MOBILITY, ACTIVITY AND EXERCISE

Learning Outcomes:

1. Describe four basic elements of normal movement.

2. Differentiate isotonic, isometric, isokinetic, aerobic, and an-aerobic exercise.
3. Compare the effects of exercise and immobility on body systems.
4. Identify factors influencing a person’s body alignment and activity.
5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility
capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to
immobility.
6. Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.
7. Use safe practices when positioning, moving, transferring, and ambulating clients.
8. Compare and contrast active, passive, and active-assistive range-of-motion (ROM) exercises.
9. Describe client teaching for clients who use mechanical aids for walking.
10. Verbalize the steps used in:
a. Moving a client up in bed.
b. Turning a client to the lateral or prone position in bed.
c. Logrolling a client.
d. Assisting a client to sit on the side of the bed.
e. Transferring between bed and chair.
f. Transferring between bed and stretcher.
g. Assisting a client to ambulate.
11. Recognize when it is appropriate to delegate aspects of moving, transferring, and ambulating a client
to unlicensed assistive personnel.
12. Demonstrate appropriate documentation and reporting of moving, transferring, and ambulating a
client.

ACTIVITY-EXERCISE PATTERN refers to a person’s routine of exercise, activity, leisure, and recreation. It
includes (a) activities of daily living (ADLs) that require energy expenditure such as hygiene, dressing,
cooking, shopping, eating, working, and home maintenance, and (b) the type, quality, and quantity of
exercise, including sports.

MOBILITY- the ability to move freely, easily, rhythmically, and purposefully in the environment, is an
essential part of living. People must move to protect themselves from trauma and to meet their basic
needs. Mobility is vital to independence; a fully immobilized person is as vulnerable and dependent as
an infant.
People often define their health and physical fitness by their activity because mental well-being and the
effectiveness of body functioning depend largely on their mobility status.

Mobility is the ability of a patient to change and control their body position. Physical mobility requires
sufficient muscle strength and energy, along with adequate skeletal stability, joint function, and
neuromuscular synchronization. Anything that disrupts this integrated process can lead to impaired
mobility or immobility. Mobility exists on a continuum ranging from no impairment (i.e., the patient can
make major and frequent changes in position without assistance) to being completely immobile (i.e., the
patient is unable to make even slight changes in body or extremity position without assistance). See
Figure 13.1[2] for an image of a patient with impaired physical mobility requiring assistance with a
wheelchair.

Normal movement and stability are the result of an intact musculoskeletal system, an intact nervous
system, and intact inner ear structures responsible for equilibrium. Body movement requires
coordinated muscle activity and neurologic integration. It involves four basic elements: body alignment
(posture), joint mobility, balance, and coordinated movement.

Alignment and Posture

Proper body alignment and posture bring body parts into position in a manner that promotes optimal
balance and maximal body function whether the client is standing, sitting, or lying down. A person
maintains balance as long as the line of gravity (an imaginary vertical line drawn through the body’s
center of gravity) passes through the center of gravity (the point at which all of the body’s mass is
centered) and the base of support (the foundation on which the body rests). In humans, the usual line of
gravity begins at the top of the head and falls between the shoulders, through the trunk, slightly
anterior to the sacrum, and between the weight-bearing joints and base of support.

The flexor muscles are stronger than the extensor muscles. Thus, when a person is inactive, the joints
are pulled into a flexed (bent) position. If this tendency is not counteracted with exercise and position
changes, the muscles permanently shorten, and the joint becomes fixed in a flexed position
(contracture).

The range of motion (ROM) of a joint is the maximum movement that is possible for that joint. Joint
range of motion varies from individual to individual and is determined by genetic makeup,
developmental patterns, the presence or absence of disease, and the amount of physical activity in
which the person normally engages.
TYPES OF JOINT MOVEMENTS:
1. Flexion: Decreasing the angle of the joint (Ex. bending the elbow)
2. Extension: Increasing the angle of the joint (ex. straightening the arm at the elbow)
3. Hyperextension: Further extension or straightening of a joint(e.g., bending the head backward)
4. Abduction Movement of the bone away from the midline of the body
5. Adduction: Movement of the bone toward the midline of the body
6. Rotation: Movement of the bone around its central axis
7. Circumduction: Movement of the distal part of the bone in a circle while the proximal end
remains fixed
8. Eversion: Turning the sole of the foot outward by moving the ankle joint
9. Inversion: Turning the sole of the foot inward by moving the ankle joint
10. Pronation: Moving the bones of the forearm so that the palm of the hand faces downward when
held in front of the body
11. Supination: Moving the bones of the forearm so that the palm of the hand faces upward when
held in front of the body
Balance
The mechanisms involved in maintaining balance and posture are complex and involve informational
inputs from the labyrinth (inner ear), from vision (vestibulo-ocular input), and from stretch receptors of
muscles and tendons (vestibulospinal input). Mechanisms of equilibrium (sense of balance) respond,
frequently without our awareness, to various head movements. The labyrinth consists of the cochlea,
vestibule, and semicircular canals. The cochlea is concerned with hearing, and the vestibule and
semicircular canals with equilibrium. Under normal conditions the equilibrium receptors in the
semicircular canals and vestibule, collectively called the vestibular apparatus, send signals to the brain
that initiate reflexes needed to make required changes in position. The receptors, hair like cells, respond
to displacement of the head in any direction. When the head moves, the fluid flow within the vestibule
and semicircular canals stimulates sensory hair cells. Information from these balance receptors goes
directly to reflex centers in the brainstem rather than to the cerebral cortex as with other special senses.
This enables fast reflexive responses to a body imbalance. Proprioception is the term used to describe
awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight,
and resistance of objects in relation to the body.

Coordinated Movement
Balanced, smooth, purposeful movement is the result of proper functioning of the cerebral cortex,
cerebellum, and basal ganglia. The cerebral cortex initiates voluntary motor activity, the cerebellum
coordinates the motor activities of movement, and the basal ganglia maintain posture. The cerebral
cortex operates movements, not muscles. The cortex, for example, may direct the arm to pick up a cup
of coffee. The cerebellum, which operates below the level of consciousness, blends and coordinates the
muscles involved in voluntary movement. It does not direct the movement but translates the
“instructions” from the cerebral cortex into detailed actions by the many different muscles in the hand,
arm, and shoulder. When a client’s cerebellum is injured, movements become clumsy, unsure, and
uncoordinated.

FACTORS AFFECTING BODY ALIGNMENT AND ACTIVITY

A number of factors affect an individual’s body alignment, mobility, and daily activity level. These
include growth and development, nutrition, personal values and attitudes, certain external factors, and
prescribed limitations.
1. Growth and Development
A person’s age and musculoskeletal and nervous system development affect posture, body
proportions, body mass, body movements, and reflexes. Newborn movements are reflexive and
random. All extremities are generally flexed but can be passively moved through a full range of
motion. As the neurologic system matures, control over movement progresses during the first
year. Gross motor development precedes fine motor skills.
The design of individualized exercise prescriptions that tailor exercise mode and dose and
address these varying states with each person will ensure greater adherence to an exercise
program (Allen & Morelli, 2011; Katz, 2012).
2. Nutrition
Both under nutrition and over nutrition can influence body alignment and mobility. Poorly
nourished people may have muscle weakness and fatigue. Vitamin D deficiency causes bone
deformity during growth. Inadequate calcium intake and vitamin D synthesis and intake increase
the risk of osteoporosis. Obesity can distort movement and stress joints, adversely affecting
posture, balance, and joint health.
3. Personal Values and Attitudes
Whether people value regular exercise is often the result of family influences. In families that
incorporate regular exercise into their daily routine or spend time together in activities, children
learn to value physical activity. Sedentary families, on the other hand, participate in sports only
as spectators, and this lifestyle is often transmitted to their children. With the increase in TV,
computer, and video activities, youth are increasingly sedentary with associated declines in
health. Values about physical appearance also influence some people’s participation in regular
exercise. People who value a muscular build or physical attractiveness may participate in regular
exercise programs to produce the appearance they desire
4. External Factors
Many external factors affect a person’s mobility. Excessively high temperatures and high
humidity discourage activity, whereas comfortable temperatures and low humidity are
conducive to activity. Proper hydration needs vary according to the individual, health status,
activity levels, and environment.
5. Prescribed Limitations
Limitations to movement may be medically prescribed for some health problems. To promote
healing, devices such as casts, braces, splints, and traction are often used to immobilize body
parts. Clients who are short of breath may be advised not to walk up stairs. Bed rest may be the
therapeutic choice for certain clients, for example, to relieve edema, to reduce metabolic and
oxygen needs, to promote tissue repair, or to decrease pain.

Impaired Physical Mobility

Functional mobility is the ability of a person to move around in their environment, including walking,
standing up from a chair, sitting down from standing, and moving around in bed. The three main areas
of functional mobility are the following:
•Bed Mobility: The ability of a patient to move around in bed, including moving from lying to sitting and
sitting to lying.
•Transferring: The action of a patient moving from one surface to another. This includes moving from a
bed into a chair or moving from one chair to another.
•Ambulation: The ability to walk. This includes assistance from another person or an assistive device,
such as a cane, walker, or crutches.
Immobility can be caused by several physical and psychological factors, including acute and chronic
diseases, traumatic injuries, and chronic pain. Several neurological and musculoskeletal disorders can
adversely affect mobility, including osteoarthritis, rheumatoid arthritis, muscular dystrophy, cerebral
palsy, multiple sclerosis, and Parkinson’s disease. Traumatic injuries, such as skeletal fractures, head
injuries, or spinal injuries, also impair mobility. Diseases that cause fatigue, such as heart failure, chronic
obstructive pulmonary disease, and depression, or conditions that cause pain also affect the patient’s
desire to move.

EXERCISE
People participate in exercise programs to decrease risk factors for chronic diseases and to increase
their health and well-being. Functional strength is another goal of exercise, and is defined as the ability
of the body to perform work. Activity tolerance is the type and amount of exercise or ADLs an individual
is able to perform without experiencing adverse effects.
Types of Exercise
Exercise involves the active contraction and relaxation of muscles. Exercises can be classified according
to the type of muscle contraction (isotonic, isometric, or isokinetic) and according to the source of
energy (aerobic or anaerobic).
1. Isotonic (dynamic) exercises are those in which the muscle shortens to produce muscle
contraction and active movement. Most physical conditioning exercises—running, walking,
swimming, cycling, and other such activities—are isotonic, as are ADLs and active
ROM exercises (those initiated by the client). Examples of isotonic bed exercises are pushing or pulling
against a stationary object, using a trapeze to lift the body off the bed, lifting the buttocks off the bed by
pushing with the hands against the mattress, and pushing the body to a sitting position. Isotonic
exercises increase muscle tone, mass, and strength and maintain joint flexibility and circulation. During
isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the
body.
2. Isometric (static or setting) exercises are those in which muscle contraction occurs without
moving the joint (muscle length does not change). These exercises involve exerting pressure
against a solid object and are useful for strengthening abdominal, gluteal, and muscles used in
ambulation; for maintaining strength in immobilized muscles in casts or traction; and for
endurance training. An example of an isometric bed exercise would be squeezing a towel or
pillow between the knees while at the same time tightening the muscles in the fronts of the
thighs by pressing the knees backwards and holding for several seconds. These are often called
“quad sets.” Isometric exercises produce a mild increase in heart rate and cardiac output, but no
appreciable increase in blood to other parts of the body.
3. Isokinetic (resistive) exercises involve muscle contraction or tension against resistance. During
isokinetic exercises, the person tenses (isometric) against resistance. Special machines or
devices provide the resistance to the movement. These exercises are used in physical
conditioning and are often done to build up certain muscle groups.
Aerobic exercise is activity during which the amount of oxygen taken into the body is greater than
that used to perform the activity. Aerobic exercises use large muscle groups that move repetitively.
Aerobic exercises improve cardiovascular conditioning and physical fitness.

