Chapter 17: Positioning Clients

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Okay, let's unpack this.

Picture this.

You have a client.

They're getting nutrition through

a nestogastric tube, you know, the tube going into their stomach, and they're not fully awake, maybe a bit groggy, and that feeding pump is just running steadily.

What's the absolute first thing that should jump into your head about how they're positioned?

Yeah, what's that critical safety check?

Exactly.

What simple thing can you do right then to keep them safe?

We'll circle back to this

critical scenario and give you the answer a bit later in our deep dive.

And it's fascinating, isn't it, how something that seems so basic like just positioning a client in bed actually has these huge, far -reaching effects.

Totally.

It's way more than just, you know, making them comfy.

Right.

It ties directly into their mobility, obviously, but more importantly, their safety.

Think about just a small adjustment, maybe shifting a pillow can impact their breathing, prevent skin breakdown, and even affect how well their treatments actually work.

It's pretty profound when you stop and think about it.

It really is.

And well, that's exactly our mission today.

We're diving deep into the essential guidelines, the principles behind client positioning.

We've got the chapter right here covering it all.

Our goal is to pull out the most crucial stuff, not just how to position someone,

but the critical why behind each position.

Yeah.

The rationale is key.

It's not just about arranging limbs.

It's actively preventing problems and helping the body heal.

And if you connect this to, you know, the bigger picture of nursing practice, proper positioning is just fundamental.

It's essential everywhere.

Couldn't agree more.

So to guide us through this, we'll start with the general principles, the foundations of safe positioning.

Then we'll get into the specifics, different positions for various body systems, different conditions.

We'll also touch on ergonomics, how we as healthcare workers can stay safe while doing this, and the tools we use, those positioning aids.

Right.

The practical side.

And then, like you said, we'll loop back to that opening question and run through some review just to really nail down the understanding.

Perfect.

So let's lay that groundwork.

General guidelines for positioning.

First up, it seems obvious,

but movement and proper body alignment are just vital for everyone.

For health, yeah.

And the chapter really points out that many of our clients, well, they have limited ability, or maybe no ability, to move or shift themselves independently.

And what's crucial there, even for folks with really limited mobility, is that the basic ideas still apply.

We're talking about keeping their body in the correct anatomical alignment.

Like how things naturally line up.

Exactly.

Joints, limbs, how they're meant to be oriented, and just as vital, maybe even more so, is changing their position frequently.

Right.

Can't leave them in one spot for too long.

No way.

Staying put for hours leads to all sorts of problems.

Skin breakdown, circulation issues, you name it.

Absolutely.

And it's not just about that perfect alignment, is it?

It's also positioning for safety, supporting that alignment,

and yeah, contributing to their comfort too.

But the chapter seems to prioritize preventing complications, even over immediate comfort sometimes.

That's a really important distinction.

Yes, comfort matters, but preventing harm takes precedence.

So the question becomes, what kind of complications are we trying to head off with careful positioning?

Good question.

Well, chapter's clear.

The positions we choose should directly address potential problems linked to their underlying conditions, their treatments, maybe a recent surgery.

And here's a huge point, really non -negotiable.

According to the text, you always, always, always have to check the primary healthcare provider's orders,

the PCP's prescriptions.

Absolutely critical.

Especially after a treatment or procedure, they might have very specific instructions, positions allowed, restrictions on movement, and those orders, they're the final word, you follow them, period.

Precisely.

Now let's shift gears just a bit.

It's not only about the client's body mechanics, we need to think about our own safety too, right?

Oh yeah.

Back entries are no joke in healthcare.

Tell me about it.

So box 17 -1 in the chapter lays out some really essential ergonomic principles, basically guidelines to help us move and reposition clients safely,

minimizing our own risk.

Okay, let's hit the highlights from that box.

Number one, get enough help.

Don't be a hero trying to lift someone heavy alone.

Definitely not.

Use those mechanical aids, lifts, slide sheets, whenever you possibly can that's huge.

And get the client involved if they can help, even a little bit makes a difference.

It does.

And then there's our own posture, keeping your back straight, avoiding twisting motions.

That's a big one.

Right.

Bend your knees, not your waist.

Get a wide, stable stance with your feet.

Simple stuff, but easy to forget in the moment makes a massive difference in preventing strain.

