07.01 Positioning

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Overview

  1. Positioning
    1. Reasons for positioning
    2. Common types
    3. Other types

Nursing Points

General

  1. Reasons for positioning
    1. Identify Needs
    2. Response to a need
    3. Think “form and function”
  2. Common Types
    1. Fowlers
      1. Elevation of the head of bed
        1. Degree dependent on the problem or complaint
        2. Higher degree indicates better thoracic expansion
        3. Decreases likelihood of aspiration
      2. Low Fowler’s
        1. 15°-30°
      3. Semi-Fowler’s
        1. 30°-45°
      4. Fowler’s
        1. 45°-60°
        2. Most common position
      5. High Fowler’s
        1. 60°-90°
        2. Promotes best chest expansion
    2. Flat types
      1. Supine
        1. Face up
        2. Most common
      2. Prone
        1. Face down
        2. Used commonly in surgery
        3. Also used with specialty beds like the Roto-Prone for respiratory disease
      3. Flat
        1. Used for spinal precautions
      4. Trendelenburg
      5. Trendelenburg
        1. Used for certain procedures
      6. Reverse Trendelenburg
        1. Used to promote gastric emptying
  3. Others
    1. Sims position
      1. Used for pregnant patients or ideal for suppository administration
    2. Dorsal recumbent
      1. Lying flat, but with arms overhead
      2. Used most commonly for abdominal exams
    3. Lithotomy
      1. Used in pelvic exams
      2. More commonly used by providers, but still used by nurses for dilation exams

Assessment

  1. Needs of patient may change ordered position.
    1. Use nursing judgment
    2. Promote prioritization
    3. Discern patient’s primary ABC needs in patient positioning
      1. Don’t sacrifice airway because of an order
  2. Take heed of any cervical or spinal precautions
  3. Assess patient’s pain and comfort needs
    1. Consider this when using interventions like traction

Therapeutic Management

  1. All positioning can be implemented unless there is a strict order
  2. Use additional resources such as UAPs or other RNs to properly position a patient
  3. Promote airways, breathing, circulation priority
    1. Consider aspiration risks

Nursing Concepts

  1. Safety
  2. Patient-Centered Care
  3. Comfort
  4. Clinical Judgment

Patient Education

  1. Educate patient on need for turning to offset pressure if capable
  2. Explain to patient that certain positions are needed
  3. Walk through with your patient the different maneuvers for patient positioning

Reference Links

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Video Transcript

In this lesson, we’re going to take a look at patient positions.

In this lesson, we’re really going to focus on the high points of patient positioning. So let’s look at some reasons as to why we use certain patient positions.

First off, we use them as a response to patient need. If a patient has a need to get better oxygen, then we can put them in positions that promote better chest expansion, which helps with oxygenation. . If we see our patient has a need that we have to protect their airway because they might throw up, and we want to prevent aspiration, then we can also sit them up.

You’ll also need to put your patients in certain positions for procedures. If they need a CT scan, they’ll have to be ok lying flat, which could be a problem for a patient with a respiratory issue, so we have to use our nursing judgment here too. Also, we can adjust our patients position for comfort.

But the biggest thing you can think to do is think about form and function of the position. If I put my patient in this position, what is going to happen to blood flow, position of organs, stuff like that. Or you can think about it the other way. I need to do x, y and z for my patient – which position is best? So let’s look at some positions.

Fowler’s position is pretty much going to be your go-to positioning for the majority of your patients. All you need to know is that the positioning is an indication of how high the bed is and we do this here.

Low Fowler’s position is where the head of the bed is between 15 and 30 degrees. Now just because they’re 15 to 30 degrees, they’ll feel almost flat, even though they aren’t. So if your patient has a hard time breathing, make sure you don’t put them in this position.

Semi-Fowler’s is a 30-45 degree head of the bed. You’ll pretty much alternate between Semi-Fowler’s and Fowler’s position. You’ll probably commonly see this in patients that have had abdominal surgeries and those with NG tubes, and they may even sit higher than that.

Fowler’s position is your go-to. This is 45-60 degrees, and your High-Fowler’s is going to be 60-90 degrees. Your patients will probably feel like they’re about to fall over. This is a great position to get them in if they can’t quite get out of bed, but they need to be upright like they’re sitting in a chair.

There are some big takeaways here though. You want to sit your patients up higher if you need to get them to improve their breathing status or oxygenation. So if your patient is satting high 80’s, sit them up first. Just remember, the higher you go, the better the chest expands, to a degree. You can also go to far, so be sure not to go too high because it can increase the pressure in the abdomen. Also, Fowler’s and High-Fowler’s really decrease the likelihood of aspiration because these positions encourage the stomach to empty its contents. But Fowler’s isn’t for every patient, so let’s take a look at some others.

So when we talk about flat types of positions, what we’re really talking about is the relation of the back of the patient to the bed.

