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12
CHAPTER

Body Mechanics
and Positioning

Learning Objectives
Terminology
Theoretical Concepts
Musculoskeletal System 345
Skeletal Muscles 345
Joints 345
Bones 345 Unit 2: Moving and Turning Clients 356
System Alterations 345 Nursing Process Data 356
Nursing Measures 346 Procedures
Body Mechanics 346 Assessing Clients for Safe Moving
ANA Promotes Safe Handling Legislation 346 and Handling 358
Nursing Diagnoses 347 Turning to Lateral Position 359
Unit 1: Proper Body Mechanics 348 Turning to a Prone Position 359

Nursing Process Data 348

Moving Client Up in Bed 360

Procedures Moving Client with Assistance 361

Applying Body Mechanics 349

Transferring Client from Bed to
Maintaining Proper Body Alignment 351
Gurney 362

Using Coordinated Movements 352

Dangling at the Bedside 363

Using Basic Principles 352

Moving from Bed to Chair 365

Documentation 354
Using a Hoyer (Sling) Lift 367
Logrolling the Client 368
Critical Thinking Application 355
Using a Footboard 369
Expected Outcomes 355
Unexpected Outcomes 355 Placing a Trochanter Roll 369
Critical Thinking Options 355 Documentation 370
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Critical Thinking Application 371 Management Guidelines 372

Expected Outcomes 371 Delegation 372
Unexpected Outcomes 371 Communication Network 373
Critical Thinking Options 371 Critical Thinking Strategies 373
Chapter Addendum 372 Scenarios 373
Gerontologic Considerations 372 NCLEX® Review Questions 373

Learning Objectives
1. Discuss the primary function of the skeletal muscles, 7. Describe the correct placement of the canvas pieces
joints, and bones. when placing a client on the Hoyer lift.
2. Describe nursing measures that assist in preserving 8. Explain the rationale of assisted ambulation for clients.
joints, bones, and skeletal muscles. 9. Demonstrate the procedures for moving a client to
3. Describe a minimum of two principles of correct body the side of the bed and dangling a client.
mechanics. 10. Outline the steps in logrolling a client.
4. State two expected outcomes of using proper body 11. Describe requirements for lift team members.
mechanics. 12. List the pertinent data that should be charted when
5. Discuss the objectives for moving and turning clients. moving a client from the bed.
6. Compare and contrast the methods used in moving 13. Write a client care plan using at least three nursing
clients up in bed for a single nurse and when assis- diagnoses for a client requiring moving and turning
tants are available. interventions.

Terminology
Alignment: referring to posture, the relationship of body Ergonomics: physical stressors involving excessive force; i.e.,
parts to one another. lifting heavy objects or working in an awkward position.
Ambulate: walking; able to walk. Flexion: the act or condition of being bent.
Appendicular skeleton: composed of 126 bones, which Footdrop: a falling or dragging of the foot from paralysis of
include the shoulder girdle, arm bones, pelvic girdle, the flexors of the ankle.
and leg bones. Fowler’s position: head of bed is at a 45° angle; client’s knees
Assistive equipment: used to remove the manual lifting may or may not be flexed.
from client care; assumes larger proportion of client’s Gravity: the force that pulls objects toward the earth’s surface.
weight. High-Fowler’s position: head of bed is at a 60° angle; often
Axial skeleton: includes the head and trunk, which form used to achieve maximum chest expansion.
the central axis to which the appendicular skeleton is
Hoyer lift: a mechanical device that enables one person to
attached.
safely transfer a client from bed to chair.
Balance: client’s ability to maintain equilibrium.
Joint: the portion of the body where two or more bones join
Base of support: surface area on which an object rests (e.g., together.
for a client lying in prone position, the base of support
Leverage: the use of a lever to apply force.
is the entire undersurface of the body).
Ligament: a band or sheet of strong fibrous connective tissue
Body mechanics: movement of the body in a coordinated
connecting the articular ends of bones serving to bind
and efficient way so that proper balance, alignment,
them together and to facilitate or limit motion.
and conservation of energy is maintained.
Line of gravity: an imaginary line that goes from the center of
Brachial plexus: network of spinal nerves supplying arm,
gravity to the base of support.
forearm, and hand.
Manual client handling: tasks such as lifting, transferring, and
Cartilage: nonvascular, dense supporting connective tissue.
Found in joints, thorax, larynx, trachea, nose, and ear. repositioning of clients without use of assistive devices.
Center of gravity: midpoint or center of the body weight. Mobility: state or quality of being mobile; facility of movement.
In an adult it is the midpelvic cavity between the Musculo: pertaining to muscles.
symphysis pubis and umbilicus. Musculoskeletal: pertaining to the muscles and bones.
Dangle: to have a client sit on the edge of the bed with Orthoses: use of external device or special equipment to
feet in a dependent position, flat on floor, if possible. support the spine and prevent back injury.
Dorsiflexion: upward or backward flexion of a part of the Paralysis: temporary or permanent loss of function, espe-
body, such as the foot at the ankle. cially loss of sensation or voluntary motion.
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Posture: attitude or position of body. Stable: when the center of gravity is close to the base of
Prone: lying horizontal with face downward. support.
Reverse Trendelenburg’s position: mattress remains unbent, Strain: injury caused by excessive force or stretching of
but head of bed is raised and foot is lowered. muscles or tendons around the joint.
Semi-Fowler’s position: head of bed is at a 30° angle; often Trendelenburg’s position: mattress remains unbent but the
used for clients with cardiac and respiratory problems. head of the bed is lowered and the foot is raised. “Shock
Skeletal system: system of separate bones (206) bound blocks” may be used under the legs of the bed to achieve
together by ligaments and responsible for supporting, this position.
moving, and giving shape to the body. Trochanter: either of the two bony prominences below the
Sprain: injury caused by wrenching or twisting of a joint that neck of the femur.
results in tearing or stretching of the associated ligaments.

