Lab 6 - Mobility & Immobility

Movement

• A complex process that requires coordination between the musculoskeletal and nervous systems.

• Nurses assess how a patient's physical and psychological condition affects body movement.

Body mechanics

• The coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living (ADLs).

Why must nurses understand body mechanics?

• Lifting techniques historically used in nursing can cause injuries to nurses.

• In Canada, legislation and employer policies require evidence-informed guidelines on body alignment, balance, gravity, and friction when positioning, assessing fall risk, and moving or transferring patients.

Body alignment and posture

The two terms are similar: the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying.

Joints, ligaments and tendons: definitions

• Joints: Structures (articulations) that connect two or more adjacent parts of the skeleton to facilitate movement.

• Ligaments: Bands of tough, fibrous tissue that surround joints and connect bone to bone

  • they reinforce joint stability and limit extreme joint movement.

• Tendons: Bands of fibrous connective tissue that attach muscle to bone.

Correct body alignment: centre of gravity and benefits

• What does correct body alignment mean for the centre of gravity:

  • The individual's centre of gravity is stable.

• Benefits of correct body alignment:

  • Reduces strain on musculoskeletal structures

  • minimizes the risk of injuries and falls

  • helps maintain adequate muscle tone

  • contributes to balance.

Balance: how enhanced and when required

• How is balance enhanced:

  • With correct body posture and when the centre of gravity is kept low within a wide base of support.

• When is balance required:

  • For maintaining a static position (e.g., sitting), moving (e.g., walking), and performing ADLs.

What compromises balance, and the consequences

• What can compromise a person's balance:

  • Disease, injury, pain, physical development (age), life changes (e.g., pregnancy), medications that cause dizziness or drowsiness, and deconditioning from prolonged immobility.

• Consequences of impaired balance:

  • A major threat to mobility and physical safety

  • contributes to fear of falling and self-imposed activity restrictions.

Weight and why unsteady patients fall

• Weight: The force exerted on a body by gravity.

  • It is always directed downward, which is why an unbalanced object falls.

• Why do unsteady patients fall:

  • Their centre of gravity becomes unbalanced

  • the gravitational pull of their weight moves outside their base of support.

Friction

• A force that occurs in a direction opposing movement.

• The greater the surface area of the object to be moved, the greater the friction (a larger object produces greater resistance).

Shear

The force exerted against the skin while the skin remains stationary and the bony structures move.

Reducing friction and shear when moving a patient

• Ergonomic assistive devices: friction-reducing transfer sheets and full-body slings.

  • sling mechanically lifts the patient off the bed surface, preventing friction, tearing, or shearing of the skin, and protects the nurse and other staff from injury.

• Patient participation when moving a patient: Use some of the patient's strength whenever possible.

  • Explain the procedure and tell the patient when and what body parts to move: a synchronized movement with less friction.

  • Participation may promote a sense of accomplishment.

Lordosis

• Exaggeration of the anterior convex curve of the lumbar spine.

• Causes: congenital, or a temporary condition such as pregnancy.

• Treated with spine-stretching exercises (based on cause).

Kyphosis

• Increased convexity in the curvature of the thoracic spine.

• Causes: congenital, rickets, osteoporosis, tuberculosis of the spine, gerontological changes.

• Treated with spine-stretching exercises, sleeping without pillows, bed board, bracing, spinal fusion.

Scoliosis

• Scoliosis: Lateral 'S'- or 'C'-shaped curvature of the spinal column with vertebral rotation and unequal heights of hips and shoulders.

• Causes: congenital, connective tissue and neuromuscular disorders, poliomyelitis, spastic paralysis, unequal leg length.

• treatment: About half of children with scoliosis require surgery.

  • Nonsurgical treatment is with braces and exercises.

Footdrop

• Inability to dorsiflex and evert the foot because of peroneal nerve damage

  • the foot is fixed in plantar flexion and the patient can't lift the toes off the ground

• causes: Congenital condition, trauma, improper positioning of a patient who is immobilized (also prolonged bed rest, peripheral neuropathy, CVA/stroke).

• treatment and prevention

  • Cannot be corrected

  • Prevent with physiotherapy and bracing with an ankle-foot orthotic.

Mobility vs immobility

• Mobility: A person's ability to move about freely.

• Immobility: The inability to move about freely.

Bed rest and its objectives

• Bed rest: An intervention that restricts patients to stay in bed for therapeutic reasons (prescribed by a health care provider; not common).

