INFORMATION SHEET 5.3-1J

INFORMATION SHEET 5.3-1J
POSITIONING AND REMOVING
What is Patient Positioning?
Patient positioning involves properly maintaining a patient’s neutral body
alignment by preventing hyperextension and extreme lateral rotation to prevent
complications of immobility and injury. Positioning patients is an essential
aspect of nursing practice and a responsibility of the registered nurse.
In surgery, specimen collection, or other treatments, proper patient positioning
provides optimal exposure of the surgical/treatment site and maintenance of
the patient’s dignity by controlling unnecessary exposure. In most settings,
positioning patients provide airway management and ventilation, maintaining
body alignment, and provide physiologic safety.

Goals of Patient Positioning

The ultimate goal of proper patient positioning is to safeguard the patient from
injury and physiological complications of immobility. Specifically, patient
positioning goals include:

• Provide patient comfort and safety. Support the patient’s airway
and maintain the circulation throughout the procedure (e.g., in
surgery, in examination, specimen collection, and treatment).
Impaired venous return to the heart, and ventilation-to-perfusion
mismatching are common complications. Proper positioning promotes
comfort by preventing nerve damage and by preventing unnecessary
extension or rotation of the body.

• Maintaining patient dignity and privacy. In surgery, proper
positioning is a way to respect the patient’s dignity by minimizing
exposure of the patient who often feels vulnerable perioperatively.

• Allows maximum visibility and access. Proper positioning allows
ease of surgical access as well as for anesthetic administration during
perioperative phase.

Guidelines for Patient Positioning

Proper execution is needed during patient positioning to prevent injury for both
the patient and the nurse. Remember these principles and guidelines when
positioning clients:

• Explain the procedure. Provide explanation to the client on why his
or her position is being changed and how it will be done. Rapport with
the patient will make them more likely to maintain the new position.

• Encourage client to assist as much as possible. Determine if the
client can fully or partially assist. Clients that can assist will save
strain on the nurse. It will also be a form exercise, increase
independence, and self-esteem for the client.

• Get adequate help. When planning to move or reposition the client,
ask help from other caregivers. Positioning may not be a one-person
task.

• Use mechanical aids. Bed boards, slide boards, pillows, patient lifts
and slings can facilitate ease of changing positions.

• Raise client’s bed. Adjust or reposition the client’s bed so that the
weight is at the level of the nurse’s center of gravity.

• Frequent position changes. Note that any position, correct or
incorrect, can be detrimental to the patient if maintained for a long
period. Repositioning the patient every 2 hours helps prevent
complications like pressure ulcers and skin breakdown.

• Avoid friction and shearing. When moving patients, lift rather than
slide to prevent friction that can abrade the skin making it more prone
to skin breakdown.

• Proper body mechanics. Observe good body mechanics for you and
your patient’s safety.
o Position self close to the client.

o Avoid twisting your back, neck, and pelvis by keeping them
aligned.

o Flex your knees and keep feet wide apart.

o Use your arms and legs and not your back.

o Tighten abdominal muscles and gluteal muscles in
preparation for the move.

o Person with the heaviest load coordinates efforts of the nurse
and initiates the count to 3.

Common Patient Positions
The following are the commonly used patient positions including a description
on how they are performed and the rationale:

Supine or Dorsal Recumbent Position
Supine position, or dorsal recumbent, is wherein the patient lies flat on the
back with head and shoulders slightly elevated using a pillow unless
contraindicated (e.g., spinal anesthesia, spinal surgery).

• Variation in position. In supine position, legs may be extended or
slightly bent with arms up or down. It provides comfort in general for
patients under recovery after some types of surgery.

• Most commonly used position. Supine position is used for general
examination or physical assessment.

• Watch out for skin breakdown. Supine position may put patients at
risk for pressure ulcers and nerve damage. Assess for skin breakdown
and pad bony prominences.

• Support for supine position. Small pillows may be placed under the
head to and lumbar curvature. Heels must be protected from pressure
by using a pillow or ankle roll. Prevent prolonged plantar flexion and
stretch injury of the feet by placing a padded footboard.

• Supine position in surgery. Supine is frequently used on procedures
involving the anterior surface of the body (e.g., abdominal area,
cardiac, thoracic area). A small pillow or donut should be used to
stabilize the head, as extreme rotation of the head during surgery can
lead to occlusion of the vertebral artery.

Fowler’s Position
Fowler’s position, also known as semi-sitting position, is a bed position
wherein the head of the bed is elevated 45 to 60 degrees. Variations of Fowler’s
position include: low Fowler’s (15 to 30 degrees), semi-Fowler’s (30 to 45
degrees), and high Fowler’s (nearly vertical).