Effects of Immobility
Patients who spend an extended period of time in bed as they recover from surgery, injury, or illness can
develop a variety of complications due to loss of muscle strength (estimated at a rate of 20% per week
of immobility). Regardless of the cause, immobility can cause degradation of cardiovascular, respiratory,
gastrointestinal, and musculoskeletal functioning. Promoting mobility can prevent these complications
from occurring. Findings from a literature review demonstrated several benefits of mobilization,
including less delirium, pain, urinary discomfort, urinary tract infection, fatigue, deep vein thrombosis
(DVT), and pneumonia, as well as an improved ability to void. Mobilization also decreased depression,
anxiety, and symptom distress, while enhancing comfort, satisfaction, quality of life, and independence.
[3] See Table 13.2a for a summary of the effects of immobility on these body systems.[4],[5],[6]
Decreased mobility is also a major risk factor for skin breakdown, as indicated on the Braden Scale. See
Figure 13.2[7] for an image of a patient with impaired mobility that developed a DVT.

Deep vein thrombosis

Effects of Immobility on Body Systems

Body System Immobility Effects Potential Complications

Decreased quality of life

Psychological Depression

Anxiety
 Distress
Decreased systemic
vascular resistance causing
Orthostatic hypotension
Cardiovascular
venous pooling in
extremities Thrombus formation
Decreased cardiac output
Decreased strength of
respiratory muscles

Diminished lung expansion

Atelectasis
Hypoventilation
Hypoxia
Impaired gas exchange
Respiratory Pneumonia
Decreased cough reflex
Pulmonary edema
Pulmonary secretion
pooling Pulmonary embolism

Blood redistribution and

fluid shifts within the lung
tissues
Decreased delivery of
oxygen and nutrients to
Skin breakdown
tissues
Pressure injuries
Integumentary
Tissue ischemia
Infection
Inflammation over bony
prominences Abrasions
Friction and shear
Musculoskeletal Reduced muscle mass Fatigue

Decreased muscle strength Decreased stability and

balance
Decreased endurance
Muscle atrophy
Shortening of connective
tissue Joint contractures

Impaired joint mobility Foot drop

Impaired calcium Osteoporosis

metabolism
 Falls

Fractures
Constipation

Fecal impaction

Decreased peristalsis Ileus

Anorexia Flatulence

Gastrointestinal Decreased fluid intake Abdominal distention

Increased intestinal gas Nausea and vomiting

Altered swallowing Heartburn

Aspiration

Malnutrition
Urinary discomfort
Genitourinary Urinary tract infection
Urinary retention

Assessing Mobility Status and the Need for Assistance

Type of Assistance
Description
Required

The patient is unable to help at all. A mechanical lift and

Dependent assistance by other personnel are required to perform
tasks.

The patient can perform 75% of the mobility task while

Maximum Assistance
the caregiver assists with 25%.

The patient can perform 50% of the mobility task while

Moderate Assistance
the caregiver assists with 50%.

Minimal Assistance The patient can perform 75% of the mobility task while
 the caregiver assists with 25%.

The caregiver places one or two hands on the patient’s

Contact Guard Assist body to help with balance but provides no other
assistance to perform the functional mobility task.

The caregiver does not touch the patient or provide

assistance, but remains close to the patient for safety in
Stand By Assist
case they lose their balance or need help to maintain
safety during the task being performed.

The patient can safely perform the functional task with no

Independent
assistance on their own.

Weight-Bearing Prescriptions

Type of Weight-Bearing Description

The leg must not touch the floor and is not

permitted to support any weight at all.
Nonweight-bearing (NWB)
Crutches or other devices are used for
mobility.

The foot or toes may touch the floor to

Toe-touch weight-bearing (TTWB) maintain balance, but no weight should be
placed on the affected leg.

Partial weight-bearing A small amount of weight may be

supported on the affected leg. Weight may
be gradually increased to 50% of body
weight, which permits the person to stand
with body weight evenly supported by both
 feet (but not walking).

The patient can support 50% to 100% of

weight on the affected leg and can
Weight-bearing as tolerated independently choose the weight
supported by the extremity based on their
tolerance and the circumstances.

The leg can support 100% of a person’s

Full weight-bearing
body weight, which permits walking.

Guidelines and Minimal Requirements for Physical Activity

FREQUENCY AND DURATION
• Aerobic: Cumulative 30 minutes or more daily (can be divided throughout the day) of “moderate
intensity” movement as measured by talk test and perceived exertion scale.
• Stretching: Should be added onto that minimum requirement so that all parts of the body are
stretched each day.
• Strength training: Should be added onto these minimum requirements so that all muscle groups are
addressed at least three times a week, with a day of rest after training.
TYPE OF EXERCISE
• Aerobic: Elliptical exercisers, walking, biking, gardening, dancing, and swimming are recommended for
all individuals, including beginners and older adults. Activities that are more strenuous include jogging,
running, Spinning®, power yoga, bouncing, boxing, and jumping rope.
• Stretching: Yoga, Pilates, qigong, and many other flexibility programs are effective.
• Strength training: Resistance can be provided with weights, bands, balls, apparatus, and body weight.
SAFETY
• Stress the importance of balance and prevention of falls, proper clothing to ensure thermal safety,
checking equipment for proper function, wearing a helmet and other protective gear, using reflective
devices at night, and carrying identification and emergency information.

Benefits of Exercise
1. MUSCULOSKELETAL SYSTEM
The size, shape, tone, and strength of muscles (including the heart muscle) are maintained with
mild exercise and increased with strenuous exercise. With strenuous exercise, muscles
hypertrophy (enlarge), and the efficiency of muscular contraction increases. Hypertrophy is
commonly seen in the arm muscles of a tennis player, the leg muscles of a skater, and the arm
and hand muscles of a carpenter.
2. CARDIOVASCULAR SYSTEM
The American Heart Association (2013) places great emphasis on physical activity by
recommending at least 150 minutes per week of moderate exercise or 75 minutes per week of
vigorous exercise, or a combination of moderate and vigorous activity. Adequateintensity
 exercise (40% to 60% of maximum capacity such as walking a mile in 15 to 20 minutes) increases
the heart rate, the strength of heart muscle contraction, and the blood supply to the heart and
muscles through increased cardiac output. Exercise also promotes heart health by mediating the
harmful effects of stress.
3. RESPIRATORY SYSTEM
Ventilation (air circulating into and out of the lungs) and oxygen intake increase during exercise,
thereby improving gas exchange. More toxins are eliminated with deeper breathing, and
problem solving and emotional stability are enhanced due to increased oxygen to the brain.
Adequate exercise also prevents pooling of secretions in the bronchi and bronchioles,
decreasing breathing effort and risk of infection.
4. GASTROINTESTINAL SYSTEM
Exercise improves the appetite and increases gastrointestinal tract tone, facilitating peristalsis.
Activities such as rowing, swimming, walking, and sit-ups work the abdominal muscles and can
help relieve constipation.
5. METABOLIC/ENDOCRINE SYSTEM
Exercise elevates the metabolic rate, thus increasing the production of body heat and waste
products and calorie use. During strenuous exercise, the metabolic rate can increase to as much
as 20 times the normal rate. This elevation lasts after exercise is completed. Exercise increases
the use of triglycerides and fatty acids, resulting in a reduced level of serum triglycerides,
glycosylated hemoglobin (HgbA1C ) levels, and cholesterol. Weight loss and exercise stabilize
blood sugar and make cells more responsive to insulin.
6. URINARY SYSTEM
With adequate exercise, which promotes efficient blood flow, the body excretes wastes more
effectively. In addition, stasis (stagnation) of urine in the bladder is usually prevented, which in
turn decreases the risk for urinary tract infections (UTIs).
7. IMMUNE SYSTEM
As respiratory and musculoskeletal effort increase with exercise and as gravity is enlisted with
postural changes, lymph fluid is more efficiently pumped from tissues into lymph capillaries and
vessels throughout the body. Circulation through lymph nodes where destruction of pathogens
and removal of foreign antigens can occur is also improved.
8. PSYCHONEUROLOGIC SYSTEM
Mental or affective disorders such as depression or chronic stress may affect a person’s desire to
move. The depressed person may lack enthusiasm for taking part in any activity and may even
lack energy for usual hygiene practices. Lack of visible energy is seen in a slumped posture with
head bowed. Chronic stress can deplete the body’s energy reserves to the point that fatigue
discourages the desire to exercise, even though exercise can energize the person and facilitate
coping. By contrast, individuals with eating disorders may exercise excessively in an effort to
prevent weight gain.
9. COGNITIVE FUNCTION
Current research supports the positive effects of exercise on cognitive functioning, in particular
decision-making and problem-solving processes, planning, and paying attention.
10. SPIRITUAL HEALTH
Yoga-style exercise improves the mind–body–spirit connection, relationship with God, and
physical well-being by establishing balance in the internal and external environment. The
combination of mind, body, and breath awareness is likely to have an impact on
psychophysiological functioning. The relaxation response (RR), first described by Dr. Herbert
Benson, is beneficial for counteracting some of the harmful effects of stress on the body and
mind. The RR is a healthful physiological relaxation that can be elicited through recitation of a
 word or phrase or prayer while sitting quietly and relaxing your muscles (Varvogli & Darviri,
2011).
NURSING MANAGEMENT
a. Assessing
Assessment relative to a client’s activity and exercise should be routinely addressed and includes
a nursing history and a physical examination of body alignment, gait, appearance and movement of
joints, capabilities and limitations for movement, muscle mass and strength, activity tolerance, problems
related to immobility, and physical fitness. The nurse collects information from the client, from other
nurses, and from the client’s records. The examination and history are important sources of information
about disabilities affecting the client’s mobility and activity status, such as contractures, edema, pain in
the extremities, or generalized fatigue.
b. Nursing History
An activity and exercise history is usually part of the comprehensive nursing history. Examples of
interview questions to elicit these data are shown in the accompanying Assessment Interview. If the
client indicates a recent pattern change or difficulties with mobility, a more detailed history is required.
This detailed history should include the specific nature of the problem, when it first began, its frequency,
its causes if known, how the problem affects daily living, what the client is doing to cope with the
problem and whether these methods have been effective.
c. Physical Examination
Conduct the physical examination focusing on activity and exercise patterns. The exam includes
assessment of body alignment, gait, appearance and movement of joints, capabilities and limitations for
movement, muscle mass and strength, activity tolerance, and problems related to immobility.
d. Body Alignment
Assessment of body alignment includes an inspection of the client while the client stands. The purpose
of body alignment assessment is to identify:
• Normal developmental variations in posture
• Posture and learning needs to maintain good posture
• Factors contributing to poor posture, such as fatigue, pain, compression fractures, or low self-esteem
• Muscle weakness or other motor impairments.

To assess alignment, the nurse inspects the client from lateral, anterior, and posterior perspectives.
From the anterior and posterior views, the nurse should observe whether:
• The shoulders and hips are level
• The toes point forward
• The spine is straight, not curved to either side.
The “slumped” posture is the most common problem that occurs when people stand. The neck is flex far
forward, the abdomen protrudes; the pelvis is thrust forward to create lordosis (an exaggerated
anterior/inward curvature of the lumbar spine), and the knees are hyperextended. Low back pain and
fatigue occur quickly in people with poor posture.
e. Gait
The characteristic pattern of a person’s gait (walk) is assessed to determine the client’s mobility and risk
for injury due to falling. Two phases of normal gait are swing and stance. When one leg is in the swing
phase, the other is in the stance phase. In the stance phase, (a) the heel of one foot strikes the ground,
and (b) body weight is spread over the ball of that foot while the other heel pushes off and leaves the
ground. In the swing phase, the leg from behind moves in front of the body.

