Positioning, Transfers, & Ambulation
Learning Objectives for Positioning, Transfers, and Ambulation
Identify the principles of proper body mechanics in relation to the performance of nursing skills.
Analyze significant assessment data to determine the type of approach to use and the amount of assistance required to position, transfer, and mobilize a patient.
Describe specific positioning techniques for Fowler’s, supine, prone, lateral, and Sims’ positions.
Discuss the specific procedures for aiding a patient when moving up in bed, helping a patient to reach a sitting position, logrolling a patient, and transferring a patient from a bed to a chair.
Discuss the principles of safe patient handling and mobility as they apply directly to various patient situations.
Demonstrate the procedures for safe and effective transferring, positioning, and mobilization to ensure both patient and nurse safety.
Discuss the various indications for performing range-of-motion (ROM) exercises.
Identify specific risk factors that lead patients to develop deep vein thrombosis (DVT).
Discuss the implications of preventing deconditioning and DVT in hospitalized patients.
Demonstrate the correct techniques for assisting with ambulation, assisting with ambulation using an assistive device, applying elastic stockings, and applying sequential compression devices (SCDs).
Key Terminology
ADLs: Activities of daily living.
Friction: The force generated when two surfaces rub together.
Shear: The force exerted on the skin while the skin remains stationary but the underlying bony structures move.
Gait: a term used to describe a particular manner or style of walking; for example, a patient may exhibit a "steady gait" or an "unsteady gait."
ROM: Range of motion, which is the primary assessment technique utilized to determine the degree of limitation or injury present in a joint.
Clinical Assessment and Cue Recognition
Identify the patient's physiologic capacity and level of endurance.
Assess the risk for falls and the patient’s cognitive function.
Evaluate proprioceptive and sensory function, as well as the level of comfort.
Determine the necessary mode of transport, required equipment, and the number of people needed for the task.
Assess range of motion and physical ability.
Identify specific risk factors including sensation, impaired mobility, impaired circulation, and age.
Check skin integrity and the presence of external equipment or surgical incisions.
Principles of Body Mechanics and Ergonomics
Definition: Body mechanics involves body alignment (posture) and balance.
Good Posture: Characterized by a balanced, upright posture.
Poor Posture Manifestations:
Forward head position.
Flat back.
Sway back.
Rounded shoulders.
Weak abdominal muscles.
"Lazy bones" posture.
"Duck" posture.
"Drum major" posture.
"Attention" posture.
Safely Lifting a Load:
Plan the lift in advance.
Ask for assistance.
Widen the base of support.
Bend the knees.
Tighten the stomach muscles.
Lift using leg muscles rather than back muscles.
Keep the load close to the body.
Keep the back straight.
Workplace Ergonomic Hazards:
Lifting heavy loads (such as clients).
Reaching and lifting with loads positioned far from the body.
Twisting while lifting.
Patient Positioning Principles and Techniques
Raise the side rail on the side opposite to where the nurse is standing.
Elevate the bed to a comfortable height for the nurse.
Assess the client’s mobility and strength before moving.
Support all joints and position them in a slightly flexed position.
Remove or decrease pressure on known pressure points.
Ensure the client is placed in correct body alignment.
A -degree lateral position is recommended for clients who are immobile.
Specific Positioning Methods
Fowler’s Position:
Pull the client up in the bed.
Elevate the head of the bed (HOB) unless contraindicated.
Rest the head against the mattress or a small pillow.
Use pillows to support the arms, hands, and elbows if necessary.
Position a pillow in the lumbar area.
Place a small pillow or roll under the thigh.
Place a pillow under the ankle to "float the heels."
Supine Position:
Place the client on their back with the HOB flat.
Place a pillow under the shoulders, neck, or head.
Place a small rolled towel under the lumbar area.
Place trochanter rolls or sandbags parallel to the thighs.
Float the heels or place feet in therapeutic boots.
Place pillows under pronated forearms.
Place hand rolls in the client’s hands or utilize hand splints.
Prone Position:
Lower the HOB completely.
Pull the client toward the edge of the mattress.
Place the client’s arm flat against the body.
Roll the client slowly onto the abdomen in the center of the bed.
Turn the client’s head to one side.
Place a small pillow under the abdomen below the diaphragm.
Support arms in a flexed position level with the shoulders.
Elevate the feet with pillows.
Lateral (Side-lying) Position:
Lower the HOB.
Position the client on the side of the bed opposite the direction of the turn.
Flex the client’s lower extremities at the hips and knees; the top leg should be supported on pillows and positioned slightly forward.
Support the head and neck with pillows.
Support the upper extremity with a pillow under the dependent shoulder if needed.
Bring the hip forward to approximately degrees.
Place a tuck-back pillow behind the client’s back.
Sims’ (Semi-prone) Position:
Lower the HOB completely.
Place the client in a supine position initially.
Roll the client onto their side, partially on the abdomen in a lateral position.
Place a small pillow under the client’s head.
Place a pillow under the flexed upper arm.
Place a pillow under the flexed upper leg.
Procedures for Patient Movement and Transfers
Moving Client Up in Bed (Standard Method):
Place one arm under the client’s head and shoulders and one arm under the thighs.
Have the client flex their neck.
Instruct the client to push with their heels on the count of three.
Moving Client Up in Bed (Drawsheet Method):
Place a drawsheet under the client extending from the shoulders to the thighs.
Lift the drawsheet and move the patient on the count of three.
Realign the client to proper alignment and protect pressure areas.
Assisting Client to Sitting Position:
Place the patient in a -degree Fowler’s position.
Turn the client into a lateral position.
Place the front arm under the client’s shoulder and the back arm over the client’s thighs.
Move the client’s feet over the side of the bed while simultaneously lifting the client’s shoulders.