And raise the bed.

Get it to a comfortable working height so you're not hunched over.

Keep the client close to your body during the move.

Use your legs and arms, not your back muscles.

And those pull sheets or slideboards, they reduce friction, make it so much easier and safer.

Oh, and engaging your core muscles.

Got to remember that for stability.

And if you're working in a team.

Coordination is key.

Yeah.

The person handling the heaviest part directs the move, uses a clear count like one, two, three, lift, so everyone moves together.

Absolutely.

All crucial for protecting both the client and ourselves.

Okay.

So moving on from ergonomics, the chapter starts getting into specific positions for safety and comfort, looking at different body systems.

Let's start with the skin, the integumentary system.

Makes sense.

Skin breakdown,

pressure injuries, big risk with immobility.

So what does the chapter say for skin related situations, like an autograph?

Right.

An autograph where they take skin from one part of the body or move it to another.

For that, the site needs to be immobilized, kept still, usually for about three to seven days or whatever the doctor prescribes.

Okay.

To let it take.

Exactly.

To allow it to adhere and start healing properly.

What about burns?

Good question.

Depends on where the burn is.

For burns on the face and head, you want to elevate the head of the bed.

Why is that?

To help prevent or reduce swelling, edema in the face, head, and potentially the airway, the trachea.

Swelling there can be dangerous.

Okay.

And if the burn goes all the way around an arm or leg, a circumferential burn.

Then you elevate that extremity, that limb, above the level of the heart, helps reduce what's called dependent edema fluid pooling due to gravity.

Got it.

And for skin graft in general.

Similar principles.

Elevate and immobilize the graft site.

You want to minimize any movement or shearing forces, that sliding motion between tissue layers, which can mess up the healing and definitely avoid putting weight on it as directed.

Okay.

Moving on.

Reproductive system.

The chapter mentions positioning after a mastectomy breast removal surgery.

Yes.

Post -op, the usual position is semi -fowler's head of the bed, up at least 30 degrees, and the arm on the side of the surgery.

Elevate it on a pillow.

And the reason for elevating the arm is?

Lymphatic drainage.

Helps the lymphatic fluid, which can sometimes pool after lymph nodes are removed, flow back better.

The chapter also says turn only to the back or the unaffected side initially.

Makes sense.

And for procedures down in the perineal area or vaginal procedures.

The standard position is lithotomy.

That's lying on the back with legs up and supported, often in stirrups.

Figure 17 -4 shows it visually.

Right.

Okay.

Endocrine system next.

After a hypophysectomy removal of the pituitary gland at the base of the brain.

Elevate the head of the bed.

Key reason.

Prevent increased intracranial pressure.

The pressure inside the skull.

And thyroidectomy surgery on the thyroid gland in the neck.

Semi -fowlers or even fowlers position so.

Head elevated 45 to 60 degrees.

This helps reduce swelling in the neck.

Sometimes they use sandbags or pillows on either side of the head for support.

To keep the neck stable.

Exactly.

And crucially, avoid extending the neck backwards.

That decreases tension on the suture line, the incision.

Wow.

Yeah, even small movements matter there.

Yeah.

Okay, gastrointestinal system.

This looks like it has quite a few different positioning points.

It really does.

Lots of variations.

For instance, after a hemorrhidectomy, hemorrhoid removal,

lateral position, side lying,

helps minimize pain and bleeding in that area.

Okay.

What about GERD, gastroesophageal reflex disease?

That common heartburn issue.

For GERD, the recommendation is reverse trendellenberg.

So head higher than feet.

Yep.

Up with the head of the bed about 6 to 12 inches.

You can use blocks under the bed legs or a big wedge pillow.

The goal is to help the stomach empty faster and stop acid from splashing back up into the esophagus.

Ah, gravity assist.

Makes sense.

Now I see a special box here.

Priority nursing actions.

Specifically for a liver biopsy.

That sounds important.

It definitely is.

Lots of key nursing points.

Before the biopsy, where they take a tiny liver sample, you position the client supine flat on their back, expose the right upper abdomen, and have them raise their right arm up behind their head.

This gives the best access to the liver and critically explain everything and make sure you have that informed consent sign.

Right.

Consent is vital.

And during the procedure?

