Positions to Ensure Safety and  When transferring a client onto - Position the client with the head of

Comfort a stretcher a slide board is the bed elevated at least 30

Guidelines for Positioning more appropriate degrees (semi-fowler’s position),
 Safe and appropriate manner  Tighten abdominal and gluteal with the affected arm elevated on
to provide safety and comfort muscles in preparation for the the pillow to promote lymphatic
move fluid return after the removal of
 Select a position that will
 Person with the heaviest load axillary lymph nodes
prevent the development of
complications related to an coordinates efforts of the team - Turn the client only to the back
existing condition, prescribed involves by counting to three and unaffected side
treatment or medical or surgical Integumentary System Perineal and Vaginal Procedures-
procedure  Autograft: after surgery, site is place the client in the lithotomy
Body Mechanics (Ergonomics) For immobilized usually for 3 to 7 days position
Health Care Workers to provide the time needed or the Endocrine System
 When planning to move a graft to adhere and attach to the Hypophysectomy – removal of the
client, arrange for adequate wound bed pituitary gland or hypophysis
help. Use mechanical aids if  Burns of the face and the head: - Elevate the head of the bed to
help is available elevate the head of the bed to prevent increased ICP or
 Encourage client to assist as prevent or reduce facial, head and Intracranial Pressure
much as possible tracheal edema Thyroidectomy – removal of the
 Keep back, neck and pelvis  Circumferential burns of the thyroid
and feet aligned. Avoid twisting extremities: elevate the
- Place the client in the semi-
 Flex knees and keep feet wide extremities above the level of the
heart to prevent or reduce fowler’s position to reduce
apart swelling and edema in the neck
 Position yourself close to the dependent edema
area
client  Skin graft: elevate and
- Sandbags or pillows may be
immobilize the graft site to prevent
 Use your arms and legs and used to support the client’s
movement and shearing of the
not your back head or neck
graft and disruption of tissue;
 Slide client toward yourself - Avoid neck extension to
avoid weight bearing
using pull sheets decrease tension on the suture
Reproductive System
line
Mastectomy
Gastrointestinal System 3 hours to provide Rectal Enema and Irrigations
Hemorrhoidectomy pressure to the site and - Place the client in the left SIM’s
- Assist the client to a side lying prevent bleeding position to allow the solution to
position to prevent pain and Paracentesis – removes fluid in the flow by gravity in the natural
bleeding peritoneal cavity direction of the colon
Gastroesophageal Reflux Disease - Client is usually positioned in a Sengstaken-Blakemore and
- Reverse Trendelenburg’s semi-fowler’s position in bed or Minnesota Tubes
sitting upright on the side of the - Not commonly used because
position may be prescribed to
bed or in a chair with the feet they are uncomfortable for the
promote gastric emptying and
supported; client is assisted to client and can case
prevent esophageal reflux
a position of comfort following complications, but their use
Liver Biopsy the procedure may be necessary when other
 During Biopsy Nasogastric Tube (NGT) Insertion interventions are not feasible
o Position the client supine, - If prescribed, maintain
- Position the client in high-
with the right side of the elevation of the head of the bed
fowler’s position with the head
upper abdomen exposed to enhance lung expansion and
tilted forward
o Client’s right arm is reduce portal blood flow,
- This positon will assist to close
raised and extended permitting effective
the trachea and open the
behind the head and over esophagogastric balloon
esophagus
the left shoulder tamponade
o The liver is located on the NGT Irrigations and Tube
Feedings Linton-Nachlas Tube- 2 ports
right side, the position
provides for maximal - Elevate the head of the bed 30- Sengstaken-Blakemore Tube- 3
exposure of the right 45 degrees (semi-fowler’s to ports
intercostal spaces (ICS) fowler’s position to prevent Minnesota- 4 ports
o Assist the client into a aspiration Chronic Obstructive Pulmonary
