What is the rational for having feet separated in a standing position when assisting a client?

1.    State the three principles underlying proper body mechanics and relate a nursing consideration for each.

2.    Demonstrate safe, comfortable, and appropriate positioning for clients in bed.

3.    State the purposes of range-of-motion exercises. Differentiate between active and passive range of motion. Demonstrate the ability to perform passive range-of-motion exercises, to supervise active range-of-motion exercises, and to perform combinations of passive and active range-of-motion exercises.

4.    Identify at least three principles related to safe movement of clients in and out of bed.

5.    Demonstrate the ability to move a partially or totally immobile client safely from bed to chair and back; safely up in bed or to the side of the bed; to a wheeled stretcher; and back to bed.

6.    Demonstrate the ability to use the wheeled stretcher (litter, gurney) safely.

7.    Demonstrate the ability to teach each of the crutch-walking gaits to a client. Practice each gait. Demonstrate and practice going up and down stairs with crutches and a hand rail.

8.    Describe the types of client reminder devices; state the precautions and nursing care for each; identify the regulations and documentation for each; and state when each is used. Differentiate between client reminder devices for safety and for medical therapeutic reasons.

9.    State at least six client positions commonly used for examinations and treatments. In the skills laboratory, demonstrate the ability to position a client safely into each of these positions.

10. Describe the evaluation of fall risk and how this applies to nursing care and client safety.

Acronyms

AROM

CPM

OOB

PROM

ROM

Nurses often need to teach clients the use of proper body mechanics for safe walking and movement. First, however, the nurse needs to understand and practice proper body mechanics himself or herself. People (clients and nurses alike) differ in weight, size, and ability to move. The nurse’s physical strength is not as important as how efficiently he or she uses the body. Ultimately, efficient use of one’s body will determine how effectively and safely the nurse is able to move clients. It is important to provide safety for both the nurse and the client.

PROPER BODY MECHANICS

Use of the safest and most efficient methods of moving and lifting is called body mechanics. This means applying mechanical principles of movement to the human body.

Principles of Body Mechanics

The laws of physics govern all movement. From these laws we derive the general principles of body mechanics (Box 48-1). In other words, some ways of moving and carrying objects are more effective than others.

Principles underlying proper body mechanics involve three major factors: center of gravity, base of support, and line of gravity.

Center of Gravity

A person’s center of gravity is located in the pelvic area. This means that approximately half the body weight is distributed above this area, half below it, when thinking of the body divided horizontally. In addition, half the body weight is to each side, when thinking of the body divided vertically. When lifting an object, bend at the knees and hips and keep the back straight. By doing so, the center of gravity remains over the feet, giving extra stability. It is thus easier to maintain balance (Fig. 48-1).

Base of Support

A person’s feet provide the base of support. The wider the base of support, the more stable the object, within limits (see Fig. 48-1). (The feet must not be too wide apart, as this would cause instability.) The feet are spread sidewise when lifting, to give side-to-side stability.

BOX 48-1. Basic Principles of Body Mechanics

1.    It is easier to pull, push, or roll an object than it is to lift it. The movement should be smooth and continuous, rather than jerky.

2.    Often less energy or force is required to keep an object moving than it is to start and stop it.

3.    It takes less effort to lift an object if the nurse works as close to it as possible. Use the strong leg and arm muscles as much as possible. Use back muscles, which are not as strong, as little as possible. Avoid reaching.

4.    The nurse rocks backward or forward on the feet and with his or her body as a force for pulling or pushing.

FIGURE 48-1 · Maintaining balance. (A) The distance between this person’s feet (base of support) is small, and the heaviest part of his body (center of gravity) is far away from the base of support, making him more likely to lose balance. (B) By increasing the distance between his feet and lowering his body toward the ground, the person has increased ability to maintain side-to-side balance. His right foot is slightly in front of the left, for back-to-front stability.

One foot is placed slightly in front of the other for back-to-front stability. The weight is distributed evenly between both feet. The knees are flexed slightly, to absorb jolts. The feet are moved to turn the object being moved. (It is important not to twist the body.)

Line of Gravity

Draw an imaginary vertical (up and down) line through the top of the head, the center of gravity, and the base of support. This becomes the line of gravity, or the gravital plane (Fig. 48-2). This is the direction of gravitational pull (from the top of the head to the feet). For highest efficiency, this line should be straight from the top of the head to the base of support, with equal weight on each side. Therefore, if a person stands with the back straight and the head erect, the line of gravity will be approximately through the center of the body, and proper body mechanics will be in place.

FIGURE 48-2 · When the body is held in proper alignment, the back is in a "neutral” position, with the curve of the lower spine intact.