MUSCULOSKELETAL SYSTEM the framework and tensile strength for the bone. The cal-
cium salts, which are about 75% of the bone, provide
The musculoskeletal system protects the body, provides a compressional strength by filling in the matrix. As a
structural framework, and allows the body to move. The result, it is very difficult to damage a bone by twisting it or
primary structures in this system are muscles, bones, and by applying direct pressure.
joints. Bone cells include osteoblasts, osteocytes, and osteo-
clasts. Osteoblasts deposit the organic matrix; osteocytes
SKELETAL MUSCLES and osteoclasts reabsorb this matrix. Because this process
Skeletal muscles move the bones around the joints by is usually in equilibrium, bone is deposited where it is
contracting and relaxing so that movement can take place. needed in the skeletal system. If increased stress is placed
Each muscle consists of a body, or belly, and tendons, on a bone, such as the stress of continued athletic activity,
which connect the muscle to another muscle or to bone. more bone is deposited. If there is no stress on a bone, as
When skeletal muscles contract, they cause two is often the case with clients on prolonged bedrest, part of
bones to move around the joint between them. One of the bone mass is reabsorbed, or lost.
these bones tends to remain stationary while the other
bone moves. The end of the muscle that attaches to the
stationary bone is called the origin. The end of the muscle SYSTEM ALTERATIONS
that attaches to the movable bone is called the insertion. Alterations in mobility can result from problems in the
Muscles are designated flexors or extensors according musculoskeletal system, the nervous system, and the
to whether they flex the joint (decrease the angle between skin. A primary cause for alterations in muscles is inac-
the bones) or extend the joint (increase the angle between the tivity. With forceful activity muscles increase in size.
bones). For example, when the deltoid muscle contracts, it With inactivity muscles decrease in size and strength.
abducts the arm and raises it laterally to the horizontal When clients are in casts or in traction, on prolonged
position. The anterior fibers aid in flexion of the arm, and bedrest, or unable to exercise, their muscles become
the posterior fibers aid in extension of the arm. weak and atrophied.
Alterations in joints result when mobility is limited
JOINTS by changes in the adjacent tissues. When muscle move-
ment decreases, the connective tissue in the joints, ten-
Joints are the places where bones meet. Their primary
dons, and ligaments becomes thickened and fibrotic.
function is to provide motion and flexibility. Although
Chronic flexion and hyperextension can also cause
the internal structure of joints varies, most joints are
alterations in the joints. Chronic flexion can cause joints
composed of ligaments, which bind the bones together,
to become contracted in one position so that they are
and cartilage, or tissue, which covers and cushions the
unmovable. Hyperextension occurs when joints are
ends of the bones.
extended beyond their normal limits, which is usually
180°. The results of hyperextension are pain and discom-
BONES fort to the client and abnormal stress on the ligaments
Bones provide the major support for all the body organs. and tendons of the joints.
Bone is composed of an organic matrix, deposits of cal- Alterations in bone are caused by disease processes,
cium salts, and bone cells. The organic matrix provides decalcification and breaks caused by trauma, or twisting.
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Encouraging clients to stand and to walk is important you can sustain severe injuries. If you do not follow
because the body functions best when it is in a vertical posi- guidelines for promoting proper body mechanics or using
tion. Physical activity forces muscles to move and increases equipment, you are putting yourself in jeopardy. It is
blood flow, which improves metabolism and facilitates advisable that health care workers do simple exercises to
such body functions as gastrointestinal peristalsis. strengthen and stretch the abdominal muscles and mus-
cles that support the back. This will assist in preventing
NURSING MEASURES back injuries.
Low back pain is an occupational hazard for many
Nursing care measures to preserve the joints, bones, and
workers. Back injuries account for about 20% of all
skeletal muscles should be carried out for all clients who
injuries and illnesses in the workplace.
require bedrest. Positions in which clients are placed,
Nursing personnel are among the most at risk for
methods of moving, and turning should all be based on
musculoskeletal disorders. The ANA research on the impact
the principles of maintaining the musculoskeletal system
of musculoskeletal injury indicates 30% of nurses who
in proper alignment. The nurse must also use good body
acquired back pain were required to leave work. Twelve per-
mechanics when moving and turning clients to preserve
cent of nurses left the profession as a result of back pain. The
her or his own musculoskeletal system from injury.
majority of the injuries occur from manual client handling.
Proper use of body mechanics helps prevent injuries
to clients and all members of the health team. Guidelines
BODY MECHANICS that underly the implementation of body mechanics
Knowledge of a client’s body and how it moves is impor- appear below.
tant. Knowledge of your own body and what happens to
• Assume a proper stance before moving or turning
it when you care for clients with altered mobility is also
clients.
important. Before you lift or move a client, determine
the causes and consequences of the client’s illness and • Distribute workload evenly before moving or turning
implement the use of Safe Patient Handling and Manage- clients.
ment Algorithms to determine the appropriate client • Establish a comfortable height when working with
moving/transfer protocols. These guidelines also indicate clients. Keep the client as close to your body as possi-
the equipment needed for safe client transfer/moving, or ble when moving.
the need for the lift team. This knowledge enables you to • Push and pull objects when moving them to conserve
move the client without causing additional discomfort. energy.
The most common client handling approaches uti- • Use large muscles for lifting and moving, not the back
lized in the United States include: manual client lifting, muscles. Move the hip and shoulders as one unit.
education related to body mechanics, education in safe • Avoid leaning and stretching.
lifting techniques, and the use of back belts. There is
• Request assistance from others or use client-handling
strong evidence that each of these approaches is not
equipment/devices when working with heavy clients
effective in reducing caregiver injuries. Evidence based
to avoid strain.
practice indicates that use of client handling equipment/
devices, client care ergonomic assessment protocols, “NO • Avoid twisting your body.
Lift” policies, education of proper use of client handling • Maintain low back in neutral position.
equipment/devices, and client lift teams reduce injury to In addition to proper use of body mechanics, ergonomic
both clients and staff. protection and education programs must be implemented
The physical environment of the health care setting in all health care facilities to decrease risk factors related
also contributes to work-related injuries. The “tight quar- to back injuries. Whereas the use of body mechanics,
ters” and configuration of client rooms, nurses’ work equipment, and devices alone does not prevent back
areas, and equipment can affect use of appropriate body injuries and musculoskeletal disorders among nurses,
mechanics as well as equipment for moving clients. together, appropriate use of body mechanics and a safe
Trying to lift or move too much weight forces you to client handling or client care ergonomics program can
use your body incorrectly and frequently causes injuries. decrease injuries in both number and severity.
The average weight of clients who require lifting is 169
pounds. The National Institute for Occupational Safety
ANA PROMOTES SAFE HANDLING
and Health (NIOSH) states that the average worker
LEGISLATION
should not lift more than 51 pounds under controlled and
limited circumstances. Incorrect lifting puts most of the The American Nurses Association has been campaigning for
pressure on the muscles of your lower back. Because the Federal Occupational Safety and Health Administration
these muscles are not strong enough to handle the stress, (OSHA) to develop standards to control ergonomic hazards
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in the workplace for the prevention of work-related mus- include the use of assistive client handling equipment and
culoskeletal disorders. This regulation would include stip- devices and the elimination of manual client handling. As
ulations requiring health care settings to use assistive lift of March, 2006, the American Nurses Association (ANA)
and transfer equipment for client handling tasks and with its constituent member associations (CMAs) has suc-
eliminate total manual client handling. In the absence of cessfully promoted state legislation designed to protect
a national standard, the ANA established the Handle With nurses from potentially career-ending musculoskeletal
Care national campaign in 2003. This proactive plan was injuries while increasing clients’ safety and comfort.
developed to promote safe client handling and the pre- Several states have already enacted legislation that
vention of musculoskeletal disorders among nurses. requires health care facilities to develop safe client han-
As part of the campaign, the ANA is fostering the dling programs and utilize safe client handling techniques
development of client care ergonomics, programs that and equipment.

➤ Nursing Diagnoses
The following nursing diagnoses are appropriate to use on client care plans when the components are related to body mechanics.

NURSING DIAGNOSIS RELATED FACTORS

Activity Intolerance Impaired motor function, weakness or paralysis, pain

Disuse Syndrome, Risk for Debilitated state, immobility, muscle weakness, decreased motor agility
Injury, Risk for Altered mobility, impaired sensory function, prolonged bedrest
Mobility: Physical, Impaired Trauma or musculoskeletal impairment, surgical procedure, muscle weakness,
pain, decreased strength
Transfer Ability, Impaired Weakness, flacidity, amputation, decreased strength
Walking, Impaired Muscle weakness, impaired motor function, orthopedic surgery; or dysfunction

Cleanse The single most important nursing action to decrease the incidence of hospital-based infections is hand hygiene.
hands
Remember to wash your hands or use antibacterial gel before and after each and every client contact.

Identify Before every procedure, check two forms of client identification, not including room number. These actions prevent errors
client
and conform to JCAHO standards.
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UNIT ➤
1
Proper Body
Mechanics

Nursing Process Data

ASSESSMENT • Data Base
Evaluate personnel’s knowledge of the principles of body mechanics.
Evaluate personnel’s knowledge of how to use correct muscle groups for specific activities.
Assess knowledge and correct any misinformation about body alignment and how to maintain it with each
position.
Assess knowledge of physical science and application to balance and body alignment.
Assess the competency of spinal cord and associated musculature.
Assess the muscle mass of the long, thick, and strong muscles of the shoulders and thighs.