Appearance and Movement of Joints

Physical examination of the joints involves inspection, palpation, assessment of range of active motion,
and if active motion is not possible, assessment of range of passive motion. The nurse should assess the
following:
• Any joint swelling or redness, which could indicate the presence of an injury or an inflammation
• Any deformity, such as a bony enlargement or contracture, and symmetry of involvement.
• The muscle development associated with each joint and the relative size and symmetry of the muscles
on each side of the body.
• Any reported or palpable tenderness.
• Crepitation (palpable or audible crackling or grating sensation produced by joint motion and
frequently experienced in joints that have suffered repeated trauma over time).
• Increased temperature over the joint. Palpate the joint using the backs of the fingers and compare the
temperature with that of the symmetric joint.
• Degree of joint movement. If indicated, measure the extent of movement with a goniometer, a device
that measures the angle of the joint in degrees.

Capabilities and Limitations for Movement

The nurse needs to obtain data that may indicate hindrances or restrictions to the client’s movement
and the need for assistance, including the following:
 How the client’s illness influences the ability to move and whether the client’s health
contraindicates any exertion, position, or movement
 Encumbrances to movement, such as an intravenous (IV) line in place or a heavy cast.
 Mental alertness and ability to follow directions. Check whether the client is receiving
medications that hinder the ability to walk safely. Narcotics, sedatives, tranquilizers, and some
antihistamines cause drowsiness, dizziness, weakness, and orthostatic hypotension.
 Balance and coordination.
 Presence of orthostatic hypotension before transfers. Specifically, assess for any increase in
pulse rate, marked fall in blood pressure, dizziness, light-headedness, and dimming of vision
when the client moves from a supine to a vertical posture.
 Degree of comfort. People who have pain may not want to move and may require an analgesic
before they are moved.
 Vision. Is it adequate to prevent falls
The nurse also assesses the amount of assistance the client requires for the following:
• Moving in the bed. In particular, observe for the amount of assistance the client requires for turning:
a. From a supine position to a lateral position
b. From a lateral position on one side to a lateral position on the other
c. From a supine position to a sitting position in bed.
• Rising from a lying position to a sitting position on the edge of the bed. Healthy people can normally
rise without support from the arms.
• Rising from a chair to a standing position. Normally this can be done without pushing with the arms.
• Coordination and balance. Determine the client’s abilities to hold the body erect, to bear weight and
keep balance in a standing position on both legs or only one, to take steps, and to push off from a chair
or bed.

Muscle Mass and Strength

Before the client undertakes a change in position or attempts to ambulate, it is essential for the nurse to
assess the client’s strength and ability to move. Providing appropriate assistance lowers the risk of
muscle strain and body injury to both the client and nurse. Assessment of upper extremity strength is
especially important for clients who use ambulation aids, such as walkers and crutches.
Activity Tolerance
By determining an appropriate activity level for a client, the nurse can predict whether the client has the
strength and endurance to participate in activities that require similar expenditures of energy. This
assessment is useful in encouraging increasing independence in people who
(a) Have a cardiovascular or respiratory disability,
(b) Have been completely immobilized for a prolonged period,
(c) Have decreased muscle mass or a musculoskeletal disorder,
(d) Have experienced inadequate sleep,
(e) Have experienced pain, or
(f) Are depressed, anxious, or unmotivated. The most useful measures in predicting activity tolerance
are heart rate, strength, and rhythm; respiratory rate, depth, and rhythm; and blood pressure. These
data are obtained at the following times:
• Before the activity starts (baseline data), while the client is at rest
• During the activity
• Immediately after the activity stops
• Three minutes after the activity has stopped and the client has rested.
The activity should be stopped immediately in the event of any physiological change indicating the
activity is too strenuous or prolonged for the client. These changes include the following:
• Sudden facial pallor (paleness)
• Feelings of dizziness or weakness
• Change in level of consciousness
• Heart rate or respiratory rate that significantly exceeds baseline or pre-established levels
• Change in heart or respiratory rhythm from regular to irregular
• Weakening of the pulse
• Dyspnea, shortness of breath, or chest pain
• Diastolic blood pressure change of 10 mmHg or more.
If, however, the client tolerates the activity well, and if the client’s heart rate returns to baseline levels
within 5 minutes after the activity ceases, the activity is considered safe. This activity, then, can serve as
a standard for predicting the client’s tolerance for similar activities

Problems Related to Immobility

When collecting data pertaining to the problems of immobility, the nurse uses the assessment methods
of inspection, palpation, and auscultation; checks results of laboratory tests; and takes measurements,
including body weight, fluid intake, and fluid output. Specific techniques for assessing immobility
problems and abnormal assessment findings related to the complications of immobility are:

Assessing Problems of Immobility

MUSCULOSKELETAL SYSTEM

assessment problem
Measure arm and leg circumferences. Decreased circumference due
to decreased muscle mass
 Palpate and observe body joints. Stiffness or pain in joints
 Take goniometric measurements of joint ROM. Decreased joint ROM, joint
contractures
CARDIOVASCULAR SYSTEM
 Auscultate the heart. Increased heart rate
Measure blood pressure. Orthostatic hypotension
Palpate and observe sacrum, legs, and feet. Peripheral dependent edema,
increased peripheral vein
engorgement
Palpate peripheral pulses. Weak peripheral pulses
Measure calf muscle circumferences. Edema
Observe calf muscles for redness, tenderness, Thrombophlebitis
and swelling.
RESPIRATORY SYSTEM
Observe chest movements. Asymmetric chest movements,
dyspnea
Auscultate chest. Diminished breath sounds,
crackles, wheezes, and
increased respiratory rate
METABOLIC SYSTEM
Measure height and weight. Weight loss due to muscle
atrophy and loss of
subcutaneous fat
Palpate skin. Generalized edema due to low
blood protein levels
URINARY SYSTEM
Measure fluid intake and output. Dehydration
Inspect urine. Cloudy, dark urine; high specific
gravity
Palpate urinary bladder. Distended urinary bladder due
to urinary retention
GASTROINTESTINAL SYSTEM
Observe stool. Hard, dry, small stool
Auscultate bowel sounds. Decreased bowel sounds due to
decreased intestinal motility
INTEGUMENTARY SYSTEM
Inspect skin Break in skin integrity

PSYCHONEUROLOGIC SYSTEM
Observe behaviors, affect, and cognition. Anger, flat affect, crying, confusion, anxiety,
Monitor developmental skills in children. decline in cognitive function, or signs such as
sleep and appetite disturbances warrant
further evaluation

Diagnosing
Mobility problems may be appropriate as the diagnostic label or as the etiology for other nursing
diagnoses. NANDA International (Herdman & Kamitsuru, 2014) includes the following nursing diagnostic
labels for activity and exercise problems:
• Activity Intolerance: insufficient physiological or psychological energy to endure or complete required
or desired daily activities. Wilkinson (2014) suggests specifying the level of endurance.
Levels include:
Level I: Walks regular pace on level ground but becomes more short of breath than normal when
climbing one or more flights of stairs.
Level II: Walks one city block or 500 feet on level ground or climbs one flight of stairs slowly without
stopping.
Level III: Walks no more than 50 feet on level ground without topping and is unable to climb one flight of
stairs without stopping.
Level IV: Dyspnea and fatigue at rest.
• Risk for Activity Intolerance: vulnerable to experiencing insufficient physiological or psychological
energy to endure or complete required or desired daily activities, which may compromise health.
• Impaired Physical Mobility: limitation in independent, purposeful physical movement of the body or of
one or more extremities. More specific versions of this diagnosis are
 Impaired Bed Mobility Impaired Transfer Ability
 Impaired Walking
 Impaired Wheelchair Mobility.
 Impaired Sitting
• Sedentary Lifestyle: reports a habit of life that is characterized by a low physical activity level.
• Risk for Disuse Syndrome: vulnerable to deterioration of body systems as the result of prescribed or
unavoidable musculoskeletal inactivity, which may compromise health.

Planning
When planning for desired outcomes, Nursing Outcomes Classification (NOC) labels that pertain to
exercise and activity can be helpful and include the following: activity tolerance; ambulation; balance;
body positioning; coordinated movement; endurance; fall prevention behavior; fatigue level; immobility
consequences, both physiological and psycho-cognitive; joint movement; mobility; physical fitness; play
participation; and self-care (Moorhead, Johnson, Maas, & Swanson, 2013).
Positioning, transferring, and ambulating clients are almost always independent nursing functions. The
primary care practitioner usually orders specific body positions only after surgery, anesthesia,
or trauma involving the nervous and musculoskeletal systems. All clients should have an activity order
written by their primary care practitioner when they are admitted to the agency for care.
The goals established for clients will vary according to the diagnosis and defining characteristics related
to each individual. Examples of overall goals for clients with actual or potential problems related to
mobility or activity follow. The client will have:
• Increased tolerance for physical activity
• Restored or improved capability to ambulate and/or participate in ADLs
• Absence of injury from falling or improper use of body mechanics
• Enhanced physical fitness
• Absence of any complications associated with immobility.

Planning for Home Care

Clients who have been hospitalized for activity or mobility problems often need continued care in the
home. In preparation for discharge, the nurse needs to determine the client’s actual and potential
health problems, strengths, and resources. The accompanying Home Care Assessment describes the
specific assessment data required before establishing a discharge plan for clients with mobility or
activity problems. A major aspect of discharge planning involves instructional needs of the client and
family.

CLIENT AND ENVIRONMENT

• Capabilities or tolerance for required and desired activities: self-care (feeding, bathing, toileting,
dressing, grooming, home maintenance, shopping, cooking); recreational activities
• Mobility aids required: cane, walker, crutches, wheelchair, transfer boards
• Equipment required if immobilized: special bed, side rails, pressure-reducing mattress, assistive lifting
equipment
• Current level of knowledge: body mechanics for use of mobility aids; specific exercises prescribed
• Home mobility hazard appraisal: adequacy of lighting; presence of handrails; safety of pathways and
stairs; congested areas; unanchored rugs, mats, or electrical cords, and any other obstacles to safe
movement; structural adjustments needed for wheelchair access
FAMILY OR CAREGIVER
• Caregiver availability, skills, and willingness to assist: assess learning needs and develop appropriate
teaching plan, primary people able to assist client with self-care, movement, shopping, and so on;
physical and emotional status to assist with care
• Family role changes and coping: effect on financial status, parenting and spousal roles, social roles
• Availability of caregiver support: other support people available for occasional duties such as
shopping, transportation, housekeeping, cooking, budgeting; refer to community agencies for respite
care, where appropriate
COMMUNITY
• Resources: availability and familiarity with sources of medical equipment and assistive lifting
equipment, financial assistance, homemaker services, hygienic care; Meals-onWheels; spiritual
counselors and visitors; sources of respite for caregiver.
Implementing
Nurses can initiate and apply a wide variety of exercise and activity interventions as needed to address a
multitude of client concerns. Nursing Interventions Classification (NIC) labels that pertain to exercise and
activity include the following: activity therapy; cardiac care; rehabilitation; constipation management;
exercise promotion (strength and stretching); exercise therapy (ambulation, balance, joint mobility,
muscle control); fall prevention; health education; mood management; pelvic muscle exercise; pressure
ulcer prevention; progressive muscle relaxation; recreation therapy; self-care assistance; self-esteem
enhancement; simple relaxation therapy; sleep enhancement; sports-injury prevention; teaching:
prescribed activity/exercise; therapeutic play; and weight management and weight reduction (Bulechek,
Butcher, Dochterman, & Wagner, 2013).

