Clinical Nursing Skills: Positioning, Mobility, and Fall Prevention

Semi-Fowler's Position

• Definition: In the Semi-Fowler's position, the head of the bed is placed at a $30$- to $45$-degree angle.
• Body Mechanics: The client's hips may or may not be flexed.
• Visual Representation: Refer to Figure $13.16$ for an image of a client in Semi-Fowler's position.
• Clinical Indications: This position is used for the same general purposes as the standard Fowler's position.
• Long-term Tolerance: Semi-Fowler's is generally better tolerated over long periods of time compared to Fowler's or High-Fowler's because there is less pressure exerted on the coccyx area.

Trendelenburg Position

• Definition: In Trendelenburg positioning, the head of the bed is placed lower than the client's feet.
• Clinical Purpose: This position is utilized in specific clinical situations to promote venous return to the head and heart.
• Indications: Commonly used during severe hypotension and medical emergencies.
• Visual Representation: Refer to Figure $13.17$ for an image of the Trendelenburg position.

Tripod Position

• Natural Occurrence: Clients feeling short of breath often naturally assume the tripod position.
• Description: The client leans forward while sitting, with their elbows resting on their knees or on a table.
• Clinical Goal: This position is used to enhance lung expansion and facilitate air exchange for clients experiencing breathing difficulties.
• Visual Representation: Refer to Figure $13.18$ for images of an individual demonstrating breathing difficulty who has assumed the tripod position.

Moving a Client Up in Bed

• Initial Assessment: Prior to movement, determine the level of assistance needed to provide optimal care.
• Safety Goal: It is vital to prevent friction and shear during the move to avoid pressure injuries.
• Policies and Equipment:     * If a client is unable to assist, follow agency policy regarding the use of lifting devices and mechanical lifts.     * If the client can assist and minimal lifting is required, follow specific guidelines with assistance from another health care professional.
• Step-by-Step Nursing Procedures (Figure $13.19$):     * Communication: Explain the process to the client and how they can contribute.     * Bed Preparation: Raise the bed to a safe working height and ensure brakes are applied. Position the client supine with the bed flat.     * Head Protection: Place a pillow at the head of the bed and against the headboard to prevent the client from bumping their head.     * Nurse Stance: Two health care professionals should stand with feet shoulder-width apart between the client's shoulders and hips. This keeps the heaviest part of the client at the providers' center of gravity. Weight should be shifted from the back foot to the front foot.     * Grip: Fan-fold the draw sheet toward the client with palms facing up to ensure a strong grip.     * Client Preparation: Ask the client to tilt their head toward their chest, fold their arms across their chest, and bend their knees to assist with the move.     * Body Mechanics for Staff: Tighten gluteal and abdominal muscles, bend knees, and keep the back straight and neutral while facing the direction of movement.     * The Move: On the lead person's count of three, gently slide (do not lift) the client up the bed, shifting weight from the back foot to the front foot.     * Completion: Replace the pillow, reposition the client, and cover them with a sheet or blanket for comfort.     * Final Safety Check: Lower the bed, raise side rails as indicated, ensure the call light is within reach, and perform hand hygiene.

Assisting Clients to Seated Position

• Purpose: Moving a client to the side of the bed is a necessary step before ambulating, repositioning, or transferring (e.g., from bed to wheelchair) to avoid clinician strain and excessive reaching.
• Clinical Benefit: It allows the health care provider to keep the client close to their center of gravity for optimal balance.
• Risk Factors:     * Vertigo: A sensation of dizziness where the room appears to be spinning.     * Orthostatic Hypotension: A drop in blood pressure occurring when changing positions. It is defined as a drop in systolic blood pressure of $20\,mm\,Hg$ or more, or a drop of diastolic blood pressure of $10\,mm\,Hg$ or more within three minutes of sitting or standing. Symptoms include feeling dizzy, faint, or light-headed.
• Preventative Action: Always begin by having the client sit on the side of the bed for a few minutes with legs dangling.
• Procedure Steps (Figure $13.20$):     * Ensure the bed is in a low and locked position.     * Stand at a $45$-degree angle to the head of the bed, feet apart, one foot in front of the other, next to the client's waist.     * Instruction: Ask the client to turn on their side facing you and move closer to the edge of the bed.     * Support: Place one hand behind the client's shoulders, supporting the neck and vertebrae.     * The Sit: On the count of three, instruct the client to push up using their elbows and grasp the side rail. Support their shoulders and shift your weight from the front foot to the back foot. Warning: Do not allow the client to place their arms around your shoulders to avoid back/neck injuries.     * Legislative/Lower Body Support: Simultaneously grasp the client's outer thighs and help slide their feet off the bed while keeping your back straight.     * Post-Procedure Assessment: Assess for vertigo or orthostatic hypotension. If symptoms occur, have the client remain dangling until they resolve.