PLANNING • Objectives
To promote proper body mechanics while caring for clients
To maintain good posture, thereby promoting optimum musculoskeletal balance
To provide knowledge of the musculoskeletal system, body alignment, and balance in order to assist the
nurse in caring for clients
To correct body mechanics, promote health, enhance appearance, and assist body function

IMPLEMENTATION • Procedures
Applying Body Mechanics
Maintaining Proper Body Alignment
Using Coordinated Movements
Using Basic Principles

EVALUATION • Expected Outcomes

Correct body mechanics are used when preparing for and providing client care.
Injuries are prevented to both the nurse and the client.
Proper body mechanics facilitate client care.
Clients and nurses are not injured when nursing care is provided.
Center of gravity is maintained when lifting objects.
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Applying Body Mechanics Guidelines on Prevention

Procedure of Low Back Pain
1. Determine need for assistance in moving or turn- for Workers
ing a client. ➤Rationale: Half of all back pain is asso- • Physical exercise is recommended for prevention of
ciated with lifting or turning clients. The most low back pain. There is insufficient evidence to rec-
common back injury is strain on the lumbar ommend for or against any specific type or intensity
muscle group. of exercises.
2. Establish a firm base of support by placing both feet
flat on the floor, with one foot slightly in front of • Lumbar supports or back belts are not recommended.
the other. • Shoe inserts/orthoses are not recommended.
There is insufficient evidence to recommend for
or against insoles, soft shoes, soft flooring, or
Clinical Alert antifatigue mats.
Proper body mechanics is a myth according to the • Temporary modified work and ergonomic workplace
American Nurses Association “Handle With Care” adaptations can be recommended to facilitate
campaign. “Proper body mechanics” training does not early return to work for individuals with low back
translate well into nursing practice. Body mechanics pain.
methods primarily concentrate on the lower back for lift- • There is insufficient consistent evidence to recom-
ing and do not account for other vulnerable body parts mend physical ergonomic interventions alone for
involved in other types of client handling tasks, such as prevention of low back pain.
lateral transfers.
• Further research is necessary to determine appropri-
ate prevention in low back pain. Future studies need
to be high quality, using randomized controlled
trials.

Source: www.WG3_Guidelines.pdf.

● Manual transfers from bed to chair should be done only if client is ● Gait belts are routinely used to assist in manual transfer in most
able to assist. facilities.
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3. Distribute weight evenly on both feet.

4. Slightly bend both knees. ➤Rationale: Allows strong
muscles of legs to do the lifting.
5. Hold abdomen firm and tuck buttocks in so that
spine is in alignment. ➤Rationale: This position
protects the back.
6. Hold head erect, and secure firm stance.
7. Use this stance as the basis for all actions in moving,
turning, and lifting clients.
8. Maintain weight to be lifted as close to your body as
possible. ➤Rationale: This position maintains the cen-
ter of gravity and provides leverage that reduces
lower back strain.
9. Align the three natural curves in your back (cervi-
cal, thoracic, and lumbar). ➤Rationale: Weight of
client is evenly distributed throughout spine,
lowering risk of back injury.
10. Prevent twisting your body when moving the client.
● Use proper body mechanics whenever moving clients or objects. ➤Rationale: This prevents injury to the back.

Evidence Based Nursing Practice

Use of Back Brace to Prevent Back Injury measures have been introduced to prevent work-related
Two studies on prevention of low back pain using a back back injuries. Training, job screening, and ergonomic
support differed in their conclusions. One study, Linton modification are recommended by NIOSH, but objective
and van Tulder, researched the literature and found 27 evidence of their effectiveness alone or in combination has
investigations that were consistently negative about the been elusive and subject to many issues and problems.
use of back braces to prevent low back pain. There is These study results have culminated in a recom-
strong evidence not only that they are ineffective in pre- mendation by the European Guidelines for Prevention in
vention, but that lumbar supports or back belts are no Low Back Pain (November 2004) to promote prevention
more beneficial than either no intervention or preventa-
tive interventions; in fact, they may be detrimental. The
results of the Linton and van Tulder study were consis-
tently negative about the use of lumbar supports. The
study indicated that exercises, conversely, showed posi-
tive results in the randomized controlled trials, providing
consistent evidence of their function in prevention.
The second study, conducted at UCLA by Kraus,
McArthur, and Samaniego, found the opposite results.
The UCLA study “found compelling evidence that back
support can play an important role in helping reduce back
injuries among workers who do a lot of lifting.” The study,
completed in 1994 with 36,000 participants, indicated
that low-back injuries are reduced by one-third when
workers wear a back support. This study recommends
worker training and proper workplace ergonomics
design, and that back supports should be part of an over-
all back injury prevention program.
The National Institute of Occupational Safety and
Health reviewed the scientific findings in the UCLA
study and issued a report in 1994 that concluded the ● Use of back brace to support back and keep body in alignment is
benefit of back supports remained unproven and did not controversial, and most current studies do not support use of the
recommend that they be used. A number of preventive back brace.
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of low back pain using activity/exercise, ergonomics, and interventions. No studies indicated harmful effects of
orthosis. Physical exercise has a positive effect in pre- exercise or increased symptoms of pain.
vention of back pain. Various types of activities were
Source: Linton and van Tulder. (2001, April 1). Preventive interven-
reviewed, such as aerobic exercises, physiotherapy, and tions for back and neck problems: What is the evidence?, Spine, 26(7),
specific trunk muscle training. The researchers found no 778–787. Available at: http://www.avenco.com/UCLA-Study/ucla.html,
specific differences in pain intensity between these www.backpaineurope.org.

Maintaining Proper Body Alignment

Procedure
1. Begin with the proper stance established in the pre-
vious intervention.
2. Evaluate working height necessary to achieve
objective.
a. Test parameters of possible heights (i.e., bed moves
within an approximate range of 18 inches from
floor).
b. Establish a comfortable height in which to work;
usual height is between waist and lower level of
hip joint.
3. Test that this level minimizes muscle strain by
extending your arms and checking that your body
maintains proper alignment.
4. If you need to work at a lower level, flex your
knees. ➤Rationale: Bending over at the waist results
in back strain.
● Ensure that height of bed allows you to work without causing injury.
5. Make accommodations for working at high
surface levels. ➤Rationale: Reaching up may result
in injury to the back through hyperextension of
muscles.
6. Work close to your body so that your center 7. Use your longest and strongest muscles (biceps, quadri-
of gravity is not misaligned and your muscles are ceps, and gluteal) when moving and turning clients.
not hyperextended. ➤Rationale: This prevents back 8. Whenever possible, roll, push, and pull objects
strain. instead of lifting.

● Correct: Keep body in correct alignment when turning and reaching ● Incorrect: Do not use stretching or twisting movements when you
for objects to prevent muscle strain or back injury. reach for objects out of close proximity to your body.
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● Correct: Work close to the body so that center of gravity is not ● Incorrect: Bending over incorrectly could injure back muscles and
misaligned. cause undue strain.

Using Coordinated Movements

Procedure 2. Move muscles in a smooth, coordinated manner.
1. Plan muscle movements to distribute workload before ➤Rationale: This avoids putting strain on one muscle
you actually begin turning, moving, or lifting clients. and is more efficient.
a. Establish a clear plan of action before you begin to move. 3. Do not make jerky, uncoordinated movements.
b. Take a deep breath so oxygen is available for energy ➤Rationale: This may cause injury or frighten the
expenditure. client.
c. Tense antagonistic muscles (abdomen) to those you will 4. When you are working with another staff member,
be using (diaphragm) in preparation for the movement. coordinate plans and movements before implement-
d. Release breath and mobilize major muscle groups ing them.
(abdominal and gluteal) to do the work.

● Correct: Move muscles as a unit and in alignment rather than ● Incorrect: Do not twist or rotate upper body when working at lower
twisting. surface levels.

Using Basic Principles

Procedure c. Tense muscles, and prepare for movement.
1. Move an object by pushing and pulling to expend d. Pull toward you by leaning away from the object and let-
minimal energy. ting arms, hips, and thighs (not back) do the work.
a. Stand close to the object. e. Push away from you by leaning toward object, using body
b. Place yourself in proper body alignment stance. weight to add force.
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● Correct: Keep body in proper alignment by bending knees and ● Incorrect: Prevent injury to back muscles; for proper alignment, bend
keeping back straight when lifting objects. at knees and use leg muscles.