The nurse stays right there offering support, monitoring.

Afterwards, positioning is absolutely crucial.

You carefully help the client onto their right side, right lateral position.

With something under the side.

Yes, a small pillow right under the puncture site.

And they stay like that for at least three hours.

Why the right side specifically?

It applies pressure directly to the biopsy site on the liver, helps compress tiny blood vessels, and really minimizes the risk of bleeding.

Ah, okay.

Makes perfect sense.

And the nurse's priority is watching vital signs like a hock heart rate, blood pressure, looking for any hint of bleeding or other issues, and of course documenting everything meticulously.

Got it.

Okay, next.

Paracentesis, draining fluid from the abdomen.

For that, positioning can be semi -fowlers in bed, or sitting up on the side of the bed, maybe legs dangling, or even sitting upright in a chair with feet supported.

Afterwards, the main thing is just ensuring their comfort, as fluid shifts can sometimes make people feel a bit off.

Okay.

What about putting in a nasogastric tube?

An NG tube.

Ah, NG tube insertion.

For that, you want high fowlers positioned head of bed way up, 60 to 90 degrees, and have them tilt their heads slightly forward.

Why a head tilt?

It helps close off the windpipe, the trachea, and open up the esophagus, the food pipe.

Makes it much more likely the tube goes down the right way, into the stomach.

Smart.

And once the tube is in, say for feedings, whether it's intermittent bolus feeds or a continuous drip, keep the head of the bed elevated at least 30 degrees semi -fowlers.

This is non -negotiable to prevent aspiration.

Food or liquid going into the lungs.

Bad news.

Very bad news.

So keep that elevation during the feed,

and for 30 minutes to an hour after an intermittent feed.

If it's continuous feeding, they need to stay elevated all the time.

Okay, here's a critical safety point then.

What if someone on continuous feeding needs care that requires them to be flat, like a bed bath?

Excellent question.

You must turn off the continuous feeding pump first.

Pause the feeding,

then you can lower them, do the care.

And then?

As soon as you raise the head of the bed back up, turn the feeding pump back on, and this is important double check that the infusion rate is set correctly.

Crucial steps.

Okay, rectal enemas or irrigations?

Left sims position is the go -to.

That side lying on the left, with the upper leg bent more than the lower one.

And the logic?

Gravity again.

It helps the enema solution flow downwards along the natural curve of the colon, making it work better.

Okay, lastly for GI, these Sengstaken Blakemore in Minnesota tubes.

Sounds specialized.

They are.

Not used super often anymore, but they're for controlling bleeding from esophageal varices, swollen vessels in the esophagus.

If they are used, elevate the head of the bed.

Why?

Helps with lung expansion, makes breathing easier, and it might also help reduce blood flow in the portal system, which is part of how the balloon tamponade works to stop the bleeding.

Got it.

Okay, shifting to the respiratory system now.

COPD, chronic obstructive pulmonary disease.

How do we position them?

Often you'll see them sitting up, leaning forward, maybe with arms resting on an overbed table or pillows.

The tripod position.

Exactly.

That position helps them use their accessory breathing muscles more effectively, and allows for better lung expansion.

Makes breathing easier for them.

Makes sense.

What about after a laryngectomy and maybe with a radical neck dissection?

Semi -foulers, or foulers.

Head elevated.

Helps maintain that open airway and minimizes swelling in the neck area after surgery.

Okay.

And post bronchoscopy, after they've had that camera down their airways.

Semi -foulers again.

This is mainly to prevent choking or aspiration, because their gag reflex might be a bit sleepy from the anesthetic or sedation.

Right.

Postural drainage.

That technique to clear secretions.

For that, you position the client so the specific lung segment you want to drain is uppermost.

Gravity helps pull the mucus out.

Sometimes Trendelenburg, feet higher than head, is used for the lower lung lobes.

Okay.

Thoracentesis, draining fluid from around the lungs.

During the procedure, positioning is key for access.

Usually sitting on the edge of the bed, leaning forward over a table, or maybe lying on the unaffected side with the head of the bed up about 45 degrees.

Why that position?

Helps spread the ribs apart, widens those intercostal spaces, making it easier and safer to get the needle in.

Afterwards, just help them find a comfortable position.

On a thoracotomy, surgically opening the chest.