• Promotes lung expansion. Fowler’s position is used for patients who
have difficulty breathing because in this position, gravity pulls
the diaphragm downward allowing greater chest and lung expansion.

• Useful for NGT. Fowler’s position is useful for patients who have
cardiac, respiratory, or neurological problems and is often optimal for
patients who have nasogastric tube in place.

• Prepare for walking. Fowler’s is also used to prepare the patient for
dangling or walking. Nurses should watch out for dizziness or
faintness during change of position.

• Poor neck alignment. Placing an overly large pillow behind the
patient’s head may promote the development of neck flexion
contractures. Encourage patient to rest without pillows for a few hours
each day to extend the neck fully.

• Used in some surgeries. Fowler’s position is usually used in surgeries
that involve neurosurgery or the shoulders

• Use a footboard. Using a footboard is recommended to keep the
patient’s feet in proper alignment and to help prevent foot drop.

• Etymology. Fowler’s position is named after George Ryerson Fowler
who saw it as a way to decrease mortality of peritonitis.

Orthopneic or Tripod Position
Orthopneic or tripod position places the patient in a sitting position or on the
side of the bed with an overbed table in front to lean on and several pillows on
the table to rest on.

• Maximum lung expansion. Patients who are having difficulty
breathing are often placed in this position because it allows maximum
expansion of the chest.

• Helps in exhaling. Orthopneic position is particularly helpful to
patients who have problems exhaling because they can press the lower
part of the chest against the edge of the overbed table.

Prone Position
In prone position, the patient lies on the abdomen with head turned to one side
and the hips are not flexed.

:

• Extension of hips and knee joints. Prone position is the only bed
position that allows full extension of the hip and knee joints. It also
helps to prevent flexion contractures of the hips and knees.

• Contraindicated for spine problems. The pull of gravity on the trunk
when the patient lies prone produces marked lordosis or forward
curvature of the spine thus contraindicated for patients with spinal
problems. Prone position should only be used when the client’s back
is correctly aligned.

• Drainage of secretions. Prone position also promotes drainage from
the mouth and useful for clients who are unconscious or those recover
from surgery of the mouth or throat.

• Placing support in prone. To support a patient lying in prone, place a
pillow under the head and a small pillow or a towel roll under the
abdomen.

• In surgery. Prone position is often used for neurosurgery, in most
neck and spine surgeries.

Lateral Position

In lateral or side-lying position, the patient lies on one side of the body with
the top leg in front of the bottom leg and the hip and knee flexed. Flexing the
top hip and knee and placing this leg in front of the body creates a wider,
triangular base of support and achieves greater stability. Increase in flexion of
the top hip and knee provides greater stability and balance. This flexion
reduces lordosis and promotes good back alignment.

• Relieves pressure on the sacrum and heels. Lateral position helps
relieve pressure on the sacrum and heels especially for people who sit
or are confined to bed rest in supine or Fowler’s position.

• Body weight distribution. In this position, most of the body weight is
distributed to the lateral aspect of the lower scapula, the lateral aspect
of the ilium, and the greater trochanter of the femur.

• Support pillows needed. To correctly position the patient in lateral
position, use of support pillows are needed.

Sims’ Position
Sims’ position or semi prone position is when the patient assumes a posture
halfway between the lateral and the prone positions. The lower arm is positioned
behind the client, and the upper arm is flexed at the shoulder and the elbow.
The upper leg is more acutely flexed at both the hip and the knee, than is the
lower one.
Sims’ position

• Prevents aspiration of fluids. Sims’ may be used for unconscious
clients because it facilitates drainage from the mouth and
prevents aspiration of fluids.

• Reduces lower body pressure. It is also used for paralyzed clients
because it reduces pressure over the sacrum and greater trochanter of
the hip.

• Perineal area visualization and treatment. It is often used for
clients receiving enemas and occasionally for clients undergoing
examinations or treatments of the perineal area.

• Pregnant women comfort. Pregnant women may find the Sims
position comfortable for sleeping.

• Promote body alignment with pillows. Support proper body
alignment in Sims’ position by placing a pillow underneath the
patient’s head and under the upper arm to prevent internal rotation.
Place another pillow between legs.

Lithotomy Position
Lithotomy is a patient position in which the patient is on their back with hips
and knees flexed and thighs apart.

Lithotomy position

• Lithotomy position is commonly used for vaginal examinations and
childbirth.

