Different Bed Positioning for Patients

1. CAREGIVING NC II
Prepared by: Jennifer B. Garcia,
RN, NTTC

2. 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 to the surgical/treatment site
and maintenance of the patient’s dignity by controlling unnecessary
exposure.
In most settings, proper positioning of patients provides airway
management and ventilation, maintains body alignment, and provides
physiologic safety.

3. Goals of Patient Positioning
The ultimate goal of proper patient positioning is to safeguard the
patient from immobility injury and physiological complications.
Specifically, patient positioning goals include:
• Provide patient comfort and safety. Support the patient’s airway
and maintain circulation throughout the procedure (e.g., surgery,
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 peri-operatively.
• Allows maximum visibility and access. Proper positioning allows
ease of surgical access as well as for anesthetic administration
during the perioperative phase.

4. 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. Explain to the client why their 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 the 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 of exercise, increasing the client’s independence and self-
esteem.
• Get adequate help. When planning to move or reposition the client, ask for 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 the ease of changing positions.
• Raise the client’s bed. Adjust or reposition the client’s bed so that the weight is
at the nurse’s center of gravity level.
• Frequent position changes. Note that any correct or incorrect position can be
detrimental to the patient if maintained for a long time. Repositioning the patient
every two hours helps prevent complications like pressure ulcers and skin
breakdown.

5. • 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 your and your patient’s safety.
• Position yourself close to the client.
• Avoid twisting your back, neck, and pelvis by keeping
them aligned.
• Flex your knees and keep your feet wide apart.
• Use your arms and legs and not your back.
• Tighten abdominal muscles and gluteal muscles in
preparation for the move.
• A person with the heaviest load coordinates the
efforts of the nurse and initiates the count to 3.

6. Common Patient Positions
The following are the commonly used patient positions, including a
description of how they are performed and the rationale:
1. Supine position - 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).

7. • 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 type of surgery.
• Most commonly used position. Supine or dorsal recumbent 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 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 an extreme rotation of the head during
surgery can lead to occlusion of the vertebral artery.

8. 2. 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).

9. • 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 with cardiac, respiratory, or
neurological problems and is often optimal for patients with a nasogastric tube.
• 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 a 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 the 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 drops.
• Etymology. Fowler’s position is named after George Ryerson Fowler, who saw it as
a way to decrease the mortality of peritonitis (a redness and swelling (inflammation) of
the tissue that lines your belly or abdomen. This tissue is called the peritoneum.)

10. Types of Fowler’s Position:
 Low Fowler's, like Supine Position, is when a patient's head is
included at a 15–30-degree angle. This position can be used post-
procedure, to reduce lower back pain, administer drugs and prevent
aspiration during tube feeding. Low Fowler's position is considered the
best position for patients to rest.

11.  Semi-Fowler's position is a position in which a patient, usually in a
hospital or nursing home, is lying on their back with the head and torso
raised between 15 and 45 degrees. The most frequently used bed angle
for this patient position is 30 degrees.

12.  High Fowler's position, the patient is usually seated upright with their
spine straight. The upper body is between 60 degrees and 90 degrees. The
legs of the patient may be straight or bent. This Position is commonly used
when the patient is defecating, eating, swallowing, taking X-Rays, or to
help with breathing.

13. 4. 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.
Orthopnea is the sensation of breathlessness in the recumbent position, relieved by sitting or standing.
Paroxysmal nocturnal dyspnea (PND) is a sensation of shortness of breath that awakens the patient,
often after 1 or 2 hours of sleep, and is usually relieved in the upright position.
•Maximum lung expansion. Patients with difficulty of breathing are often placed
in this position because it allows maximum chest expansion.
•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.

14. 5. Prone position, the patient lies on the abdomen with their head turned
to one side and the hips are not flexed.

15. • 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 is useful for unconscious clients or those recovering from
surgery on 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.

16. 6. 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. An increase in
flexion of the top hip and knee provides greater stability and balance. This
flexion reduces lordosis and promotes good back alignment.

17. • 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 and comfortably position the patient
*Sacrum is a shield-shaped bony structure that is located at the base of the lumbar vertebrae
and that is connected to the pelvis. The sacrum forms the posterior pelvic wall and strengthens
and stabilizes the pelvis.in lateral position, support pillows are needed.

18. 7. 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.

19. • 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 the legs.

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

21. • 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:
• 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.
• 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.
• Hemilithotomy Position: The patient’s non-operative leg is positioned in
standard lithotomy. The patient’s operative leg may be placed in traction.
• 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.
• 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.

22. 9. 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.

23. 10. Reverse Trendelenburg’s is a patient position wherein 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.

24. 11. Knee-chest position can be in a lateral or prone position. In lateral knee-
chest position, the patient lies on their side, the torso lies diagonally across
the table, and the hips and knees are flexed. In prone knee-chest position,
the patient kneels on the table and lowers their shoulders onto the table, so
their chest and face rest on the table.
•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.

25. 12. 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.

26. • 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 on 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 pillows are required on the operating
table to support the body and reduce pressure on the pelvis, back,
and abdomen. The jackknife position also puts excessive pressure
on the knees. While positioning, surgical staff should put extra
padding for the knee area.

27. 13. 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. The patient is turned on their contralateral side with
their back placed on the edge of the table. The contralateral kidney is
placed over the break in the table or over the kidney body elevator (if
an attachment is available). The uppermost arm is placed in a gutter
rest at no more than 90º abduction or flexion.

28. • Access to the retroperitoneal area. The kidney position allows
access and visualization of the retroperitoneal area. A kidney rest or
a small pillow is placed under the patient at the location of the lift.
• Risk for falls. The patient may fall off the table at any time until the
position is secured.
• Padding and stabilization support. The contralateral arm
underneath the body is protected with padding. The contralateral
knee is flexed, and the uppermost leg is left straight to improve
stability. A large soft pillow is placed in between the legs. A kidney
strap and tape are placed over the hip to stabilize the patient.

29. 14. Dorsal Recumbent position - a position in which the patient lies on
the back with the lower extremities moderately flexed and rotated
outward. It is employed in the application of obstetrical forceps, repair of
lesions following parturition, vaginal examination, and bimanual
palpation.

30. 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 placed under the
mattress’s entire surface area and are useful for increasing back
support and body alignment.
• Foot Boots. Foot boots are rigid plastic or heavy foam shoes that
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 slight adduction
and the wrist in slight dorsiflexion.

31. • Pillows. Pillows provide support, elevate body parts and 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 substances that can
be used to shape or contour 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 increased mobility. They
also assist in rolling from side to side or sitting in bed. Check with your
agency’s policies regarding the use of side rails as they vary from state
to state.
• Trochanter Rolls. These rolls prevent the 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.

32. 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 is given.
• Patient’s response to the procedure.