Physical Assessment
Integument

Skin: The client’s skin is uniform in color, unblemished and no presence of any
foul odor. He has a good skin turgor and skin’s temperature is within normal limit.

Hair: The hair of the client is thick, silky hair is evenly distributed and has a
variable amount of body hair. There are also no signs of infection and infestation
observed.

Nails: The client has a light brown nails and has the shape of convex curve. It is
smooth and is intact with the epidermis. When nails pressed between the fingers
(Blanch Test), the nails return to usual color in less than 4 seconds.
Head

Head: The head of the client is rounded; normocephalic and symmetrical.

Skull: There are no nodules or masses and depressions when palpated.

Face: The face of the client appeared smooth and has uniform consistency and
with no presence of nodules or masses.
Eyes and Vision

Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically
aligned and showed equal movement when asked to raise and lower eyebrows.

Eyelashes: Eyelashes appeared to be equally distributed and curled slightly
outward.

Eyelids: There were no presence of discharges, no discoloration and lids close
symmetrically with involuntary blinks approximately 15-20 times per minute.

Eyes
o
The Bulbar conjunctiva appeared transparent with few capillaries
evident.
o
The sclera appeared white.
o
The palpebral conjunctiva appeared shiny, smooth and pink.
o
There is no edema or tearing of the lacrimal gland.
o
Cornea is transparent, smooth and shiny and the details of the iris are
visible. The client blinks when the cornea was touched.
o
The pupils of the eyes are black and equal in size. The iris is flat and
round. PERRLA (pupils equally round respond to light accommodation),
illuminated and non-illuminated pupils constricts. Pupils constrict when
looking at near object and dilate at far object. Pupils converge when
object is moved towards the nose.
o
When assessing the peripheral visual field, the client can see objects in
the periphery when looking straight ahead.
o
When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
o
The client was able to read the newsprint held at a distance of 14
inches.
Ears and Hearing

Ears: The Auricles are symmetrical and has the same color with his facial skin.
The auricles are aligned with the outer canthus of eye. When palpating for the
texture, the auricles are mobile, firm and not tender. The pinna recoils when
folded. During the assessment of Watch tick test, the client was able to hear
ticking in both ears.
Nose and Sinus

Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness
and lesions

Mouth:
o
The lips of the client are uniformly pink; moist, symmetric and have a
smooth texture. The client was able to purse his lips when asked to
whistle.
o
Teeth and Gums: There are no discoloration of the enamels, no
retraction of gums, pinkish in color of gums
o
The buccal mucosa of the client appeared as uniformly pink; moist,
soft, glistening and with elastic texture.
o
The tongue of the client is centrally positioned. It is pink in color, moist
and slightly rough. There is a presence of thin whitish coating.
o
The smooth palates are light pink and smooth while the hard palate has
a more irregular texture.

o
The uvula of the client is positioned in the midline of the soft palate.
o
The neck muscles are equal in size. The client showed coordinated,
Neck:
smooth head movement with no discomfort.
o
The lymph nodes of the client are not palpable.
o
The trachea is placed in the midline of the neck.
o
The thyroid gland is not visible on inspection and the glands ascend
during swallowing but are not visible.
Thorax, Lungs, and Abdomen

Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s
a full and symmetric expansion and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory excursion. The client manifested
quiet, rhythmic and effortless respirations.

The spine is vertically aligned. The right and left shoulders and hips are of the
same height.

Heart: There were no visible pulsations on the aortic and pulmonic areas. There
is no presence of heaves or lifts.

Abdomen: The abdomen of the client has an unblemished skin and is uniform in
color. The abdomen has a symmetric contour. There were symmetric movements
caused associated with client’s respiration.
o
The jugular veins are not visible.
o
When nails pressed between the fingers (Blanch Test), the nails return
to usual color in less than 4 seconds.
Extremities

The extremities are symmetrical in size and length.

Muscles: The muscles are not palpable with the absence of tremors. They are
normally firm and showed smooth, coordinated movements.

Bones: There were no presence of bone deformities, tenderness and swelling.

Joints: There were no swelling, tenderness and joints move smoothly.
Nursing Assessment in Tabular Form
Assessment
Findings
Integumentary

Skin

Hair

Nails
Skull
Face
When skin is pinched it goes to previous
state immediately (2 seconds).
With fair complexion.
With dry skin
Evenly distributed hair.
With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and
toenails.
Convex and with good capillary refill time of
2 seconds.
Rounded, normocephalic and symmetrical,
smooth and has uniform
consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral
fissures equal in size, symmetric nasolabial
folds.
Eyes and Vision
Hair evenly distributed with skin intact.
Eyebrows are symmetrically aligned and
have equal movement.
Equally distributed and curled slightly
outward.
Skin intact with no discharges and no
discoloration.
Lids close symmetrically and blinks
involuntary.