• Modifications of the lithotomy position include low, standard, high,
hemi, and exaggerated based on how high the lower body is raised or
elevated for the procedure. Please check with your facility’s guidelines
but typically:

o Low Lithotomy Position: The patient’s hips are flexed until
the angle between the posterior surface of the patient’s thighs
and the O.R. bed surface is 40 degrees to 60 degrees. The
patient’s lower legs are parallel with the O.R. bed.2

o Standard Lithotomy Position: The patient’s hips are flexed
until the angle between the posterior surface of the patient’s
thighs and the O.R. bed surface is 80 degrees to 100 degrees.
The patient’s lower legs are parallel with the O.R. bed.

o Hemilithotomy Position: The patient’s non-operative leg is
positioned in standard lithotomy. The patient’s operative leg
may be placed in traction.

o High Lithotomy Position: The patient’s hips are flexed until
the angle between the posterior surface of the patient’s thighs
and the O.R. bed surface is 110 degrees to 120 degrees. The
patient’s lower legs are flexed.

o Exaggerated Lithotomy Position: The patient’s hips are
flexed until the angle between the posterior surface of the
patient’s thighs and the O.R. bed surface is 130 degrees to
150 degrees. The patient’s lower legs are almost vertical.

Trendelenburg’s Position

Trendelenburg’s position involves lowering the head of the bed and raising
the foot of the bed of the patient. The patient’s arms should be tucked at their
sides

• Promotes venous return. Hypotensive patients can benefit from this
position because it promotes venous return.

• Postural drainage. Trendelenburg’s position is used to provide
postural drainage of the basal lung lobes. Watch out for dyspnea,
some patients may require only a moderate tilt or a shorter time in
this position during postural drainage. Adjust as tolerated.

Reverse Trendelenburg’s Position
Reverse Trendelenburg’s is a patient position wherein the the head of the bed
is elevated with the foot of the bed down. It is the opposite of Trendelenburg’s
position

Gastrointestinal problems. Reverse trendelenburg is often used for patients
with gastrointestinal problems as it helps minimize esophageal reflux.

• Prevent rapid change of position. Patients with decreased cardiac
output may not tolerate rapid movement or change from a supine to a
more erect position. Watch out for rapid hypotension. It can be
minimized by gradually changing the patient’s position.

• Prevent esophageal reflux. Promotes stomach emptying and prevents
reflux for clients with hiatal hernia.

Knee-Chest Position
Knee-chest position, can be in lateral or prone position. In lateral knee-chest
position, the patient lies on their side, torso lies diagonally across the table,
hips and knees are flexed. In prone knee-chest position, the patient kneels on
the table and lower shoulders on to the table so chest and face rests on the
table.

Lateral knee-chest position. Can also be done prone.

• Two ways. Knee-chest position can be lateral or prone.
• Sigmoidoscopy. Usual position adopted for sigmoidoscopy without

anesthesia.
• Patient dignity. Prone knee-chest position can be embarrassing for

some patients.
• Gynecologic and rectal examinations. Knee-chest position is

assumed for a gynecologic or rectal examination.

Jackknife Position

Jackknife position, also known as Kraske, is wherein the patient’s abdomen
lies flat on the bed. The bed is scissored so the hip is lifted and the legs and
head are low.

• In surgery. Jackknife position is frequently used for surgeries
involving the anus, rectum, coccyx, certain back surgeries, and
adrenal surgery.

• Requires team effort. At least four people are required to perform the
transfer and position the patient in the operating table.

• Cardiovascular effects. In jackknife position, compression of the
inferior vena cava from abdominal compression also occurs, which
decreases venous return to the heart. This could increase the risk
for deep vein thrombosis.

• Support paddings. Many pillow sare required on the operating table
to support the body and reduce pressure on the pelvis, back, and the
abdomen. Jackknife position also puts excessive pressure on the
knees. While positioning, surgical staff should put extra padding for
the knee area.

Kidney Position

In kidney position, the patient assumes a modified lateral position wherein
the abdomen is placed over a lift in the operating table that bends the body.
Patient is turned on their contralateral side with their back placed on the edge
of the table. Contralateral kidney is placed over the break in the table or over
the kidney body elevator (if attachment is available). The uppermost arm is
placed in a gutter rest at no more than 90º abduction or flexion.

Right lateral kidney position

• Access to retroperitoneal area. Kidney positions allows access and
visualization of the retroperitoneal area. A kidney rest is placed under
the patient at the location of the lift.

• Risk for falls. Patient may fall off the table at anytime until the
position is secured.