This is a big one where the chapter really stresses.

Always check the surgeon's specific orders for positioning after surgery.

Why the emphasis?

Because the best position depends entirely on what type of surgery was done, like removing just a wedge of lung, a whole lobe, or even an entire lung, pneumonectomy.

The orders are critical.

Got it.

Surgeon's orders rule there.

Okay.

Cardiovascular system next.

Abdominal aortic aneurysm repair, fixing a bulge in the main artery in the belly.

Right.

If it's an open repair, the surgeon's orders are again key.

Often, they limit how much you can elevate the head initially.

To avoid bending the graft.

Exactly.

Don't want to kink or stress that new graft.

Gentle turning side to side is usually allowed per orders.

What about the less invasive kind?

The endovascular repair?

Yeah.

That's done through catheters.

Generally, fewer positioning restrictions afterwards, and usually a shorter hospital stay compared to the open surgery.

Okay.

Amputation of a lower leg or thigh.

In the first 24 hours, often the foot of the bed is elevated slightly to help with swelling in the residual limb.

Just the foot of the bed, not the limb itself.

Correct.

You support the limb with pillows, but the chapter warns against elevating the residual limb on pillows.

Big risk of developing hip flexion contractures.

The hip getting stuck in a bent position.

That makes rehab and fitting a prosthesis much harder later on.

Oh, okay.

That's a key distinction.

And later, the surgeon might order prone positioning, lying flat on the stomach for 20, 30 minutes a couple of times a day.

To stretch things out.

Exactly.

Stretches those hip flexors, helps prevent those contractures.

Good tip.

Arteriovascular grafting, putting in a new vessel and an arm or leg.

Goal here is keeping that new graft open and flowing.

Usually bed rest for about 24 hours.

Keep the affected limb straight.

No bending.

Limit movement.

Avoid bending the hip and knee on that side during that initial period to protect the graft.

Cardiac catheterization, accessing the heart via an artery, often the femoral and the groin.

Yep.

If the femoral artery was used, it's usually bed rest for four to six hours, maybe longer, depending on the place.

That leg has to stay straight.

And head elevation.

Keep the head of the bed pretty low, no more than 30 degrees.

Sometimes flat until they're sure the bleeding at the puncture site has stopped.

Hemostasis.

Gentle turning side to side is okay within those limits.

Okay.

What about heart failure or pulmonary edema fluid in the lungs?

Position them upright.

Sitting up, maybe even legs dangling over the side of the bed if they can tolerate it.

Why upright?

Helps decrease the amount of blood returning to the heart, venous return, which reduces the workload on the heart and eases lung congestion.

It fits that general rule, head up for heart and lung problems.

Right.

Peripheral arterial disease, poor artery flow to the legs.

Here, you definitely need to check the PHCP's specific orders.

Sometimes gentle foot elevation at rest is okay for swelling, but you generally don't want the feet higher than the heart.

Because that would hinder arterial flow even more.

Exactly.

It could slow down the already poor blood supply.

Sometimes a slightly dependent position, feet a bit lower than the heart, might actually be preferred to help blood get down there.

Interesting.

Okay.

DBT, deep vein thrombosis, a blood clot and a leg vein.

If the leg is red, swollen, painful classic signs and they're on traditional heparin, then it's usually bed rest with the leg elevated.

But what if they're on the newer heparin, low molecular weight heparin?

Then they can often be up and about OAB after maybe 24 hours if the pain allows.

Different approach.

Good to know.

Varicose veins or venous insufficiency where leg veins don't return blood well?

For those, leg elevation above the heart level is generally good.

Helps that venous blood return and tell them to avoid sitting or standing still for long periods.

Okay.

Moving to the sensory system.

Eyes after cataract surgery.

Elevate the head of the bed semi -fowlers to fowlers.

Position them on their back or the non -operative side.

Helps prevent swelling and pressure on the eye.

And activity restrictions.

Crucial.

Avoid anything that increases pressure inside the eye.

Interocular pressure.

So no lifting heavy things.

Rule of thumb is often 10 pounds and no excessive bending over.

Got it.

Retinal detachment where the back layer of the eye pulls away.

If it's a large detachment, initial treatment might be strict bed rest with patches on both eyes.

Both eyes.

Why?