• General objectives of bed rest:

  • Reduce physical activity and the body's oxygen needs

  • reduce pain (including postoperative pain) and the need for large doses of analgesics

  • promote safety in patients recovering from anesthetics or sedated

  • allow ill or debilitated patients to rest

  • allow exhausted patients uninterrupted rest.

Muscular deconditioning

• The effect of lack of physical activity, often apparent within days.

• Can occur in any individual regardless of age.

• lose bout 3% of muscle strength a day (for an average-weight person without chronic illness).

muscle deconditioning vs atrophy

• muscle deconditioning = weaker muscle

• muscle atrophy = smaller muscle

Disease atrophy

The tendency of cells and tissue to reduce in size and function in response to prolonged inactivity from bed rest, trauma, casting of a body part, or local nerve damage.

Impaired physical mobility (NANDA)

A state in which the individual experiences, or is at risk of experiencing, limitation of physical movement.

Extent of immobility; why limit bed rest

• The greater the extent and the longer the duration of immobility, the more pronounced the consequences.

• limit bed rest especially in older persons: Loss of walking independence increases hospital stays, need for rehabilitation, or long-term care placement.

• Activity should be more than movement from bed to chair.

• Deconditioning from reduced walking increases the risk of patients falling

Metabolic changes: BMR, negative nitrogen balance, tissue catabolism

• Decreased metabolic rate:

  • altered carbohydrate, fat and protein metabolism

  • fluid, electrolyte and calcium imbalances

  • decreased appetite and slowed peristalsis

  • In hypermetabolic states (infection, fever, wound healing) BMR may be increased.

• Negative nitrogen balance: The immobile body excretes more nitrogen (end product of amino acid breakdown) than protein ingested.

• Tissue catabolism: = Tissue breakdown causes weight loss, decreased muscle mass, and weakness.

Calcium resorption

= When calcium is removed from the bones and released into the blood

• If the kidneys can't remove the extra calcium, too much calcium builds up in the blood (hypercalcemia).

• Over time, the bones become weaker and can break more easily, causing pathological fractures.

Pseudodiarrhea and fecal impaction

• Pseudodiarrhea: Liquid stool passing around an area of hardened, stuck poop (Not normal diarrhea)

• Constipation and impaction in immobility:

  • Fecal impaction left untreated can cause a mechanical bowel obstruction (distension, depressed intestinal function, dehydration, absorption stops, fluid and electrolyte disturbances worsen).

Atelectasis

• Collapse of alveoli.

• Secretions block a bronchiole or bronchus and the distal alveoli collapse as air is absorbed, causing hypoventilation.

Hypostatic pneumo nia

Inflammation of the lung from stasis or pooling of secretions.

Cardiovascular effects of immobility

• Orthostatic hypotension

• increased cardiac workload

• thrombus formation.

Orthostatic hypotension

• A drop in BP greater than 20 mm Hg systolic and 10 mm Hg diastolic.

• Symptoms: dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when changing from lying or sitting to standing.

• why it occurs in immobilized patients:

  • Decreased circulating fluid volume

  • pooling of blood in the lower extremities, and decreased autonomic response

  • especially evident in older persons.

Thrombus

An accumulation of platelets, fibrin, clotting factors, and blood cells attached to the interior wall of a vein or artery, sometimes occluding the vessel.

Thrombus: Virchow's triad

Three factors in venous thrombus formation:

1) loss of vessel wall integrity/damaged vessel (e.g., surgical injury)

2) altered blood flow (slow flow in calf veins on bed rest)

3) altered blood composition/constituents (clotting factors, platelet activity).

Embolus and pulmonary embolus

• Embolus: A blood clot (or other material) that breaks loose, travels through the bloodstream, and can block a blood vessel somewhere else in the body.

• Pulmonary embolism (PE): A blood clot that travels to the lungs and blocks a blood vessel.

  • It can be life-threatening

  • More than 90% of these clots originate in the deep veins of the legs or pelvis.

Deep vein thrombosis (DVT)

• A thrombus in a deep vein (usually the legs)

• a major concern in immobilized patients, especially perioperatively.

Muscle effects and disuse atrophy

• Muscle effects of immobility: Loss of lean body mass (protein breakdown), loss of endurance, strength and muscle mass, decreased stability and balance, so the patient is at risk for falls.

• Disuse atrophy: Reduction in the normal size of muscle fibres after prolonged bed rest, trauma, casting, or local nerve damage.