right lateral (side lying - Maintain head elevation for 1 Disease (COPD)
position) hour after an intermittent - In advanced setting, place the
o Place a small pillow or feeding client in a sitting position,
folded towel under the - The head of the bed should leaning forward, with the
puncture site for at least remain elevated for continuous client’s arms over several
feedings
 pillows or on over bed table; of the bed elevated about 45 - To promote graft patency after
this position will assist the degrees (fowler’s position) procedure, bed rest usually is
client to breathe easier - After the procedure, assist maintained for approximately
Laryngectomy client to a position of comfort 24 hours and the affected
- Place the client in a semi- Abdominal Aortic Aneurism (AAA) extremity is kept straight
fowler’s or fowler’s position to Resection - Limit movement and avoid
maintain a patent and minimize - After surgery, limit elevation of flexion of the hip and knee
edema the head of the bed to 45 Cardiac Catheterization
Bronchoscopy Post Procedure degrees (fowler’s position) to - If the femoral artery was
- Place the client in a semi- avoid flexion of the graft accessed for procedure, the
fowler’s position to prevent - The client may be turned from client is maintained on bed rest
choking or aspiration resulting side to side for 4 to 6 hours; the client may
from an impaired ability to Amputation of the Lower turn from side to side
swallow Extremities - The affected extremity is kept
- During the first 24 hours after straight and the head is
Postural Drainage
amputation, elevate the foot of elevated no more than 30
- The lung segment to be degrees (some HCPs prefer
drained should be in the the bed (the stump is
supported with the pillows but the flat position) until
uppermost position; homeostasis is adequately
Trendelenburg’s position may not elevated because of the
risk of flexion contractures) to achieved
be used
reduce edema Peripheral Arterial Disease
Thoracentesis
- Consult with the health care - Because swelling can prevent
- During the procedure, to provider (HCP) and if arterial blood flow, clients may
facilitate removal of fluid from prescribed, position the client in be advised to elevate feet at
the pleural space, position the a prone position twice a day for rest but should not raise legs
client on the edge of the bed 20-30 minutes’ period to stretch above the level of the heart
and leaning over the bed side muscles and prevent flexion because extreme elevation
table with the feet supported on contractures of the hip slows arterial blood flow
a stool or lung in bed on the - Some clients may be advised
Arterial Vascular Grafting of an
unaffected side with the head to maintain slightly dependent
Extremity
position (wherein the extremity
 or legs is below the level of the - Post op: elevate the head of Cerebral Angiography
heart like sitting or standing) to the bed (semi fowler’s to - Maintain bed rest for the length
promote perfusion fowler’s position) of time as prescribed
- Claudication- pain of lower - Position client on the back or - The extremity into which the
extremity related to sustained the non-operative side to contrast medium was injected
exercise, cold feet, pain when prevent the development of is kept straight and immobilized
you walk edema at the operative side for about 6-8 hours
Deep Vein Thrombosis Retinal Detachment Brain Attack (Stroke)
- If the extremity is red, - If detachment is large, bed rest - In clients with hemorrhagic
edematous, and painful, and bilateral eye patching to strokes, the head of the bed is
traditional heparin sodium minimize eye movement and usually elevated to 30 degrees
therapy may be initiated. Bed prevent extension of the to reduce intracranial pressure
rest with leg elevation may also detachment and to facilitate venous
be prescribed for the client - Restriction in activity and drainage
- Client receiving low molecular positioning following repair of - For clients with ischemic
weight heparin usually can be the detachment depends on strokes (Mild Strokes), the
out of bed after 24 hours if pain the HCP’s preference and the head of the bed is usually kept
level permits surgical procedures performed flat