Using Body Mechanics

Body mechanics is the term used to describe the efficient, coordinated, and safe use of the body to
move objects and carry out the ADLs. When a person moves, the center of gravity shifts continuously in
the direction of the moving body parts. Balance depends on the interrelationship of the center of
gravity, the line of gravity, and the base of support. The closer the line of gravity is to the center of the
base of support, the greater the person’s stability. Conversely, the closer the line of gravity is to the
edge of the base of support, the more precarious the balance. If the line of gravity falls outside the base
of support, the person falls.
Body mechanics involves the coordinated effort of muscles, bones, and the nervous system to maintain
balance, posture, and alignment during moving, transferring, and positioning patients. Proper body
mechanics allows individuals to carry out activities without excessive use of energy, and helps prevent
injuries for patients and health care providers (Perry, Potter, & Ostendorf, 2014).
A musculoskeletal injury (MSI) is an injury or disorder of the muscles, tendons, ligaments, joints or
nerves, blood vessels, or related soft tissue including a sprain, strain, or inflammation related to a work
injury. MSIs are the most common health hazard for health care providers (WorkSafeBC, 2013).
TABLE 3.1 FACTORS THAT CONTRIBUTE TO AN MSI

Factor Special Information

Ergonomic risk Repetitive or sustained awkward postures, repetition, or forceful exertion

factors

Individual risk Poor work practice; poor overall health (smoking,

factors drinking alcohol, and obesity); poor rest and recovery;
poor fitness, hydration, and nutrition

Data source: Perry et al., 2014; Workers Compensation Board, 2001; WorkSafeBC, 2013

ELEMENTS OF BODY MECHANICS

Body movement requires coordinated muscle activity and neurological integration. It involves the basic
elements of body alignment (posture), balance, and coordinated movement. Body alignment and
posture bring body parts into position to promote optimal balance and body function. When the body is
well aligned, whether standing, sitting, or lying, the strain on the joints, muscles, tendons, and ligaments
is minimized (WorkSafeBC, 2013).
Body alignment is achieved by placing one body part in line with another body part in a vertical or
horizontal line. Correct alignment contributes to body balance and decreases strain on muscle-skeletal
structures. Without this balance, the risk of falls and injuries increase. In the language of body
mechanics, the centre of gravity is the centre of the weight of an object or person. A lower centre of
gravity increases stability. This can be achieved by bending the knees and bringing the centre of gravity
closer to the base of support, keeping the back straight. A wide base of support is the foundation for
stability. A wide base of support is achieved by placing feet a comfortable, shoulder width distance
apart. When a vertical line falls from the centre of gravity through the wide base of support, body
balance is achieved. If the vertical line moves outside the base of support, the body will lose balance.
PRINCIPLES OF BODY MECHANICS

Action Principle

Assess the environment. Assess the weight of the load before lifting and determine if assistance is
required.

Plan the move. Plan the move; gather all supplies and clear the area of obstacles.

Avoid stretching and twisting. Avoid stretching, reaching, and twisting, which may place the line of gravity
outside the base of support.

Ensure proper body stance. Keep stance (feet) shoulder-width apart.

Tighten abdominal, gluteal, and leg muscles in anticipation of the move.

Stand up straight to protect the back and provide balance.

Stand close to the object being Place the weight of the object being moved close to your centre of gravity for
moved. balance.
 Equilibrium is maintained as long as the line of gravity passes through its base of
support.

Hold objects close to your centre of

gravity

Face direction of the movement. Facing the direction prevents abnormal twisting of the spine.

Avoid lifting. Turning, rolling, pivoting, and leverage requires less work than lifting.

Do not lift if possible; use mechanical lifts as required.

Encourage the patient to help as much as possible.

Work at waist level. Keep all work at waist level to avoid stooping.

Raise the height of the bed or object if possible.

Do not bend at the waist.

Reduce friction between Reduce friction between surfaces so that less force is required to move the
surfaces. patient.
Bend the knees. Bending the knees maintains your centre of gravity and lets the strong muscles of
your legs do the lifting.

Push the object rather than pull It is easier to push an object than to pull it.
it, and maintain continuous
movement. Less energy is required to keep an object moving than it is to stop and start it.

Use assistive devices. Use assistive devices (gait belt, slider boards, mechanical lifts) as required to
 position patients and transfer them from one surface to another.
Work with others. The person with the heaviest load should coordinate all the effort of the others
involved in the handling technique.
Data source: Berman & Snyder, 2016; Perry et al., 2014; WorkSafeBC, 2013

ASSISTIVE DEVICES
An assistive device is an object or piece of equipment designed to help a patient with activities of daily
living, such as a walker, cane, gait belt, or mechanical lift (WorkSafeBC, 2006). Table 3.3 lists some
assistive devices found in the hospital and community setting.

ASSISTIVE DEVICES

Type Definition

Gait belt or Used to ensure a good grip on unstable patients. The device provides more stability when
transfer belt transferring patients. It is a 2-inch-wide (5 mm) belt, with or without handles, that is
placed around a patient’s waist and fastened with Velcro. The gait belt must always be
applied on top of clothing or gown to protect the patient’s skin. A gait belt can be used
with patients in both one-person or two-person pivot transfer, or in transfer with a slider
board.

Gait belt

Slider board or
transfer board

Slider board (red) on a stretcher

 Placing a slider board (transfer board) under a patient

A slider board is used to transfer immobile patients from one surface to another while the
patient is lying supine. The board allows health care providers to safely move immobile,
bariatric, or complex patients.

Mechanical lift A mechanical lift is a hydraulic lift, usually attached to a ceiling, used to move patients
who cannot bear weight, who are unpredictable or unreliable, or who have a medical
condition that does not allow them to stand or assist with moving.

Mechanical lift

Data source: Perry et al., 2014; WorkSafeBC, 2006

VIDEO 3.1

Watch the video How to use a Ceiling Lift by Renée Anderson & Wendy McKenzie, Thompson Rivers
University.

Special considerations:
 Use assistive devices only if properly trained in their safe use.
 Always tell patients what you are about to do and how they should assist you in the procedure.
 Always perform a patient risk assessment or mobility assessment prior to using any assistive
devices. The following link provides additional information regarding assistive devices
from WorkSafeBC.
 Use proper body mechanics when using assistive devices.
Back injuries are caused by force, repetition, and awkward positions. The most common injuries
among health care workers are low back pain, herniated disks, strained muscles, pulled and/or
torn ligaments, and disk degradation.
Lifting
It is important to remember that nurses should not lift more than 35 pounds without assistance
from proper equipment and/or other individuals. Types of assistive equipment include mobile-
powered or mechanical lifts, ceiling-mounted lifts, sit-to-stand powered lifts, friction-reducing
devices, and transfer chairs. See Figure 44–43 •through Figure 44–48 •.
Pulling and Pushing
When pulling or pushing an object, a person maintains balance with least effort when the base of
support is increased in the direction in which the movement is to be produced or opposed. For
example, when pushing an object, a person can enlarge the base of support by moving the front
foot forward. When pulling an object, a person can enlarge the base of support by (a) moving the
rear leg back if the person is facing the object or (b) moving the front foot forward if the person
is facing away from the object. It is easier and safer to pull an object toward one’s own center of
gravity than to push it away, because a person can exert more control of the object’s movement
when pulling it.

A mobile electric lift functions to

lift clients from bed, chair, toilet,
and floor.
 A ceiling-mounted lift.

A sit-to-stand power lift allows for client transfers from bed to chair.
The client must be cognitive and provide some muscle tone in at
least one leg and the trunk. A mobile floor-based hydraulic lift
functions to lift clients from bed, chair, toilet, and floor
The Slipp® Patient Mover is a client-
moving device that reduces the
nurse’s exposure to back injuries and
maximizes client comfort.

•An air transfer system. Once inflated,

the client can be transferred laterally
or repositioned on a frictionless air
surface

Lateral-assist devices such as horizontal air transfer mattresses and transfer chairs are essential
equipment for most client care areas. They help prevent acute and chronic back pain and
disability. Observing principles of body mechanics is recommended even when using assistive
equipment, because any lifting and forceful movement is potentially injurious, especially when
repeated over time.
Pivoting
Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. To
pivot, place one foot ahead of the other, raise the heels very slightly, and put the body weight on
the balls of the feet. When the weight is off the heels, the frictional surface is decreased and the
knees are not twisted when turning. Keeping the body aligned, turn (pivot) about 90 degrees in
the desired direction. The foot that was forward will now be behind.
Preventing Back Injury
Nurses provide clients with the opportunity to change positions, expand their lungs, or change
their environments as appropriate. It is important, however, that nurses not jeopardize their own
health while caring for clients. Client positioning, lifting, and transferring are significant risk
factors for back injuries. As mentioned earlier, 35 pounds of client weight should be the
maximum a nurse should attempt. Two movements to avoid because of their potential for
causing back injury are twisting (rotation) of the thoracolumbar spine and acute flexion of the
back with hips and knees straight (stooping). Undesirable twisting of the back can be prevented
by squarely facing the direction of movement, whether pushing, pulling, or sliding, and moving
the object directly toward or away from one’s center of gravity.
Preventing Back Injuries
• Understand that the use of body mechanics will not necessarily prevent injury if manually
handling a load greater than 35 pounds without the use of assistive devices.
• Avoid lifting anything greater than 35 pounds. Use assistive equipment, get help from co-
worker’s, and participate in the purchasing/ordering process of appropriate assistive equipment
for your work setting.
• Become consciously aware of your posture and body mechanics.
• When standing for a period of time, periodically move legs and hips, and flex one hip and knee
and rest your foot on an object if possible.
• When sitting, keep your knees slightly higher than your hips.
• Use a firm mattress and soft pillow that provide good body support at natural body curvatures.
• Exercise regularly to maintain overall physical condition and regulate weight; include exercises
that strengthen the pelvic, abdominal, and spinal muscles.
• Avoid movements that cause pain or require spinal flexion with straight legs (e.g., toe-touching
and sit-ups) or spinal rotation (twisting).
• When moving an object, spread your feet apart to provide a wide base of support.
• Wear comfortable low-heeled shoes that provide good foot support and reduce the risk of
slipping, stumbling, or turning your ankle.
Positioning Clients
Positioning a client in good body alignment and changing the position regularly (every 2 hours)
and systematically are essential aspects of nursing practice. Clients who can move easily
automatically reposition themselves for comfort. Such people generally require minimal
positioning assistance from nurses, other than guidance about ways to maintain body alignment
and to exercise their joints. However, people who are weak, frail, in pain, paralyzed, or
unconscious rely on nurses to provide or assist with position changes. For all clients, it is
important to assess the skin and provide skin care before and after a position change
When positioning clients in bed, the nurse can do a number of things to ensure proper alignment
and promote client comfort and safety:
  Make sure the mattress is firm and level yet has enough give to fill in and support natural
body curvatures. A sagging mattress, a mattress that is too soft, or an under filled
waterbed used over a prolonged period can contribute to the development of hip flexion
contractures and low back strain and pain.
 Ensure that the bed is clean and dry. Wrinkled or damp sheets increase the risk of
pressure ulcer formation. Make sure extremities can move freely whenever possible.
 Place support devices in specified areas according to the client’s position
 Avoid placing one body part, particularly one with bony prominences, directly on top of
another body part. Excessive pressure can damage veins and predispose the client to
thrombus formation. Pressure against the popliteal space may damage nerves and
blood vessels in this area.
• Avoid friction and shearing. Friction is a force acting parallel to the skin surface. For
example, sheets rubbing against skin create friction. Friction can abrade the skin (i.e.,
remove the superficial layers), making it more prone to breakdown. Shearing force is a
combination of friction and pressure.

