. Support the patient’s airway and maintain the circulation throughout the procedure (e.g., in surgery, in examination, specimen collection, and treatment). Impaired venous return to the heart, and ventilation-toperfusion mismatching are common complications. Proper positioning promotes comfort by preventing nerve damage and by preventing unnecessary extension or rotation of the body.  Maintaining patient dignity and privacy. In surgery, proper positioning is a way to respect the patient’s dignity by minimizing exposure of the patient who often feels vulnerable perioperatively.  Allows maximum visibility and access. Proper positioning allows ease of surgical access as well as for anesthetic administration during perioperative phase.

Guidelines for Patient Positioning Proper execution is needed during patient positioning to prevent injury for both the patient and the nurse. Remember these principles and guidelines when positioning clients:  Explain the procedure. Provide explanation to the client on why his or her position is being changed and how it will be done. Rapport with the patient will make them more likely to maintain the new position.

 Encourage client to assist as much as possible. Determine if the client can fully or partially assist. Clients that can assist will save strain on the nurse. It will also be a form exercise, increase independence, and self-esteem for the client.  Get adequate help. When planning to move or reposition the client, ask help from other caregivers. Positioning may not be a one-person task.  Use mechanical aids. Bed boards, slide boards, pillows, patient lifts and slings can facilitate ease of changing positions.  Raise client’s bed. Adjust or reposition the client’s bed so that the weight is at the level of the nurse’s center of gravity.  Frequent position changes. Note that any position, correct or incorrect, can be detrimental to the patient if maintained for a long period. Repositioning the patient every 2 hours helps prevent complications like pressure ulcers and skin breakdown.  Avoid friction and shearing. When moving patients, lift rather than slide to prevent friction that can abrade the skin making it more prone to skin breakdown.  Proper body mechanics. Observe good body mechanics for you and your patient’s safety.  Position self close to the client.  Avoid twisting your back, neck, and pelvis by keeping them aligned.  Flex your knees and keep feet wide apart.  Use your arms and legs and not your back.  Tighten abdominal muscles and gluteal muscles in preparation for the move.  Person with the heaviest load coordinates efforts of the nurse and initiates the count to 3.

Common Patient Positions The following are the commonly used patient positions including a description on how they are performed and the rationale:

Supine or Dorsal Recumbent Position Supine position, or dorsal recumbent, is wherein the patient lies flat on the back with head

and shoulders slightly elevated using a pillow unless contraindicated (e.g., spinal anesthesia, spinal surgery).

 Variation in position. In supine position, legs may be extended or slightly bent with arms up or down. It provides comfort in general for patients under recovery after some types of surgery.  Most commonly used position. Supine position is used for general examination or physical assessment.  Watch out for skin breakdown. Supine position may put patients at risk for pressure ulcers and nerve damage. Assess for skin breakdown and pad bony prominences.  Support for supine position. Small pillows may be placed under the head to and lumbar curvature. Heels must be protected from pressure by using a pillow or ankle roll. Prevent prolonged plantar flexion and stretch injury of the feet by placing a padded footboard.  Supine position in surgery. Supine is frequently used on procedures involving the anterior surface of the body (e.g., abdominal area, cardiac, thoracic area). A small pillow or donut should be used to stabilize the head, as extreme rotation of the head during surgery can lead to occlusion of the vertebral artery.

Fowler’s Position Fowler’s position, also known as semi-sitting position, is a bed position wherein the head of the bed is elevated 45 to 60 degrees. Variations of Fowler’s position include: low Fowler’s (15 to 30 degrees), semi-Fowler’s (30 to 45 degrees), and high Fowler’s (nearly vertical).

 Promotes lung expansion. Fowler’s position is used for patients who have difficulty breathing because in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.  Useful for NGT. Fowler’s position is useful for patients who have cardiac, respiratory, or neurological problems and is often optimal for patients who have nasogastric tube in place.  Prepare for walking. Fowler’s is also used to prepare the patient for dangling or walking. Nurses should watch out for dizziness or faintness during change of position.  Poor neck alignment. Placing an overly large pillow behind the patient’s head may promote the development of neck flexion contractures. Encourage patient to rest without pillows for a few hours each day to extend the neck fully.  Used in some surgeries. Fowler’s position is usually used in surgeries that involve neurosurgery or the shoulders  Use a footboard. Using a footboard is recommended to keep the patient’s feet in proper alignment and to help prevent foot drop.  Etymology. Fowler’s position is named after George Ryerson Fowler who saw it as a way to decrease mortality of peritonitis.