2. When changing direction, use pivotal movement— stance when reaching to prevent twisting or hyper-
moving muscles as a unit and in alignment, rather extension of muscles.
than rotating or twisting upper part of body. 5. Lift clients or objects with the maximum use of
3. When working at lower surface levels, do not stoop these body alignment principles:
by bending over. Flex body at knees and, keeping a. Determine that the movement is within your capability to
back straight, use thigh and gluteal muscles to perform without injury.
accomplish task. b. Place yourself in proper body alignment stance.
4. Use muscles of arms and upper torso in an c. Stand close to and grasp the object or person near the
extended, coordinated movement parallel to body center of gravity.

● Correct: Hold objects close to the body to prevent muscle strain and ● Incorrect: Holding objects away from the body may cause back strain
possible back injury. or injury.
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● Correct: When pushing an object, place yourself in proper body alignment. ● Incorrect: Standing away from object puts body out of proper alignment.

d. Prepare muscles by taking a deep breath, and set f. Carry object close to your body to prevent strain on your
muscles. back.
e. Lift object with arms or by stooping and using leg and g. Take frequent rest periods to prevent additional
thigh muscles. strain.

The Veteran’s Health Administration completed a litera-

ture review and determined that body mechanics training ➤ Documentation for
has proven to be ineffective. Body Mechanics
1. Body mechanics training alone is not effective to
prevent job-related injuries. • Injury to client resulting from poor body mechanics
2. There is no evidence that back belts are effective in • Devices needed for turning and moving
reducing risks to caregivers. • Number of personnel required for turning and moving
3. Literature does not support the myth that physically • Ways in which client assists in moving
fit nurses are less likely to be injured.
• Special requirements of client for proper body alignment,
4. The average worker should lift no more than such as support pillows
51 pounds and only under controlled circumstances.
5. The long-term benefits of proper equipment and
mechanical lifts far outweigh the costs related to
work-related injuries.
6. Staff will use the equipment when they are included
in the decision-making process for purchasing new
equipment.

Source: ANA http://www.NursingWorld.org. 2002.

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➤ Critical Thinking Application

EXPECTED OUTCOMES
• Correct body mechanics are used when preparing for and providing client care.
• Injuries are prevented to both the nurse and the client.
• Proper body mechanics facilitate client care.
• Clients and nurses are not injured when nursing care is provided.
• Center of gravity is maintained when lifting objects.

UNEXPECTED OUTCOMES CRITICAL THINKING OPTIONS

Incorrect body mechanics are used while • Identify areas of your body where you feel stress and strain.
giving client care. • Evaluate the way you use body mechanics.
• Attend an in-service program on using body mechanics appropriately.
• Concentrate on how you are using your body when moving and turning
clients.
• Position bed and equipment at a comfortable height and proximity to working
area.
• Use your longest and strongest muscles to prevent injury.
Nurse injures self while giving client care. • Wear a back brace to support back.
• Prevent future episodes of back pain by increasing physical activity and exer-
cises, changing ergonomics, and evaluating use of orthosis.
• Report any back strain immediately to supervisor.
• Complete unusual occurrence form.
• Go to health service or emergency room for evaluation and immediate care.
• Evaluate any activities that led to injury to determine incorrect use of body
mechanics.
• Prevent additional injury by obtaining assistance when needed.
• Use devices such as turning sheets or assistive devices to assist in turning
difficult clients.
Nurse uses poor body mechanics • Assess the extent of client’s injury.
and injures client. • Notify client’s physician.
• Complete unusual occurrence form.
• Carry out physician’s orders for follow-up treatment.
Due to staffing shortage, nurse is unable • Place turning sheets on bed for all clients who are difficult to move.
to obtain sufficient assistance with turning • Use principles of leverage in moving clients.
and moving clients. • Until adequate staff is available, turn and position client from side to side at
least every 2 hours.
• Use Hoyer lift.
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UNIT ➤
2
Moving and
Turning Clients

Nursing Process Data

ASSESSMENT • Data Base
Observe the client and identify ways to improve the client’s position and alignment.
Determine the client’s physical ability to assist you with positioning.
Assess appropriate mechanical device for moving clients requiring assistance.
Note the presence of tubes and incisions that alter the positioning and alignment procedures.
Assess joint mobility.
Assess skin condition with each turn.

PLANNING • Objectives
To provide increased comfort
To provide optimal lung excursion and ventilation
To prevent contractures due to constant joint flexion
To promote optimal joint movement
To help maintain intact skin
To prevent injury due to improper movement
To move and transfer clients using mechanical devices

IMPLEMENTATION • Procedures
Assessing Clients for Safe Moving and Handling Dangling at the Bedside
Turning to Lateral Position Moving from Bed to Chair
Turning to a Prone Position Using a Hoyer (Sling) Lift
Moving Client Up in Bed Logrolling the Client
Moving Client with Assistance Using a Footboard
Transferring Client from Bed to Gurney Placing a Trochanter Roll
EVALUATION • Expected Outcomes
Client’s comfort is increased.
Skin remains intact without evidence of breakdown as a result of moving and turning.
Breathing is adequate and unlabored.
Joint movement is maintained.
Footdrop is prevented.
Body alignment is maintained.
Mechanical equipment and devices are used in client transfers and repositioning as needed.
Client is moved safely using appropriate device.
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TABLE 12–1 BED POSITIONS FOR CLIENT CARE

Positions Placement Use

High-Fowler’s Head of bed 60° angle Thoracic surgery, severe respiratory conditions
Fowler’s Head of bed 45°–60° angle; hips Postoperative, gastrointestinal conditions,
may or may not be flexed promotes lung expansion
Semi-Fowler’s Head of bed 30° angle Cardiac, respiratory, neurosurgical conditions
Low-Fowler’s Head of bed 15° angle Necessary degree elevation for ease of breathing,
promotes skin integrity, client comfort
Knee-Gatch Lower section of bed (under knees) For client comfort; contraindicated for vascular
slightly bent disorders
Trendelenburg Head of bed lowered and foot raised Percussion, vibration, and drainage (PVD)
procedure; promotes venous return
Reverse Trendelenburg Bed frame is tilted up with foot of bed down Gastric conditions, prevents esophageal reflux

● High-Fowler’s position at 60° angle. ● Fowler’s position at 45°–60° angle.

● Semi-Fowler’s position at 30° angle. ● Low-Fowler’s position at 15° angle.

● Reverse Trendelenburg position. ● Trendelenburg position.

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● Elevated knee gatch. ● Angle gauge on bed.

Assessing Clients for Safe Moving and Handling

Equipment 4. Complete check list or document findings in nurses’ notes.
Mechanical equipment or devices based on assessment a. Identify client’s level of assistance.
of functional level. 1. Independent: able to perform task safely with or with-
out staff assistance or assistive devices.
Procedure 2. Partial Assist: requires stand-by assistance, cueing, or lift-
1. Perform hand hygiene. ing no more than 35 pounds of client’s weight by staff.
2. Identify client and introduce yourself. 3. Dependent: requires staff to lift more than 35 pounds
3. Explain use of assessment criteria in preparation for of client’s weight, or is unpredictable in amount of
safe moving and handling. assistance needed. Assistive devices need to be utilized.

Source: Nelson, A. VISN 8 Patient Safety Center. www.VISN8.med.va.gov/ Source: Nelson, A. VISN 8 Patient Safety Center. www.VISN8.med.va.gov/
patientsafetycenter patientsafetycenter
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b. Weight-bearing capacity. 2. Weight.