To minimize all eye movement, trying to prevent the detachment from getting worse before repair.

After surgery, the specific positioning and activity limits really depend on the and what procedure was done.

Okay.

Neurological system now.

Autonomic dysreflexia, that emergency in spinal cord injury patients.

Immediate action.

Get the head of the bed way up high fowler's position right away.

Why so urgent?

Helps with breathing, but mainly it helps lower that dangerously high blood pressure that happens with dysreflexia, trying to prevent a hypertensive stroke.

Wow.

Okay.

Critical.

Cerebral aneurysm, weak spot in a brain artery.

Bed rest, typically.

Head of the bed elevated, usually 30 to 45 degrees.

Helps reduce pressure on the aneurysm and promotes venous drainage from the brain.

Cerebral angiography, the brain vessel dye test.

Bed rest afterwards for a set time.

And the arm or leg where they went in, keep it straight and umbilized for maybe six to eight hours to prevent bleeding at the site.

Stroke or brain attack.

Positioning depends on the type.

Yes.

For a hemorrhagic stroke, bleeding in the brain, elevate the head of the bed about 30 degrees.

Helps lower intracranial pressure, ICP, and helps blood drain out.

And for a ischemic stroke caused by a clot or blockage.

Usually minimal head elevation, maybe keep them flatter.

The idea is to maximize blood flow, perfusion, to the brain tissue that's starved of oxygen.

And head position for both.

Keep the head midline neutral.

Don't let it flop to the side.

Facilitates that venous drainage.

Also, avoid extreme bending at the hips or neck.

Why avoid the bending?

Can impede blood flow out of the head, potentially raising that intracranial pressure.

Got it.

Craniotomy brain surgery involving opening the skull.

General rule, don't position them on the side where the surgery was, especially if a piece of bone flap was removed.

Okay.

And head elevation.

Head of bed up 30 to 45 degrees, semi -fowlers to fowlers.

Head midline and neutral again for venous drainage.

And again, avoid that extreme hip and neck flexion.

Okay.

Laminectomy or other spine surgeries?

Often they get out of bed pretty quickly post -op, sometimes wearing a back brace if ordered.

When they are up, keep the back straight, sitting in a straight back chair, feet flat.

Increased intracranial pressure, ICP, regardless of the cause.

Consistent positioning goals.

Head of bed 30 to 45 degrees, head midline neutral.

Avoid extreme hip neck flexion and a big don't.

Never put clients with head injuries or high ICP flat or in Trendelenburg.

That makes ICP worse.

Okay.

Crucial point, lumbar puncture, spinal tap.

During the procedure,

side -lying fetal position, back bowed out, knees to chest, chin to chest.

Why that position?

It opens up the spaces between the vertebrae and the lower back, making it easier and safer to get the needle in.

And after the lumbar puncture?

Usually supine flat on their back for a prescribed time, maybe 4 to 12 hours, helps prevent that post -LP headache.

Okay.

Lastly, for neuro spinal cord injury.

Immediate priority is immobilization.

On a spinal backboard, head neutral.

Critical to prevent making the injury worse, like turning an incomplete injury into a complete one.

So no movement.

Prevent any head flexion, rotation or extension.

Use a firm padded cervical collar and only log roll them.

Turn the whole body as one unit.

No twisting, no sitting up until the spine is cleared or stabilized.

After surgery, or if they're in halo traction, then specific activity orders beyond just log rolling will be given.

Got it.

Okay.

Final system.

Musculoskeletal.

Big one here is total hip replacement.

Yes.

And positioning here is super specific and always depends on the surgeon's approach and preferences.

You absolutely must follow their orders to the letter.

But are there general principles?

Generally, yes.

Avoid extreme turning of the leg inward or outward, internal external rotation that can pop the new hip out.

And no crossing the legs.

Definitely no adduction moving the leg towards the midline or across the body.

That's why they often use that abduction pillow, the wedge between the legs.

You keep the legs apart?

Exactly.

Keeps them in adduction.

Lying on the non -operative side is usually okay with the pillow, but even turning might be restricted by some surgeons initially.

Maintain abduction when they're supine.

Box 17 -2 probably shows this.

Okay.

And hip flexion.

Bending the hip.

Check the surgeon's orders on how much head elevation or hip flexion is allowed.