Body Alignment

When lifting, walking, or performing any body activity, proper body alignment is essential to maintain balance. When a person’s body is in correct alignment, all the muscles work together for the safest and most efficient movement, without muscle strain. Stretching the body as tall as possible produces proper alignment. This can be accomplished through proper posture (see Fig. 48-2). When standing, the weight is slightly forward and is supported on the outside part of the feet. Again, the head is erect, the back is straight, and the abdomen is tucked in. (Remember that the client in bed should be in approximately the same position as if he or she were standing [Fig. 48-3].)

FIGURE 48-3 · When a person is in proper alignment, an imaginary straight line can be drawn connecting the person’s nose, breastbone (sternum), and pubic bone. Alignment in bed should be approximately the same as when standing. (A) Proper body alignment for a person lying on the back (supine). (B) Proper body alignment for a person lying on the side (lateral). (C) Proper body alignment for a person lying on the stomach in bed (prone). A small pillow or folded towel should be placed under the shoulder toward which the head is turned.

POSITIONING THE CLIENT

Encouraging clients to move in bed, get out of bed, or walk serves several positive purposes. Clients may be reluctant to move or may stay in bed unnecessarily. This immobility can contribute to a number of disorders, among which are pressure ulcers, blood clots, constipation, muscle weakness and atrophy, pneumonia, joint deformities, and mental disorders. By assisting clients to maintain or regain mobility, you promote self-care practices and help to prevent these complications (Fig. 48-4).

It is important to practice good body mechanics when lifting and moving clients. In this way, the nurse prevents injury to self and client (Fig. 48-5).

Moving and Positioning Clients

There are many reasons to change the client’s position, including promoting comfort, restoring body function, preventing deformities, relieving pressure, preventing muscle strain, stimulating proper respiration and circulation, providing diversion, and giving nursing treatments. In Practice: Nursing Care Guidelines 48-1 gives tips on positioning clients for their maximum comfort.

It is important to explain to the client why his or her position is being changed and how it will be done. The client’s understanding is important because he or she will be more likely to maintain the new position. If he or she can help, explain how. The client’s assistance will save strain on the nurse and will give the client some exercise, increase independence and self-esteem, and instill a feeling of control.

Sometimes turning the client is such an important part of treatment that the provider specifies how often to do it. This consideration is especially important for older or immobile clients. Some conditions do not permit turning the client, such as fractures that require traction appliances. In other conditions, such as unstabilized spinal injuries, turning may be harmful. In most other conditions, turning is helpful and encouraged.

In some situations, the client is turned only to wash or rub the back; to assess skin condition, wounds, or dressings; or to change the bed linens. Some clients may not be allowed or able to turn at all and must remain in a supine position. If this is the case, and the client is physically able, the nurse may ask him or her to pull up slightly on the overhead trapeze to provide back care and other interventions as needed. If the client is able to help move himself or herself, explain what he or she can do and why it is important. Encourage the client to help as much as possible.

Key Concept It is important to give meticulous skin care to the person who must remain on his or her back. If the person can pull up off the bed, the nurse can wash and gently massage the back with the hand held flat. This helps to prevent skin breakdown. In other situations, a special bed is often used (see Chap. 49).

FIGURE 48-4 · There are many dangers to the immobile client.

Special beds operate in different ways to relieve pressure and provide back support. Although not commonly used, in some cases, the client who cannot turn is placed in a circle bed, which rotates the client from head to toe, or on a Stryker (wedge) turning frame, which rotates the client from side to side. More commonly, the client is placed in a rotating or oscillating bed (e.g., the Roto-Rest), a flotation bed, or other special type of bed.

Nursing Alert Be sure to request help from another person if the client is heavy or if you are unsure that you can move the person by yourself. It is also important to be sure you know how to use special equipment for moving and lifting clients before use.

Positioning for Examinations and Treatments

The client is sometimes helped into a special position as part of a treatment or examination. Many different positions are used for physical examinations, nursing treatments and tests, and to obtain specimens. Because nurses assist clients into some of these positions and will see other positions used, it is important to know how to assist the client and how to place the necessary drapes. Important client positions are supine (dorsal recumbent—lying on the back), prone (lying on the abdomen), Sims’ (semi-prone—lying on the side [usually the left]—with the upper knee flexed), Fowler’s (lying on the back, with the head elevated), knee-chest or genupectoral (lying on the knees, with the chest resting on the bed), dorsal lithotomy (lying on the back, with the feet in stirrups), and lateral (lying on the side). The supine position may be modified by bending the knees and placing the feet flat on the bed. Trendelenburg’s (the head-down position—lying with the head lower than the feet)—is used to treat shock, by promoting blood flow to the brain. This position is also used for some portions of postural drainage, to help drain secretions from particular segments of the lungs. Reverse Trendelenburg’s position may be used to enhance tube feeding and as an emergency procedure to help stop bleeding in a head injury (see Chap. 43). Two other, less commonly used positions are the modified standing position (standing while bending over forward), and the position used for lumbar puncture. Special positioning is shown in Table 48-1.