1. Full. 3. Client more than 300 pounds, must use Bariatric
2. Partial. Algorithms for assistance.
3. None. f. Identify conditions which will likely affect transfer/reposi-
c. Bilateral upper extremity strength. tioning techniques, i.e., surgical incision, fragile skin,
1. Yes. fractures, etc.
2. No.
Note: See Sample Assessment Criteria and Care Plan for Safe
d. Client’s level of cooperation and comprehension.
Patient Handling and Movement and Algorithms. (Nelson, A.
1. Cooperative: may need prompting, able to follow sim-
VISN 8 Patient Safety Center.)
ple commands.
2. Unpredictable or varies: Client’s behavior changes fre- 5. Review algorithms or appropriate use of equipment
quently, client is not cooperative, or unable to follow and devices to determine equipment necessary to
simple commands. meet client’s needs.
e. Record client’s: 6. Determine number of staff needed for moving/
1. Height. handling based on algorithms or client assessment.

Turning To Lateral Position

Equipment 4. Elevate bed to a comfortable working height.
Pillows for positioning 5. Move client to your side of bed. Put side
Lateral-assist device or friction-reducing sheet rails up, and move to other side of bed. Use
(see Table 12.3) lateral-assist device or friction-reducing
Drawsheet for trochanter roll sheet if necessary.
6. Flex client’s knees.
7. Place one hand on client’s hip and one hand on
Procedure client’s shoulder; roll onto side.
1. Identify client and perform hand hygiene. 8. Position pillow to maintain proper alignment.
2. Explain rationale for procedure to client. 9. Be sure to position client’s arms so they are not
3. Lower head of the bed completely or to a position as under the body.
low as client can tolerate. 10. Perform hand hygiene.

● Use pillows to support proper alignment. ● Lateral (side-lying) position.

Turning to a Prone Position

Equipment 3. Lower head of bed completely or to a position that
Pillows for positioning is as low as client can tolerate.
Lateral-assist device or friction-reducing sheet 4. Elevate bed to a comfortable working height.
5. Move client to side of bed away from side where
Procedure he or she will finally be positioned. Use
1. Identify client and perform hand hygiene. lateral-assist device or friction-reducing sheet if
2. Explain rationale for procedure to client. necessary.
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6. Position pillows on side of bed for client’s head, tho- 8. Reposition pillows as necessary for client’s
rax, and feet. comfort.
7. Roll client onto pillows, making sure that client’s 9. Perform hand hygiene.
arms are not under his or her body.

● Supine position. ● Prone position.

Moving Client Up in Bed

Equipment 7. Flex your knees and hips. Move feet close to bed.
Trapeze (optional) 8. Place your weight on your back foot.
Friction-reducing sheet 9. Instruct client to put arms across chest, bend legs,
and put feet flat on the bed.
Procedure 10. Shift your weight from back to front foot as you lift
1. Identify client and perform hand hygiene. client up in bed. ➤Rationale: Shifting weight reduces
2. Explain rationale for procedure to client. force needed to move client up in bed.
3. Lower head of bed so that it is flat or as low as client 11. Ask client to push with feet as you move him/her.
can tolerate.
4. Raise bed to a comfortable working height.
➤Rationale: Allows nurse’s center of gravity to assist in
turning.
5. Remove pillow and place it at head of bed.
➤Rationale: This prevents striking client’s head against
bed.
6. Place one arm under client’s shoulders and other
arm under client’s thighs. Use this method of
moving only if the client can assist with move.

● Place one arm under shoulders and other under thighs.

● Encourage client to help when moving up in bed. ● Maintain proper body alignment when moving client up in bed.
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12. Position client comfortably, replacing pillow and Note: There are several other methods of moving a client up in bed—
arranging bedding as necessary. including using assist devices such as friction-reducing sheet or total lift
13. Perform hand hygiene. devices for clients who are unable to assist with moving and turning.

Moving Client with Assistance

Equipment
Friction-reducing sheet
Procedure
1. Identify client and perform hand hygiene.
2. Explain rationale for procedure to client.
3. Lower head of bed so that it is flat or as low as client
can tolerate.
4. Raise bed to a comfortable working height.
5. Remove pillow, and place it at head of bed. ➤Rationale:
To prevent head being bumped when moved.
6. Coordinate the movements of all nurses. ➤Rationale:
One nurse is responsible for stating when to move
client, “on count of three.”
● Use friction-reducing sheet and shift weight from back to front leg
7. Position client with two nurses or staff members. when moving client up.
a. Position one nurse on each side of client. Assume broad
base of support; position front foot facing head of bed,
body slightly turned toward head of bed.
b. Assist client to flex knees, if possible. Client Lift Teams
c. Each nurse firmly grasps sheet at level of client’s upper back
with one hand and at level of buttocks with other hand. A lift team consists of two physically fit individuals compe-
d. Each nurse places weight on back foot. tent in lifting techniques, who work together to perform
e. Then with one firm, coordinated, rocking movement high-risk client transfers.
(shifting weight from back to front foot), lift client toward The individuals on the team must have no prior history
head of bed. of a musculoskeletal injury and must depend on their phys-
f. Place client in a comfortable position. ical strength and capabilities. They must have a physical
8. Perform hand hygiene. examination and an x-ray of their spine, in addition to not
having a history of back injury. They are trained on the use
of mechanical lifting devices. Several clinical trials have
been conducted on the use of client lift teams. The out-
Clinical Alert comes indicated this intervention was effective in decreas-
The ANA reports that an average health care worker ing the loss of work days, and compensable injury costs.
should lift no more than 51 pounds and only under very
controlled circumstances. It is advisable to use lifting
and transferring devices.

Cultural Competence
Different cultures may have cultural variances regarding
distance and space. When clients are being moved, trans-
ferred to a bed or gurney, client is brought close to nurse’s
body. It is important to explain the transfer process to
client, particularly Americans, Canadians, and British
clients. They may be threatened by invasion of personal
Source: Nelson, A. and Baptiste, A. Evidence-based practices for safe
space and touch. Japanese, Arabs, and Latin Americans patient handling and movement. Available at www.nursingworld.org/ojin.
aren’t as concerned about personal space. Accessed September 30, 2004.
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Evidence Based Nursing Practice

Use of Draw Sheet for Moving Clients Most low back injuries are not the result of a single
Few evidence-based studies disagree that the critical task of exposure to a high load but repeated small loads (bend-
repositioning a client in bed places caregivers at an increased ing) or a sustained load (sitting). Low back pain is shown
risk of back injury due to high spinal loads. Although the to result from repetitive motion and excessive loading.
two-person draw sheet method of repositioning clients has Source: Marras et al. A comprehensive analysis of low-back disorder risk
the lowest low-back disorder risk, spinal loads were still and spinal loading during transferring and repositioning of patients
high, thus increasing the risk of a back injury. using different techniques. Ergonomics, 42(7), 904–926, July 1, 1999.

Transferring Client from Bed to Gurney

Equipment
Transfer board: polyethylene board 3. Cover client with sheet or bath blanket and cover
about 18–22 inches board and gurney with sheets.
wide by 72 inches long 4. Position client on side of bed away from gurney in
Sheets to cover board, gurney, and client lateral position.
Bath blanket (optional) 5. First nurse supports client while second nurse places
Gurney, bed, or CT table board as close to client as possible. ➤Rationale: This allows
client to be positioned on entire board after turn.
Procedure 6. Instruct client to turn onto back, directly onto
1. Perform hand hygiene. board. Client may need assistance to turn.
2. Introduce self and explain procedure to client and 7. Place both nurses on side of gurney or bed toward
show client transfer board. ➤Rationale: To allay which client will be turned.
client’s fears of being dropped from board.

● Use handholds on board to move client to gurney; maintain proper

● Move client to side of bed in lateral position and position transfer board. body mechanics.

● Two nurses move to transfer board side of gurney before moving client. ● Remove transfer board after centering client on gurney.
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8. Assume appropriate body mechanics (broad base of 10. Center client on gurney or bed and remove board
support, one foot in front of the other, knees and by pulling board out and up using handholds along
hips flexed). Place weight on front foot. edge of board and using good body mechanics.
9. Transfer weight on count of three from front to back 11. Place side rails in UP position, or according to facil-
foot as you lift board and pull it toward you. ity policy.