Varicose Veins Neurological System - Maintain the head in midline
- Leg elevation above heart level Autonomic Dysreflexia position, neutral position to
usually is prescribed; the client - Elevate head of the bed to high facilitate venous drainage from
also is advised to minimize fowler’s position to assist with the head
prolonged sitting or standing the adequate ventilation and - Avoid extreme hip and neck
during daily activities assist in the prevention of flexion; extreme hip flexion may
Venous Insufficiency and Leg hypertensive stroke increase intrathoracic pressure;
Ulcers whereas extreme neck flexion
Cerebral Aneurysm
prohibits venous drainage from
- Leg elevation is usually - Bed rest is maintained with the the brain
prescribed head of the bed elevated 30 to
Craniotomy
Sensory System 45 degrees to prevent pressure
on the aneurysm side - Client should not be positioned
Cataract Surgery
on the site that was operated
 on, especially if the bone flap edge of the examining table, - Avoid extreme internal and
has been removed, because the knees flexed up to the external rotation
the brain has no bony covering abdomen and the neck flexed - Avoid adduction; in most cases
on the affected side so the chin is resting on the side-lying is permitted as long
- Elevate the head of the bed 30 chest as an abduction pillow is in
to 45 degrees and maintain the - After the procedure, place the place; some surgeons allow
head in a midline, neutral client in the supine position for turning to only one side
position to facilitate venous 4 to 12 hours as prescribed - Maintain abduction when the
drainage from the head Spinal Cord Injury client is in a supine position or
- Avoid extreme hip and neck - Immobilize the client on a positioned on the non-operative
flexion spinal backboard with the head side
Laminectomy in a neutral position, to prevent - Place a pillow between the
- Logroll the client incomplete injury to becoming client's legs to maintain
- When the client is out of the complete abduction; instruct the client
bed, the client’s lack back is - Prevent head flexion, rotation not to cross the legs
kept straight with the feet or extension; the head to - Check the health care
resting comfortably on the floor immobilized with a firm padded provider's (HCP's) prescriptions
cervical collar regarding elevation of the head
Increase Intracranial Pressure
- Logroll the client; no part of the of the bed and hip flexion
(ICP)
body should be twisted or Device Used for Proper
- Elevate the head of the bed 30
turned, nor should the client be Positioning
to 45 degrees and maintain the
allowed to assume a sitting 1. Pillows
head in midline, neutral
position 2. Sandbags
position to facilitate venous
drainage from the head Musculoskeletal System 3. Trapeze bar
- Avoid extreme hip and neck Total Hip Replacement 4. Wedge pillow
flexion 5. Trochanter rolls
- Positioning depends on the
6. Hand rolls
Lumbar Puncture surgical techniques used
7. Foot boots
- During the procedure, assist (anterior or posterior
8. Bed boards
the client to the lateral position approach), the method of
9. Hand-wrist splints
with the back bowed at the implantation and the prosthesis
10. Side rails
Bed Boards during activity, coughing or the client perform upper arm
- These plywood boards are deep breathing strengthening exercises
placed under the entire surface - Should be of the appropriate Trochanter Rolls
area of the mattress and are size for the body part to be - These rolls prevent external
useful for increasing back positioned rotation of the legs when the
support and body alignment Sandbags client is in the supine position
Foot Boots - Soft devices filled with a - To form a roll, use a cotton
- Made of rigid plastic or heavy substance that can be shaped bath blanket or sheet folded
foam and keep the foot bleed to body contours to provide lengthwise to a width extending
at the proper angle support from the greater trochanter of
- Should be removed 2-3 times a - Immobilize extremities and the femur to the lower border of
day to assess skin integrity and maintain specific body the popliteal space
joint mobility alignment Wedge Pillows
Hand Rolls Side Rails - Triangular pillow that is made