Disuse osteoporosis and skeletal effects

• Disuse osteoporosis: Bone resorption makes bone tissue less dense, putting the patient at risk for pathological fractures

  • calcium released into the blood can cause hypercalcemia.

• Skeletal effects of immobility:

  • 1. Impaired calcium metabolism

  • 2. joint abnormalities.

Joint contracture

• An abnormal, possibly permanent condition of fixation of a joint

  • the joint can't reach full ROM and may be left in a nonfunctional position.

• Why do contractures form:

  • Flexor muscles are stronger than extensor muscles.

  • Disuse, atrophy and shortening of muscle fibres cause joint contraction

Urinary stasis

• When the patient is flat, urine may not drain as easily from the kidneys toward the bladder because gravity provides less assistance.

• Urine can collect in the renal pelvis (the area that collects urine in the kidney), which may contribute to urine stasis.

• This can increase the risk of urinary tract infections (UTIs) and kidney stones (renal calculi).

Renal calculi

= kidney stone

• Calcium stones that lodge in the renal pelvis and pass through the ureters.

• Immobile patients are at risk from urinary stasis and hypercalcemia.

Urine changes and UTI risk in immobility

• Fluid intake falls = urine output may decline around day 5 to 6 and urine becomes highly concentrated, raising risk of calculi and infection.

• Why is UTI risk higher in immobile patients:

  • Urinary stasis, residual urine from incomplete emptying (bedpan/urinal don't give the usual stimulation or gravity), catheterization (intermittent or indwelling), and poor perineal hygiene (E. coli contamination).

Pressure injury

• Localized damage to the skin and/or underlying soft tissue from prolonged ischemia (decreased blood supply).

• Can be intact skin or an open ulcer, may be painful, starts with inflammation over a bony prominence.

• How does ischemia develop in a pressure injury: When pressure on the skin is greater than the pressure inside the small peripheral blood vessels, pressure decreases or eliminates tissue circulation.

At-risk areas and the skin care program

• Skin over bony prominences: scapulae, elbows, coccyx, heels.

• skin care program: accurate, consistent assessment and documentation, turning the patient every 2 hours, and mechanical devices such as lifts to reduce friction and shear.

Psychosocial effects of immobility

• Decreased social interaction, social isolation, sensory deprivation, loss of independence, role changes, worry, depression.

• Depression (in immobility): An affective disorder with exaggerated sadness, dejection, worthlessness, emptiness and hopelessness out of proportion to reality.

• Worry about disability, health and finances can lead to withdrawal.

• Assess behavioural changes to recognize early signs.

Physiological hazards of immobility (metabolic, respiratory, cardiovascular)

1. Metabolic system

What to assess:

• Wound healing: Delayed wound healing.

• Muscles: Muscle atrophy (muscles become smaller).

• Laboratory results: Abnormal laboratory values.

• Anthropometric measurements:

  • Decreased mid-upper arm circumference (MUAC).

  • Decreased triceps skinfold thickness.

  • These may indicate loss of muscle mass and subcutaneous fat.

• Inspection and palpation: Generalized edema (swelling throughout the body).

2. Respiratory system

What to assess:

• Inspection:

  • Asymmetrical chest wall movement.

  • Dyspnea (difficulty breathing).

  • Increased respiratory rate.

• Auscultation (listening with a stethoscope):

  • Crackles.

  • Wheezes.

  • Decreased air entry (reduced breath sounds).

3. Cardiovascular system

What to assess:

• Orthostatic hypotension (blood pressure drops when changing position).

• Increased heart rate.

• Third heart sound (S3).

• Weak peripheral pulses.

• Dependent edema (swelling caused by fluid pooling):

  • Feet and legs when sitting.

  • Sacral area (lower back/buttocks) when lying down.

4. Musculoskeletal system

What to assess:

• Decreased range of motion (ROM).

• Erythema (skin redness).

• Asymmetrical calf or thigh circumference.

• Joint contractures (joints become stiff and difficult to move).

• Activity intolerance (fatigue or difficulty tolerating activity).

• Muscle atrophy (muscles become smaller and weaker).

5. Elimination system (urinary and bowel)

What to assess:

Urinary elimination

• Decreased urine output.

• Cloudy or concentrated urine.

• Distended bladder (bladder feels enlarged due to urine retention).

Bowel elimination

• Decreased frequency of bowel movements (constipation).

• Abdominal distension (swollen or bloated abdomen).

• Decreased bowel sounds on auscultation.

6. Skin / integumentary system

What to assess:

• Inspection: Impaired skin integrity, such as redness, skin breakdown, or pressure injuries.

