Chapter 23 Timby: Body Mechanics, Positioning, and Moving

Chapter 23 Timby: Body Mechanics, Positioning, and Moving

Learning Objectives

• On completion of this chapter, the student should be able to:

  1. Identify characteristics of good posture in a standing, sitting, or lying position.

  2. Describe principles of correct body mechanics.

  3. Explain the purpose of ergonomics.

  4. Give examples of ergonomic recommendations in the workplace.

  5. Describe common client positions.

  6. Describe different positioning devices used for safety and comfort.

  7. Discuss advantages of three different pressure-relieving devices.

  8. Identify types of transfer devices.

  9. Outline general guidelines that apply to transferring clients.

  10. Describe signs and symptoms associated with the disuse syndrome.

• Student Learning Outcomes (SLOs): Safety, Patient-centered Care, Teamwork and Collaboration.

Inactivity and Its Consequences

• Inactivity can lead to:

  • Deterioration of health.

  • Complications such as disuse syndrome: signs and symptoms resulting from inactivity.

• Nursing care activities focus on positioning clients and addressing the potential for injury.

Terminology and Effects of Inactivity

• Disuse Syndrome Effects on Body Systems:

  • Muscular: Weakness, decrease in tone/strength, decrease in size.

  • Skeletal: Poor posture, contractures, foot drop.

  • Cardiovascular: Impaired circulation, thrombus formation, dependent edema.

  • Respiratory: Pooling of secretions, shallow respirations, atelectasis.

  • Urinary: Oliguria, urinary tract infections (UTI), calculi formation, incontinence.

  • Gastrointestinal: Anorexia, constipation, fecal impaction.

  • Integumentary: Pressure sores.

  • Endocrine: Decrease in metabolic rate, decreased hormonal secretions.

  • Central Nervous System: Sleep pattern disturbances, psychological changes.

Basic Concepts of Body Mechanics

• Gravity: Force that pulls objects toward the center of the Earth.

• Energy: Capacity to do work; needed to overcome the force of gravity.

• Balance: Steady position with weight distribution.

• Center of Gravity: Point where mass of an object is centered.

• Line of Gravity: Imaginary vertical line passing through the center of gravity.

• Base of Support: Area on which an object rests.

• Alignment: Proper relationship of the body parts.

• Neutral Position: Limb turned neither toward nor away from the body’s midline.

• Anatomic Position: Body positioned with arms at sides and palms facing forward.

• Functional Position: Effective position for performing an activity.

Maintaining Good Posture

• Good posture influences:

  • Appearance

  • Stamina

  • Efficiency of the musculoskeletal system

• Standing Posture Guidelines:

  • Keep feet parallel.

  • Even weight distribution on both feet.

  • Slightly bend knees; do not lock them.

  • Hips should be even.

  • Contract abdominal and gluteal muscles.

  • Chest slightly forward, stretch waist.

  • Shoulders even above hips.

  • Head erect, facing forward, chin slightly tucked.

• Sitting Posture Guidelines:

  • Base of support from buttocks and upper thighs.

  • Feet resting on the floor.

  • Knees bent and clear of chair edge.

• Lying-Down Posture Guidelines:

  • Neutral head and neck position centered between shoulders.

  • Shoulders leveled; arms and legs slightly flexed.

  • Trunk straight and hips level; feet at right angles.

Gerontologic Considerations

• Skeletal Changes in Older Adults:

  • Conditions such as kyphosis, lordosis, and scoliosis can alter the center of gravity.

• Kyphotic Changes:

  • May cause pressure on cervical vertebrae when supine.

• Educate older adults on the importance of good body mechanics during movement.

Body Mechanics in Healthcare

• Injury Statistics:

  • Healthcare workers have high rates of musculoskeletal injuries (CDC, 2020).

• Proper body mechanics can:

  • Increase muscle effectiveness.

  • Reduce fatigue.

  • Help avoid repetitive strain injuries.

• Safe Patient Handling and Mobility:

  • Align with interprofessional national standards (ANA & CDC).

  • Focus on reducing injuries through assistive equipment and devices.

Ergonomics

• Definition of Ergonomics:

  • A specialized field focused on promoting comfort, performance, and health in the workplace.

• Examples:

  • Using assistive devices to lift heavy items or clients.

  • Alternative equipment for tasks requiring repetitive motions.

Positioning Clients

• General Positioning Principles:

  • Change an inactive client's position every 2 hours.

  • Use at least one other caregiver for assistance.

  • Adjust bed height to the caregiver's elbow level.

  • Remove pillows and devices as needed.

  • Unfasten drainage tubes from linens.

  • Utilize low friction fabrics, roller sheets, or positioning slings.

  • Lift and glide the client when repositioning—not dragging.

• Client Positioning Guidelines:

  • Turn the client as a complete unit to avoid spinal twisting.

  • Maintain good alignment with joints slightly flexed.

  • Replace pillows and positioning devices after adjustment.

  • Support limbs in a functional position.

  • Elevate limbs to relieve swelling or enhance comfort.

  • Provide skin care following repositioning.

Client Positions

• Supine Position:

  • Laying on back; prolonged pressure can cause foot drop.