- Maintain fingers in a slightly - Bars positioned along the sides of heavy foam and is used to
flexed and functional position of the length of the bed maintain the legs in abduction
- Keep the thumb slightly - Ensure client safety and useful following total hip replacement
adducted in opposition to the for increasing mobility surgery
fingers - Provide assistance in rolling Types of Joint Movements
from side to side or sitting up in Flexion - decreasing the angle of the
bed joint (ex. Bending the elbow)
Hand-wrist Splints
Trapeze Bar Extension - increasing the angle of
- Individually molded for the
client to maintain proper - This bar descends from a the joint (ex. Straightening the arm at
alignment of the thumb in slight securely fastened overhead bar the elbow)
adduction and the wrist in slight attached to the bed frame Hyperextension - further extension
dorsiflexion - Allows client to use the upper or straightening of a joint (ex. Bend
extremities to raise the trunk off the head backwards)
Pillows
the bed, assist in transfer from Abduction - movement of the bone
- Provide support, elevate body bed to a wheelchair and helps away from the midline of the body >
parts, splint incisional areas,
and reduce postoperative pain
Adduction - movement of the bone Female: 4.2-5.4 - The PT measures the amount
toward the midline of the body million/L of time it takes in seconds for
Rotation - movement of the bone Coagulation Studies clot formation and is used to
around its central axis Bleeding Time monitor response to warfarin
Circumduction - movement of the sodium (Coumadin) therapy or
- Assesses overall hemostatic
distal part of the bone in a circle to screen for dysfunction of the
function (platelet response injury
while the proximal end remains fixed extrinsic clotting system
and vasoconstrictive ability)
resulting from liver disease,
Eversion - turning the sole of the - Useful in detecting disorders of
Vitamin K deficiency or
foot outward by moving the ankle platelet function disseminated intravascular
joint Nursing Considerations: coagulation
Inversion - turning the sole of the 1. Validate that the client has not - PT value is within 2 seconds of
foot inward by moving the ankle joint been receiving anticoagulants, the control is considered
Pronation -moving the bones of the aspirin, or aspirin containing normal
forearm so that the palm of the hand products for 3 days prior to the - INR - frequently used test to
faces downward when held in front test measure the effects of oral
the body 2. For clients with bleeding anticoagulants
Supination - moving the bones of tendencies a pressure dressing Nursing Consideration
the forearm so that the palm of the may be needed post testing
1. If a PT is prescribed, baseline
hand faces upward when held in 3. Inform the client that punctures
specimen should be drawn
front the body are made to measure the time
before anticoagulation therapy
Normal Values it takes for bleeding to stop
is started; note the time of
Bleeding Time 1-9 mins Prothrombin Time (PT) and collection on the laboratory
Prothrombin 10-13 seconds International Normalized Ratio form
Time (INR) 2. Provide direct pressure to the
Hematocrit Male: 42-52% - Prothrombin is a vitamin K venipuncture site for 3-5
Female: 36-48% dependent glycoprotein minutes
Hemoglobin Male: 13.5-16 g/dl produced by the liver that is 3. Diets high in green leafy
Female: 12-16 g/dl necessary for fibrin clot vegetables can increase the
Platelet 150, 000- 400, 000 formation absorption of vitamin K, which
RBC Male: 4.5-6.2 million/L shortens the PT
 4. Orally administered - A blood test that measures clot 1. Provide direct pressure to the
anticoagulation therapy usually formation and lysis that results venipuncture site for 3-5
maintains the PT at 1.5 to 2 from the degradation of fibrin minutes
times the laboratory control - Helps to diagnose the 2. The aPTT should be between
value presence of thrombus in 1.5 to 2.5 times normal when
5. If the PT value is longer than conditions such as I deep vein the client is receiving heparin
30 seconds in a client receiving thrombosis (DVT), pulmonary therapy
warfarin therapy, initiate embolism or stroke; it is also 3. If the aPTT value is prolonged