Eyebrows

Eyelashes

Eyelids

Bulbar conjunctiva
Transparent with capillaries slightly visible

Palpebral Conjunctiva
Shiny, smooth, pink

Sclera
Appears white.

Lacrimal gland, Lacrimal sac,
No edema or tenderness over the lacrimal
gland and no tearing.
Nasolacrimal duct
Cornea
Assessment

Clarity and texture

Corneal sensitivity
Pupils
Visual Fields
Visual Acuity
Findings
Transparent, smooth and shiny upon
inspection by the use of a penlight which is
held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.
Blinks when the cornea is touched through a
cotton wisp from the back of the client.
Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils
constrict when looking at near objects,
dilates at far objects, converge when object
is moved toward the nose at four inches
distance and by using penlight.
When looking straight ahead, the client can
see objects at the periphery which is done
by having the client sit directly facing the
nurse at a distance of 2-3 feet.
The right eye is covered with a card and
asked to look directly at the student nurse’s
nose. Hold penlight in the periphery and ask
the client when the moving object is spotted.
Able to identify letter/read in the newsprints
at a distance of fourteen inches.
Patient was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing

Auricles
Color of the auricles is same as facial skin,
symmetrical, auricle is aligned with the outer
canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.

External Ear Canal
Without impacted cerumen.

Hearing Acuity Test
Voice sound audible.
Watch Tick Test
Able to hear ticking on right ear at a distance
of one inch and was able to hear the ticking
on the left ear at the same distance

Nose and sinuses

External Nose

Nasal Cavity
Symmetric and straight, no flaring, uniform
in color, air moves freely as the clients
breathes through the nares.
Mucosa is pink, no lesions and nasal
septum intact and in middle with no
Assessment
Mouth and Oropharynx

Teeth

Tongue and floor of the mouth

Tongue movement
Uvula
Gag Reflex
Neck
Head movement
Muscle strength
Lymph Nodes

Thyroid Gland
Thorax and lungs
Posterior thorax

Spinal alignment
Breath Sounds

Anterior Thorax
Abdomen
Abdominal movements

Auscultation of bowel sounds
Upper Extremities
Lower Extremities
Findings
tenderness.
Symmetrical, pale lips, brown gums and
able to purse lips.
With dental caries and decayed lower
molars
Central position, pink but with whitish
coating which is normal, with veins
prominent in the floor of the mouth.
Moves when asked to move without difficulty
and without tenderness upon palpation.
Positioned midline of soft palate.
Present which is elicited through the use of
a tongue depressor.
Positioned at the midline without tenderness
and flexes easily. No masses palpated.
Coordinated, smooth movement with no
discomfort, head laterally flexes, head
laterally rotates and hyperextends.
With equal strength
Non-palpable, non tender
Not visible on inspection, glands ascend but
not visible in female during swallowing and
visible in males.
Chest symmetrical
Spine vertically aligned, spinal column is
straight, left and right shoulders and hips are
at the same height.
With normal breath sounds without
dyspnea.
Quiet, rhythmic and effortless respiration
Unblemished skin, uniform in color,
symmetric contour, not distended.
Symmetrical movements cause by
respirations.
With audible sounds of 23 bowel
sounds/minute.
Without scars and lesions on both
extremities.
With minimal scars on lower extremities
Assessment
Muscles
Bones and Joints
Mental Status
Language
Orientation
Attention span
Level of Consciousness
Findings
Equal in size both sides of the body, smooth
coordinated movements, 100% of normal full
movement against gravity and full
resistance.
No deformities or swelling, joints move
smoothly.
Can express oneself by speech or sign.
Oriented to a person, place, date or time.
Able to concentrate as evidence by
answering the questions appropriately.
A total of 15 points indicative of complete
orientation and alertness.
Motor Function
Gross Motor and Balance

Walking gait
Standing on one foot with eyes closed
Heel toe walking
Toe or heel walking
Fine motor test for Upper Extremities
Finger to nose test
Alternating supination and pronation of
hands on knees
Finger to nose and to the nurse’s finger
Fingers to fingers
Fingers to thumb
Has upright posture and steady gait with
opposing arm swing unaided and
maintaining balance.
Maintained stance for at least five (5)
seconds.
Maintains a heel toe walking along a straight
line
Able to walk several steps in toes/heels.
Repeatedly and rhythmically touches the
nose.
Can alternately supinate and pronate hands
at rapid pace.
Perform with coordinating and rapidity.
Perform with accuracy and rapidity.
Rapidly touches each finger to thumb with
each hand.
Fine motor test for the Lower Extremities
Pain sensation
Able to discriminate between sharp and dull
sensation when touched with needle and
cotton.
Intravenous solutions are used in fluid replacement therapy by changing the composition
of the serum by adding fluids and electrolytes. Listed below is a table which may serve as
your quick reference guide on the different intravenous solutions.
Type
Use

