Clinical Skills and Positioning: Midterm, Lab Skills, and Bed Mobility Notes

Midterm logistics and video submission

• Midterm videos: four midterm videos in total. You film yourself performing the skills. There are four videos, and midterms are due on: $September\ 23$.
• Video submission and references:
  • Information on YouTube submission is available on iLearn; if unsure, check iLearn for the video on how to submit a skill.
  • There is a video on iLearn about creating an unlisted video. If you notice you missed something after you’ve filmed, you can acknowledge the missing item in the notes section and seek approval rather than re-filming (
    e.g., adding a missing gear).
  • If you’ve completed whole video but realize you forgot a critical step, you may include an acknowledgement in the notes and request approval from the instructor or Steve.
• Evaluation structure (two-skill approach):
  • Of the four skills, two will be graded for midterm one. If a skill has, for example, 15 steps, your mark for that skill depends on how many steps you completed correctly.
  • Example scoring: if you complete 13 out of 15 steps for one skill, you’ll receive partial credit for that skill; if you complete all 15/15 steps, you’ll maximize that skill’s contribution.
  • Overall, two skills contribute to your midterm mark. For a skill with 13/15 you get partial credit; for a perfect 15/15 you get full credit for that skill.
• Passing criteria and critical indicators:
  • To pass the skill, you must complete at least $80\%$ of the steps in all the critical indicators. In this course, many indicators for some skills (such as hand washing) are labeled as critical indicators, meaning you must achieve full credit on those indicators to pass that skill.
• Grading breakdown (practical midterm):
  • The first set of four videos is the practical midterm; out of these, two are evaluated (skills 5–10).
  • The next set (skills 11–16) are all submitted, and two of those will be graded.
• In-person midterms and video use: next round for the four remaining skills (skills 5–10 in-person in the lab; 11–16 also involve video submission).
• Summary: the grading is designed around a two-skill evaluation framework, with a clear threshold ($80\%$ on critical indicators) and a structured process for video submission and resubmission if necessary.

Course outcomes and learning outcomes for today

• Learning outcome 1 (lab-focused): Describe and discuss the effects of physical, sexual, or psychological abuse or trauma on patients’ responses in a clinical care setting, and outline actions to help a patient feel safe.
• Learning outcome 2: Describe common cultural considerations for draping and how to accommodate patient fluids.
• Group activity: Form groups of two or three to read a scenario and discuss patient comfort, privacy, and cultural considerations in care.
• Emphasis on trauma-informed care: assume every patient could have a trauma history; practice universal precautions and respectful consent; observe nonverbal cues and ask questions about patient preferences.
• Trauma-informed care resources: online certificates and modules are available; consider completing a trauma-informed care module to understand prevalence and impact of trauma on patient care, including sexual abuse prevalence statistics and safety considerations.

Privacy, dignity, and lab video content

• Course materials reference privacy and dignity when donning hospital attire:
  • Donning hospital pants while a gown is worn; privacy is maintained with curtains or doors as appropriate.
  • If the patient is wearing a gown, you adjust the pants underneath; adapt to whether the patient wears shorts or pants in different settings.
• Lab videos and YouTube resources:
  • YouTube channel contains several longer videos (10–15 minutes) showing complete treatment sessions, as well as separate skills videos.
  • Some students prefer to review full-session videos to see how individual skills fit into the care plan; others prefer targeted skills videos.
• Two-slider-sheet method (in lab):
  • Demonstrations show using two slider sheets for safe patient transfer and repositioning; a common practice is to place one slider sheet under the patient and use a second one to facilitate movement.
  • In the live lab, you will practice with two slider sheets to reduce friction and shear; in the video demonstration, only one slider sheet was shown, which was a simplification due to the video format.
  • It is generally not recommended to place a slider sheet under a patient who is in a wheel chair without assistance; position the patient and then transfer using two sheets for safer movement.
• Lifts and slings:
  • Slings exist for lifts; many facilities leave the slings under patients, but best practice is to avoid unnecessary pressure from long-term use of under-patient devices.
• Practical note on technique:
  • When repositioning, you may position a patient who cannot assist (e.g., in bed or wheelchair) with a two-sheet method and coordinate with a partner to scoot or roll safely.
  • For patients who can assist, verbal cues and guided assistance enable greater independence.
• Restraints and safety:
  • Restraints should be used only when absolutely necessary and in the least restrictive form; monitor patients closely; remove restraints during activity where they can safely participate, and reapply as needed.
• Practical tips during lab demonstrations:
  • If a patient is wearing pants, you can use them as part of the transfer; otherwise, you should use sheet-assisted movements to protect the patient’s skin.
  • Avoid lifting patients by the upper extremities; minimize friction and shear; ensure you have adequate support for the pelvis and spine during transfers.