bleeding precautions used to diagnose disseminated (longer than 90 seconds) in a
Platelet Count intravascular coagulation client receiving IV heparin
- Platelets function in hemostatic (DIC) and to monitor the therapy, initiate bleeding
effectiveness of the treatment precautions
plug formation, clot retraction
4. If the client is receiving
and coagulation factor Activated Partial Thromboplastin
intermittent heparin therapy,
activation Time (APTT)
draw the blood sample 1 hour
- Platelets are produced by the - Evaluates how well the before the next scheduled dose
bone marrow to function in coagulation sequence (intrinsic
hemostasis Erythrocytes Studies
clotting system) is functioning by
Nursing Considerations: measuring the amount of time it Hemoglobin and Hematocrit
1. Monitor the venipuncture site takes in seconds for recalcified - Hemoglobin is the main
for bleeding in clients with citrated plasma to clot after partial component of erythrocytes and
known thrombocytopenia (low thromboplastin is added to it serves as the vehicle for
blood platelet count) - The test screens for deficiencies transporting oxygen and
2. High altitude, chronic cold and inhibitors of all factors, except carbon dioxide
weather and exercise increase factors VII and XIII - Hemoglobin determinations are
platelet count - Usually, the aPTT is used to important in identifying anemia
3. Bleeding precautions should be monitor the effectiveness of > Hematocrit represents red
instituted in clients with low heparin therapy and screen for blood cell (RBC) mass and is
platelet count coagulation disorders an important measurement in
D-Dimer Test - Value: 20-36 seconds, depending the identification of anemia or
on the type of activator used polycythemia or erythrocytosis
(↑ RBC)
Nursing Considerations
 - Nursing consideration: Fasting and indirectly aids in the return - Nursing consideration: Fasting
is not required of carbon dioxide to the lungs is not necessary, but a fatty
RBC Count (Erythrocytes) - Aids in diagnosing anemias meal may cause plasma
- RBCs function in hemoglobin and hemolytic disorders alterations
transport, which results in - Normal value: Male 65-175 Serum Gastrointestinal Values
delivery of oxygen to the body mcg/dL. Female 50-170 Amylase 80-180 IU/L
tissues mcg/dL Direct: 0-0.4md/dl
- RBCs are formed by the red - Nursing Consideration: Level of Bilirubin Indirect: 0.2-0.8 mg/dl
bone marrow, have a life span of iron will be increased if the (serum) Total: 0.3-1 mg/dl or lower
120 days and are removed from client has ingested iron before than 1.5 mg/dl
the blood via the liver, spleen the test ABG Values
and bone marrow SOURCE OF IRON PaCo2 35-45
- The RBC count aids in 1. Meat pH 7.35-7.45
diagnosing anemias and blood 2. Liver HCO3 22-26 mEq/L
dyscrasias 3. Dark green vegetables Pa O2 80-100 mmHg
- The RBC count evaluates the 4. Breads and cereals SaO2 96-100%
ability of the body to produce 5. Dried fruits
AMYLASE
RBCs in sufficient numbers 6. Egg yolk
- Nursing consideration: Fasting is 7. Legumes - This enzyme, produced by the
not required 8. Lentils pancreas and salivary glands,
ERYTHROCYTE SEDIMENTATION aids in the digestion of complex
Normal Values carbohydrates and is excreted
- Female adult: 4-5.5 million RATE
by the kidneys
cells/μL (microliter) - A nonspecific test used to - In acute pancreatitis, the
- Male: 4.5-6.2 million cells/μL detect illnesses associated with amylase level may exceed five
acute and chronic infection, times the normal value; the
Serum Iron
inflammation, advanced level starts rising 6 hours after
- Iron is found predominantly in neoplasm and tissue necrosis
hemoglobin the onset of pain, peaks at
or infarction about 24 hours and returns to
- Iron acts as a carrier of oxygen - Normal: 0-30 mm/hour
from the lungs to the tissues normal in 2-3 days after the
depending on the age of client onset of pain
 - In chronic pancreatitis, the rise - Total bilirubin levels increase - Presence of detectable albumin
in serum amylase usually does with any type of jaundice; direct or protein in the urine is
not normally exceed three time (conjugated) and indirect indicative of abnormal renal
the normal value (unconjugated) bilirubin levels function