Transfer from Bed to Chair/Wheelchair:
Position the chair or wheelchair at a -degree angle to the bed.
Apply a transfer belt or use a transfer board.
Place the client’s weight-bearing leg forward.
Align your knees with the client's knees.
Help the client to a standing position.
Maintain the stability of the client’s weak leg.
Pivot the client toward the chair.
Instruct the client to use the armrest for support.
Transfer from Bed to Stretcher:
Lower the HOB.
Cross the client’s arms across their chest.
Lower the side rails.
Lift the drawsheet while a transfer board is positioned under the client.
One nurse pulls the transfer board while another pushes.
Remove the transfer board once the move is complete.
Using a Hoyer Lift:
Attach the sling to the lift.
Elevate the HOB.
Use the mechanical lift to raise the client off the mattress.
Transfer the client to the desired location and lower them.
Remove the straps and the lift.
Weight-Bearing Status Classifications
Full Weight Bearing (FWB): There are no weight-bearing restrictions; the patient can bear their full body weight on involved extremities.
Partial Weight Bearing (PWB): The patient can bear (or a specifically prescribed amount) of their body weight on the involved extremity.
Toe Touch Weight Bearing (TTWB): The patient can place the foot of the involved extremity on the floor for balance purposes only, but must bear no body weight on it.
Non-Weight Bearing (NWB): No weight is permitted on the involved extremity; the foot should remain off the floor when standing.
Weight Bearing as Tolerated (WBAT): There are no restrictions other than those dictated by comfort; the patient can bear as much weight as is comfortable.
Ambulation Assistance and Devices
Ambulation Without Devices (One Nurse): Stand on the client’s strong or uninjured side and hold the gait belt in the middle of the client’s back.
Ambulation Without Devices (Two Nurses): One nurse stands on each side of the client, both holding the gait belt in the middle of the client’s back.
Ambulation with a Walker:
If able to bear weight on both extremities: Advance with either foot and follow through with the other.
If unilateral weakness exists: Advance with the weaker leg first while supporting with the arms, then follow through with the stronger leg.
If unable to bear weight on one extremity: The client should swing into the step while supporting themselves with their hands.
Crutch Fitting and Usage:
There should be a fingers width space between the crutch and the underarm.
The elbow should have a slight bend.
Weight must go through the hands, not the axilla.
The bottom ends of the crutches should be placed more than shoulder-width apart.
Range-of-Motion (ROM) Exercises
Goals: Maintain coordination and motor skills for functional activities, maintain joint and soft tissue integrity, and minimize the formation of contractures.
Types of ROM:
Active: The patient performs the movement independently.
Passive: The nurse or therapist performs the movement for the patient.
Active-Assistive: The patient performs the movement with some assistance.
Procedure:
Complete exercises in a head-to-toe sequence.
Support the joints throughout the movement.
Repeat each exercise smoothly and rhythmically times.
Monitor for discomfort or pain.
Document observable and measurable reactions to the therapy.
Venous Thromboembolism (VTE) and Deep Vein Thrombosis (DVT)
Virchow’s Triad (Risk Factors):
Hypercoagulability.
Venous wall abnormalities.
Blood flow stasis.
VTE Assessment:
Look for calf swelling and tenderness.
Observe for dilated superficial veins.
Check for color changes in the skin.
Check for edema.
Assess for contraindications to mechanical prophylaxis.
Prevention Strategies:
Anticoagulation therapy for acutely or critically ill inpatients with acceptable bleeding risk.
Mechanical prophylaxis (compression stockings and SCDs).
Applying Elastic Stockings:
Measure the circumference of the calf.
For knee-high: Measure from the base of the heel to the fold of the knee.
For thigh-high: Measure from the base of the heel to the bottom of the buttocks.
Fold the stocking inside out down to the foot.
Place the client's foot inside and extend the stocking up the leg.
Ensure there are no wrinkles and keep the toes covered.
Applying Sequential Compression Devices (SCDs):
Place the sleeve under the leg; align the back of the ankle with the ankle marking and the back of the knee with the popliteal opening.
Wrap securely and ensure a fit that allows fingers between the leg and sleeve.
Connect the sleeve to the mechanical unit by lining up the arrows.
Turn on the unit and monitor for one full cycle.
Bedside Mobility Assessment Tool (BMAT) for Nurses
Assessment Level 1 (Trunk Strength and Seated Balance):
Task (Sit and Shake): From a semi-reclined position, have the patient sit upright and rotate to the side of the bed. Ask the patient to reach across the midline to shake hands.
Failure: Proceed to Mobility Level 1 (Use total lift, sling, repositioning sheet, or lateral transfer devices).
Pass: Proceed to Level 2 if the patient can maintain seated balance for greater than minutes.
Assessment Level 2 (Lower Extremity Strength and Stability):
Task (Stretch and Point): Seated at the bedside with feet on the floor, the patient stretches one leg, straightens the knee, and flexes/points the toes.
Failure: Proceed to Mobility Level 2 (Use total lift if unable to weight-bear on one leg, or sit-to-stand lift if they can weight-bear on at least one leg).
Pass: Proceed to Level 3.
Assessment Level 3 (Lower Extremity Strength for Standing):
Task (Stand): Patient elevates off the bed or chair to a standing position (may use assistive devices) and holds for a count of .
Failure: Proceed to Mobility Level 3 (Use non-powered stand aid, total lift with ambulation accessories, or assistive devices like walkers/canes).
Pass: Proceed to Level 4 if no assistive device is needed.
Assessment Level 4 (Standing Balance and Gait):
Task (Step): Patient marches in place, then steps forward and backward.
Failure: Revert to Mobility Level 3.
Pass: Mobility Level 4 (Modified Independence; no assistance needed; use clinical judgment for supervision).