Trauma-informed care and cultural sensitivity in practice

• Trauma-informed care basics:
  • Universal precautions: treat every patient as if they might have trauma histories.
  • Respect for consent and patient preferences; ask permission before privacy-invasive procedures; explain what you’re about to do.
  • Observe body language and respond with empathy; if a patient becomes apprehensive, pause, ask what would make them more comfortable, and adapt procedures.
  • Some patients may need to involve a family member or someone they trust in their care; accommodate safety and comfort as needed.
• Cultural considerations during care:
  • When draping or exposing patients, consider cultural or religious norms and personal modesty preferences.
  • Ask patients about cultural sensitivities, including preferences for privacy, gender concordance with clinicians, or modesty considerations.
  • The goal is to practice respectful, culturally aware, patient-centered care.
• Additional notes:
  • Trauma-informed care training is available as online certificates; some programs integrate it into clinical education because trauma exposure is common among patients.
  • The instructor emphasizes creating a safe environment and acknowledging that trauma can shape patient responses to care.

Positioning: short-term vs long-term concepts

• Core idea: short-term positioning focuses on safety, comfort, access (ability to perform care), and maintaining good spinal alignment; long-term positioning considers risks of prolonged immobilization and potential injuries.
• Key phrase: proximal stability equals distal mobility. When the trunk is well-supported, distal mobility and functional movement improve.
• Short-term positioning priorities (SCA, SAC, CAF — safety, comfort, access):
  • Ensure safety, ensure comfort, ensure access to treatment.
  • Maintain good spinal alignment; support trunk and extremities; promote proximal stability to enable distal movement.
• Long-term positioning considerations:
  • Risk of pressure injuries, contractures, edema, and systemic effects on multiple body systems.
  • Contractures: shortening of muscles across joints (e.g., iliopsoas, hip flexors; hamstrings when knees are flexed for long periods).
  • Pressure injuries: ulcers that develop under prolonged pressure; often start subsurface before visible; can be life-threatening if not managed.
  • Skin, muscular, nervous, cardiopulmonary, and integumentary system risks with immobility.
• Systemic effects of long-term positioning by body system:
  • Integumentary: skin breakdown and ulcers.
  • Musculoskeletal: contractures, muscle atrophy, decreased strength, joint stiffness.
  • Neurological: decreased nerve conduction efficiency due to disuse.
  • Cardiopulmonary: reduced ventilation and circulation; higher risk of pneumonia and venous thromboembolism; decreased exercise tolerance.
  • Psychological: boredom, mood changes, reduced quality of life.
• Practical rules for long-term positioning:
  • Use neutral spine alignment; avoid sustained flexion and excessive rotation.
  • Promote sleep and rest positions that minimize pressure on bony prominences.
  • Use pillows and supports to maintain neutral hip, knee, and ankle angles; for long-term supine, avoid sustained knee flexion that could promote contractures.
  • Regularly reassess skin integrity and sensation; monitor for edema and poor perfusion.
• Pressure injury risk factors and assessment:
  • Risk factors include immobility, incontinence, impaired sensation, poor nutrition, Cognition issues, edema, and vascular compromise.
  • Risk assessment tools or clinical judgment guide turning schedules and pressure-reducing strategies.
• Blanch test for tissue viability:
  • A blanch test involves pressing the skin to see if color returns; if the skin does not blanch, tissue may be compromised.
  • The rate of color return after blanching can indicate tissue health and risk of breakdown.
• Special precautions for surgical populations:
  • Total hip arthroplasty (THA): posterior approach requires avoiding hip flexion beyond $90^ ext{o}$, adduction, and internal rotation for the initial weeks; use raised twists and cushions to minimize extension and rotation.
  • Abduction wedges and restraints may be used to maintain alignment; avoid crossing legs or excessive internal/external rotation depending on approach.
  • Anterior THA approaches often have fewer restrictions, but always follow surgeon-specific precautions and timelines (e.g., 6–12 weeks depending on surgeon).
  • For posterior-lateral THA approaches, avoid flexion beyond $90^ ext{o}$, adduction, and internal rotation until cleared; use pillows or anti-rotation supports as needed.
• Lower-extremity amputation considerations:
  • Post-operative phase emphasizes extending the knee and preparing for prosthetic fitting; avoid knee flexion contractures early in rehab.
• Positioning for other conditions:
  • Trendelenburg position (head down) may be used for certain chest physiotherapy or respiratory reasons; used selectively and with care.
  • High-power bed adjustments: bed angle changes to optimize patient comfort and access during treatment.
• Practical positioning cues for nurses/therapists:
  • When seating a patient, a 90° rule is often used: 90° hip flexion, 90° knee flexion, and 90° ankle dorsiflexion are common joint angles for safe sitting.
  • Use spinal supports, knee supports, and lumbar cushions to maintain neutral alignment.
  • In wheelchair use, consider a tilt-in-space wheelchair to periodically redistribute pressure and reduce ulcer risk.