• Palpation: Changes in skin temperature, moisture, texture, or swelling.

System	Key findings to remember
Metabolic	Delayed healing, muscle atrophy, abnormal labs, fat loss, edema
Respiratory	Dyspnea, increased RR, asymmetrical chest movement, abnormal breath sounds
Cardiovascular	Orthostatic hypotension, increased HR, S3, weak pulses, dependent edema
Musculoskeletal	Decreased ROM, contractures, muscle atrophy, activity intolerance
Elimination	Decreased urine output, urinary retention, constipation, abdominal distension
Skin	Impaired skin integrity, redness, pressure injuries

Respiratory Deconditioning

• Side effects: Decreased lung expansion, hypoventilation, impaired gas exchange, pulmonary secretion pooling.

• Complications: Atelectasis, pneumonia, hypoxemia, pulmonary edema, pulmonary embolism.

• Nursing actions:

  • Frequent respiratory assessment (rate, rhythm, depth, quality, effort, SpO2, auscultation of anterior and posterior lung fields)

  • position in bed for maximum lung expansion

  • deep-breathing and coughing exercises

  • incentive spirometry

  • chest physiotherapy

  • daily ambulation

Circulatory Deconditioning

• Side effects: Venous pooling and peripheral edema in the extremities (decreased systemic vascular resistance), decreased cardiac output.

• Complications: Thrombus formation, emboli, orthostatic hypotension.

• Nursing actions:

  • Frequent circulatory assessment (pulse, BP, skin colour, extremity colour/sensation/movement/temperature/edema, peripheral pulses, heart sounds)

  • compression stockings with ongoing assessment

  • passive ROM

  • assess BP before ambulating to prevent injury

  • daily ambulation

Integumentary Deconditioning

• Side effects: Decreased delivery of oxygen and nutrients to tissues, inflammation over bony prominences, shearing of skin during movement, tissue ischemia from pressure between bony prominences and bed or chair.

• Complications: Skin breakdown, abrasions/excoriation, pressure injuries, infection.

• Nursing actions:

  • Frequent assessment of posterior skin surfaces

  • reposition every 2 to 3 hours

  • keep skin clean and dry

  • apply skin barriers

Musculoskeletal Deconditioning

• Side effects: Reduced muscle mass, decreased muscle strength, impaired joint mobility, decreased endurance, fatigue.

• Complications: Muscle atrophy, decreased stability and balance, joint contractures.

• Nursing actions:

  • Isotonic and isometric exercises

  • passive ROM

  • daily ambulation

  • splints to prevent joint contractures

Gastrointestinal Deconditioning

• Side effects: Decreased peristalsis, decreased fluid intake, decreased appetite.

• Complications: Abdominal distension, constipation, ileus, aspiration.

• Nursing actions:

  • Frequent abdominal assessment (inspection, auscultation, palpation)

  • assess fluid intake and output, oral intake, daily bowel activity

  • daily ambulation

  • high-protein diet

the six checkpoints for transferring a patient

When a patient is unable to assist, use a mechanical lift and proper body mechanics to ensure the safety of both the patient and healthcare worker.

1. THREE FOR THE TOP — Keep the spine neutral

Remember: Ears → Shoulders → Hips

1. Ears in line with shoulders.

2. Shoulders in line with hips.

3. Keep the spine in a neutral position.

Purpose: Maintains proper spinal alignment and reduces strain on the back.

2. THREE FOR THE BOTTOM — Maintain a stable posture

Remember: Stomach → Buttocks → Heels

1. Tighten your stomach muscles to engage your core.

2. Push your buttocks backward.

3. Keep your body weight over your heels.

Key point: Bend at the hips, not the waist, when moving your trunk forward.

3. ELBOWS TUCKED IN

• Keep your elbows tucked close to your sides.

• Avoid reaching too far away from your body.

• This helps reduce strain on your arms and back.

4. PALMS-UP GRIP

• Use a palms-up grip when appropriate for the task and your training.

• Keep your wrists and arms in a comfortable, aligned position.

5. WORK WITHIN YOUR COMFORT ZONE

• The comfort zone is the area between your shoulders and hips.

• Keep your hands and movements within this area as much as possible.

• Bend your elbows and keep them tucked into your sides.

• Move your hands from shoulder level toward hip level when appropriate.

6. WEIGHT TRANSFER

• Maintain a stable base of support with your feet.

• Transfer your weight from side to side and from front to back.

