PROPER POSITIONING, TURNING, AND DRAPING Flashcards
Positioning
arrangement of body parts in relation to one another
technique of placing the patient safely, comfortably, and effectively
Reasons for Positioning
prepare pt to gain access for part in the body
stability and support
relieve pressure to prevent bedsores
optimize organ system function
optimal aligned position
prevent contractures
Interval of positioning
every 2 hrs
Goals for proper positioning
- prevent contractures
- provide comfort
- provide support and stability
- provide access and exposure
- promote efficient function
- relieve excessive pressure
Effects of Immobilization
reduced cardiac efficiency
redistribution in body fluids
pulmonary deconditioning and dysfunction
stagnation of urine and incomplete bladder emptying
gastrointestinal dysfunction
NS affectation
electrolyte changes
hormonal disorders
Deconditioning Syndrome
reduced functional capacity of body system/s
treatment as a separate entity from the disease itself
affects integumentary, musculoskeletal, cardiovascular pulmonary, genitourinary, gastrointestinal, and nervous system
Effects of Immobilization on Integumentary System
pressure sores/ bed sores
Pressure Sores/ Bed Sores
normal capillary pressure: 30 mmHg
greater external pressure than normal capillary pressure
occlusion of blood flow –> ischemia –> necrosis
ischemia: no blood supply
necrosis: cell death
bony prominences are prone to injury
Extrinsic Factors to Skin Breakdown (Pretty French Skirts Hide In Redon)
- pressure
- friction
- skin maceration
- hydration status (important to note)
- infection in the area
- reduced activity
Intrinsic Factors to Skin Breakdown (Genie Said Bring Nuts Here Lazy Aladdin)
- general health
- skin condition
- body build and composition
- nutrition status
- hydration status
- location of wound
- adequate blood flow to wound
How to Check Intrinsic Factors to Skin Breakdown
ocular inspection
subjective: ask pt or people involved
objective: IE, general systems review, imperative to check signs of pressure
Bedwridden
unable to go out of bed due to injury (immobilization)
Bedbound
- constraints or contractions that bind pt to the bed
- pt with monitors/ attachments/ intubations
- medical orders/ doctor’s advice
Bedfast
pt who are strong, able, and are allowed to get out of the bed
Common Areas for Pressure Sore Formation During Supination
back of head
shoulder blade
lower back
bone prominence of elbow
heel
Common Areas for Pressure Sore Formation During Sidelying
ear
shoulder
lateral aspect of elbow
lateral aspect of hip
bony areas between knees and ankles
Common Areas for Pressure Sore Formation During Wheel Chair Sitting
back of head
shoulder blade
lower back
hip
sacrum
underside and back of heel
Common Areas for Pressure Sore Formation During Long Sitting
back of head
shoulder blade
lower back
sacrum
heel
Bed Grading in Pressure Sores
Grade 1: erythema- redness, skin intact and does not blanch in pressure
Grade 2: superficial ulceration that extends to dermis (skin loss, moist, pink, no necrotic tissue, partial thickness wound, reversible if treated)
Grade 3: ulcer advances to subcutaneous tissue (full thickness wound, necrosis, undermining, infection)
Grade 4: ulcer affecting muscle/ fascia
Grade 5: extensive ulcer with extensions into bursa of joints/ body cavities
Contracture Formation in Musculoskeletal Formation
adaptive shortening of muscle resulting to LOM
shortening and tightening of skin, muscle, fascia, and joint capsule
Factors Affecting Contracture Formation
- duration of immobilization
- limb position
- mobilization of joint
Decrease in Muscle Strength and Size
muscle loss:
1-3% per day
10-15% per week
50% in 3-5 weeks
muscle size may shrink to 50% of its original size in 2 months: atrophy
Contracture and Atrophy: Depletion of Biochemical Components
decrease in oxidative enzymes
Type I muscle fibers more subject to immobilization atrophy
decrease fuel/ energy sources
Baseline Measure
anthropometric measures using a tape measure, measure from medial tibial plateau to the bulkiest part of thigh
Chronic Atrophy
guttering of hands
loss of muscle components at hands
flattening of eminences
denervation of radial or ulnar nerve
Immobilization Osteoporosis
Wolff’s Law
-bone morphology and density are dependent upon the forces that act on the bone
- immobilized pt: decrease in stress on their bone due to lack of activity
-decreased bone tissue (bone mass) per unit volume (bone density)