It varies.

Gotcha.

And that Box 17 -2 you mentioned lists devices for positioning.

Right.

It covers things like bed boards for firmness, foot boots to prevent foot drop, hand rolls or splints for hand position.

Pillows, obviously.

Pillows for everything, sandbags for immobilization, side rails mentioning agency policy on use, trapeze bars to help the client move themselves.

Crochenter rolls.

Yep.

Placed by the hips to stop legs rolling outwards when supine.

And wedge pillows like the abduction pillow or for elevating the upper body.

Lots of tools in the toolbox.

Definitely.

Okay.

So let's circle all the way back to that first critical thinking question.

Client getting intermittent NG tube feedings.

What are the key positioning actions?

Based on everything we've covered, the answer is clear.

For those intermittent feeds via NG tube, position them upright semi -foulers or high foulers.

During the feed.

During the entire feed.

And then keep them elevated for 30 minutes to an hour after the feed is done.

And if it were continuous feeding.

Upright position at all times.

The absolute fundamental reason.

Prevent aspiration.

Keep that food or liquid out of the lungs.

Perfect.

Makes complete sense now.

And the chapter includes practice questions to hammer these points home.

Exactly.

They're great for checking understanding.

Like question 141 about moving a heavy dependent client over 250 pounds.

Right.

What are the correct actions there?

Use a friction reducing sheet.

Definitely use a mechanical lift.

Keep your body mechanics right.

Elbows close.

Work near client.

Get help.

Trendyl and BIRB is wrong and pain meds five minutes before isn't enough time.

Okay.

Question 142.

Positioning after cardiac cath via femoral artery.

Supine, flat, or head of bed no more than 30 degrees.

Keep that leg straight to prevent bleeding.

143.

Home care after cataract surgery.

What indicates understanding?

Client knows not to sleep on the operated side.

Knows sitting up to eat or in a recliner is okay.

And crucially knows not to lift anything heavy over 10 pounds.

Bending or push -ups?

No way.

Okay.

144.

Why right side lying after a liver biopsy?

To apply pressure to the site.

Limit bleeding.

145.

Why left sims for an enema?

Follows the colon's natural curve.

Uses gravity effectively.

146.

Preparing for thoracentesis.

Key instructions.

Tell them about the position.

Leaning over table or sitting up.

It's fluid removal, not usually biopsy.

There'll be a timeout.

And they'll get local anesthetic for numbing.

147.

Best position for NG tube insertion.

High fowlers.

Head tilted slightly forward.

Opens the esophagus.

Closes the trachea.

148.

Safe position after craniotomy.

Generally, semi -fowlers.

Head up 30 degrees.

Foot of bed flat.

Promotes drainage.

Maintains perfusion.

Not prone or trindling bird.

149.

Client had a left side craniotomy.

Safe positioning.

Elevate head of bed, like semi -fowlers, and avoid positioning them on the left operative side.

Protect the site.

Promote drainage.

And a 150.

Positioning right after an above knee amputation.

Support the residual limb with pillows, but don't elevate the limb itself, especially first 24 hours.

Elevating the foot of the bed is okay for general edema,

but elevating the limb risks hip contractures.

So you can really see, can't you?

Understanding positioning isn't just a nice to know.

It's absolutely fundamental to safe, effective nursing care.

It really is.

It goes so far beyond just comfort.

It directly impacts safety, prevents a whole host of complications we've talked about, and actively supports recovery across every single body system.

Absolutely.

And this deep dive, pulling from the chapter, really shows how comprehensive these guidelines are, covering so many different conditions and procedures.

Every point we discuss is grounded right there in the source material.

So here's a final thought for you, the listener.

Think about how a seemingly simple action, like adjusting a pillow, can be such a critical intervention based on everything we've discussed.

What other small details in care might have these really significant, maybe hidden impacts on well -being and recovery?

It's a good reminder, isn't it?

To always question the why behind everything we do as nurses.

It really is.

And with that, we have officially journeyed through all of chapter 17 from Saunders Comprehensive Review for the NCLE -XPN Examination, 7th edition.

We get the key concepts, assessment points, procedures, safety protocols, priority actions, and even those review questions.

We define terms along the way too, all within the context of positioning.

So that wraps up this in -depth exploration.