Orthopneic or Tripod Position Orthopneic or tripod position places the patient in a sitting position or on the side of the bed with an overbed table in front to lean on and several pillows on the table to rest on.

 Maximum lung expansion. Patients who are having difficulty breathing are often placed in this position because it allows maximum expansion of the chest.  Helps in exhaling. Orthopneic position is particularly helpful to patients who have problems exhaling because they can press the lower part of the chest against the edge of the overbed table.

Prone Position In prone position, the patient lies on the abdomen with head turned to one side and the hips are not flexed.

 Extension of hips and knee joints. Prone position is the only bed position that allows full extension of the hip and knee joints. It also helps to prevent flexion contractures of the hips and knees.  Contraindicated for spine problems. The pull of gravity on the trunk when the patient lies prone produces marked lordosis or forward curvature of the spine thus contraindicated for patients with spinal problems. Prone position should only be used when the client’s back is correctly aligned.  Drainage of secretions. Prone position also promotes drainage from the mouth and useful for clients who are unconscious or those recover from surgery of the mouth or throat.  Placing support in prone. To support a patient lying in prone, place a pillow under the head and a small pillow or a towel roll under the abdomen.  In surgery. Prone position is often used for neurosurgery, in most neck and spine surgeries.

Lateral Position In lateral or side-lying position, the patient lies on one side of the body with the top leg in front of the bottom leg and the hip and knee flexed. Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and achieves greater stability. Increase in flexion of the top hip and knee provides greater stability and balance. This flexion reduces lordosis and promotes good back alignment.

 Relieves pressure on the sacrum and heels. Lateral position helps relieve pressure on the sacrum and heels especially for people who sit or are confined to bed rest in supine or Fowler’s position.  Body weight distribution. In this position, most of the body weight is distributed to the lateral aspect of the lower scapula, the lateral aspect of the ilium, and the greater trochanter of the femur.  Support pillows needed. To correctly position the patient in lateral position, use of support pillows are needed.

Sims’ Position Sims’ position or semiprone position is when the patient assumes a posture halfway between the lateral and the prone positions. The lower arm is positioned behind the client, and the upper arm is flexed at the shoulder and the elbow. The upper leg is more acutely flexed at both the hip and the knee, than is the lower one.

 Prevents aspiration of fluids. Sims’ may be used for unconscious clients because it facilitates drainage from the mouth and prevents aspiration of fluids.  Reduces lower body pressure. It is also used for paralyzed clients because it reduces pressure over the sacrum and greater trochanter of the hip.  Perineal area visualization and treatment. It is often used for clients receiving enemas and occasionally for clients undergoing examinations or treatments of the perineal area.

 Pregnant women comfort. Pregnant women may find the Sims position comfortable for sleeping.  Promote body alignment with pillows. Support proper body alignment in Sims’ position by placing a pillow underneath the patient’s head and under the upper arm to prevent internal rotation. Place another pillow between legs.

Lithotomy Position Lithotomy is a patient position in which the patient is on their back with hips and knees flexed and thighs apart.  Lithotomy position is commonly used for vaginal examinations and childbirth.  Modifications of the lithotomy position include low, standard, high, hemi, and exaggerated based on how high the lower body is raised or elevated for the procedure. Please check with your facility’s guidelines but typically:  Low Lithotomy Position: The patient’s hips are flexed until the angle between the posterior surface of the patient’s thighs and the O.R. bed surface is 40 degrees to 60 degrees. The patient’s lower legs are parallel with the O.R. bed.2  Standard Lithotomy Position: The patient’s hips are flexed until the angle between the posterior surface of the patient’s thighs and the O.R. bed surface is 80 degrees to 100 degrees. The patient’s lower legs are parallel with the O.R. bed.  Hemilithotomy Position: The patient’s non-operative leg is positioned in standard lithotomy. The patient’s operative leg may be placed in traction.  High Lithotomy Position: The patient’s hips are flexed until the angle between the posterior surface of the patient’s thighs and the O.R. bed surface is 110 degrees to 120 degrees. The patient’s lower legs are flexed.  Exaggerated Lithotomy Position: The patient’s hips are flexed until the angle between the posterior surface of the patient’s thighs and the O.R. bed surface is 130 degrees to 150 degrees. The patient’s lower legs are almost vertical.

Trendelenburg’s Position Trendelenburg’s position involves lowering the head of the bed and raising the foot of the bed of the patient. The patient’s arms should be tucked at their sides

 Promotes venous return. Hypotensive patients can benefit from this position because it promotes venous return.  Postural drainage. Trendelenburg’s position is used to provide postural drainage of the basal lung lobes. Watch out for dyspnea, some patients may require only a moderate tilt or a shorter time in this position during postural drainage. Adjust as tolerated.