- decreased bone mass is accompanied by a decrease in mineral content
- more susceptible to fracture
Degenerative Joint Disease / Osteoarthritis
joint loses its normal lubrication needed for joint nutrition
Cardiovascular System
Postural/ Orthostatic Hypotension
impaired ability of the circulatory system to adjust in the upright position
completely lost after 3 weeks
retraining would take 20-72 days
decrease on venous return from LE
decrease filling of left ventricle
decrease cardiac output
decreased cerebral perfusion (blood to the brain)= dizziness or syncope
key determiner: BP
Intervention on constrained pt who got unconscious while gradually tilting them upright
bring the pt flat on bed
ankle pumping for 2-3 mins straight
purpose: to increase cerebral perfusion and venous return, and to retrieve consciousness of pt
Signs and Symptoms of Orthostatic Hypotension
tingling, burning in the LE
light headedness, dizziness, fainting, vertigo
sweating (cold sweat)
pallor
increased pulse rate (> 20 bpm)
decreased systolic blood pressure (> 20 mmHg)
decreased pulse pressure
Reduced Cardiac Efficiency
HR progressively increased by 0.5 bpm/ day; 12-13 bpm in 10 days (immobilization tachycardia)
in 3 weeks, 25% decreased in cardiac volume performance
Resting HR of Sedentary Person Compared to Athletes
higher since they require more force to produce efficient cardiac output
Redistribution of Body Fluids
decrease in plasma volume –> increase in RBC –> increased blood viscosity –> increase thrombus formation (clot in big veins)
Thrombus
blood clot in big veins
calf veins is the common side d/t dec muscle pumpling
Embolus
traveling thrombus thru venous circulation
Respiratory System
decrease in lung volume
decrease diaphragmatic movement and chest expansion
contracture formation of intercostal muscles and costal joints
accumulation of secretions in lungs
leads to atelectasis (lung collapse) and pneumonia
Genitourinary System: Stagnation of Urine and Incomplete Bladder Emptying
voiding is difficult in supine position (needs gravity)
promotes kidney stone formation and UTI (urine is septic)
Gastrointestinal System
decrease in appetite
atrophy in intestinal mucosa and glands
slower rate of absorption
greater gas intake compared to food intake
constipation and fecal impaction
Body Composition
decrease in lean body mass
increase in body fat content
Nervous System: Sensory Deprivation
silent hazard of prolonged bed rest (sensory compartment is impaired)
intelligence is compromised
emotional lability and anxiety
impaired balance and coordination
other manifestations:
electrolyte changes
hormonal disorders
PT management for deconditioning
positioning
wound management
cardiovascular training: improve tolerance to upright posture
Exercises
range of motion (active/ passive/ assisted)
stretching
joint mobilizations
aerobic exercises
Positioning Equipment
bed
bed board
pneumatic mattress
foot board (neutralize feet or ankle position)
side rails
overhead trapeze
positioning frames and powered rotating frames
pillows
bolsters/ rolls
linens/ draw sheet
rubber sheet
canvas or safety strap/ restraints
sliding board
elbow or heel protector
splints (for hand resting)
spacers
Guidelines for Positioning and Turning
introduce yourself to pt
inform pt of the planned treatment and obtain pt’s consent
pt must be lifted not dragged
in a new position, check pt’s skin after 5-10 mins
inspect skin color and integrity
pillows, rolled blankets, or towels are used to support body parts and to avoid pressure
sheets, blankets, linens should not be tucked in tightly at the foot of the bed
whenever possible, always let the pt participate actively
when turning a pt, check if assistance is needed
pt must be repositioned atleast 2 hrs
assess the area before turning a pt from one position to another
make sure pt is secure during turning and when placed in a new position
observe proper body mechanics
Supine Position
avoid excessive neck and upper back flexion or scapular abduction
shoulder parallel to hips
spine straight
UE positioned wherever pt is comfortable (sides, reverse T, folded on top of the chest)
do not extend pt’s hands or feet beyond treatment table (avoid dangling)
small pillow under head
small pillow under knees (not more than 30 mins)
rolled towels under heels
Prone Position
small pillow under pt’s head or may turn the head to one side (alter head position every 30 mins)
rolled towel under anterior shoulder to adduct scapula (avoid rotation and promote retraction)
pillow under abdomen/ pelvis