• Padding and stabilization support. Contralateral arm underneath
the body is protected with padding. Contralateral knee is flexed and
the uppermost leg is left straight to improve stability. A large soft over
the hip to stabilize the patient. pillow is placed in between the legs.
Kidney strap and tape are placed

Support Devices for Patient Positioning

The following are the devices or apparatus that can be used to help position the
patient properly.

• Bed Boards. Bed boards are plywood boards that are placed under the
entire surface area of the mattress and are useful for increasing back
support and body alignment.

• Foot Boots. Foot boots are shoes made of rigid plastic or heavy foam
and keep the foot flexed at the proper angle. It is recommended that
they should be removed 2 to 3 times a day to assess the skin
integrity and joint mobility.

• Hand Rolls. Hand rolls maintain the fingers in a slightly flexed and
functional position and keep the thumb slightly adducted in
opposition to the fingers.

• Hand-Wrist Splints. These splints are individually molded for the
client to maintain proper alignment of the thumb in a slight adduction
and the wrist in slight dorsiflexion.

• Pillows. Pillows provide support, elevate body parts, splint incision
areas, and reduce postoperative pain during activity, coughing or deep
breathing. They should be of the appropriate size for the body to be
positioned.

• Sandbags. Sandbags are soft devices filled with substance that can be
used to shape or contour to the body’s shape and provide support.
They immobilize extremities and maintain specific body alignment.

• Side Rails. Side rails are bars along the sides of the length of the bed.
They ensure client safety and are useful for increasing mobility. They
also provide assistance in rolling from side to side or sitting up in bed.
Check with your agencies policies regarding the use of side rails as
they vary state to state.

• Trochanter Rolls. These rolls prevent external rotation of the legs
when the client is in the supine position. To form a roll, use a cotton
bath blanket or a sheet folded lengthwise to a width extending from
the greater trochanter of the femur to the lowest border of the popliteal
space.

• Wedge Pillows. Are triangular pillows made of heavy foam and are
used to maintain legs in abduction following total hip replacement
surgery.

Documenting Patient Positioning

Documenting change of patient position in the patient’s chart. Note the
following:

• Date and time of the procedure.
• Explanation of the procedure to the patient.
• Notation of the position the patient was placed in including rationale.
• Pertinent teaching given.
• Patient’s response to the procedure.

Moving a Patient up in Bed

Steps Additional Information

1. Make sure an additional health care
provider is available to help with the This procedure requires two health care providers.
move.

2. Explain to the patient what will Doing this provides the patient with an opportunity
happen and how the patient can help. to ask questions and help with the positioning.

3. Complete risk assessment of This step prevents injury to patient and health care
patient’s ability to help with the provider.
positioning.

4. Raise bed to safe working height Principles of proper body mechanics help prevent
and ensure that brakes are applied. MSI.
Health care providers stand on each Safe working height is at waist level for the shortest
side of the bed. health care provider.

Bed at waist level

5. Lay patient supine; place pillow at This step protects the head from accidentally hitting
the headboard during repositioning.
the head of the bed and against the
headboard.

This keeps the heaviest part of the patient closest to
the centre of gravity of the health care providers.

6. Stand between shoulders and hips
of patient, feet shoulder width apart.
Weight will be shifted from back foot to
front foot.

Feet shoulder width apart

This provides a strong grip to move the patient up
using the draw sheet.

7. Fan-fold the draw sheet toward the
patient with palms facing up.

Fold sheet with fingers facing upward

This step prevents injury from patient and prepares
patient for the move.

8. Ask patient to tilt head toward
chest, fold arms across chest, and
bend knees to assist with the

movement. Let the patient know when
the move will happen.

Chin tucked in and arms across chest

9. Tighten your gluteal and abdominal The principles of proper body mechanics help prevent
muscles, bend your knees, and keep injury.
back straight and neutral.

10. On the count of three by the lead The principles of proper body mechanics help
person, gently slide (not lift) the prevent injury.
patient up the bed, shifting your

weight from the back foot to the front, Facing direction of movement
keeping back straight with knees
slightly bent.

11. Replace pillow under head, This step promotes comfort and prevents harm to
position patient in bed, and cover with patient.
sheets.

Placing bed and side rails in safe positions reduces
the likelihood of injury to patient. Proper placement of
call bell facilitates patient’s ability to ask for
assistance.

12. Lower bed, raise side rails as
required, and ensure call bell is within
reach. Perform hand hygiene.

Bed in lowest position, side
rail up, call bell within reach

Hand hygiene reduces the spread of microorganisms.