Short-term vs long-term positioning: practical examples and terminology

• Short-term postural setups for comfort and care access:
  • Supine with knees bent and a pillow under the head to maintain spinal curvature; ensure neutral neck and spine alignment.
  • Sideline positioning with a pillow between knees to prevent hip adduction and maintain hip/knee alignment.
  • Three-quarter supine or prone variants with careful head support and neck alignment depending on clinical need (e.g., care for back or shoulder access).
  • Use of a roll under the back or under the knees to adjust lumbar lordosis and comfort.
• Long-term considerations and techniques:
  • For long-term bed rest, avoid prolonged hip flexion and maintain neutral pelvis to reduce contractures.
  • Use rolls or towels to correct lordosis and reduce strain on the spine.
  • Pressure-relief strategies include alternating pressure surfaces and tilt-in-space wheelchairs.
  • For stroke or neuro rehab, progressively progress from supine to sit to standing while ensuring safety and independence.
• Special positioning for specific surgeries and devices:
  • After THA, avoid adduction/rotation and deep flexion; use wedges and cushions to maintain safe angles.
  • For amputees, extend the knee to prevent flexion contractures early in rehab.
  • When using trapeze bars or bed rails, ensure patient safety and avoid over-reliance on upper-extremity lifting.

Bed mobility: progression, techniques, and independence

• Bed mobility progression (developmental sequence):
  • Start with supine on the back; progress to supine with elbows, prone on elbows, bridging, rolling to side, and then sit.
  • Progress to long sitting, kneeling, half-kall on all fours, and eventual standing.
  • The progression mirrors developmental milestones (head and neck control → rolling → sitting → standing).
• Bed mobility techniques: three main methods
  • Rolling: move from supine to side-lying, then to sitting; assistive cues and hand placements near the thorax or pelvis.
  • Prop-up: from supine, open elbows, push up to partial sit, and shift limbs to align for sitting; used when hip restrictions or other limitations apply.
  • Log roll: a controlled pivot to avoid spinal rotation; use a pivot at the knees and maintain alignment while moving the body to a side-lying or sitting position.
• Precautions and independence goals:
  • The aim is to promote independence, with therapists providing cues and minimal manual assistance as appropriate.
  • Use bed rails and trapeze to help movement; keep bed flat before attempting to reposition if the patient is in an unsafe position.
  • For patients with limited mobility, stabilize the feet and pelvis to facilitate smoother transfers.
• Techniques for scooting and lateral transfers in bed:
  • Scoot laterally by shifting the trunk and hips, using arms to push and guiding the pelvis; ensure the bed is flat for easier movement.
  • Use trapeze and bed rails as used in rehab labs to aid movement with minimal friction.
• Wheelchair transfers and safety (two techniques overview):
  • Technique 1: patient unable to assist: use two slider sheets to transfer into/out of a wheelchair with careful counting and body mechanics; ensure the patient’s legs aren’t in a vulnerable position and pivot the torso to avoid twisting.
  • Technique 2: patient can assist mildly: instruct and guide to help with sheet movement; ensure the patient maintains position and use supports to prevent slipping.
  • Technique 3: additional measures when patient has a higher risk of shear: use a two-sheet method with one sheet acting as a top layer and the other as a bottom layer to minimize friction; remove the bottom sheet first to reduce drag.
  • Technique 4: ensure safety with leg positioning to prevent patient from sliding out of the chair; strap a belt or use a chair belt if needed to maintain alignment.
• Practical cautions during transfers:
  • Do not lift a patient using the upper extremities to prevent shoulder injuries or strains.
  • Do not slide or drag a patient by clothing; avoid dragging by the arms or by the buttocks; use sheets to reduce friction.
  • Do not leave the patient on a single technique; switch to safer approaches depending on patient ability and safety.
• Barriers to safe bed mobility:
  • Staffing and time constraints can limit the ability to perform ideal transfers; prioritize safety and the best possible technique with available resources.
• Documentation and clinical notes:
  • Record the techniques used, patient response, and any precautions or deviations from standard procedure; update caregiver instructions accordingly.