Support Devices
• Pillows. Different sizes are available. Used for support or elevation of an arm or leg. Specially
designed dense pillows can be used to elevate the upper body. Pillows can also be used as a
trochanter roll by placing the pillow from the client’s iliac crest to mid-thigh. This prevents
external rotation of the leg when the client is in a supine position.
• Mattresses. There are two types of mattresses: ones that fit on the bed frame (e.g., standard bed
mattress) and mattresses that fit on the standard bed mattress (e.g., egg-crate mattress).
Mattresses should be evenly supportive.
• Suspension or heel guard boot. These are made of a variety of substances. They usually have a
firm exterior and padding of foam to protect the skin. They prevent foot drop and relieve
pressure on heels.
• Footboard. A flat panel often made of plastic or wood. It keeps the feet in dorsiflexion to
prevent plantar flexion.
• Hand roll. Can be made by rolling a washcloth. Purpose is to keep hand in a functional position
and prevent finger contractures.
• Abduction pillow. A triangular-shaped foam pillow that maintains hip abduction to prevent hip
dislocation following total hip replacement
 Suspension boots

Fowler’s position, or a semisitting position, is a bed position in which the head and trunk are
raised 45° to 60° relative to the bed (visualize a 90° right angle to orient your thinking) and the
knees may or may not be flexed. Nurses may need to clarify the meaning of the term Fowler’s
position in their particular setting. Typically, Fowler’s position refers to a 45° angle of elevation
of the upper body.
Semi-Fowler’s position is when the head and trunk are raised 15 to 45 degrees. This position is
sometimes called low Fowler’s and typically means 30 degrees of elevation.
high-Fowler’s position, the head and trunk are raised 60° to 90°, and most often means the
client is sitting upright at a right angle to the bed. Fowler’s position is the position of choice for
people who have difficulty breathing and for some people with heart problems. When the client
is in this position, gravity pulls the diaphragm downward, allowing greater chest expansion and
lung ventilation.
Orthopneic Position
In the orthopneic position, the client sits either in bed or on the side of the bed with an overbed
table across the lap. This position facilitates respiration by allowing maximum chest expansion.
It is particularly helpful to clients who have problems exhaling, because they can press the lower
part of the chest against the edge of the over bed table.
Dorsal Recumbent Position
In the dorsal recumbent (back-lying) position, the client’s head and shoulders are slightly
elevated on a small pillow. In some agencies, the terms dorsal recumbent and supine are used
interchangeably; strictly speaking, however, in the supine or dorsal position the head and
shoulders are not elevated. In both positions, the client’s forearms may be elevated on pillows or
place the client’s sides.
Prone Position
In the prone position, the client lies on the abdomen with the head turned to one side. The hips
are not flexed. Both children and adults often sleep in this position, sometimes with one or both
arms flexed over their heads. It is the only bed position that allows full extension of the hip and
knee joints. When used periodically, the prone position helps to prevent flexion contractures of
the hips and knees, thereby counteracting a problem caused by all other bed positions. The prone
position also promotes drainage from the mouth and is especially useful for unconscious clients
or those clients recovering from surgery of the mouth or throat.
Lateral Position
In the lateral (side-lying) position, the client lies on one side of the body. Flexing the top hip and
knee and placing this leg in front of the body creates a wider, triangular base of support and
achieves greater stability. The greater the flexion of the top hip and knee, the greater the stability
and balance in this position.
Sims’ Position
In Sims’ (semiprone) position, the client assumes a posture halfway between the lateral and the
prone positions. The lower arm is positioned behind the client, and the upper arm is flexed at the
shoulder and the elbow. Both legs are flexed in front of the client. The upper leg is more acutely
flexed at both the hip and the knee than is the lower one.
Moving Client Up in bed
PURPOSE
• To assist clients who have slid down in bed from the Fowler’s position to move up in bed.
ASSESSMENT
Before moving a client, assess the following:
• Client’s physical abilities to assist with the move (e.g., muscle strength, presence of paralysis)
• Client’s ability to understand instructions and willingness to participate
• Client’s degree of comfort or discomfort when moving. If needed, administer analgesics or
perform other pain relief measures prior to the move
• Client’s weight
• The availability of equipment and other personnel to assist you.
PLANNING
Review the client record to determine if previous nurses have recorded information about the
client’s ability to move. Use proper assistive equipment and additional personnel whenever
needed. Ensure that the client understands instructions, and provide an interpreter as needed.
Determine the number of personnel and type of equipment needed to safely perform the
positional change to prevent injury to staff and client.
DELEGATION
The skills of moving and turning clients in bed can be delegated to unlicensed assistive personnel
(UAP). The nurse should make sure that any needed equipment and additional personnel are
available to reduce risk of injury to the health care personnel. Emphasize the need for the UAP to
report changes in the client’s condition that require assessment and intervention by the nurse.
Equipment
• Assistive devices such as an overhead trapeze, friction-reducing device, or a mechanical lift
IMPLEMENTATION
Preparation:
Determine:
• Assistive devices that will be required
• Encumbrances to movement such as an IV or an indwelling urinary catheter
• Medications the client is receiving, because certain medications may hamper movement or
alertness of the client
• Assistance required from other health care personnel.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she
can participate. Listen to any suggestions made by the client or support people.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Adjust the bed and the client’s position.
• Adjust the head of the bed to a flat position or as low as the client can tolerate.
Rationale: Moving the client upward against gravity requires more force and can cause back
strain.
• Raise the bed to a height appropriate for personnel safety (i.e., at the caregiver’s elbows).
• Lock the wheels on the bed and raise the rail on the side of the bed opposite you.
• Remove all pillows, then place one against the head of the bed. Rationale: This pillow protects
the client’s head from inadvertent injury against the top of the bed during the upward move.
5. For the client who is able to reposition without assistance:
• Place the bed in flat or reverse Trendelenburg’s position (as tolerated by the client). Stand by
and instruct the client to move self. Assess if the client is able to move without causing friction
to the skin.
• Encourage the client to reach up and grasp the upper side rails with both hands, bend knees,
and push off with the feet and pull up with the arms simultaneously.
• Ask if a positioning device is needed (e.g., pillow).
6. For the client who is partially able to assist:
• For a client who weighs less than 200 pounds: Use a friction-reducing device and two
assistants.
Rationale: Moving a client up in bed is not a one-person task. During any client handling, if the
caregiver is required to lift more than 35 lb of a client’s weight, then the client should be
considered fully dependent and assistive devices should be used. This reduces risk of injury to
the caregiver.
• For a client who weighs between 201–300 pounds: Use a friction-reducing slide sheet and four
assistants OR an air transfer system and two assistants. Rationale: Moving a client up in bed is
not a one-person task. During any client handling, if the caregiver is required to lift more than 35
lb of a client’s weight, then the client should be considered fully dependent and assistive devices
should be used. This reduces risk of injury to the caregiver.
• For a client who weighs more than 300 pounds: Use an air transfer system and two assistants
OR a total transfer lift.
• Ask the client to flex the hips and knees and position the feet so that they can be used
effectively for pushing.
Rationale: Flexing the hips and knees keeps the entire lower leg off the bed surface preventing
friction during movement, and ensures use of the large muscle groups in the client’s legs when
pushing, thus increasing the force of movement.
• Place the client’s arms across the chest. Ask the client to flex the neck during the move and
keep the head off the bed surface. Rationale: This keeps the arms and head off the bed surface
and minimizes friction during movement.
• Use the friction-reducing device and assistants to move client up in bed. Ask the client to push
on the count of three.
Position yourself appropriately, and move the client.
• Face the direction of the movement, and then assume a broad stance with the foot nearest the
bed behind the forward foot and weight on the forward foot. Lean your trunk forward from the
hips. Flex the hips, knees, and ankles.
• Tighten your gluteal, abdominal, leg, and arm muscles and rock from the back leg to the front
leg and back again. Then, shift your weight to the front leg as the client pushes with the heels so
that the client moves toward the head of the bed.
8. For the client who is unable to assist:
• Use the ceiling lift with supine sling or mobile floor-based lift and two or more caregivers.
Follow manufacturer’s guidelines for using the lift. Rationale: Moving a client up in bed is not a
one-person task. During any client handling, if the caregiver is required to lift more than 35 lb of
a client’s weight, then the client should be considered to be fully dependent, and assistive
devices should be used. This reduces risk of injury to caregiver.
9. Ensure client comfort.
• Elevate the head of the bed and provide appropriate support devices for the client’s new
position.
10. Document all relevant information. Record:
• Time and change of position moved from and position moved to
• Any signs of pressure areas
• Use of support devices
• Ability of client to assist in moving and turning
• Response of client to moving and turning (e.g., anxiety, discomfort, dizziness)
Turning a Client to the Lateral or Prone Position in Bed
PURPOSE
• Movement to the lateral (side-lying) position may be necessary when placing a bedpan beneath
the client, when changing the client’s bed linen, or when repositioning the client.
IMPLEMENTATION
Preparation
Determine:
• Assistive devices that will be required (e.g., friction-reducing device or mechanical lift)
• Encumbrances to movement such as an IV or an indwelling urinary catheter
• Medications the client is receiving, because certain medications may hamper movement or
alertness of the client
• Assistance required from other health care personnel.
Rationale: Moving a client is not a one-person task. During any client handling, if the caregiver
is required to lift more than 35 lb of a client’s weight, then the client should be considered to be
fully dependent and assistive devices should be used. This reduces risk of injury to caregiver.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she
can participate.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Position yourself and the client appropriately before performing the move. Other individual(s)
stands on the opposite side of the bed.
• Adjust the head of the bed to a flat position or as low as the client can tolerate. Rationale: This
provides a position of comfort for the client.
• Raise the bed to a height appropriate for personnel safety (i.e., at the caregiver’s elbows).
• Lock the wheels on the bed.
• Move the client closer to the side of the bed opposite the side the client will face when turned.
Rationale: This ensures that the client will be positioned safely in the center of the bed after
turning. Use a friction-reducing device or mechanical lift (depending on level of client assistance
required) to pull the client to the side of the bed. Adjust the client’s head and reposition the legs
appropriately.
• While standing on the side of the bed nearest the client, place the client’s near arm across the
chest. Abduct the client’s far shoulder slightly from the side of the body and externally rotate the
shoulder.
Rationale: Pulling the one arm forward facilitates the turning motion. Pulling the other arm
away from the body and externally rotating the shoulder prevents that arm from being caught
beneath the client’s body during the roll.
• Place the client’s near ankle and foot across the far ankle and foot. Rationale: This facilitates
the turning motion. Making these preparations on the side of the bed closest to the client helps
prevent unnecessary reaching.
• The person on the side of the bed toward which the client will turn should be positioned
directly in line with the client’s waistline and as close to the bed as possible.
5. Roll the client to the lateral position. The second person(s) standing on the opposite side of the
bed helps roll the client from the other side.
• Place one hand on the client’s far hip and the other hand on the client’s far shoulder. Rationale:
This position of the hands supports the client at the two heaviest parts of the body, providing
greater control in movement during the roll.
• Position the client on his or her side with arms and legs positioned and supported properly.
Variation: Turning the Client to a Prone Position
To turn a client to the prone position, follow the preceding steps, with two exceptions:
• Instead of abducting the far arm, keep the client’s arm alongside the body for the client to roll
over.
Rationale: Keeping the arm alongside the body prevents it from being pinned under the client
when the client is rolled.
• Roll the client completely onto the abdomen. Rationale: It is essential to move the client as
close as possible to the edge of the bed before the turn so that the client will be lying on the
center of the bed after rolling. Never pull a client across the bed while the client is in the prone
position.
Rationale: Doing so can injure a woman’s breasts or a man’s genitals.
6. Document all relevant information. Record:
• Time and change of position moved from and position moved to
• Any signs of pressure areas
• Use of support devices
• Ability of client to assist in moving and turning
• Response of the client to moving and turning (e.g., anxiety, discomfort, dizziness).
Logrolling a Client
PURPOSE
• Logrolling is a technique used to turn a client whose body must at all times be kept in straight
alignment (like a log). An example is the client with back surgery or a spinal injury.
Considerable care must be taken to prevent additional injury.
This technique requires two nurses or, if the client is large, three nurses. For the client who has a