Legal Alert
Back Injuries from Lifting and Transferring
A suit was filed against a large nursing home chain by nursing assistants at five Pennsylvania nursing homes. The com-
plaint with OSHA alleged they had suffered back injuries from lifting and transferring clients. After a 15-month inves-
tigation, OSHA issued citations against the nursing home for ergonomics violations under the “general duty” clause of
the Occupational Safety and Health Act. The clause states that an employer must provide employees with a workplace
free of recognized hazards that are causing or likely to cause death or physical harm. OSHA argued that transferring
clients exposed CNAs to serious injury to the upper back and upper extremities. OSHA settled with the nursing home
chain. Under the terms of the settlement the nursing home chain agreed to purchase mechanical lifting equipment at
all facilities, nationwide, and to train all workers in the use of the equipment.
Source: Mannix, Richard. Health Care Law, 2002.

TABLE 12–2 ASSISTIVE DEVICES FOR MOVING/TURNING CLIENTS

Equipment/Device Use for Client Moving/Handling

Gait belt Assists client to walk when he/she has leg strength, can cooperate, and requires minimal
assistance.
Lateral-assist devices (roller Assists clients in lateral transfers, bed-to-gurney, and reduces client-surface friction
boards, side boards, friction- during transfers, thus preventing skin breakdown and client discomfort. Friction-reducing
reducing lateral-assist devices) sheets are used to position clients in bed and in lateral transfers.
Electric beds Assists clients in lateral transfers. Position the bed so transfer surface (gurney) slightly
lower than bed to allow client to move onto new surface. Beds can be placed in high-
Fowler’s position to assist client into sitting position for easier transfer out of bed.
Nonmechanical sit-to-stand aids Assists clients with some arm strength and weight-bearing ability, and who can follow
simple directions to move out of bed. Once client stands, pulling self up by holding onto
bars, a seat flap is lowered and the client can rest on the seat. Transfers to commodes,
toilets, showers can be accomplished using this device.
Powered stand-assist device Assists clients who can bear weight on at least one leg, can follow simple instructions.
Client is instructed to place feet on footrest, while a sling is placed under arms and around
back. Legs are positioned against padded shin rest and client’s hands are placed on han-
dles. Machine will lift client to a standing position, once electronic hand control is pushed
by nurse. Device can be used to transport client to bathroom or chair.
Powered full-body lifts Assists clients who are unable to bear any weight. These lifts can also be used to pick
clients off the floor following falls. Sling is placed under client, then attached to a position-
ing bar. Client is then lifted from bed or floor. These lifts are portable or ceiling mounted.

Dangling at the Bedside

Procedure 5. Turn client onto side, keeping knees flexed, or place
1. Perform hand hygiene. bed in Fowler’s position (head elevated at 45 angle).
2. Introduce self and explain procedure to client. ➤Rationale: This position is sometimes preferred; it may
3. Lower bed to lowest position. be easier for nurse to pivot client to sitting position.
4. Move client to edge of bed and instruct client to 6. Stand at client’s hip level. Assume broad base of
bend knees. ➤Rationale: This allows client to easily support with forward foot closest to client. Flex
move legs and feet over side of bed onto floor. your knees, hips, and ankles.
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● Move client to side of bed and instruct to flex knees. ● Turn client onto side, maintaining knees in flexed position.

7. Place one of your arms under client’s shoulders and orthostatic hypotension if he/she has been on bed
other arm beneath client’s thighs near knees. rest for a period of time.
Instruct client to use arms to push shoulders up 10. Take vital signs especially if this is first time client is
from bed. ➤Rationale: This prevents client falling dangled. ➤Rationale: To determine if orthostatic
backward onto bed. hypotension is present.
8. Lift client’s thighs slightly and pivot on balls of your feet 11. Dangle client with feet flat on the floor for a few
as you move client into sitting position. Use gluteal, minutes before transferring to chair or ambulating.
abdominal, leg, and arm muscles to move client. ➤Rationale: When feet are on floor, it helps to prevent
9. Stand in front of client until client is stable in clot formation.
upright position. ➤Rationale: Client may experience

● Maintain broad base of support as you pivot client to sitting ● Dangle client with feet flat on floor for several minutes before
position. transferring to chair or ambulating.
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Moving from Bed to Chair

Equipment 8. Move client to side of bed using gait belt for sup-
Chair port. ➤Rationale: Helps stabilize client to prevent falls
Gait belt during transfer to chair.
9. Place your foot closest to chair between client’s feet.
Procedure 10. Rock client and, on count of three, assist client to
1. Identify the client and perform hand hygiene. standing position.
2. Lock bed in place. 11. Grasp gait belt firmly for safe transfer, while using
3. Place chair at head of bed. If using wheelchair, leg muscles to pivot client to chair.
remove arm and foot closest to bed to facilitate 12. Slowly lower client into chair.
transfer. 13. Position client in chair to prevent pressure areas. If
4. Lock chair wheels or have someone hold chair as client has circulatory impairment, elevate legs while
you move client. out of bed. ➤Rationale: This promotes venous return.
5. Follow steps 4–6 in skill Dangling at the Bedside. Note: It is preferable to use the nonmechanical sit-to-stand aid
6. Dangle client until he or she is stable. for transferring clients out of bed unless they require minimal
7. Give client nonslip shoes or slippers. assistance.

● When using wheelchair, remove arm and ● Pivot client to dangling position ● Move client to side of bed using gait belt for
foot closest to bed for ease of transfer. before placing feet on floor. support.

● Stand with your foot between client’s ● Grasping gait belt for safe transfer, use ● Slowly lower client into chair while hold-
feet; assist client to standing position. leg muscles to pivot client into chair. ing gait belt securely.
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Effectiveness of Safe Client Handling Using Assistive Equipment

and Devices
Client Benefits in Use of Assistive Devices
Health Care Staff Benefits and Equipment
• Use of assistive client handling equipment and devices • Reduction in client falls and skin tears, as a result of
has made manual client handling unnecessary. the new equipment and devices.
• New assistive devices control the ergonomic hazard • Clients feel more secure with transfer and ambulation
associated with lifting and transferring clients, pre- with new equipment and devices.
venting injuries to staff. • Client is more comfortable in moving and turning
• Injuries to nursing staff have decreased dramatically using the new devices and equipment.
since the advent of the new devices and equipment, • Client’s dignity is protected by using assistive equip-
leading to cost savings for facilities for worker’s com- ment and devices.
pensation benefits. • Assistive devices and equipment are selected to match
the client’s ability to assist in own movement, allowing
client more autonomy.

TABLE 12–3 SAFE CLIENT HANDLING DEVICES

Device Use

Gait belt Assist client in walking if he/she has leg

strength, can cooperate, and requires
minimal assistance.

Lateral assist device Slide boards can be used to transfer clients

from bed to gurney.

Nonmechanical sit-to-stand aid Used to assist clients who have some arm
strength and some weight-bearing ability out
of bed. Client pulls self up by holding onto
bar. Unfold a seat flap and have client sit
on seat.

(continued)
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TABLE 12–3 SAFE CLIENT HANDLING DEVICES (continued)

Device Use
Friction-reducing sheet Allows clients to be positioned in bed without
causing shearing of the skin.

Powered full-body lift Used for clients unable to bear weight. Clients
can be moved out of bed or lifted off the floor
following a fall. Ceiling-mounted lifts are also
available.

Note: Follow manufacturer’s directions for use of these assist devices.