• Use your body weight and leg movements rather than relying only on your arms and back.

IMPORTANT SAFETY NOTE: When a patient is unable to assist, follow the facility's mechanical-lift procedures, check the lift and sling, and obtain the required assistance. Proper body mechanics do not replace the use of a mechanical lift.

principles for a patient who can't assist (stability and body position)

• Two-person supine transfer: Always work in the comfort zone of the shorter person.

• Base of support: The wider the base of support, the greater the stability.

• Centre of gravity: The lower the centre of gravity, the greater the stability.

• Direction: Facing the direction of movement prevents abnormal twisting of the spine.

• Arms and legs: Dividing balanced activity between the arms and legs reduces the risk of back injury.

principles (leverage, friction, force and fatigue)

• Leverage: Leverage, rolling, turning, or pivoting requires less work than lifting.

• Transfer sheets: Reduce friction between the patient and the surface, reducing the force required to reposition the patient.

• Force and fatigue:

  • Reducing the force of work reduces the risk of injury

  • Good body mechanics reduce muscle fatigue

  • alternating rest and activity also reduces fatigue

Range of motion (ROM)

• The maximum movement available at a joint (in one of four planes)

• Assess for stiffness, swelling, pain, limited movement, and unequal movement

• a baseline ROM allows later comparison

Active vs passive vs active-assisted ROM

• Active ROM: The patient moves all joints unassisted.

• Passive ROM: The patient cannot move, the nurse moves each joint (e.g., paralysis, sedation, generalized weakness).

• Active-assisted ROM: In between, the nurse supports while the patient does most of the movement.

ROM abnormal findings: limited vs excessive

• Limited ROM: causes Inflammation (arthritis), joint fluid, altered nerve supply.

• Excessive ROM (beyond normal): causes connective tissue disorders, ligament tears, possible joint fractures.

flexion/extension, hyperextension, dorsiflexion/plantar flexion, abduction/adduction

• Flexion: decreasing the angle between bones.

• Extension: increasing the angle.

• Hyperextension: Movement beyond the normal resting extension.

• Dorsiflexion: toes and foot pointed upward.

• Plantar flexion: toes and foot pointed downward.

• Abduction: away from the midline.

• Adduction: toward the midline.

eversion/inversion, pronation/supination, rotation, circumduction, opposition

• Eversion: turning the sole away from the midline (laterally).

• Inversion: turning the sole toward the midline (medially).

• Pronation: palm (ventral surface) faces down.

• Supination: palm faces up.

• Internal rotation: turning inward.

• Externa rotation: turning outward.

• Circumduction: Circular, cone-shaped movement (a combination of all movements of a ball-and-socket joint).

• Opposition: Touching the thumb to each finger of the same hand.

movements: neck, shoulder, elbow, forearm

• Neck:

  • Flexion (chin to chest)

  • extension (head back to erect)

  • hyperextension, lateral flexion (tilt toward each shoulder)

  • rotation (turn to look to each side).

• Shoulder: Flexion, extension, hyperextension, abduction, adduction, internal rotation, external rotation, circumduction.

• Elbow: Flexion and extension.

• Forearm: Supination (palm up) and pronation (palm down).

movements: wrist, fingers, thumb

• Wrist: Flexion, extension, hyperextension, abduction (radial deviation, toward the thumb), adduction (ulnar deviation, toward the fifth finger).

• Fingers: Flexion (make a fist), extension, hyperextension, abduction (spread apart), adduction (bring together).

• Thumb: Flexion (across the palm), extension (away from hand), abduction, adduction, opposition.

movements: hip, knee, ankle

• Hip: Flexion, extension, hyperextension, abduction, adduction, internal rotation, external rotation, circumduction.

• Knee: Flexion (heel toward back of thigh) and extension.

• Ankle: Dorsiflexion (toes up) and plantar flexion (toes down).

movements: foot, toes

• Foot: Inversion (sole medially) and eversion (sole laterally).

• Toes: Flexion (curl down), extension (straighten), abduction (spread apart), adduction (bring together).

Hip rotation: precaution

Do not perform hip rotation in patients who have had a total hip arthroplasty.

Continuous passive motion (CPM) machine

• Moves an extremity to a prescribed angle for a prescribed period (e.g., after total knee arthroplasty).

• Physiotherapists usually do the first-time setup, assess pain and give analgesia first.

Mobility assessment: what do you assess?

• Patient expectations

• range of motion

• gait

• exercise and activity tolerance

• body alignment (standing, sitting, lying).