cervical injury, one nurse must maintain the client’s head and neck alignment.
IMPLEMENTATION
Preparation
Determine:
• Assistive devices that will be required
• Encumbrances to movement such as an IV or a urinary catheter
• Medications the client is receiving, because certain medications may hamper movement or
alertness of the client
• Assistance required from other health care personnel. At least 2–3 additional people are needed
to perform this skill safely.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she
can participate.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Position yourselves and the client appropriately before the move.
• Place the client’s arms across the chest. Rationale: Doing so ensures that they will not be
injured or become trapped under the body when the body is turned.
5. Pull the client to the side of the bed.
• Use a friction-reducing device to facilitate logrolling. First, stand with another nurse on the
same side of the bed. Assume a broad stance with one foot forward, and grasp the rolled edge of
the friction-reducing device. On a signal, pull the client toward both of you.
• One nurse counts: “One, two, three, go.” Then, at the same time, all staff members pull the
client to the side of the bed by shifting their weight to the back foot. Rationale: Moving the client
in unison maintains the client’s body alignment.
6. One person moves to the other side of the bed, and places supportive devices for the client
when turned.
• Place a pillow where it will support the client’s head after the turn. Rationale: The pillow
prevents lateral flexion of the neck and ensures alignment of the cervical spine.
• Place one or two pillows between the client’s legs to support the upper leg when the client is
turned.
Rationale: This pillow prevents adduction of the upper leg and keeps the legs parallel and
aligned.
Using a friction-reducing slide sheet, the nurses pull the sheet with the client on it to the edge of
the bed.
7. Roll and position the client in proper alignment.
• Go to the other side of the bed (farthest from the client), and assume a stable stance.
• Reaching over the client, grasp the friction-reducing device, and roll the client toward you.
• One nurse counts: “One, two, three, go.” Then, at the same time, all nurses roll the client to a
lateral position.
• The second nurse (behind the client) helps turn the client and provides pillow supports to
ensure good alignment in the lateral position.
• Support the client’s head, back, and upper and lower extremities with pillows.
• Raise the side rails and place the call bell within the client’s reach.
8. Document all relevant information. Record:
• Time and change of position moved from and position moved to
• Any signs of pressure areas
• Use of support devices
• Ability of client to assist in moving and turning
• Response of client to moving and turning (e.g., anxiety, discomfort, dizziness).
Assisting a Client to Sit on the Side of the Bed (Dangling)
PURPOSE
• The client assumes a sitting position on the edge of the bed before walking, moving to a chair
or wheelchair, eating, or performing other activities.
IMPLEMENTATION
Preparation
Determine:
• Assistive devices that will be required
• Encumbrances to movement such as an IV or a urinary catheter
• Medications the client is receiving, because certain medications may hamper movement or
alertness of the client
• Assistance required from other health care personnel.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she
can participate.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Position yourself and the client appropriately before performing the move.
• Assist the client to a lateral position facing you, using an assistive device depending on client
assistance needs.
• Raise the head of the bed slowly to its highest position.
Rationale: This decreases the distance that the client needs to move to sit up on the side of the
bed.
• Position the client’s feet and lower legs at the edge of the bed. Rationale: This enables the
client’s feet to move easily off the bed during the movement, and the client is aided by gravity
into a sitting position.
• Stand beside the client’s hips and face the far corner of the bottom of the bed (the angle in
which movement will occur). Assume a broad stance, placing the foot nearest the client and head
of the bed forward. Lean your trunk forward from the hips. Flex your hips, knees, and ankles.
5. Move the client to a sitting position, using an assistive device depending on client assistance
needs.
• Place the arm nearest to the head of the bed under the client’s shoulders and the other arm over
both of the client’s thighs near the knees. Rationale: Supporting the client’s shoulders prevents
the client from falling backward during the movement. Supporting the client’s thighs reduces
friction of the thighs against the bed surface during the move and increases the force of the
movement.
• Tighten your gluteal, abdominal, leg, and arm muscles.
• Pivot on the balls of your feet in the desired direction facing the foot of the bed while pulling
the client’s feet and legs off the bed. Rationale: Pivoting prevents twisting of the nurse’s spine.
The weight of the client’s legs swinging downward increases downward movement of the lower
body and helps make the client’s upper body vertical.
• Keep supporting the client until the client is well balanced and comfortable. Rationale: This
movement may cause some clients to become light-headed or dizzy.
• Assess vital signs (e.g., pulse, respirations, and blood pressure) as indicated by the client’s
health status.
6. Document all relevant information. Record:
• Ability of the client to assist in moving and turning
• Type of assistive device, if one was used
• Response of the client to moving and turning (e.g., anxiety, discomfort, dizziness).
EVALUATION
• Check the skin integrity of the pressure areas from the previous position. Relate findings to
previous assessment data if available. Conduct follow-up assessment for previous and/or new
Skin breakdown areas.
• Check for proper alignment after the position change. Do a visual check and ask the client for a
comfort assessment.
• Determine that all required safety precautions (e.g., side rails) are in place.
• Determine client’s tolerance of the activity (e.g., vital signs before and after dangling),
particularly the first time the client changes position.
• Report significant changes to the primary care practitioner
Positioning, Moving, and Turning Clients
INFANTS
• Position infants on their back for sleep, even after feeding. There is little risk of regurgitation and
choking, and the rate of sudden infant death syndrome (SIDS) is significantly lower in infants who sleep
on their backs.
• The skin of newborns can be fragile and may be abraded or torn (sheared) if the infant is pulled across a
bed.
CHILDREN
• Carefully inspect the dependent skin surfaces of all infants and children confined to bed at least three
times in each 24-hour period.
OLDER ADULTS
• In clients who have had cerebrovascular accidents (strokes), there is a risk of shoulder displacement on
the paralyzed side from improper moving or repositioning techniques. Use care when moving, positioning
in bed, and transferring. Pillows or foam devices are helpful to support the affected arm and shoulder and
prevent injury.
• Decreased subcutaneous fat and thinning of the skin place older adults at risk for skin breakdown.
Repositioning approximately every 2 hours (more or less, depending on the unique needs of the
individual client) helps reduce pressure on bony prominences and avoid tissue trauma.
Transferring Clients
A gait belt, sometimes called a transfer or walking belt, has traditionally been used to transfer a client
from one position to another and for ambulation. A gait belt can have handles that allow the nurse to
control movement of the client during the transfer or during ambulation.
Transferring Between Bed and Chair
PURPOSE
• A client may need to be transferred between the bed and a wheelchair or chair, the bed and the
commode, or a wheelchair and the toilet. There are numerous variations in the technique.
ASSESSMENT
Before transferring a client, assess the following:
• The client’s body size
• Ability to follow instructions
• Ability to bear weight
• Ability to position/reposition feet on floor
• Ability to push down with arms and lean forward
• Ability to achieve independent sitting balance
• Activity tolerance
• Muscle strength
• Joint mobility
• Presence of paralysis
• Level of comfort
• Presence of orthostatic hypotension
• The technique with which the client is familiar
• The space in which the transfer will need to be maneuvered (bathrooms, for example, are usually
cramped)
• The number of assistants (one or two) needed to accomplish the transfer safely
Equipment
• Robe or appropriate clothing
• Slippers or shoes with non-skid soles
• Gait/transfer belt
• Chair, commode, wheelchair as appropriate to client need
• Slide board, if appropriate
• Lift, if appropriate
.
IMPLEMENTATION
Preparation
• Plan what to do and how to do it.
• Obtain essential equipment before starting (e.g., gait/transfer belt, wheelchair), and check that all
equipment is functioning correctly.
• Remove obstacles from the area so clients do not trip. Make sure there are no spills or liquids on the
floor on which clients could slip.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
Explain the transfer process to the client. During the transfer, explain step by step what the client should
do, for example, “Move your right foot forward.”
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Position the equipment appropriately.
• Lower the bed to its lowest position so that the client’s feet will rest flat on the floor. Lock the wheels of
the bed.
• Place the wheelchair parallel to the bed and as close to the bed as possible. ❶ Put the wheelchair on the
side of the bed that allows the client to move toward his or her stronger side. Lock the wheels of the
wheelchair and raise the footplate.
5. Prepare and assess the client.
• Assist the client to a sitting position on the side of the bed
• Assess the client for orthostatic hypotension before moving the client from the bed.
• Assist the client in putting on a bathrobe and non-skid slippers or shoes.
• Place a gait/transfer belt snugly around the client’s waist. Check to be certain that the belt is securely
fastened.
6. Give explicit instructions to the client. Ask the client to:
• Move forward and sit on the edge of the bed (or surface on which the client is sitting) with feet placed
flat on the floor.
Rationale: This brings the client’s center of gravity closer to the nurse’s.
• Lean forward slightly from the hips. Rationale: This brings the client’s center of gravity more directly
over the base of support and positions the head and trunk in the direction of the movement.
• Place the foot of the stronger leg beneath the edge of the bed (or sitting surface) and put the other foot
forward.
Rationale: In this way, the client can use the stronger leg muscles to stand and power the movement. A
broader base of support makes the client more stable during the transfer.
• Place the client’s hands on the bed surface (or available stable area) so that the client can push while
standing.
Rationale: This provides additional force for the movement and reduces the potential for strain on the
nurse’s back. The client should not grasp your neck for support. Doing so can injure the nurse.
7. Position yourself correctly.
• Stand directly in front of the client and to the side requiring the most support. Hold the gait/transfer belt
with the nearest hand; the other hand supports the back of the client’s shoulder. Lean your trunk forward
from the hips. Flex your hips, knees, and ankles. Assume a broad stance, placing one foot forward and
one back. Brace the client’s feet with your feet to prevent the client from sliding forward or laterally.
Mirror the placement of the client’s feet, if possible. Rationale: This helps prevent loss of balance during
the transfer.
8. Assist the client to stand, and then move together toward the wheelchair or sitting area to which you
wish to transfer the client.
• On the count of three or the verbal instructions of “Ready–steady–stand” and on the count of three or the
word “Stand,” ask the client to push down against the mattress/side of the bed while you transfer your
weight from one foot to the other (while keeping your back straight) and stand upright moving the client
forward (directly toward your center of gravity) into a standing position. (If the client requires more than
a very small degree of pulling, even with the assistance of two nurses, a mechanical device should be
obtained and used.)
• Support the client in an upright standing position for a few moments. Rationale: This allows the nurse
and the client to extend the joints and provides the nurse with an opportunity to ensure that the client is
stable before moving away from the bed.
• Together, pivot on your foot farthest from the chair, or take a few steps toward the wheelchair, bed,
chair, commode, or car seat.
9. Assist the client to sit.
• Move the wheelchair forward or have the client back up to the wheelchair (or desired seating area) and
place the legs against the seat. Rationale: Having the client place the legs against the wheelchair seat
minimizes the risk of the client falling when sitting down.
Make sure the wheelchair brakes are on.
• Have the client reach back and feel/hold the arms of the wheelchair.
• Stand directly in front of the client. Place one foot forward and one back.
• Tighten your grasp on the transfer belt, and tighten your gluteal, abdominal, leg, and arm muscles.
• Have the client sit down while you bend your knees/hips and lower the client onto the wheelchair seat.
10. Ensure client safety.
• Ask the client to push back into the wheelchair seat.
Rationale: Sitting well back on the seat provides a broader base of support and greater stability and
minimizes the risk of falling from the wheelchair. A wheelchair or bedside commode can topple forward
when the client sits on the edge of the seat and leans far forward.
• Remove the gait/transfer belt.
• Lower the footplates, and place the client’s feet on them, if applicable.
11. Document relevant information:
• Client’s ability to bear weight and pivot
• Number of staff needed for transfer and safety measures/precautions used
• Length of time up in chair
• Client response to transfer and being up in chair or wheelchair.
Transferring Between Bed and Stretcher
PURPOSE
• The stretcher, or gurney, is used to transfer supine clients from one location to another. Whenever the
client is capable of accomplishing the transfer from bed to stretcher independently, either by lifting onto it
or by rolling onto it, the client should be encouraged to do so. If the client cannot move onto the stretcher
independently and weighs less than 200 pounds, a friction-reducing device (i.e., slide sheet) and/or a
lateral transfer board ❶ or an air transfer system should be used, and at least two caregivers are needed to
assist with the transfer. Some friction-reducing devices have handles or long straps to avoid awkward