- Value: 25-151 units/L help differentiate the cause of - Value: 3.4-5 g/dL
NURSING CONSIDERATIONS: the jaundice Nursing consideration: Fasting is
- On the laboratory form, list the Electrolytes Level (Normal) not required
medications that the client has Sodium 135-145 mEq/L AMMONIA
taken during the previous 24 Potassium 3.5-5.0 mEq/L
- A byproduct of protein
hours before the test Calcium 8.6-10 mg/dL catabolism; most of it is created
- Note that many medications Chloride 98-108 mEq/L by bacteria acting on proteins
may cause false positive or Magnesium 1.5-2.5 mg/dl present in the GI system or gut
false negative results Kidney Function Test (Normal) or stomach
- Results are invalidated if the BUN 10-20 mg/dl - Metabolized by the liver and
specimen was obtained less Creatinine 0.4-1.2 excreted by the kidneys as
than 72 hours after CPK-MB (Cardiac Male: 50-325 urea
cholecystography with Muscle) mu/ml - ↑ levels result from hepatic
radiopaque dyes Female: 50-250 dysfunction may lead to
BILIRUBIN mu/ml encephalopathy
- Is produced by the liver, ALBUMIN - Venous ammonia levels are not
spleen, and bone marrow and - A main plasma protein of blood a reliable indicator of hepatic
is also a by- product of - Transports bilirubin, fatty acids, coma
hemoglobin breakdown medications, hormones and - Vale: 10-80 mcg/dL
- Total bilirubin levels can be other substances that are Nursing considerations:
broken down into direct insoluble in water 1. Instruct client to fast, except for
bilirubin, which is excreted - Maintains oncotic pressure water and to refrain from
primarily via the intestinal tract - ↑ in conditions such as smoking for 8-10 hours before
and indirect bilirubin, which dehydration, diarrhea, and the test; smoking increases
circulates primarily in the blood metastatic carcinoma ammonia levels
stream - ↓ in conditions such as acute
infection, ascites, alcoholism
 2. Place specimen on ice and 1. Previous IM injections may Triglycerides: lower than 150 mg/dL
transport to laboratory cause elevated levels - Triglycerides are in synthesized in
immediately 2. No fasting is required the liver from fatty acids, protein
ALT -ALANINE 3. SGOT-serum glutamic and glucose, and are obtained
AMINOTRANSFERASE oxaloacetic transaminase from the diet
- Used to identify hepatocellular LIPASE - Increased cholesterol levels, LDL
injury and inflammation of the - This pancreatic enzyme levels and triglyceride levels place
liver and to monitor converts fats and triglycerides the client at risk for coronary
improvement or worsening of into fatty acids and glycerol artery disease
the disease - ↑ lipase levels occur in Values: Total Cholesterol: below
- Value: 10-40 units/L pancreatic disorders 200 mg/dL
Nursing Considerations: - Elevations may not occur until LDL: lower than 130 mg/dL
1. Previous IM (intramuscular) 24 hours to 36 hours after the HDL: 60 mg/dL and above
injections may cause elevated onset of illness and may
Triglycerides: lower than 150
levels remain elevated for up to 14
mg/dL
2. No fasting is required days
- Value: 10-140 units/L NURSING CONSIDERATIONS:
3. SGPT - serum glutamic pyruvic
Nursing Consideration: ERCP 1. Oral contraceptives may
transaminase
(Endoscopic Retrograde increase the lipid level
AST-ASPARTATE 2. Instruct the client to abstain
AMINOTRANSFERASE Cholangiopancreatography) may
increase lipase activity from foods and fluid except
- Used to evaluate a client with water for 12-14 hours and from
suspected hepatocellular LIPIDS alcohol for 24 hours before the
disease, injury or inflammation - Total cholesterol: below 200 test
(may also be used along with mg/dL 3. Instruct client to avoid
cardiac markers to evaluate - Lipid assessment includes total consuming high cholesterol
coronary artery occlusive cholesterol, high-density foods with the evening meal
disease) lipoprotein (HDL-good before the test
- Value: 10-30 units/L cholesterol), low-density Fibrinogen 200-400 mg/dl
Nursing Considerations: lipoprotein (LDL-bad cholesterol) Uric Acid 2.5-8 mg/dl
and triglycerides ESR Male
HDL: 60 mg/dL and above
 15-20 mm/hr
Female
20-30 mm/hr
Cholesterol 150-200 mg/dl
Triglyceride below 150 mg/dL
Lactic 100-225 mu/ml
Dehydrogenase
Alkaline 32-92 U/L
Phosphokinase
Albumin 3.2-5.5 mg/dl