As you can see here, supine is where the patient’s back is against the bed and the front part of the patient’s exposed.

Prone is the opposite. When a patient is prone, they’re lying on their abdomen.

And when I say flat, what I’m talking about is that they are 0 degrees at the hips, or there is no bend in the waist. You can have a patient who is supine and Fowler’s. The first two positions really just talk about if the patient is on their back or on their belly. You can have combinations of these positions based on the needs of your patient.

Ah, good ole Trendelenburg, which you’ll hear people always call “Trend.”

Basically, your patient is flat, and it just tells you that you need to change the patient’s head higher or lower than their feet.

Standard Trendelenburg is this guy, feet above head. You might hear older nurses say that this position really helps to promote bloodflow back to the heart, but the truth is the only time you’ll really see this is if a patient is getting a procedure like a central line or if you need to move a heavy patient up in bed. When you use this position, you utilize gravity pulling the patient’s head toward the head of the bed, using help from other providers. Using this maneuver is really efficient. Just be sure to know the difference between Trendelenburg and reverse Trendelenburg.

Reverse Trendelenburg is the opposite. Head above the feet. So, remember back to the patient that we talked about lying flat that can’t bend at the waist. You would use this guy here. You get the head of the patient way up here to promote expansion (because all of the organs are starting to shift down because of gravity), but you’re still keeping your patient flat. It also helps prevent aspirations for your patients who can’t bend as well. We use this position for spinal precaution patients all the time. Those patients can’t bend or twist, so lying flat, but elevating their head…that’ll promote chest expansion while not compromising their spinal position.

Now let’s look at some less common positions.

You’re not really going to see these positions unless you’re in some specialized areas like OR, or gynecology or even L&D, but you need to know them because sometimes they’ll help you out.

Sims’ position is basically a side-lying position with one knee up toward the chest. This one is really common for pregnant women, but also is really helpful if you need to give a suppository or enema because it puts the patient in a much more comfortable position. You can also use his position for your patient’s who are recovering after surgery or even your patients who are throwing up – this will prevent aspiration.

Dorsal recumbent is another one of those OR positions, or a rare one if you need to get your patient more comfortable. It’s basically flat, or supine, but the arms are above the patient’s head and it relaxes the patient’s abdomen. What you need to know here is that they’re basically supine.

Lithotomy is also one of those positions that you’ll see in pretty much specialized areas like L&D. This is it here. Supine, with the legs and hips raised to promote better reproductive access for the provider.
Ok let’s recap:

Know your different types of positions and what’s appropriate. If you have a spinal patient, and your order is for High-Fowler’s, question it. Use your judgment.

Use positions to promote and encourage safety and priority. If you have an order for Semi-Fowlers and you need to sit your patient up high because they’re decompensating, then do it.

There’s no one size fits all position. Every patient has different needs, so accomodate for their needs and comfort.

Think “form and function”. Recognize that you may have to put your patient in a position that may be a little uncomfortable, but it may make the procedure go more quickly, and as long as you don’t risk any of their safety needs, then you’re doing right by your patient.

That’s it for our lesson on patient positioning. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!

Read more

  • Question 1 of 10

The nurse is caring for a client who is being hospitalized for illness. The nurse is repositioning the client into the Trendelenburg position. This position is best used for a client with which condition?

  • Question 2 of 10

A nurse is caring for a client that is healing from an Achilles tendon surgery. While practicing active range of motion with the client, the nurse notes that the client is still unable to point the toes up toward the ceiling. The nurse should chart this as the client being unable to do which of the following?

  • Question 3 of 10

The nurse is caring for a client who has just had a bronchoscopy. In which of the following positions should the nurse position this client?

  • Question 4 of 10

A client presents to the ER complaining of shortness of breath. The client is able to get 2-3 words at a time between breaths. They are in the tripod position and keep saying, “Help me.” What is the priority nursing intervention for this patient?

  • Question 5 of 10

A nurse is positioning a client on the table in the operating suite while preparing him for surgery. Which of the following principles would the nurse follow when properly positioning this patient? Select all that apply.

  • Question 6 of 10

A client just returned from the OR after a gastrectomy. What position would be most appropriate for the client after this particular surgery?

  • Question 7 of 10

A client who underwent neurosurgery must remain prone in bed for the next 24 hours. Which of the following principles should the nurse adhere to when positioning this client in bed? Select all that apply.

  • Question 8 of 10

A nurse is caring for a 35-year-old client who has been diagnosed with hypovolemic shock as a result of severe hemorrhage. In which position should the nurse place this client to promote optimal circulation?

  • Question 9 of 10

A nurse is assisting the provider with a lumbar puncture on a client with potential meningitis. Which actions are part of assisting with a lumbar puncture? Select all that apply.

  • Question 10 of 10

A nurse has positioned a client in the high Fowler’s position for an intervention. For which intervention is this position useful? Select all that apply.

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