Restraints, monitoring, and safety in mobility

• Restraints:
  • Used only when absolutely necessary; apply the least restrictive option and monitor closely.
  • Quick-release buckles or knots are preferred; ensure supervision and removal during activity when safe to do so.
  • If restraints are used during exercise, remove and re-seat as needed to maintain safety and patient comfort.
• Safety considerations during mobility:
  • Always confirm spinal alignment and central trunk stability during repositioning.
  • Confirm patient consent and preference before initiating repositioning; explain steps clearly.
  • Use safe lifting techniques, avoid levering or pulling on the patient’s arms or chest; support the pelvis and torso.

Quick reference: key terms and concepts to memorize

• Terminology:
  • Supine: lying on the back.
  • Prone: lying on the stomach.
  • Sideline: lying on the side.
  • Three-quarter supine/prone: transitional positions used for access and comfort.
  • Trendelenburg: head-down position (to approx. $30^ ext{o}$) used selectively for certain respiratory or hemodynamic needs.
  • Proximal stability equals distal mobility: stable trunk enables better limb movement.
• Joint angles and safeguards:
  • Sitting posture: $90^ ext{o}$ hip flexion, $90^ ext{o}$ knee flexion, and ankle in a neutral position; use lumbar support and arm supports as needed.
  • THA precautions: posterior approach restricts hip flexion > $90^ ext{o}$, adduction, and internal rotation for several weeks; anterior approach may have fewer restrictions; follow surgeon guidance.
• Pressure injury concepts:
  • Risk factors: immobility, incontinence, impaired sensation, nutrition, cognition, edema, vascular issues.
  • Prevention: frequent repositioning, pressure-relieving surfaces, proper alignment, and skin checks.
  • Blanch test: press skin; if it does not blanch (turn pale) when pressure is applied, tissue may be compromised.
• Equipment and best practices:
  • Slider sheets: used to reduce friction during transfers; typically two sheets are used in practice.
  • Spider sheets: designed to reduce drag and friction for long-term repositioning.
  • Pelvic and spinal supports: pillows, rolls, and wedges to maintain neutral alignment and comfort.
  • Trapeze and bed rails: assist with movement and provide stability during bed mobility.
• Real-world takeaway:
  • The overarching aim is to balance safety, comfort, and accessibility to care while preventing complications associated with immobility and trauma-informed care.

Quick study prompts and connections to prior learning

• How do short-term positioning goals differ from long-term positioning goals? Provide examples of each in the context of a stroke patient.
• Explain why proximal stability is important for distal mobility and give an example in bed mobility or a transfer task.
• List the three primary considerations for short-term care and explain how they affect daily practice in rehab settings.
• Describe the two-slider-sheet technique and why it reduces friction during transfers. Include a step-by-step outline of the method.
• What are the THA precautions for a posterior approach, and why are they important for preventing dislocation and tissue damage?
• Outline a progression from supine to sit for bed mobility and explain how to assess readiness for the next step (e.g., bridging, rolling, long sitting).
• Identify risk factors for pressure injuries and describe a plan to monitor and mitigate these risks during hospitalization or rehab.
• Explain trauma-informed care principles and provide an example of how you would respond to a patient who becomes anxious during a procedure.

Note on structure and usage

• These notes are designed to mirror the breadth of topics covered in the transcript, including midterm logistics, lab procedures, trauma-informed care, cultural considerations, positioning theory, and bed mobility techniques.
• Use these notes as a replacement for the original source for study purposes. They include definitions, practical guidelines, and examples mentioned in the transcript, as well as LaTeX-formatted expressions for key numerical references.