  • Recommended for infants to reduce the risk of Sudden Infant Death Syndrome (SIDS).

• Lateral Position:

  • Side-lying; fewer concerns regarding foot drop.

• Lateral Oblique Position:

  • Side-lying with top leg flexed at 30 degrees at the hip and 35 degrees at the knee.

• Prone Position:

  • Client lying on abdomen.

• Sims Position:

  • Left side lying with right knee drawn toward the chest.

• Fowler Position:

  • Semi-sitting position, facilitates eating and talking.

Detailed Overview of Client Positions

1. Supine Position (Dorsal Recumbent)

   • Description: The client lies on their back with the head and shoulders slightly elevated with a small pillow unless contraindicated.

   • Clinical Use: Physical examination, resting, and post-surgery recovery.

   • Nursing Considerations: Prolonged supine positioning can lead to foot drop (permanent plantar flexion) and pressure ulcers on the sacrum and heels. Place a small pillow under the lumbar curve and use footboards to maintain dorsiflexion.

2. Fowler’s Positions

   • Low Fowler’s: Head of the bed is elevated to $15$ to $30$ degrees. Used to ease breathing and for resting.

   • Semi-Fowler’s: Head of the bed is elevated to $30$ to $45$ degrees. This is the preferred position for clients with nasogastric tubes or those receiving tube feedings to prevent aspiration. It also helps with cardiac and respiratory distress.

   • High Fowler’s: Head of the bed is elevated to $60$ to $90$ degrees. This position facilitates maximum chest expansion, making it ideal for clients with severe dyspnea. It is also used during eating, swallowing, and for the insertion of a nasogastric tube.

3. Lateral Position (Side-Lying)

   • Description: The client lies on their side with weight distributed on the lower scapula and the lower ilium.

   • Clinical Use: To provide rest and to relieve pressure on the sacrum and heels for clients who have been supine.

   • Nursing Considerations: Ensure the upper arm and leg are supported with pillows to maintain alignment and prevent internal rotation of the joints.

4. Lateral Oblique Position

   • Description: A variation of the lateral position where the client is tilted with the top leg flexed at a $30$ degree angle at the hip and a $35$ degree angle at the knee.

   • Clinical Use: This position is specifically designed to reduce pressure on the trochanter (hip bone), which is a common site for pressure ulcers in the standard lateral position.

5. Prone Position

   • Description: The client lies on their abdomen with the head turned to one side.

   • Clinical Use: Used to improve oxygenation in clients with Acute Respiratory Distress Syndrome (ARDS) and to promote drainage of secretions from the mouth for post-operative clients who cannot swallow.

   • Nursing Considerations: This position is often uncomfortable for long periods and can cause significant back strain due to the hyperextension of the lumbar spine.

6. Sims Position (Semi-Prone)

   • Description: The client lies on their left side with the right knee and thigh drawn up toward the chest. The left arm is positioned behind the client.

   • Clinical Use: This is the standard position for rectal examinations, the administration of enemas, and the insertion of rectal suppositories.

7. Trendelenburg Position

   • Description: The entire bed frame is tilted with the head of the bed lower than the foot of the bed.

   • Clinical Use: Historically used to treat hypotension or shock to promote venous return to the brain and heart. It is also used during procedures to help move abdominal organs away from the pelvis (e.g., during some surgeries) or to manage umbilical cord prolapse.

8. Reverse Trendelenburg Position

   • Description: The entire bed frame is tilted with the foot of the bed lower than the head of the bed.

   • Clinical Use: Used to promote gastric emptying and to prevent esophageal reflux in clients with hiatal hernias or GORD.

9. Orthopneic Position

   • Description: The client sits at the side of the bed or in the bed with an over-bed table across their lap, leaning forward onto pillows.

   • Clinical Use: Used for clients with severe COPD or other respiratory distress (orthopnea) who cannot breathe unless they are sitting upright. Leaning forward allows for maximum lung expansion by utilizing the accessory muscles of respiration.

Positioning Devices

• Types of Positioning Devices:

  • Adjustable beds

  • Mattresses

  • Bed boards (rigid structure under mattresses)

  • Pillows

  • Roller sheets

Turning and Moving Clients

• Turning and Moving Guidelines:

  • Assistance is required for clients unable to reposition independently.

  • Follow specific protocols based on client mobility levels.

• Patient Handling Algorithm:

  • Determine if the patient can assist with movement.

  • Encourage partial assistance with positioning aids when possible.

  • For patients <200 lbs, use friction-reducing devices & 2-3 caregivers.

  • For patients >200 lbs, use assistive devices with three caregivers.

• Prevent Shearing Forces during repositioning, especially in stage III or IV pressure ulcers.

Assistive Devices for Turning and Movement

• Hand Rolls:

  • Devices placed in the palm to maintain the thumb in slight adduction and in opposition to the fingers.

  • preserves functional ability by preventing contractures (such as claw-hand deformities) and keeping fingers slightly flexed.

• Trapeze:

  • A triangular metal bar suspended from an overhead frame at the head of the bed.