UE positioned for comfort (along sides, T position, hands under head)
pillow under legs (not more than 30 mins)
rolled towels: under shoulder or distal things)
Side Lying
pt at the center of the table/ mat
small pillow under head
pillow between LE with hips and knee flexed
uppermost LE should be supported on pillows and positioned slightly forward of the lowermost extremity
rolled towel under lower lateral malleous
pillow between chest and upper arm
pillow behind trunk
other arm in comfortable position (upward or on pillow)
Sitting Position
adequate support and stability of the trunk
place feet on footstool, floor, or any support
free the distal posterior thigh of excessive pressure from the edge of the chair
Receiving Treatment In Sitting Position
leaning forward: support anterior trunk with pillow
leaning backward: support posterior trunk with pillow
UE: supported on pillows, chair arm rests, treatment table, lap board, or pillow on patient’s lap
General Considerations in Positioning and Turning
pt should not be positioned for more than 30 mins
excessive bending or rotation of the spine
bilateral or unilateral scapular abduction or forward head position
compression of the thorax or chest
plantarflexion of the ankles and feet
hip or knee flexion; hyperextension of knees
adduction and internal rotation of the glenohumeral joint
elbow, wrist, or finger flexion
hip adduction or internal/ external rotation
Precautions for Patient Positioning
avoid presence of clothing or linen folds beneath pt
observe skin color before, during, and after treatment
protect bony prominence from excessive and prolonged pressure
avoid positioning the pt’s extremities beyond the supporting surfaces
avoid excessive, prolonged pressure to soft tissue, circulatory, and neurological structures
Additional Precautions
mentally incompetent or confused, agitated
comatose
very young or elderly
paralyzed
lacking normal circulation or sensation
impaired cardiopulmonary system
Preventive Positioning for Amputation
transfemoral: avoid prolonged hip flexion or hip abduction
-AKA (above knee amputation)
transtibial: avoid prolonged hip and knee flexion
- BKA (below knee amputation)
may sit no more than 40 mins of each hour
periodic prone lying is recommended
Preventive Positioning for Hemiplegia
avoid position of synergy (counteract)
UE
-shoulder adduction, internal rotation, elbow flexion, forearm pronation, wrist and finger flexion, thumb flexion and adduction
LE
-hip and knee flexion, hip external rotation, ankle plantarflexion and inversion
normal alignment of pt’s head and trunk should be maintained
Preventive Positioning for Arthritis
swollen joints tend to assume the open packed position (loose packed, usually in flexion)
promotes flexion contractures
frequently gentle exercises of the involved joint is necessary unless in acute inflammatory stage
Preventive Precautions for Burns and Grafted Burn Areas
avoid position of comfort
frequent gentle exercises of the involved joints is necessary
stretched position (extension) to avoid contracture
use of airplane splinting in burn of arms/ armpits
Preventive Precautions for Hip Replacement
hip flexion of more than 90 degrees is not allowed
do not bend
do not sit on lower seat heights
abduction not more than 45 degrees
adduction beyond midline is not allowed (add pillow in middle)
Draping
manner of arranging the covering with sheets or towels to expose the part being examined, treated, or cleaned
exposing body parts that are only needed to be treated
protect the patient’s skin or clothing from being damaged or soiled
maintain appropriate/ comfortable body temperature
Guidelines for Draping
introduce yourself and inform pt of the planned treatment; apply principles for informed consent
if pt is wearing street clothes, indicate specific articles of clothing to be removed and request permission to remove pt’s clothing if assistance is necessary
provide temporary clothing or linen
provide safe and secure storage for the patient’s valuable items
describe proper use of linen items, gown, robe or exercise clothing
provide privacy while disrobing
instruct patient to inform you when he is draped
confirm if the patient is draped so that you may enter the cubicle
At the Conclusion of the Treatment
instruct pt to remove draping and reapply clothing; provide assistance if required
provide privacy while dressing
provide linen so pt can remove perspiration, gels, water or other substance
Key Areas
shoulder and hips
Location of Head Pillow
below the level of the shoulders