Reverse Trendelenburg’s Position Reverse Trendelenburg’s is a patient position wherein the the head of the bed is elevated with the foot of the bed down. It is the opposite of Trendelenburg’s position.

 Gastrointestinal problems. Reverse trendelenburg is often used for patients with gastrointestinal problems as it helps minimize esophageal reflux.  Prevent rapid change of position. Patients with decreased cardiac output may not tolerate rapid movement or change from a supine to a more erect position. Watch out for rapid hypotension. It can be minimized by gradually changing the patient’s position.  Prevent esophageal reflux. Promotes stomach emptying and prevents reflux for clients with hiatal hernia.

Knee-Chest Position Knee-chest position, can be in lateral or prone position. In lateral knee-chest position, the patient lies on their side, torso lies diagonally across the table, hips and knees are flexed. In prone knee-chest position, the patient kneels on the table and lower shoulders on to the table so chest and face rests on the table.

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Two ways. Knee-chest position can be lateral or prone. Sigmoidoscopy. Usual position adopted for sigmoidoscopy without anesthesia. Patient dignity. Prone knee-chest position can be embarrassing for some patients. Gynecologic and rectal examinations. Knee-chest position is assumed for a gynecologic or rectal examination.

Jackknife Position Jackknife position, also known as Kraske, is wherein the patient’s abdomen lies flat on the bed. The bed is scissored so the hip is lifted and the legs and head are low.

 In surgery. Jackknife position is frequently used for surgeries involving the anus, rectum, coccyx, certain back surgeries, and adrenal surgery.  Requires team effort. At least four people are required to perform the transfer and position the patient in the operating table.  Cardiovascular effects. In jackknife position, compression of the inferior vena cava from abdominal compression also occurs, which decreases venous return to the heart. This could increase the risk for deep vein thrombosis.  Support paddings. Many pillow sare required on the operating table to support the body and reduce pressure on the pelvis, back, and the abdomen. Jackknife position also puts excessive pressure on the knees. While positioning, surgical staff should put extra padding for the knee area.

Kidney Position In kidney position, the patient assumes a modified lateral position wherein the abdomen is placed over a lift in the operating table that bends the body. Patient is turned on their contralateral side with their back placed on the edge of the table. Contralateral kidney is placed over the break in the table or over the kidney body elevator (if attachment is available). The uppermost arm is placed in a gutter rest at no more than 90º abduction or flexion.

 Access to retroperitoneal area. Kidney positions allows access and visualization of the retroperitoneal area. A kidney rest is placed under the patient at the location of the lift.  Risk for falls. Patient may fall off the table at anytime until the position is secured.  Padding and stabilization support. Contralateral arm underneath the body is protected with padding. Contralateral knee is flexed and the uppermost leg is left straight to improve stability. A large soft pillow is placed in between the legs. Kidney strap and tape are placed over the hip to stabilize the patient.

Support Devices for Patient Positioning The following are the devices or apparatus that can be used to help position the patient properly.  Bed Boards. Bed boards are plywood boards that are placed under the entire surface area of the mattress and are useful for increasing back support and body alignment.  Foot Boots. Foot boots are shoes made of rigid plastic or heavy foam and keep the foot flexed at the proper angle. It is recommended that they should be removed 2 to 3 times a day to assess the skin integrity and joint mobility.  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.

 Hand-Wrist Splints. These splints are individually molded for the client to maintain proper alignment of the thumb in a slight adduction and the wrist in slight dorsiflexion.  Pillows. Pillows provide support, elevate body parts, splint incision areas, and reduce postoperative pain during activity, coughing or deep breathing. They should be of the appropriate size for the body to be positioned.  Sandbags. Sandbags are soft devices filled with substance that can be used to shape or contour to the body’s shape and provide support. They immobilize extremities and maintain specific body alignment.  Side Rails. Side rails are bars along the sides of the length of the bed. They ensure client safety and are useful for increasing mobility. They also provide assistance in rolling from side to side or sitting up in bed. Check with your agencies policies regarding the use of side rails as they vary state to state.  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 lowest border of the popliteal space.  Wedge Pillows. Are triangular pillows made of heavy foam and are used to maintain legs in abduction following total hip replacement surgery.

Documenting Patient Positioning Documenting change of patient position in the patient’s chart. Note the following:     

Date and time of the procedure. Explanation of the procedure to the patient. Notation of the position the patient was placed in including rationale. Pertinent teaching given. Patient’s response to the procedure....