Editing Fundamentals of Nursing (section)

== Mobility, positioning, and safe patient handling ==

=== Hazards of immobility ===

Immobility harms every body system, and most complications are preventable by nursing action.
* '''Musculoskeletal:''' muscle atrophy, contractures, foot drop, disuse osteoporosis with hypercalcemia.
* '''Cardiovascular:''' orthostatic hypotension, increased cardiac workload, venous stasis and venous thromboembolism.
* '''Respiratory:''' decreased chest expansion, pooled secretions, atelectasis, hypostatic pneumonia.
* '''Integumentary:''' pressure injury.
* '''Gastrointestinal:''' decreased peristalsis, constipation, and fecal impaction.
* '''Genitourinary:''' urinary stasis, renal calculi, urinary tract infection.
* '''Psychosocial:''' depression, disorientation, sleep disturbance, learned helplessness.

Preventive nursing interventions: reposition on a schedule, range of motion exercises, early and frequent ambulation, incentive spirometry with deep breathing and coughing every one to two hours while awake, adequate fluid and fiber, sequential compression devices and prescribed anticoagulants, and a high protein diet to support tissue integrity.

=== Positions ===

* '''Supine (dorsal recumbent):''' flat on the back. Support the lumbar curve, place a small pillow under the head, and use a trochanter roll along the outer thigh to prevent external hip rotation. Foot supports prevent foot drop.
* '''Prone:''' on the abdomen, head turned to the side. Promotes hip extension. Poorly tolerated by patients with cardiac or respiratory compromise.
* '''Lateral (side lying):''' pillow between the knees and supporting the upper arm to prevent internal rotation and adduction.
* '''Sims:''' semiprone left side lying with the upper leg flexed. The position of choice for enema administration and rectal suppository insertion because it follows the natural curve of the sigmoid colon.
* '''Fowler variations:''' low or semi Fowler at 30 to 45 degrees, Fowler at 45 to 60 degrees, high Fowler at 60 to 90 degrees. High Fowler maximizes lung expansion and is used for dyspnea and for feeding.
* '''Trendelenburg:''' head lower than feet. Rarely used and contraindicated with increased intracranial pressure.
* '''Modified Trendelenburg:''' flat with legs elevated, sometimes used for hypotension or shock.
* '''Orthopneic:''' sitting up, leaning forward over a bedside table. Relieves severe dyspnea by allowing maximal chest expansion.

Position specific safety notes: elevate the head of the bed to at least 30 degrees for any patient receiving enteral feeding and keep it elevated for 30 to 60 minutes afterward to prevent aspiration. For pressure redistribution, however, avoid sustained head elevation above 30 degrees, because higher angles increase shear at the sacrum. Reposition patients in bed at least every two hours and patients sitting in a chair at least every hour, or teach chair bound patients to shift weight every 15 minutes.

=== Pressure injury prevention ===

Risk is assessed with the Braden Scale, which scores six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction and shear). Lower scores mean higher risk, and a score of 18 or less generally indicates risk in adults.

Staging in brief:
* '''Stage 1:''' intact skin with nonblanchable erythema.
* '''Stage 2:''' partial thickness loss of dermis, shallow open ulcer or intact or ruptured serum filled blister. No slough or eschar.
* '''Stage 3:''' full thickness loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
* '''Stage 4:''' full thickness loss with exposed bone, tendon, or muscle.
* '''Unstageable:''' the base is obscured by slough or eschar, so depth cannot be determined.
* '''Deep tissue pressure injury:''' persistent nonblanchable deep red, maroon, or purple discoloration, or a blood filled blister, over intact or nonintact skin.

Prevention: repositioning schedule, pressure redistribution surfaces, heel offloading with pillows under the calves so the heels float, keeping skin clean and dry, moisture barrier products, adequate protein and calorie intake, and avoiding massage over bony prominences or reddened areas. Do not use donut or ring cushions, which concentrate pressure at the rim.

=== Ambulation and assistive devices ===

* Use a gait belt for any patient at risk of falling. Grasp the belt from underneath, keep the patient close to your center of gravity, and walk slightly behind and to the weaker side.
* '''Cane:''' hold on the strong or unaffected side. Advance the cane and the weak leg together, then step with the strong leg.
* '''Walker:''' a standard walker is lifted and set down about one step ahead, then the patient steps into it. The patient should not lean over the walker or pull up on it to stand.
* '''Crutches:''' the axillary pad should sit two to three finger widths below the axilla, and weight is borne on the hands, not the axillae, to prevent brachial plexus injury. A three point gait is used when one leg cannot bear weight.
* '''Stairs:''' the strong leg goes up first and the weak leg goes down first. A common memory aid is "up with the good, down with the bad."
* '''Transfers:''' move the patient toward the stronger side, lock the wheels, lower the bed, position the chair at a slight angle, and dangle the patient at the bedside first to check for orthostatic symptoms.

=== Body mechanics and safe handling ===

Widen the base of support, bend at the knees and hips rather than the waist, keep the load close to the body, avoid twisting by pivoting the feet, push rather than pull when possible, and raise the bed to waist height. Use mechanical lifts and additional staff for dependent patients. Injury prevention for the nurse is a patient safety issue as well, because a nurse who drops a patient causes harm.

=== Range of motion ===

Active range of motion is performed by the patient and maintains strength and joint flexibility. Active assistive range of motion is performed with partial help. Passive range of motion is performed by the nurse for a patient who cannot move the joint, and it maintains flexibility but does not build strength. Move joints slowly and smoothly to the point of resistance, never to the point of pain, support the joint above and below, and perform each movement approximately five times, generally two to three times daily.