Short Period
can place a pillow underneath the knee, not for more than 30 minutes
Trochanter Rolls
rolls of towels at the side of the hips, ankles, hands
Unconscious or deconditioned pt
maintain functional positioning of the hand by playing roll of towel on hand, maintain thumb abduction, reflex inhibition patterns
Color Coding of Towels
blue towels: LE
yellow towels: UE and face
THR Positioning and Draping
pillow between the legs, rolls on lateral side for pt, draping along the hip fracture or replacement
no rotation
no flexion greater than 90 degrees
no abduction greater than 45 degrees
no adduction beyond midline
Purpose of Footboard
prevents plantarflexion of knees and foot
Two Kinds of Turning
segmental turning: di sabay yung pag turn
log rolling: one segment or turning as one (always prevent rotation of the trunk)
Turning for Bedwridden pt
segmental turning
Sustained Positioning
precaution of the hip at all times
not recommended or done in prone
prone: LBP
Supine > Side Lying > Prone (Areas Prone to Pressure Ulcers)
inferior angles/ shoulder blades of the scapula
elbow
sacral part of the feet
heels of the feet
Supine > Side Lying > Prone (General Reminders)
Arm can be put either on the side, across abdomen, or reverse T position or whichever is comfortable for the patient
Can put pillow underneath knees and rolled towel underneath heels for lower extremities
Stress ball or rolled towel for hands to prevent tightness of the muscles and joints of wrist and hand
Attachments such as OI > IV line, O2 cannula, cardiac monitor, catheter, etc. should be taken into consideration
For burned patients with burns on the ventral aspect of the arm, much better if extended yung arms to prevent elbow flexion contracture (to expose sites that need to be treated)
Prevention for Post Op Patients (Stroke pt)
be mindful of weak side
no limbs dangling
place footboard at the soles of feet (avoid shortening of achilles tendon and conserves sensory mechanisms of the feet)
What To Do Before Positioning
Rapport and VS
Check the chart of the patient to determine the precautions and if assistance is needed
Inform and involve the patient on the activity (if possible)
Supine > Sidelying
make sure there is space
move the pt towards the PT
move pt with their shoulders and pelvis/ hip as points of control
secure locks in the wheels and level of the plinth is just right to prevent bending and back strains
move on the side where the pt will be turned
cross one leg on top of the other
raise arm diagonally
place hand on pelvis and one hand on shoulder
perform log rolling
place pillow behind back, in front of the chest to let the arm rest, and on leg (leg is semi flexed or extended)
do not lie on weak side
Supine > Prone
cross one leg on top of the other
make sure there is space
arm should either be on the side or diagonally above head
turning arm is on the abdominal area
turn head of pt sidewards towards the raised hand
shorten the lever arm by moving closer to the pt
move the pt using the points of control (supine–> side lying–> prone)
drive the turning shoulder towards the plinth when lifting the contralateral pelvis to minimize spinal rotation
adjust pt’s arm (side or T)
adjust pt’s head (sidewards; consider if pt presents with one sided neglect)
make sure pt is in the middle of the bed
prevent pressure ulcers by: putting pillow under the head, rolled towel below anterior shoulder area, pillow under lower leg (prevent hyperflexion on knee and plantarflexion of ankle)
compression in the thoracic area
*AKA: prevent hip flexion contracture
special consideration for older pts because prone position will apply pressure to the thoracic area (baka mahirapan silang makahinga)
Supine > Long Sitting (General Guidelines)
Monitor blood pressure (especially for patients who may have been unable to assume upright position due to immobilization
Allow the patient to actively participate in the activity as much as he can
Prioritize patient safety at all times
Observe proper body mechanics
Supine > Long Sitting (Pt is able to move)
give instructions to assume long sitting
support neck and upper back
monitor VS
Supine > Long Sitting (Pt is coherent, unconscious, semi unconscious)
add pillow son pt’s back to continue to assume long sitting (passive activity if pt is unable to support the activity)
guard pt from falling
Supine > Long Sitting (Pt unable to assist the activity)
manually bring pt to long sitting
hold upper back and shoulder and lift
PT behind pt to further stabilize the back
