A client with severe generalized weakness is confined to bed. To promote physical comfort and prevent complications related to immobility, which positioning techniques should the practical nurse implement? (Select all that apply.)
- Maintain the client in a 30-degree lateral incline position when turning.Answer
- Support the calves with a cushion to completely suspend the heels off the mattress.Answer
- CPosition the client's weight directly on the hip bone when assisting them to a side-lying posture.
- DPlace a firm, rolled towel directly under the popliteal space while the client rests on their back.
- Restrict the upward angle of the bed's headrest to 30 degrees or lower except when eating.Answer
Answer
The correct positioning techniques include maintaining a 30-degree lateral incline, supporting the calves to suspend the heels, and restricting the headrest angle to 30 degrees or lower.
Proper positioning aims to minimize pressure, friction, and shear forces that lead to skin breakdown and circulatory impairment. A 30-degree lateral incline effectively shifts body weight off the greater trochanter and onto the gluteal muscles. Suspending the heels removes all pressure from a highly vulnerable bony prominence. Limiting the headrest elevation to 30 degrees prevents the client from sliding downward, thereby reducing severe shearing forces on the sacrum.
Step-by-Step Solution
Key Concept
Prevention of Complications of Immobility