Increases
circulating plasma
Special Considerations

patients with heart
volume when red
Normal Saline (NS)

0.9% NaCl in
Water

Shock

Fluid replacement
Crystalloid
Isotonic (308
mOsm)
or hypernatremia,
because NSS
replaces extracellula
in patients
r fluid and can lead
with diabetic
Solution

failure, edema,
cells are adequate

ketoacidosis

Hyponatremia

Blood transfusions

Resuscitation

Metabolic Alkalosis

Hypercalcemia

Water replacement

Raises total fluid
to fluid overload.

1/2 Normal Saline (1/2
NS)

concentrations.



in Water
dextrose infusion
Crystalloid

cardiovascular
Solution

Hypotonic
collapse or increase
in intracranial

pressure.

Sodium and
trauma, or burns.


fluid, but is of less
Gastric fluid loss
value for
from nasogastric
replacement of NaCl
suctioning or
vomiting.
Useful for daily
maintenance of body
chloride depletion
(154 mOsm)
Don’t use in patients
with liver disease,
Hypertonic dehydra
tion
Use cautiously; may
cause
normal saline
solution and before
Helpful for Na+
replacement
DKA after initial
0.45% NaCl
Replaces losses
without altering fluid
volume

Do not use in
deficit.

Helpful for
establishing renal
function.

Fluid replacement
for clients who don’t
need extra glucose
(diabetics)

Has similar
electrolyte content
with serum but
doesn’t contain
magnesium.

Has potassium there
fore don’t use to

Lactated Ringer’s
(LR)



Replaces fluid and
patients with renal
buffers pH
failure as it can
Hypovolemia due
cause hyperkalemia
Normal
to third-space
saline
shifting.
disease because the

Don’t use in liver
with electrolyt

Dehydration
patient can’t
es and buffer

Burns
metabolize lactate; a
Isotonic (275

Lower GI tract fluid
functional liver
loss
converts it to
Acute blood loss
bicarbonate; don’t
mOsm)

give if patient’s pH >
75.

Normal saline with
K+, Ca++, and
lactate (buffer)

Often seen
with surgery
D5W


Dextrose 5%
Raises total fluid

Solution is isotonic
volume.
initially and becomes
Helpful in
hypotonic when
Crystalloid
rehydrating and
dextrose is
solution
excretory purposes.
metabolized.
in water


Isotonic (in

the bag)

*Physiologica

Fluid loss

Not to be used for
and dehydration
resuscitation; can
Hypernatremia
cause hyperglycemi
lly hypotonic
a

(260 mOsm)
Use in caution to
patients with renal or
cardiac disease, can
cause fluid overload

Doesn’t provide
enough daily
calories for
prolonged use; may
cause eventual
breakdown of
protein.

Provides 170-200
calories/1,000cc for
energy.

Physiologically
hypotonic -the
dextrose is
metabolized quickly
so that only water
remains – a
hypotonic fluid

Hypotonic dehydrat
ion
D5NS




Do not use in
Replaces
patients with cardiac
Dextrose 5%
fluid sodium,
or renal failure
in 0.9%
chloride, and
because of danger
saline
calories.
of heart failure and
Temporary
pulmonary edema.
Hypertonic
(560 mOsm)

treatment of
circulatory
insufficiency and

Watch for fluid
volume overload
shock if plasma
expanders aren’t
available

SIADH (or use
3% sodium chloride
).

Addisonian crisis

DKA after initial
treatment with
normal saline
D5 1/2 NS



when glucose falls <
solution and halfDextrose 5%
normal saline
in 0.45%
solution –
saline
prevents hypoglyce
Hypertonic
mia and cerebral
(406 mOsm)
edema (occurs
In DKA, use only
250 mg/dl

Most common
postoperative fluid

Useful for daily
maintenance of body
fluids and nutrition,
when serum
and for rehydration.
osmolality is
reduced rapidly).