Supine > Long Sitting (Pt has sufficient strength to assist)
have pt grab on flexed arm for them to hold on to PT when assuming long sitting
instruct pt and maintain proper body mechanics
support shoulder
Supine > Sitting (Special Conditions) for S/P THR on Left
not allowed to move hip or have legs adducted, abducted beyond 45 degrees, rotation (minimal as much as possible), flexion beyond 90 degrees
instruct pt to slowly assume sitting position
remove adductor pillow
pt’s elbow on back
hold pt at back of shoulder and lower leg
rotate slowly and instruct them to kembot (one motion)
monitor bp
make sure left LE is supported thru the use of a chair
Supine > Sitting (Special Conditions) for Hemiparesis on the Left- turning on weak side
bring pt to supine then side lying then assume short sitting
instruct pt to abduct the shoulder
to position in side lying, instruct pt to raise hip and cross over the weaker leg
rotate pt to sidelying
with the strong LE, bring foot at the back and instruct pt to push down with stronger UE
rotate to short sitting position
Supine > Sitting (Special Conditions) Hemiparesis on the Left- turning towards the strong side
have pt bend or flex strong hip and knee
reach weaker arm using stronger arm and clasp hands
bring the bended knee towards the left side lying (weaker LE)
weaker UE on chest
pt will be propping on the bed with stronger UE
move pt to short sitting position
Reasons for Positioning in Prone
Relieve pressure
Prevent skin breakdown
Prevent contractures
Provide patient comfort
Provide trunk and extremity alignment, support, and stabilization
What to Remember when Positioning pt in Prone
aligned
supported
stabilized
Positioning Guide Sheet
- Preparation
Pillows
Rolled towels
Bolsters - Establish rapport
Greet patient (and caregivers)
Introduce yourself
Confirm patient’s identity and current condition
Orient patient about your visit’s purpose and provide rationale
Confirm patient’s precautions and contraindications (if applicable)
Describe how patient will be positioned
Obtain consent to begin - Position patient
Demonstrate positioning technique with positional devices
Monitor patient
Get patient feedback (level of comfort)
Instruct patient/ caregiver about positioning guidelines
- change position q 2hrs
- check for redness, blanching, skin irritations - Aftercare
Pack up unused materials
Greet patient (and caregivers, if applicable)
Optimal Position in Prone
Check pt is comfortable
Check if the body segments are aligned
Head should be turned on either side (where pt is more comfortable)
Arms could be positioned on the sides or in the reverse T
To maintain scapula in an adducted position, use a rolled towel or blanket and place them on the anterior aspect of the shoulder on both sides
For low back and pelvis, use a thin pillow and blanket and place under abdomen to maintain an optimal alignment on the lumbar segment
Use another rolled towel and place them under the patella (distal thigh) to achieve comfortability of pt
When there is tension on hamstrings, in prolonged positioning it is advised to put a pillow on the distal leg to release the tension against the hamstring (should not be sustained in a long period, for 30 minutes only)
Bony Prominences that are Prone to Pressure Sores
ischial tuberosities
posterior area of the thigh
sacrum
spinous process of vertebrae (if pt leans against chair)
medial epicondyle of humerus (if elbow rest is on hard surface)
Proper Sitting Position
Ensure that pt’s both feet should be well placed on the floor
Pillow on the back
Hips and knees at 90 degrees
Turning on Mat (Supine to Sidelying)
PT is on the side of turn
PT in half kneel position
PT’s “down knee” is the level of pt’s hip
PT’s “up knee” is at the level of pt’s shoulder
Draping Guidelines
Provides modesty
Maintain appropriate body temperature
Provides access to treated areas
Protects pt’s skin and clothing
Guidelines Prior to Treatment
Introduce yourself and confirm your pt’s name and dx
Give rationale of draping, reasons why clothing will be removed
Keep your pt’s belonging secured and ensure a safe environment
Provide linens or gown during draping
Ensure pt understands the treatment
Guidelines During Treatment
Only expose the areas that needed to be exposed
Ensure modesty and warmth during treatment
Use linens, towels or gown that are unused and clean
Drape neatly, appropriately, and accordingly
Pt’s clothes should not be used for draping
Avoid folds and wrinkled during draping to avoid skin pressure