Ambulating a Client

• Definition: The ability to walk safely and independently, with assistance from a person, or with assistive devices (cane, walker, or crutches).
• Criteria for Ambulation: The client should be cooperative, weight-bearing on their own, have good trunk control, and be able to stand independently. If criteria are not met, use a mechanical sit-to-stand lift.
• Preparation: Apply a gait belt snugly over clothing and around the waist. Ensure canes or walkers are nearby.
• Procedure Steps (Figure $13.22$):     * Sit the client on the side of the bed to assess for vertigo/orthostatic hypotension. Ensure they have proper footwear (shoes or nonslip socks).     * Stand in front of the client with your legs outside theirs. Grasp the gait belt side-handles, rock your weight backward, and steady them into a standing position.     * Once stable, move to the client's unaffected side and grasp the gait belt in the middle of their back.     * Falling Prevention Grip: Place one arm under the client's arm, grasp their forearm, and lock your arm under the client's axilla to provide shoulder support if needed.     * Confirmation: Before walking, ask if they feel dizzy. If symptoms occur, sit them back down immediately.     * Walking: Instruct the client to look ahead and lift each foot. Walk only as far as they can tolerate.     * Safety Monitoring: Periodically check for dizziness or weakness. For early ambulation, a second staff member may follow with a wheelchair or walker.     * Assisting Back: Have the client stand until the back of their knees touch the bed/chair. Use the gait belt to assist them to a sitting position while keeping your back straight and knees bent.     * Post-Mobility: Reposition in bed, lower the bed, raise side rails, and provide the call light. Document the distance and tolerance.

Transfer From Bed to Chair or Wheelchair

• Candidacy: Client must be cooperative, predictable, weight-bearing on both legs, and able to take small steps and pivot for a one-person assist. Otherwise, a two-person or mechanical lift is required.
• Procedure Steps (Figure $13.23$):     * Explain the transfer and ensure proper footwear is on.     * Lower the bed to a $45$-degree angle. (Note: Per transcript text).     * Position the wheelchair next to the bed and apply brakes. Place the wheelchair on the client's strong side if they have one-sided weakness.     * Assist the client to a seated position with feet on the floor and apply the gait belt.     * Nurse Stance: Legs outside client's legs. Ask the client to place their hands on your waist. Warning: Do not lift; avoid having the client's arms around your neck.     * Pivot: Ask the client to pivot and take small steps back until they feel the wheelchair on the back of their legs.     * Seating: Have the client grasp the armrests and lean forward. Lower them while shifting your weight from back leg to front leg, keeping knees bent and trunk straight.
• Reflective Question: "What could be improved during this transfer?"

Lowering A Client to the Floor

• Risk Mitigation: If a client begins to fall from a standing position, do not attempt to catch or stop the fall as this causes back injury. Instead, control the descent.
• Procedure Steps (Figure $13.24$):     * Move behind the client and take one step back.     * Support the client around the waist/hips or grab the gait belt.     * Bend one leg and place it between the client's legs.     * Slowly slide the client down your leg while lowering yourself to the floor.     * Primary Priority: Always protect the client's head first.     * Post-Fall: Assess for injuries before moving. Use a mechanical lift if they cannot get up. Complete an incident report per agency policy.

Preventing Falls

• General Responsibility: Nurses must manage and eliminate fall hazards. All client-handling (positioning, transfers, ambulation) poses risks.
• High-Risk Populations: Older adults are at increased risk due to impaired status, decreased strength, balance issues, and sensory perception loss.
• Fall Risk Factors:     * Gait problems.     * Cognitive ability and impairments.     * Visual problems.     * Urinary frequency.     * Generalized weakness.     * Medications causing hypotension or drowsiness.
• Consequences: Head injuries, fractures, and lacerations.
• Prevention Strategies:     * If a client feels dizzy, assist them immediately to a chair or the floor.     * In the event of a fall, seek help and stay with the client.     * Always assess for injuries prior to moving a client who has fallen.     * If a client remains weak or dizzy, do not attempt further ambulation; transfer them to a chair or bed with assistance.