Chapter 7: Moving and positioning
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Source: Adapted from CSP ([24]). Reproduced with permission of The Chartered Society of Physiotherapy.
Evidence‐based approaches
Rationale
Moving and positioning are important aspects of patient care because together they have a major impact on patients’ rehabilitation and wellbeing, affecting them physically and psychologically. Optimum positioning is a good starting point to maximize the benefit of other interventions, such as bed exercises and breathing exercises; it can also assist rest and mobility, thereby facilitating recovery and enhancing function. However, although it is important, it must not be seen in isolation and is just one aspect of patient management where the overall goal is to optimize independence.
It is essential to frequently evaluate the effect that moving and positioning is having on the individual to ensure that the intervention is helping to achieve the desired result or goal. Consider whether the moving and positioning procedure is being clinically effective and, where possible, is evidence based.
There are several points to consider with regard to the clinical effectiveness of moving and positioning:
- Is the timing right for moving the patient? For example, is the pain relief adequate?
- Is it being carried out in the correct way? This relates to manual handling with regard to preventing trauma to both the patient and the practitioner. Manual handling causes over a third of all workplace injuries. These include work‐related musculoskeletal disorders (MSDs) such as pain and injuries to arms, legs and joints, and repetitive strain injuries of various sorts (HSE [50]). Approved patient handling techniques are essential for safe practice.
- Is the required position taking into account all the pertinent needs of the patient? This emphasizes the need to consider the patient in a holistic manner and take into account any co‐morbidities as well as the primary issue that is being addressed.
- Is it achieving the desired outcome or preventing a detrimental result?
Indications
Patients should always be encouraged to move themselves. Assistance in moving and positioning is indicated for patients who have difficulty moving or require periods of rest when normal function is impaired. The severity of an illness may leave no choice except bedrest, but rest alone is rarely beneficial.
Contraindications
There are no general contraindications for moving and positioning; however, some clinical conditions may require special considerations, preparation and specialist assistance.
Principles of care
The main principles underpinning all interventions regarding patient positioning and mobilization focus on the short‐ and long‐term goals of rehabilitation and management for each specific patient. It is imperative that a thorough assessment is carried out prior to any intervention in order to plan appropriate goals of treatment. Wherever possible, goal setting should be a joint patient and healthcare professional discussion. It may be necessary to compromise on one principle, depending on the overall goal. For example, for the palliative patient, after discussing the patient's goals it may be that the primary aim of any intervention is to facilitate comfort at the cost of reducing function. Regular reassessment is necessary to allow for modification of plans to reflect changes in status. Communication and involvement of the multidisciplinary team will assist rehabilitation interventions as treatment can be incorporated during positional changes. This potentially allows an opportunity for multiprofessional working and allows many individuals to act with a common purpose and with co‐ordinated activity (Health Foundation [44]).
Benefits of optimal positioning and mobilizing
Encouraging a normal routine and the provision of supported self‐management can only be beneficial to patients. Encouraging patients to sit out of bed for meals, get dressed and mobilize (as able) reduces the risk of:
- pressure ulcers
- falls
- deep vein thrombosis
- chest infections
- increased length of stay in hospital.
Facilitating mobility supports harm‐free care, with significant benefits to clinical outcomes and the costs of patient care (Chief Allied Health Professions Officer's Team [21]). For many, wearing pyjamas reinforces being sick and can prevent recovery. Studies show that three in five immobile, older patients in hospital had no medical reason that required bedrest and doubling the amount of walking while in hospital reduces the length of stay (NHS England [82]). The #EndPJparalysis initiative is global social movement embraced by nurses, therapists and medical professionals to get patients up, dressed and moving. Having patients in their day clothes while in hospital, rather than in pyjamas (PJs) or gowns, enhances dignity and autonomy and, in many instances, shortens their length of stay. For patients over the age of 80, a week in bed can lead to 10 years of muscle ageing and 1.5 kg of muscle loss, and may lead to increased dependency and demotivation. Getting patients up and moving has been shown to reduce falls, improve patient experiences and reduce length of stay by up to 1.5 days (NHS England [82]).