Using a Hoyer (Sling) Lift

Equipment 15. Roll client away from you to opposite side, and
Hoyer lift base straighten out canvas pieces. Turn client to supine
2 canvas pieces: 1 large, 1 small position.
2 sets of canvas straps 16. Place U base of frame under bed on side where chair
is positioned.
Procedure 17. Lock wheels of frame. Lower side rail.
1. Check orders and client care plan. Determine that 18. Attach canvas straps from swivel bar to each canvas
lift can safely move the weight of the client. piece using hooks.
2. Explain procedure to client. ➤Rationale: Clients may 19. Place straps evenly on canvas pieces. Sling extends
be frightened by use of a mechanical device. from shoulders to knees. ➤Rationale: This supports
3. Perform hand hygiene. client’s weight equally.
4. Bring Hoyer frame to bedside. 20. Elevate head of bed.
5. Provide privacy for client. 21. Raise client by turning release knob clockwise to
6. Lock wheels of bed. close pressure valve.
7. Place client’s chair by the bed. Allow adequate space 22. Pump lift handle until client is lifted clear of the bed.
to maneuver the lift. 23. Maneuver client over the chair.
8. Raise bed to HIGH position and adjust head and 24. Lower client by turning release knob slowly
knee gatch so that mattress is flat. counterclockwise.
9. Keep side rail on opposite side in UP position. 25. Guide client into chair.
10. Roll client away from you. 26. Align client into chair.
11. Place lower edge of wide canvas piece under client’s 27. Remove straps from bar, and move lift out of
knees. the way.
12. Place upper edge of narrow canvas piece under 28. Check for client’s comfort in chair; place call bell
client’s shoulders. close at hand.
13. Raise side rail on your side of bed. 29. Perform hand hygiene.
14. Move to opposite side of bed, and lower side rail. 30. Return client to bed using reverse method.
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● Place canvas piece under client from knees ● Raise client off bed by turning release ● Use one nurse to stabilize client as sec-
to shoulders. knob clockwise. ond nurse guides client into chair.

Logrolling the Client

Equipment 5. Position two nurses on side of bed to which client
Pillows, towels, blankets for positioning will be turned. Position third nurse on other side
Turning sheet of bed.
6. Designate person at head of bed to be in charge of
Procedure coordinating move.
7. Assume correct position for client move:
1. Check order for logrolling client and client care plan
a. Nurse at head: one arm supports client’s head, second arm
as to exactly why client needs to be logrolled.
supports shoulders and neck.
2. Perform hand hygiene.
b. Second nurse: one hand grasps client’s other shoulder, the
3. Obtain sufficient assistance to complete procedure
other hand and arm around knee.
with ease. Three nurses are preferable.
c. Third nurse: on the opposite side of the bed, nurse holds
4. Place a pillow between the client’s knees before
drawsheet firmly to support torso. ➤Rationale: This main-
moving the client. ➤Rationale: To prevent adduction
tains the body in alignment.
of hip. This will prevent spinal torque.

● 1. Position nurses on each side of client ● 2. Maintain proper alignment while turning client.
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8. Instruct client to place arms across chest to keep moved at the same time. If not, injury to client’s
body straight. neck and spinal column may occur.
9. Assume broad stance with one foot ahead of the 11. Maintain client’s position in alignment with pillows,
other and knees flexed. towels, or folded blankets.
10. Rock onto back foot, and use leg and arm muscles 12. Change client’s position frequently (minimum
to move client in one coordinated movement when 2 hours) according to physician’s orders.
nurse at head of bed signals. ➤Rationale: To maintain
Note: It is recommended that a friction-reducing sheet be used
proper alignment, all of the body parts must be
instead of manual turning.

● 3. Maintain client’s position with pillow support under client’s back. ● 4. After positioning pillow, allow client to lean back for support.

Using a Footboard Clinical Alert

Equipment
Footboards are used to prevent plantar flexion. Extended
Footboard periods of plantar flexion can lead to footdrop.
Procedure
1. Provide a footboard if client is unable to place feet in
dorsal flexion or plantar flexion is continuous. 6. Put feet and ankles through range-of-motion exer-
2. Cover footboard with a bath blanket to protect feet cises every 4 hours for clients on prolonged bedrest.
from rough surfaces. 7. Observe heels and ankles frequently for signs of
3. Place footboard on bed in a place where client’s feet breakdown.
can firmly rest on it without sliding down in bed. 8. Place pillow under client’s calves (not under heels)
4. Observe legs to ensure that they are not in a flexed allowing heels to be off mattress if skin breakdown
position when feet are against the board. is assessed.
5. Tuck top linen under mattress at foot of bed, and
bring linen up over the footboard to the top of the Note: Clients are encouraged to wear high-top sneakers while on
bed. Do not drape top linen over footboard as it can bedrest, along with the footboard. ➤Rationale: Aids in preventing
easily be pulled off the bed. footdrop.

Placing a Trochanter Roll

Equipment 3. Extend blanket from greater trochanter to thigh or
knee.
Bath blanket
4. Place blanket edge under leg and buttocks to anchor.
Procedure 5. Roll bath blanket toward client by rolling it under.
1. Perform hand hygiene and place client in supine or 6. Rotate affected leg to slight internal hip rotation.
prone position. ➤Rationale: The purpose is to prevent external rota-
2. Place folded bath blanket on bed next to client. tion of the head of the femur in the acetabulum.
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7. Tighten the roll by tucking the roll under the hip

joint.
8. Allow affected leg to rest against trochanter roll. Hip
should be in normal alignment, not internally or
externally rotated. Patella should be facing upward
if client in supine position. ➤Rationale: This is used
most commonly for clients who have a muscle
weakness or paralysis of that side of the body.

Handroll Positioning
When positioning clients who are on long-term bedrest,
all areas of the body must be considered. Handrolls made
● Use trochanter rolls made from bath blankets to align client’s hips.
from folded washcloths rolled into a cone shape (or com-
mercially available) may be used to position and maintain
wrist and fingers in a functional position. The purpose is
to prevent deformity and contractures.

➤ Documentation for Moving and Turning Clients

• How often client turned or moved • Number of staff needed to complete the procedure
• Condition of skin and joint movement • Transferred by assistance devices from bed to chair, if appro-
• Unexpected problems with moving or positioning client and priate
solutions to problems • Time client was in chair or dangling at bedside
• Client’s acceptance of and feelings about the procedure • Use of a footboard or trochanter roll
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➤ Critical Thinking Application

EXPECTED OUTCOMES
• Client’s comfort is increased.
• Skin remains intact without evidence of breakdown as a result of moving and turning.
• Breathing is adequate and unlabored.
• Joint movement is maintained.
• Footdrop is prevented.
• Body alignment is maintained.
• Mechanical equipment and devices are used in client transfers and repositioning as needed.
• Client is moved safely using appropriate device.