stretching by the caregivers when pulling the client during the lateral transfer. For clients between 201
and 300 pounds, a slide sheet or transfer board and four caregivers or an air transfer system and two
caregivers should be used. For clients who weigh more than 300 pounds, two caregivers and either an air
transfer system or a ceiling lift with supine sling should be used.
Depending on the client’s condition (e.g., neck immobilizer, IVs, drains, chest tube), additional assistants
may be needed.
ASSESSMENT
Before transferring a client, assess the following:
• The client’s body size and weight
• Ability to follow instructions
• Activity tolerance
• Level of comfort
• The space in which the transfer is maneuvered
• The number of assistants (one to four) needed to accomplish the transfer safely.
PLANNING
Review the client record to determine if previous nurses have recorded information about how the client
tolerated similar transfers. If indicated, implement pain-relief measures so that they are effective when the
transfer begins.
Equipment
• Stretcher
• Transfer assistive devices (e.g., slide sheet, transfer board, air transfer system, lift)
DELEGATION
The skill of transferring a client can be delegated to UAP who have demonstrated safe transfer technique
for the involved client. It is important for the nurse to assess the number of staff needed, assistive devices
needed, and the client’s ability to assist and to communicate specific information about what the UAP
should report to the nurse.
IMPLEMENTATION
Preparation
Obtain the necessary equipment and nursing personnel to assist in the transfer.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
Explain to the client what you are going to do, why it is necessary, and how he or she can participate.
Explain the transfer to the nursing personnel who are helping and specify who will give directions (one
person needs to be in charge).
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Adjust the client’s bed in preparation for the transfer.
• Lower the head of the bed until it is flat or as low as the client can tolerate.
• Place the friction-reducing device under the client.
• Raise the bed so that it is slightly higher (i.e., 1/2 in.) than the surface of the stretcher. Rationale: It is
easier for the client to move down a slant.
• Ensure that the wheels on the bed are locked.
• Place the stretcher parallel to the bed next to the client and lock the stretcher wheels.
• Fill the gap that exists between the bed and the stretcher loosely with the bath blankets (optional).
5. Transfer the client securely to the stretcher.
• If the client can transfer independently, encourage him or her to do so and stand by for safety.
• If the client is partially able or not able to transfer:
• One caregiver needs to be at the side of the client’s bed, between the client’s shoulder and hip.
• The second and third caregivers should be at the side of the stretcher: one positioned between the
client’s shoulder and hip and the other between the client’s hip and lower legs.
• All caregivers should position their feet in a walking stance.
• Ask the client to flex the neck during the move, if possible, and place the arms across the chest.
Rationale: This prevents injury to those body parts.
• On a planned command, the caregivers at the stretcher’s side pull (shifting weight to the rear foot), and
the caregiver at the bedside pushes the client toward the stretcher (shifting weight to the front foot).
6. Ensure client comfort and safety.
• Make the client comfortable, unlock the stretcher wheels, and move the stretcher away from the bed.
• Immediately raise the stretcher side rails and/or fasten the safety straps across the client. Rationale:
Because the stretcher is high and narrow, the client is in danger of falling unless these safety precautions
are taken.
7. Document relevant information:
• Equipment used
• Number of people needed for transfer and safety measures/precautions used
• Destination if reason for transfer is transport from one location to another
Providing Passive ROM Exercises
• Ensure that the client understands the reason for doing ROM exercises.
• If there is a possibility of hand swelling, make sure rings are removed.
• Clothe the client in a loose gown, and cover the body with a bath blanket.
• Use correct body mechanics when providing ROM exercises to avoid muscle strain or injury to both
yourself and the client.
• Position the bed at an appropriate height.
• Expose only the limb being exercised to avoid embarrassing the client and to maintain warmth.
• Support the client’s limbs above and below the joint as needed to prevent muscle strain or injury. This
may also be done by cupping joints in the palm of your hand or cradling limbs along your forearm. If a
joint is painful (e.g., arthritic), support the limb in the muscular areas above and below the joint.
• Use a firm, comfortable grip when handling the limb.
• Move the body parts smoothly, slowly, and rhythmically. Jerky movements cause discomfort and,
possibly, injury. Fast movements can cause spasticity (sudden, prolonged involuntary muscle contraction)
or rigidity (stiffness or inflexibility).
• Avoid moving or forcing a body part beyond the existing range of motion. Muscle strain, pain, and
injury can result. This is particularly important for people with flaccid (limp) paralysis, whose muscles
can be stretched and joints dislocated without their awareness.
• If muscle spasticity occurs during movement, stop the movement temporarily, but continue to apply
slow, gentle pressure on the part until the muscle relaxes; then proceed with the motion.
• If a contracture is present, apply slow firm pressure, without causing pain, to stretch the muscle fibers.
• If rigidity occurs, apply pressure against the rigidity, and continue the exercise slowly.
• Teach client’s caregiver the purposes and technique of performing passive ROM at home if appropriate.
• Avoid hypertension of joints in older adults if joints are arthritic.
• Use the exercises as an opportunity to also assess skin condition.
Assisting a Client to Ambulate
PURPOSE
• To provide a safe condition for the client to walk with whatever support is needed
ASSESSMENT
Assess
• Length of time in bed and the amount and type of activity the client was last able to tolerate
• Baseline vital signs
• Range of motion of joints needed for ambulating (e.g., hips, knees, ankles)
• Muscle strength of lower extremities
• Need for ambulation aids (e.g., cane, walker, crutches, lift with ambulation sling)
• Client’s intake of medications (e.g., narcotics, sedatives, tranquilizers, and antihistamines) that may
cause drowsiness, dizziness, weakness, and orthostatic hypotension and seriously hinder the client’s
ability to walk safely
• Presence of joint inflammation, fractures, muscle weakness, or other conditions that impair physical
mobility
• Ability to understand directions
• Level of comfort
PLANNING
Implement pain relief measures so that they are effective. The amount of assistance needed while
ambulating will depend on the client’s condition, for example, age, health status, length of inactivity, and
emotional readiness. Review any previous experiences with ambulation and the success of such efforts.
Plan the length of the walk with the client, considering the nursing or primary care practitioner’s orders
and the medical condition of the client. Be prepared to shorten the walk according to the client’s activity
tolerance.
DELEGATION
Ambulation of clients is frequently delegated to UAP. However, the nurse should conduct an initial
assessment of the client’s abilities in order to direct other personnel in providing appropriate assistance.
Any unusual events that arise from assisting the client in ambulation must be validated and interpreted by
the nurse.
INTERPROFESSIONAL PRACTICE
Assisting a client to ambulate may be within the scope of practice for specific health care providers. For
example, in addition to nurses, physical therapists may help a client to ambulate. Although the physical
therapist may verbally communicate their findings and plan to the health care team members, the nurse
must also know where to locate their documentation in the client’s medical record.
Equipment
• Assistive devices required for safe ambulation of client (e.g., gait/transfer belt, walker, cane, sit to stand
assist device, lift with ambulation sling)
• Wheelchair for following client, or chairs along the route if the client needs to rest
• Portable oxygen tank if the client needs it
IMPLEMENTATION
Preparation
Be certain that others are available to assist you if needed. Also, plan the route of ambulation that has the
fewest hazards and a clear path for ambulation.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
Explain to the client how you are going to assist, why ambulation is necessary, and how he or she can
participate. Discuss how this activity relates to the overall plan of care. Stress that the client must keep the
nurse informed as to how the activity is being tolerated as it progresses.
2. Perform hand hygiene and observe appropriate infection prevention procedures.
3. Ensure that the client is appropriately dressed to walk and has shoes or slippers with non-skid soles.
4. Prepare the client for ambulation.
• Have the client sit up in bed for at least 1 minute prior to preparing to dangle legs.
• Assist the client to sit on the edge of the bed and allow dangling for at least 1 minute.
Assess the client carefully for signs and symptoms of orthostatic hypotension (dizziness, light-
headedness, or a sudden increase in heart rate) prior to leaving the bedside.
Rationale: Allowing for gradual adjustment can minimize drops in blood pressure (and fainting) that
occur with shifts in position from lying to sitting, and sitting to standing.
• Assist the client to stand by the side of the bed for at least 1 minute until he or she feels secure.
• Carefully attend to any IV tubing, catheters, or drainage bags. Keep urinary drainage bags below level
of the client’s bladder. Rationale: To prevent backflow of urine into bladder and risk of infection.
• If the client is a high safety risk (e.g., cannot follow commands, medical instability, lack of experience
with assistive device, neurologic deficits), use a lift with ambulation sling and 1-2 caregivers.
• If the client is a high safety risk and has upper extremity strength and is able to grasp with at least one
hand, use a lift with ambulation sling or a sit-to-stand lift with ambulation capability and 1-2 caregivers.
• If the client is a low safety risk (e.g., able to follow commands, medically stable, and experienced with
assistive device), use a gait/transfer belt for standby assist as needed and assistive devices as needed (e.g.,
crutches, walker, cane) and 1-2 caregivers. Make sure the belt is pulled snugly around the client’s waist
and fastened securely. Grasp the belt at the client’s back, and walk behind and slightly to one side of the
client.
5. Ensure client safety while assisting the client to ambulate.
• Encourage the client to ambulate independently if he or she is able, but walk beside the client’s weak
side, if appropriate. If the client has a lightweight IV pole because of infusing fluids, he or she may find
that holding onto the pole while ambulating helps with balance. If the pole or other equipment is
cumbersome in any way, the nurse must push it to match the client’s pace, securing any assistance
necessary in order to move smoothly with the client.
• Remain physically close to the client in case assistance is needed at any point.
• If it is the client’s first time out of bed following surgery, injury, or an extended period of immobility, or
if the client is weak or unstable, have an assistant follow you and the client with
a wheelchair in the event that it is needed quickly.
• Encourage the client to assume a normal walking stance and gait as much as possible. Ask the client to
straighten the back and raise the head so that the eyes are looking forward in a normal horizontal plane.
Rationale: Clients who are unsure of their ability to ambulate tend to look down at their feet, which makes
them more likely to fall.
6. Protect the client who begins to fall while ambulating.
• If a client begins to experience the signs and symptoms of orthostatic hypotension or extreme weakness,
quickly assist the client into a nearby wheelchair or other chair, and help the client to lower the head
between the knees.
• Stay with the client. Rationale: A client who faints while in this position could fall head first out of the
chair.
• When the weakness subsides, assist the client back to bed.
• If a chair is not close by, assist the client to a horizontal position on the floor before fainting occurs.
a. Assume a broad stance with one foot in front of the other.
Rationale: A broad stance widens your base of support. Placing one foot behind the other allows you to
rock backward and use the femoral muscles when supporting the client’s weight and lowering the center
of gravity (see the next step), thus preventing back strain.
b. Bring the client backward so that your body supports the person. Rationale: Clients who faint or start to
fall usually pitch slightly forward because of the momentum of ambulating. Bringing the client’s weight
backward against your body allows gradual movement to the floor without injury to the client.
c. Allow the client to slide down your leg, and lower the person gently to the floor, making sure the
client’s head does not hit any objects.
Variation: Two Nurses
• Place a gait/transfer belt around the client’s waist. Each nurse grasps the side handle with the near hand
and the lower aspect of the client’s upper arm with the other hand.
• Walk in unison with the client, using a smooth, even gait, at the same speed and with steps the same size
as the client’s.
Rationale: This gives the client a greater feeling of security
6. Document distance and duration of ambulation and assistive devices, if used, in the client record
using forms or checklists supplemented by narrative notes when appropriate. Include description
of the client’s gait (including body alignment) when walking; pace; activity tolerance when
walking (e.g., pulse rate, facial color, any shortness of breath, feelings of dizziness, or weakness);
degree of support required; and respiratory rate and blood pressure after initial ambulation to
compare with baseline data.
7. EVALUATION
• Establish a plan for continued ambulation based on expected or normal ability for the client.
Using Mechanical Aids for Walking
Mechanical aids for ambulation include canes, walkers, and crutches.
Canes
Three types of canes are commonly used: the standard straightlegged cane; the tripod cane, which has
three feet; and the quad cane, which has four feet and provides the most support. Cane tips should have
rubber caps to improve traction and prevent slipping. The standard cane is 91 cm (36 in.) long; some
aluminum canes can be adjusted from 56 to 97 cm (22 to 38 in.). The length should permit the elbow to
be slightly flexed. Clients may use either one or two canes, depending on how much support they require.