Body alignment assessment: standing, sitting, lying

• Standing:

  • Head erect and midline

  • shoulders and hips straight and parallel

  • vertebral column straight

  • reversed S curve from the side

  • abdomen tucked in

  • knees and ankles slightly flexed

  • arms at sides

  • feet slightly apart with toes forward.

• Sitting:

  • Head erect

  • neck and spine straight

  • weight evenly on buttocks and thighs

  • thighs parallel and horizontal

  • feet supported on floor or footrests

  • 2.5 to 5 cm space between seat edge and popliteal space

  • forearms supported.

• Lying

  • remove all supports except a head pillow

  • vertebrae aligned and no discomfort

Gait and how to assess it

• Gait (The manner of walking): requires sensory function, muscle strength, proprioception, balance, and a functioning CNS.

• Assessing gait: Observe entry (speed, stride, balance), walking across the room and back, and heel-to-toe walking; stay at the patient's side.

Activity tolerance and monitoring after inactivity

• Activity tolerance: The type and amount of exercise a person can do without undue exertion or injury.

• Decreasing recovery time means improved tolerance.

• After prolonged inactivity, what do you monitor:

  • Dyspnea, fatigue, chest pain

  • check heart rate and BP if they occur.

assessment before turning and positioning

• before turning and positioning: Identify the patient (two identifiers)

• assess alignment, comfort and skin

• assess risk factors for immobility complications

• check the prescription for contraindicated positions

• hand hygiene

• check tubes, incisions and equipment.

• Contraindicated positions, check for:

  • Spinal cord injury, respiratory difficulty, neurological conditions, incisions, drains, and tubing.

• If unsure of a patient's abilities, where do you start:

  • In the most supportive position and progress: lying, then sitting in bed, transfer to chair, then gait.

functional assessment for repositioning

• Can the patient communicate and follow directions?

  • Vision and hearing

  • medical status

  • hand grip strength

  • ability to bridge

  • ability to roll side to side

• = If deficient in any, at least two nurses are required

Positioning devices: pillows, wedge pillow, foot cradle

• Pillows (positioning): Support, elevate, and splint incisions

  • a thick pillow under the head increases cervical flexion.

  • Use folded sheets, blankets or towels if needed.

• Wedge (abductor) pillow: Keeps the legs abducted after total hip replacement.

• Foot cradle: Reduces pressure on the toes for patients with poor peripheral circulation.

Positioning devices: foot boot, trochanter roll, sandbags

• Foot boot: Keeps the foot dorsiflexed, prevents footdrop, and keeps sheet weight off the toes.

  • Remove 2 to 3 times daily to assess skin and joint mobility.

• Trochanter roll: Prevents external rotation of the hips in supine

  • the patella faces upward when aligned.

• Sandbags: Immobilize an extremity or maintain alignment.

Positioning devices: hand roll, hand-wrist splint, trapeze bar

• Hand roll: Keeps the thumb slightly adducted and in opposition to the fingers

  • for paralyzed or unconscious patients.

  • Rolled washcloths should NOT be used (thumb isn't kept abducted, especially in spastic paralysis).

• Hand-wrist splint: Moulded for the individual

  • thumb slightly adducted, wrist slightly extended.

  • Use only on the patient it was made for and follow the splint schedule.

• Trapeze bar: Lets the patient lift the trunk, assist transfers, and do arm exercises

  • decreases shear and maintains upper body strength.

Supported Fowler's position

• pillows support arms and hands if no voluntary control

• pillow at lower back

• small pillow under the thigh (prevents knee hyperextension and popliteal artery occlusion)

• heel boots

• foot support to prevent footdrop.

Supported supine position

• Head of bed flat if tolerated

• small rolled towel under the lumbar area

• pillow under upper shoulders, neck or head

• trochanter rolls or sandbags along thighs

• heel boots and foot support in dorsiflexion

• pillows under pronated forearms with upper arms parallel

• hand rolls

Prone position

• Two staff.

• Used for ARDS to improve oxygenation.

• Head turned to the side on a small pillow

• small pillow under the abdomen below the diaphragm

• arms flexed level with shoulders

• pillows under the lower legs to lift the toes.

30-degree lateral (side-lying) position

• Pillow under head and neck

• upper arm on a pillow level with the shoulder

• dependent hip brought slightly forward so the angle is about 30 degrees (reduces pressure on the trochanter)

• tuck-back pillow behind the back

• pillow under the semiflexed upper leg from groin to foot

• foot support in dorsiflexion.