UNEXPECTED OUTCOMES CRITICAL THINKING OPTIONS

Client unwilling to move due to fear of pain • Explain rationale and need for the procedure more thoroughly
or discomfort. • If possible, check if client can be medicated before the procedure.
• Obtain additional assistance to decrease client’s apprehension.
Client unable to assist with movement. • Use a friction-reducing sheet to provide more support for client.
• Obtain additional assistance to help with moving “dead” weight.
Client unable to maintain any type of position • Use trochanter roll to prevent external rotation of client’s hip
without assistance. • Use foam bolsters to maintain side-lying positions.
• Using folded towels, blankets, or small pillows, position client’s hands and
arms to prevent dependent edema.
Skin begins to break down. • Change client position every 2 hours.
• Check with physician for therapeutic mattress or dressings for pressure ulcer(s) care.
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CHAPTER ADDENDUM
GERONTOLOGIC CONSIDERATIONS
PHYSIOLOGIC AGE CHANGES IN THE MUSCULOSKELETAL • More susceptible to hazards of immobility—maintain
SYSTEM THAT AFFECT NURSING CARE OF THE ELDERLY own ADLs as much as possible and change position
• Contractures—muscles atrophy, regenerate slowly; every 2 hours.
tendons shrink and sclerose.
• Range of motion of joints decreases—lack of ade- AGING AND CHANGES IN ABILITY TO MAINTAIN ACTIVITY LEVELS
quate joint motion, ankylosis. • As aging occurs, there is a decrease in the rate or speed
of activity.
• Mobility level is limited—muscle strength lessens
and gait may be unsteady. • Loss of muscle mass interferes with activities that
require strength such as bending down, dressing, and
• Kyphosis occurs—cervical vertebrae may be
reaching for objects.
flexed; intervertebral discs narrow.
• Dexterity decreases, leading to a change in performing
• Bodies of thoracic vertebrae compress slowly
manipulative skills.
with aging leading to the hunchback appearance—
loss of overall height results from disk shrinkage
and kyphosis.
N URSING CARE FOR POSITIONING ELDERLY CLIENTS
• Ambulate within limitations of age.
• Bone changes—loss of trabecular bones and
bones become brittle. • Alter position every 2 hours; align correctly.
• Osteoporosis occurs as a result of calcium loss • Prevent osteoporosis of long bones by providing exer-
from the bone and insufficient replacement. cises against resistance as ordered.
• Osteoarthritis increases with age, equally affecting • Provide active and passive exercises—rest periods
men and women. This condition results in physical necessary and exercise paced throughout the day for
stress on joints as a result of long-term mechanical, the elderly.
horizontal, chemical, and genetic factors. • Provide range-of-motion exercises to all joints three
times a day.
PSYCHOSOCIAL AND PHYSIOLOGICAL CHANGES IN • Educate family that allowing the client to be seden-
ELDERLY WHO ARE IMMOBILIZE
tary is not helpful.
• At risk for confusion, depression and disorienta- • Encourage walking, which is best single exercise for
tion— keep clock and calendar in room to help the elderly.
reorient to time and place.

MANAGEMENT GUIDELINES
Each state legislates a Nurse Practice Act for RNs and • Positioning clients in bed can be assigned to all levels
LVN/LPNs. Health care facilities are responsible for of health care workers.
establishing and implementing policies and proce- • Frequently, the physical therapist is assigned to work
dures that conform to their state’s regulations. Verify with postoperative clients or clients requiring special
the regulations and role parameters for each health transfer techniques or ambulation until clients are
care worker in your facility. released to nursing.
• Before assigning staff to logroll a client or use the
DELEGATION Hoyer lift for moving a client out of bed, ensure they
• All levels of health care workers can be assigned have been properly instructed in the procedures and
to move and turn clients, and provide assistance safety issues associated with these activities.
with transfers.
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COMMUNICATION NETWORK • A team conference may be necessary if special equip-

• The RN must give specific directions to the health ment or specific activities are required by a client. This
care workers on appropriate positions for clients conference ensures all staff will be given a demonstration
on bed rest or specifics on how to transfer clients and provided information necessary for safe client care.
to a chair or gurney. • The RN must ensure that all new personnel are proficient
• Before physical therapy releases clients to nursing in transfers, logrolling and use of the Hoyer lift before
for transfer or ambulation activities, the RN must assigning them to care for clients requiring these skills.
obtain explicit information on the procedures to • It is crucial for safe client care that the RN monitors
be used. This information must be written on the health care workers when they perform logrolling or
Kardex or computer record, as well as reviewed use mechanical devices for transfer after the initial
with all staff assigned to the client. demonstration.

CRITICAL THINKING STRATEGIES

SCENARIO 1 2. How will you determine the client’s ability to
assist with his or her own care and movement in
You are assigned to a medical unit where many of the
bed?
clients require assistance moving in and out of bed.
3. For each client, identify the type of assistance he
The following clients are assigned to you for care on
or she might need; provide rationale for your
the day shift.
answer.
• Onica Jones, 89-year-old (CVA) client who has 4. Describe the body mechanics you will use when
weakness on the right side and is unable to com- moving clients; this will be based on the type of
municate but seems to understand directions. She moving that will need to be performed for each of
has been in the hospital for 4 days and will be the four clients.
transferred to a SNF this afternoon.
• James Metcalf, 60-year-old (MI) client who is SCENARIO 2
about to be discharged. However, you notice he You are assigned to care for a client who weighs 300
still has not been able to ambulate by himself. pounds. The client was out of bed for lunch and now insists
• Madeline Oscar, 70-year-old client with Parkinson’s on getting back into bed. There are no male staff members
disease and hospitalized for pneumonia. She was available to help you.
admitted last night. She has orders to be up in the The client is able to weight bear but needs maximal
chair b.i.d. assistance to stand.
• Joseph Nichols, 40-year-old client, hospitalized 1. Suggest creative resolutions to this problem.
for possible kidney stones. He is in severe pain
2. Describe the procedure you will use to transfer the
and the MD has ordered that he remain on
client from chair to bed.
bedrest until further orders.
1. Which client will you assess first? Provide 3. If mechanical devices are not available, what action
rationale for your answer. will you take?

NCLEX® REVIEW QUESTIONS

Unless otherwise specified choose only one (1) answer.
1 The most effective method for teaching student 2 According to the National Institute for Occupational
nurses principles of moving clients is to discuss Safety and Health (NIOSH), the average client weight
1. Using a back brace when lifting clients. that should be lifted by health care workers is ______
2. Instructions on safe lifting techniques using pounds.
2 to 3 nurses for heavy clients. 1. 51.
3. Education related to body mechanics. 2. 75.
4. Proper use of lift teams for moving 3. 100.
clients. 4. 169.
continued
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continued

3 Applying body mechanics includes which of the 7 During report the team leader stated the client needs
following principles? to be turned to a lateral position every two hours.
Select all that apply. You recall the best way to turn the client is to
1. Establish a base of support by placing the feet 1. Ask a second nurse to assist you in turning the
close together. client to his/her side.
2. Hold abdomen firm and bend at the waist 2. Ask the lift team to come every two hours to turn
when lifting client. the client.
3. Keep weight to be lifted as close to your body 3. Place a friction-reducing sheet under the client to
as possible when moving clients. assist in turning.
4. Align three natural curves in your back when 4. Explain to the client that he/she needs to move
moving clients. up in bed before you can assist in turning the
client to a lateral position.
4 Maintaining proper body alignment is critical
for nurses to prevent injuries when providing 8 A client is being moved from the bed to a gurney
client care. Which of the following steps would using a transfer board. The directions given to the
not be included in teaching appropriate body client include
alignment? 1. “You need to move toward the side of the bed
1. The most comfortable height at which to nearest the gurney before being placed on the
provide client care is above the nurse’s slide board.”
waist. 2. “Roll directly onto the transfer board and position
2. Flex your knees if you need to work at lower yourself on your side.”
than waist level. 3. “The nurse will place the board close to you and
3. Triceps, quadriceps and gluteal muscles are you need to roll over the edge of the board onto
used when moving and turning clients. the gurney while staying in a side-lying position.”
4. Push, pull, or roll objects instead of lifting 4. “Turn onto your back, directly onto the transfer
whenever possible. board.”
9 A client assessment indicates the client has some arm
5 If you are injured while providing client care, it is
strength and weight-bearing ability, and can follow sim-
important you immediately ple directions to move out of bed. The most appropriate
1. Complete an unusual occurrence form. assistive device to move this client out of bed is the
2. Inform charge nurse you need to go home to 1. Powered full-body lift.
rest and apply ice. 2. Powered stand assist device.
3. Report the injury to your supervisor. 3. Non-mechanical sit-to-stand aid.
4. Ask for a change in your assignment to pre- 4. Lateral assist device.
vent reinjury.
10 As part of an admission assessment, you need to
6 There is an order for a client to be placed in a determine a client’s “Safe Handling and Movement”
low-Fowler’s position. You will place the bed abilities. This assessment criteria includes
in a ______________ degree position. Select all that apply.
1. 60. 1. Weight bearing capability.
2. 45. 2. Client’s level of cooperation and comprehension.
3. 30. 3. Body Mass Index (BMI).
4. 15. 4. Client’s level of assistance.