Quad cane

Using Canes
• Hold the cane with the hand on the stronger side of the body to provide maximum support and
appropriate body alignment when walking.
• Position the tip of a standard cane (and the nearest tip of other canes) about 15 cm (6 in.) to the side and
15 cm (6 in.) in front of the near foot, so that the elbow is slightly flexed.
WHEN MAXIMUM SUPPORT IS REQUIRED
• Move the cane forward about 30 cm (1 ft), or a distance that is comfortable while the body weight is
borne by both legs
• Then move the affected (weak) leg forward to the cane while the weight is borne by the cane and
stronger leg.
• Next, move the unaffected (stronger) leg forward ahead of the cane and weak leg while the weight is
borne by the cane and weak leg.
• Repeat the steps. This pattern of moving provides at least two points of support on the floor at all times.
AS YOU BECOME STRONGER AND REQUIRE LESS SUPPORT
• Move the cane and weak leg forward at the same time, while the weight is borne by the stronger leg.
• Move the stronger leg forward, while the weight is borne by the cane and the weak leg.
Walkers
Walkers are mechanical devices for ambulatory clients who need more support than a cane provides and
lack the strength and balance required for crutches. Walkers come in many different shapes and sizes,
with devices suited to individual needs. The standard type is made of polished aluminum. It has four legs
with rubber tips and plastic hand grips. Many walkers have adjustable legs.
The standard walker needs to be picked up to be used. The client therefore requires partial strength in
hands and wrists, strong elbow extensors, and strong shoulder depressors. The client also needs the ability
to bear at least partial weight on both legs. Four-wheeled and two-wheeled models of walkers (roller
walkers) do not need to be picked up to be moved, but they are less stable than the standard walker is.
They are used by clients who are too weak or unstable to pick up and move the walker with each step.
Some roller walkers have a seat at the back so the client can sit down to rest when desired. An adaptation
of the standard and four-wheeled walker is one that has two tips and two wheels.
This type provides more stability than the four-wheeled model yet still permits the client to keep the
walker in contact with the ground all the time. The legs with wheels allow the client to easily push the
walker forward, and the legs without wheels prevent the walker from rolling away as the client steps
forward. The nurse may need to adjust the height of a client’s walker so that the hand bar is just below the
client’s waist and the client’s elbows are slightly flexed. This position helps the client assume a more
normal stance. A walker that is too low causes the client to stoop; one that is too high makes the client
stretch and reach.
Crutches
Crutches may be a temporary need for some clients and a permanent one for others. Crutches should
enable a client to ambulate independently; therefore, it is important to learn to use them properly. The
most frequently used kinds of crutches are the underarm crutch, or axillary crutch with hand bars, and the
Lofstrand crutch, which extends only to the forearm. On the Lofstrand crutch, the metal cuff around the
forearm and the metal bar stabilize the wrists and thus make walking easier, especially on stairs. The
platform, or elbow extensor crutch also has a cuff for the upper arm to permit forearm weight bearing. All
crutches require suction tips, usually made of rubber, which help to prevent slipping on a floor surface.
 Standard walker

Using Walkers
WHEN MAXIMUM SUPPORT IS REQUIRED
• Move the walker ahead about 15 cm (6 in.) while your body weight is borne by both legs.
• Then move the right foot up to the walker while your body weight is borne by the left leg and both arms.
• Next, move the left foot up to the right foot while your body weight is borne by the right leg and both
arms.
IF ONE LEG IS WEAKER THAN THE OTHER
• Move the walker and the weak leg ahead together about 15 cm (6 in.) while your weight is borne by the
stronger leg.
• Then move the stronger leg ahead while your weight is borne by the affected leg and both arms
Measuring Clients for Crutches
When nurses measure clients for axillary crutches, it is most important to obtain the correct length for the
crutches and the correct placement of the hand piece. There are two methods of measuring crutch length:
1. The client lies in a supine position and the nurse measures from the anterior fold of the axilla to the
heel of the foot and adds 2.5 cm (1 in.).
2. The client stands erect and positions the crutch as shown in Figure 44–66 •. The nurse makes sure the
shoulder rest of the crutch is at least three finger widths, that is, 2.5 to 5 cm (1 to 2 in.), below the axilla.
To determine the correct placement of the hand bar:
1. The client stands upright and supports the body weight by the hand grips of the crutches.
2. The nurse measures the angle of elbow flexion. It should be about 30 degrees. A goniometer may
be used to verify the correct angle.
Crutch Gaits The crutch gait is the gait a person assumes on crutches by alternating body weight on one
or both legs and the crutches. The gait used depends on the following individual factors:
(a) The ability to take steps,
(b) The ability to bear weight and keep balance in a standing position on both legs or only one,
(c) The ability to hold the body erect.
Crutch Stance (Tripod Position) Before crutch walking is attempted, the client needs to learn facts about
posture and balance. The proper standing position with crutches is called the tripod (triangle) position .
The crutches are placed about 15 cm (6 in.) in front of the feet and out laterally about 15 cm (6 in.),
creating a wide base of support. The feet are slightly apart. A tall client requires a wider base than does a
short client. Hips and knees are extended, the back is straight, and the head is held straight and high.
There should be no hunch to the shoulders and thus no weight borne by the axillae. The elbows are
extended sufficiently to allow weight bearing on the hands. If the client is unsteady, the nurse places a
gait/transfer belt around the client’s waist and grasps the belt from above, not from below. A fall can be
prevented more effectively if the belt is held from above.
Four-Point Alternate Gait This is the most elementary and safest gait, providing at least three points of
support at all but it requires coordination. Clients can use it when walking in crowds because it does not
require much space. To use this gait, the client needs to be able to bear weight on both legs.
Three-Point Gait To use this gait, the client must be able to bear the entire body weight on the
unaffected leg. The two crutches and the unaffected leg bear weight alternately, reading from bottom to
top. The nurse asks the client to:
1. Move both crutches and the weaker leg forward.
2. Move the stronger leg forward.
Two-Point Alternate Gait This gait is faster than the four-point gait. It requires more balance because
only two points support the body at one time; it also requires at least partial weight bearing on each foot.
In this gait, arm movements with the crutches are similar to the arm movements during normal walking
reading from bottom to top). The nurse asks the client to:
1. Move the left crutch and the right foot forward together.
2. Move the right crutch and the left foot ahead together.
Swing-To Gait The swing gaits are used by clients with paralysis of the legs and hips. Prolonged use of
these gaits results in atrophy of the unused muscles. The swing-to gait is the easier of these two gaits. The
nurse asks the client to:
1. Move both crutches ahead together.
2. Lift body weight by the arms and swing to the crutches.
Swing-Through Gait This gait requires considerable skill, strength, and coordination. The nurse asks the
client to:
1. Move both crutches forward together.
2. Lift body weight by the arms and swing through and beyond the crutch.
Getting into a Chair Chairs that have armrests and are secure or braced against a wall are essential for
clients using crutches. For this procedure, the nurse instructs the client to:
1. Stand with the back of the unaffected leg centered against the chair. The chair helps support the client
during the next steps.
2. Transfer the crutches to the hand on the affected side and hold the crutches by the hand bars. The client
grasps the arm of the chair with the hand on the unaffected side. This allows the client to support the body
weight on the arms and the unaffected leg.
3. Lean forward, flex the knees and hips, and lower into the chair. Getting Out of a Chair For this
procedure, the nurse instructs the client to:
1. Move forward to the edge of the chair and place the unaffected leg slightly under or at the edge of the
chair. This position helps the client stand up from the chair and achieve balance, because the unaffected
leg is supported against the edge of the chair.
2. Grasp the crutches by the hand bars in the hand on the affected side, and grasp the arm of the chair by
the hand on the unaffected side. The body weight is placed on the crutches and the hand on the armrest to
support the unaffected leg when the client rises to stand.
3. Push down on the crutches and the chair armrest while elevating the body out of the chair.
4. Assume the tripod position before moving.
Going Up Stairs For this procedure, the nurse stands behind the client and slightly to the affected side if
needed. The nurse instructs the client to:
1. Assume the tripod position at the bottom of the stairs.
2. Transfer the body weight to the crutches and move the unaffected leg onto the step.
3. Transfer the body weight to the unaffected leg on the step and move the crutches and affected leg up to
the step. The affected leg is always supported by the crutches.
4. Repeat steps 2 and 3 until the client reaches the top of the stairs.
Going Down: Stairs For this procedure, the nurse stands one step below the client on the affected side if
needed. The nurse instructs the client to:
1. Assume the tripod position at the top of the stairs.
2. Shift the body weight to the unaffected leg, and move the crutches and affected leg down onto the next
step.
3. Transfer the body weight to the crutches, and move the unaffected leg to that step. The affected leg is
always supported by the crutches.
4. Repeat steps 2 and 3 until the client reaches the bottom of the stairs.
Evaluating
The goals established during the planning phase are evaluated according to specific desired outcomes,
also established in that phase.
If outcomes are not achieved, the nurse, client, and support person if appropriate need to explore the
reasons before modifying the care plan. For example, the following questions may be considered if an
immobilized client fails to maintain muscle mass and tone and joint mobility:
• Has the client’s physical or mental condition changed motivation to perform required exercise?
• Were appropriate range-of-motion exercises implemented?
• Was the client encouraged to participate in self-care activities as much as possible?
• Was the client encouraged to make as many decisions as possible when developing a daily activity plan
and to express concerns?
• Did the nurse provide appropriate supervision and monitoring?
• Was the client’s diet adequate to provide appropriate nourishment for energy requirements?