Sims' (left lateral recumbent / semiprone) position

• One nurse.

• Patient rolled partially onto the abdomen with the dependent shoulder lifted out and the arm at the side

• small pillow under head

• pillows under the flexed upper arm and upper leg

• foot support in dorsiflexion.

• Weight on anterior ilium, humerus and clavicle.

Positioning schedule: turning, chair sitting, joints

• patients be turned every 1 to 2 hours (at least every 2 hours, even with pressure-relieving mattresses).

• Increase if pressure areas appear, joint mobility worsens, or the patient is uncomfortable.

• Chair sitting limits: No more than 1 hour uninterrupted

• patients who are able should shift weight every 15 minutes.

• Joints must be slightly flexed (unsupported joints lose alignment);

• assess bony prominences during positioning.

Moving up in bed: staff and setup

SETUP

• Use two or more nurses.

• Position the patient supine (lying on their back) with the head of the bed flat, or in Trendelenburg position if tolerated and appropriate.

• One nurse stands on each side of the bed.

• Lower the side rails on the working sides.

• Move the pillow to the head of the bed.

• Turn the patient from side to side to place the sliding device under the shoulders and hips.

• Fanfold the sliding device on both sides so the nurses can grasp it firmly.

• Never expect the patient to move up the bed alone.

• Moving a completely immobilized patient alone is dangerous and is not allowed in many healthcare agencies.

Moving up in bed: patient and nurse position

Patient position:

• Lie flat on their back (supine).

• Cross arms over the chest.

• Bend the knees; place a pillow under the lower legs if the patient cannot bend them.

• Flex the neck by bringing the chin toward the chest to prevent hyperextension.

• If able, push with the heels during the movement.

Nurse position:

• Stand with feet shoulder-width apart.

• Use a forward-backward stance, with the foot nearest the head of the bed pointing in the direction of movement.

• Grasp the sliding device firmly with palms facing up, near the patient.

• Keep elbows close to the body.

• Use a stable base of support and shift weight from the back leg to the front leg.

• Rock and transfer body weight rather than pulling with the arms alone.

Moving up in bed: the 1-2-3 count and afterwards

The count:

• The primary nurse coordinates the movement and counts, "1-2-3, SLIDE!"

• Nurses rock and shift their weight from the back leg to the front leg to move the patient.

• If able, the patient pushes with their heels and exhales on "SLIDE."

When does the movement happen?

• Count "1-2-3," then give the command.

• Movement begins at the start of the command word: "SLIDE," "TURN," "SIT," or "STAND."

Why does the patient exhale on "SLIDE"?

- Exhaling helps prevent the Valsalva manoeuvre, which involves holding the breath while straining and can cause changes in blood pressure.

After the movement:

• Reposition the patient comfortably and maintain proper body alignment.

• Tuck in the top sheet.

• Remove the temporary sliding device if required by the device instructions and facility policy, because leaving it in place may allow the patient to slide.

• Ensure the patient is safe and raise the side rails as appropriate.

Logrolling: when and how many nurses

• when is it used: Spinal cord injury, vertebral surgery, or suspected vertebral fracture

• keep the spine in straight alignment and move the patient as a unit.

• Three nurses minimum, a fourth stabilizes the head and neck for spinal cord injury or suspected vertebral fracture (a fifth may be added)

Logrolling: key steps

• Patient supine near the side opposite the turn

• small pillow between knees

• cross arms on chest

• sheet fanfolded, palms up, elbows at sides

• count '1-2-3 roll'

• move as a unit

• pillows along the back and lean the patient against them

• hand hygiene.

after care and unexpected outcomes

1. AFTER POSITIONING

• Perform hand hygiene.

• Evaluate the patient's comfort and body alignment after each position change.

• Assess pressure areas for erythema (redness) or skin breakdown.

• Document and report observations.

2. UNEXPECTED OUTCOMES AND INTERVENTIONS

A. Contractures

• Cause: Improper positioning causes muscles to shorten.

• Interventions:

  • Consult physiotherapy or occupational therapy.

  • Ensure prescribed activity and range-of-motion (ROM) exercises are performed consistently.

B. Skin erythema or breakdown

• Cause: Inadequate frequency of repositioning.

• Interventions:

  • Increase the frequency of turning and repositioning.

  • Post a turning schedule.

  • Follow the facility's skin care policy.

  • Assess the skin more frequently.

  • Consult a dietitian if needed.