FIGURE 48-5 · Lifting techniques using good body mechanics. Use long, strong muscles of arms and legs. Hold the object so the line of gravity falls within the base of support. Keep the back straight and the load close to the body. Ask for assistance, if necessary.

The following measures are carried out before draping the client for examination:

• The client is asked to empty the bladder, unless contraindicated. Rationale: This helps the person feel more relaxed and helps the examiner to better palpate the area being examined. (In some cases, a full bladder aids in the examination.)

IN PRACTICE :NURSING CARE GUIDELINES 48-1

POSITIONING THE CLIENT FOR COMFORT

•    Maintain functional client body alignment. (Alignment is similar whether the client is standing or in bed.)

•    Maintain client safety.

•    Reassure the client, to promote comfort and cooperation.

•    Properly handle the client’s body, to prevent pain or injury

•    Follow proper body mechanics, to protect yourself and the client.

•    Obtain assistance, if needed, to move heavy or immobile clients.

•    Follow specific provider’s orders.

•    Remember that a specific order is needed for a client to be out of bed.

•    Do not use special devices (eg, splints, traction) unless ordered and trained to use this equipment.

•    Make sure the client is comfortable and has the nurse signal cord available after positioning.

•    A urine specimen is collected, as ordered.

•    The client is encouraged to defecate before most examinations, particularly a rectal examination.

•    The client is provided with an examination gown and/or bath towel to cover the chest and perineal area.

•    A bath blanket or sheet is provided for warmth and privacy. In some cases, a small pillow is provided.

•    The examination procedure is explained to the client.

•    The body is draped appropriately for client privacy and examiner’s access.

•    Appropriate lighting is provided for the examiner.

•    Needed equipment and supplies are prepared before the examination begins.

•    The nurse stays with the client during the examination.

•    Examiner and nurse wash or sanitize their hands before and after any examination.

•    Gloves are worn in many cases.

•    Other personal protective equipment is worn when needed.

•    A signed release is obtained from the client when needed.

•    The nurse observes, in order to document the procedure and to maintain client safety and confidentiality. In addition, the nurse provides comfort to the client and answers questions.

•    After the examination, the nurse assists in disposing of equipment and supplies and readying the examination room for the next examination.

•    The nurse needs to know why the examination is being done so the client’s questions can be answered and to anticipate problems that might arise.

TABLE 48-1. Client Positions

POSITION	COMMENTS	USES
	Back-lying, legs extended or slightly bent. Arms up or down. Small pillow allowed. May be uncomfortable for client with back problem.	General examination; examination of chest, abdomen, pelvic area.
	On abdomen, head to side. Arms above head or beside body. (Small pillow or folded towel may be placed under shoulder toward which head is turned. Difficult for pregnant woman, obese client, or client with abdominal incision or breathing problem.	Examination of spine, back. (Long time in this position may cause neck strain and/or headache.)
	Side-lying, bottom arm behind or in front of client, not as extreme as Sims’. Pillow placed under top leg for support. Comfortable for longer time than prone.	Client positioned for extended rest periods.
	Side-lying (usually left side), upper knee flexed sharply, bottom arm behind body. Small pillow allowed under head. Pillow may be placed under top leg. Difficult for client with arthritis or leg injuries.	Rectal examination; procedures such as colonoscopy or enema.

TABLE 48-1. Client Positions Continued

POSITION	COMMENTS	USES
	Supine, with head raised. Semi-Fowler’s (30°-45°); high Fowler’s (nearly vertical). Knees elevated slightly. Watch for dizziness or faintness.	Promotes drainage; assists with breathing; preparation for dangling or walking.
	High Fowler’s, leaning on overbed table, arms outstretched, head held up or turned to side on pillows.	Facilitates breathing in client with severe cardiac or respiratory disorders. Can be used for ar extended length of time.
	Client on knees with chest resting on bed. Arms above head or to the side; head turned to side. Thighs straight up and down; lower legs flat on bed. Client may become dizzy; do not leave alone.	Rectal or vaginal examination; treatment to bring retroflexed uterus into normal position.
	Supine, with legs separated, knees acutely flexed, hips at end of examination table, and feet in stirrups.	Pelvic or perineal examination.

TABLE 48-1. Client Positions Continued

POSITION	COMMENTS	USES
	Standing, with chest, head, and arms on table.	Prostate examination.
	Lying on right side, knees and head flexed as sharply as possible; back exposed. Held in position by healthcare worker	Lumbar puncture for examination of spinal fluid, spinal anesthesia, specific drug administration
	Head lower than feet. (May be simulated using pillows under feet in emergency.) Place pillow between client’s head and headboard of bed.	Treatment of shock, simulated using drainage, promoting venous return.
	Head higher than feet. Place pillow between client’s feet and footboard of bed.	To facilitate tube feedings, emergency treatment in severe bleeding, head injury

FIGURE 48-6 · The hand roll (a rolled washcloth or commercially prepared hand roll) helps prevent contractures of the fingers.