Effects of bedrest and decreased mobility
Patients with acute medical conditions and decreased mobility are at risk of developing secondary complications (Ye et al. [135]). Bedridden patients are prone to dehydration, progressive cardiac deconditioning and postural hypotension. They show reduced lung function and increased susceptibility to respiratory tract infections. Prolonged bedrest often leads to venous stasis and blood vessel damage, which, together with increased blood coagulability, predisposes bedridden patients to deep vein thrombosis and potentially pulmonary embolism (Ye et al. [135]).
Therefore, patients should be encouraged and/or assisted to mobilize or change position, at frequent intervals. All healthcare professionals should see facilitating mobility as part of their role. For example, nurses and healthcare support staff are perfectly placed to initiate rehabilitation and to identify those whose mobility is deteriorating during their inpatient stay. Early referrals to therapy services ensure that patients regain their independence in the shortest possible time. Starting rehabilitation early can improve physical and non‐physical functioning and prevent future problems. The needs of a person in intensive or critical care can change very quickly; therefore, goals should be continually reviewed and updated within the rehabilitation programme.
Prolonged immobility is harmful, with rapid reductions in muscle mass, bone mineral density and impairment in other body systems evident within the first week of bedrest, which is further exacerbated in individuals with critical illness (Parry and Puthucheary [98]). Research has shown that many patients who survive critical illness (and therefore prolonged immobility) suffer long‐term effects (NICE [90]).
Patients should be encouraged to maintain muscle strength and length. Active ankle movements (Figure 7.1) are to be encouraged to assist the circulation.
Figure 7.1 (a) Ankle in dorsiflexion (DF). (b) Ankle in plantarflexion (PF).
Risk assessment
There is an absolute requirement to assess the risks arising from moving and handling patients (CSP [24]). Local policy on risk assessment and documentation should be referred to and local manual handling training adhered to. Once the risk of not moving the patient is deemed to be greater than moving the patient, consider the following (TILE):
| T | Task/operation: achieving the desired position or movement. |
| I | Individual: this refers to the handler(s). In patient handling, this relates to the skills, competence and physical capabilities of the handlers. It is also important to consider health status, height, gender, pregnancy status, age and disability. |
| L | Load: in the case of patient handling, the load is the patient. The aim of rehabilitation is, where possible, to encourage patients to move for themselves or contribute towards this goal. This may mean that additional equipment is needed. For assistance and guidance, liaise with the physiotherapist and/or occupational therapist. |
| E | Environment: before positioning or moving the patient, think about the space, placement of equipment and removal of any hazards. |
Other factors, for example any intravenous infusions or monitoring attached to the patient, must also be considered when undertaking a risk assessment. The key points to consider are summarized in Box 7.1.
Where there is any doubt about patients with complex needs, seek advice from the physiotherapist or the occupational therapist. Once a risk assessment has been carried out, this needs to be recorded prior to proceeding with any manual handling intervention (CSP [24]).
Consent must be obtained before any intervention is started. Consent is the voluntary and continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature and likely risks of the treatment, including the likelihood of its success and any alternatives to it. Valid consent must be obtained before commencing an examination, starting treatment or physical investigation, or providing care (RCN [105]).
Box 7.1
Risk assessment
- Assess the patient clinically.
- Consider realistic clinical goals and functional outcomes in discussion with the patient and ascertain the level at which the patient will be able to participate in the task.
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Consider whether the proposed intervention involves hazardous manual handling and reduce the hazard by:
- adapting the technique
- introducing equipment as needed following assessment
- seeking advice/assistance from appropriately skilled colleagues.
- Risk assessment should be an ongoing process and be constantly updated.
- After the procedure, document the risk assessment, being sure to include the date, the number of staff involved and the equipment needed to perform the task. Also document any changes in the patient's condition, such as skin redness. It is important to also document the intended duration for which the patient should be maintained in this new position.