  • Use a pressure-relieving mattress as appropriate.

C. Patient avoids moving

• Possible reason: Pain or fear of discomfort.

• Interventions:

  • Administer prescribed analgesia and allow time for it to take effect.

  • Educate the patient about the benefits of movement.

Safety: head of bed, doughnut devices, suspected DVT

• head of bed height: Do not use head of bed above 60 degrees (increases shear on back and heels).

• doughnut devices: Do not use doughnut-shaped devices for chair-bound patients.

• suspected DVT: Report immediately, elevate the leg, avoid pressure on the area, and do NOT massage (could dislodge the thrombus).

tubes and drains, side rails, nurse safety

• tubes and drains: Account for all tubes, drains and equipment before lowering the head of the bed or moving the patient.

• side rails: Keep the rail up on the side opposite the nurse.

• Recognize your limits: request help the first time you do a technique

  • use safe patient-handling devices (friction-reducing sheets, slings, mechanical lifts)

  • follow employer lifting policies

  • use proper body mechanics

Comfortable environment and care hours

• Privacy (door/curtains)

• bed at a comfortable working height (tallest nurse's comfort zone)

• explain the procedure

• treat pain first and let analgesia take effect.

• Do not schedule care between: 2200 and 0700

• where possible: combine medications, vital signs and turning to protect sleep.

Transfers: when to assess

• transfer assessment is done before each transfer.

• Check the care plan and/or ADL sheet for the transfer type.

Transfer assessment: what do you assess?

• Level of consciousness

• cognition (oriented, able to follow directions)

• sensory status (alert, vision and hearing adequate, glasses/hearing aids)

• grip strength

• arm strength

• leg strength

• bridge.

Transfer assessment: strength tests (grip, arm, leg, bridge)

• Grip: Patient squeezes the nurse's fingers (2 fingers only).

• Arm: Patient pushes against the nurse's hand.

• Leg: With knees bent, patient pushes the legs down against the nurse's hand to straighten the leg.

• Bridge: The patient moves the hips: lifts the buttocks off the bed.

Before every transfer, check for

• Medical contraindications (sedative medications, suspected head/spinal injury, suspected fracture) and mobility restriction orders (bedrest, non-weight bearing, partial weight bearing).

Standing transfer tool: equipment and preparing the patient

• Prepare and check the equipment: transfer belt, walker, cane, wheelchair or chair, and patient footwear with good grip.

• Standing transfer tool - preparing the patient:

  • Assess for pain and treat before the transfer

  • assess leg strength (bridge)

  • explain the procedure

  • make sure glasses or hearing aids are in place and working.

Standing transfer tool: the questions and outcomes

1. YES/NO QUESTIONS

1. Is the patient cooperative and not resistive to care?

2. Is the patient alert and able to follow directions?

3. Can the patient move from lying to sitting at the edge of the bed independently or with assistance from one person?

4. Can the patient balance while sitting at the edge of the bed independently or with minimal assistance?

5. Can the patient stand up and maintain balance independently or with supervision?

6. Can the patient actively move to the destination?

2. OUTCOMES AND ACTIONS

If the answer to Question 1 is NO:

• Do not proceed with the standing transfer.

• Collaborate with the healthcare team.

• Document the findings.

If the patient cannot stand or actively move to the destination:

• Document the findings.

• Refer to physiotherapy for assessment.

• If the transfer is necessary, use a full mechanical lift according to facility policy.

If all questions are YES:

- The patient may be suitable for a standing transfer, provided the appropriate equipment, assistance, and safety procedures are in place.

Dizziness check, transfer belt, documenting

• Dizziness: Do not transfer until it clears

  • monitor BP if it continues

  • reassess pain

• Transfer belt: Around the waist of the patient

  • help with shoes

  • make sure the feet contact the floor.

• Documenting: Indicate whether independent or assisted, what mobility aid, and whether 2 people are required to manage equipment or lines.

What perspective do you use for right and left when positioning a client?

What perspective do you use for right and left when positioning a client?

If a client has a right-sided stroke, which side of the body is typically weak?

• Weakness is typically on the opposite side.

• Right-sided brain stroke → left-sided weakness.

Client is lying in bed with left-sided weakness. Where do you position the wheelchair?

• On the WEAK side, near the foot of the bed

• Left-sided weakness → wheelchair on the left.

Client is sitting at the bedside with left-sided weakness. Where do you position the wheelchair?

• On the STRONG side, near the foot of the bed.

• Left-sided weakness → wheelchair on the right.