  • Enables clients with upper-body strength to lift their trunk off the bed, assist in moving up in bed, or facilitate transfers to a wheelchair.

  • Helps maintain muscle tone and increases independence for tasks like repositioning or lifting for linen changes.

• Trochanter Rolls:

  • Formed by folding a sheet or towel and placing it against the hip from the iliac crest to the midthigh.

  • Prevents external rotation of the legs (turning outward at the hips), maintaining neutral alignment.

  • Essential for clients who have had hip surgery or exhibit lower-extremity paralysis.

• Footboards, Boots, and Foot Splints:

  • Used to maintain the feet in a position of dorsiflexion (at a 90 degree angle to the lower leg).

  • Specifically designed to prevent foot drop, a permanent shortening of calf muscles caused by prolonged plantar flexion.

  • Foot splints and boots are often preferred as they protect the heels from pressure better than standard footboards.

Protective Devices

• Types of Protective Devices:

  • Side rails

  • Mattress overlays (egg-crate foam mattresses, foam/gel mattresses)

  • Static and alternating air mattresses

  • Water mattresses

  • Cradles for lower legs and feet

  • Specialty beds (low-air-loss beds, air-fluidized beds, oscillating support beds, circular beds)

Nursing Implications

• Comprehensive Client Assessment:

  • Mobility and Dependence Level: Evaluate the client's ability to assist with repositioning and transfers using standard scales. Determine the degree of assistance required (e.g., independent, partial assist, or total dependent).

  • Physical Status: Assess baseline muscle strength (using a $0$-$5$ scale), joint range of motion (ROM), and balance. Check for any pre-existing musculoskeletal or neurological conditions that affect movement.

  • Skin Integrity: Inspect skin thoroughly, especially over bony prominences (e.g., sacrum, heels, trochanters), for signs of redness, breakdown, or shearing. Utilize the Braden Scale to quantify the risk for pressure injuries.

  • Cognitive and Sensory Status: Ensure the client can understand and follow instructions safely. Assess for visual or auditory deficits that might impair coordination during movement.

  • Continence and Nutrition: Evaluate for incontinence (which increases skin breakdown risk) and nutritional status (which affects skin healing and muscle strength).

• Selection of Appropriate Devices:

  • Dynamic Decision Making: Continually re-evaluate the need for positioning, transfer, and protective devices as the client’s level of independence or physical condition changes.

  • Equipment Integrity: Inspect all mechanical lifts, slings, and beds before use to ensure they are functional and safe for the client's weight capacity.

• Potential Nursing Diagnoses:

  • Impaired Physical Mobility: Related to decreased muscle strength or prescribed activity restrictions.

  • Risk for Impaired Skin Integrity: Related to prolonged pressure, shearing forces, or moisture from incontinence.

  • Risk for Disuse Syndrome: Potential for deterioration of body systems due to prescribed or unavoidable musculoskeletal inactivity.

  • Deficient Knowledge: Regarding proper body mechanics or the importance of frequent position changes.

  • Risk for Falls: Related to impaired balance or orthostatic hypotension secondary to prolonged bed rest.

Client and Family Teaching

• Teaching Strategies and Education Content:

  • Activity and Rest Cycles: Explain the physiological need to balance activity with rest to prevent fatigue while avoiding the complications of stasis.

  • Risks of Inactivity: Educate the client and family on specific dangers such as deep vein thrombosis (DVT), pneumonia, and permanent joint contractures.

  • Structured Activity Planning: Encourage the family to set a schedule for daily movements, ROM exercises, and supervised ambulation if permitted.

  • Psychosocial Wellbeing: Promote social engagement and mental stimulation; suggest community resources or support groups for clients with chronic mobility issues.

  • Home Safety Audit: Instruct on environmental modifications to prevent injury:

  • Remove tripping hazards like throw rugs and electrical cords.

  • Ensure adequate lighting in hallways and bathrooms.

  • Install grab bars in the tub or shower and near the toilet.

  • Recommend the use of sturdy, non-skid footwear at all times.

  • Caregiver Body Mechanics: Teach family members how to assist the client using their own body mechanics (e.g., wide base of support, lifting with legs) to prevent caregiver back injuries.

Questions and Answers

• Question #1: In what position should the infant be placed to reduce the incidence of sudden infant death syndrome?
  Answer: B. Supine

  • Explanation: The infant should be placed in a supine position (on their back) to reduce the incidence of SIDS.

• Question #2: Which type of mattress provides the least pressure reduction?
  Answer: C. Egg-crate foam

  • Explanation: Egg-crate foam provides minimal pressure reduction compared to water, static air, or gel mattresses.

• Question #3: Which positioning device is foundational for good body alignment?
  Answer: A. Mattress

  • Explanation: A mattress is essential for maintaining proper body alignment and supporting the body.

• Question #4: Match each term with the best description.

  • Balance: C. Steady position with weight distributed

  • Center of Gravity: D. Point where mass of an object is centered

  • Base of Support: A. Area on which an object rests

  • Alignment: E. Parts in proper relationship to one another

  • Neutral Position: F. Position of a limb in alignment with the body’s midline

  • Functional Position: B. Position in which an activity is performed properly and normally