Contraindicated in
newborns (≤ 28 days

of age), even if
Same as LR plus
separate infusion
provides about 180
D5LR
lines are used (risk
calories per

Dextrose 5%
in Lactated

of fatal ceftriaxone-
1000cc’s.

calcium salt
Indicated as a
Ringer’s
source of
Hypertonic
water, electrolytes
(575 mOsm)
and calories or as
an alkalinizing
precipitation in the
neonate’s
bloodstream).

Contraindicated in
patients with a
agent
known
hypersensitivity to
sodium lactate.
Normosol-R

Replaces fluid and

Not intended to

Normosol

Isotonic (295

mOsm)

buffers pH
supplant transfusion
Indicated for
of whole blood or
replacement of
packed red cells in
acute extracellular
the presence of
fluid volume losses
uncontrolled
in surgery,
hemorrhage or
trauma, burns or
severe reductions of
shock.
red cell volume
Used as an adjunct
to restore a
decrease in
circulatory volume
in patients with
moderate blood
loss
Common Positions
Fowler’s

Fowler’s position, is a bed position wherein the head and trunk are raised 40 to
90 degrees.

Fowler’s position is used for people who have difficulty breathing because in this
position, gravity pulls the diaphragm downward allowing greater chest and lung
expansion.

In low Fowler’s or semi-Fowler’s position, the head and trunk are raised to 15
to 45 degrees; in high Fowler’s, the head and trunk are raised 90 degrees.

This position is useful for patients who have cardiac, respiratory, or neurological
problems and is often optimal for patients who have nasogastric tube in place.

Using a footboard is recommended to keep the patient’s feet in proper alignment
and to help prevent foot drop.
Orthopneic or Tripod

Orthopneic or tripod position places the patients in a sitting position or on the side
of the bed with an overbed table in front to lean on and several pillows on the
table to rest on.

Patients who are having difficulty breathing are often placed in this position since
it allows maximum expansion of the chest.
Dorsal Recumbent

In dorsal recumbent or back-lying position, the client’s head and shoulders are
slightly elevated on a small pillow.

This position provides comfort and facilitates healing following certain surgeries
and anesthetics.
Supine or Dorsal position

Supine is a back-lying position similar to dorsal recumbent but the head and
shoulders are not elevated.

Just like dorsal recumbent, supine position provides comfort in general for
patients recover after some types of surgery.
Prone

In prone position, the patient lies on the abdomen with head turned to one side;
the hips are not flexed.

This is the only bed position that allows full extension of the hip and knee joints.

Prone position also promotes drainage from the mouth and useful for clients who
are unconscious or those recover from surgery of the mouth or throat.

Prone position should only be used when the client’s back is correctly aligned,
and only for people with no evidence of spinal abnormalities.

To support a patient lying in prone, place a pillow under the head and a small
pillow or a towel roll under the abdomen.
Lateral position

In lateral or side-lying position, the patient lies on one side of the body with the
top leg in front of the bottom leg and the hip and knee flexed.

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. This flexion reduces lordosis and promotes good back
alignment.

Lateral position helps relieve pressure on the sacrum and heels in people who sit
for much of the day or confined to bed rest in Fowler’s or dorsal recumbent.

In this position, most of the body weight is distributed to the lateral aspect of the
lower scapula, the lateral aspect of the ilium, and the greater trochanter of the
femur.
Sims’ Position

Sims’ is a semi-prone position where the patient assumes a posture halfway
between the lateral and 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.

Sims’ may be used for unconscious clients because it facilitates drainage from
the mouth and prevents aspiration of fluids.

It is also used for paralyzed clients because it reduces pressure over the sacrum
and greater trochanter of the hip.

It is often used for clients receiving enemas and occasionally for clients
undergoing examinations or treatments of the perineal area.

Pregnant women may find the Sims position comfortable for sleeping.

Support proper body alignment in Sims’s position by placing a pillow underneath
the patient’s head and under the upper arm to prevent internal rotation. Place
another pillow between legs.
Trendelenburg’s

Trendelenburg’s position involves lowering the head of the bed and raising the
foot of the bed of the patient.

Patient’s who have hypotension can benefit from this position because it
promotes venous return.
Reverse Trendelenburg

Reverse Trendelenburg is the opposite of Trendelenburg’s position.

Here the HOB is elevated with the foot of bed down.

This is often a position of choice for patients with gastrointestinal problems as it
can help minimize esophageal reflux.
Cheat Sheet for Patient Positions
Below is the cheat sheet for the common patient positioning. You can also download the
PDF file:

Patient Positioning Cheat Sheet (PDF, 142 KB)
Condition
Bronchoscopy
Position
After: Semi-Fowler’s
Rationale & Additional Info
To reduce aspiration risk from
difficulty of swallowing
During: Flat on bed with
arms at sides; kept still.
Cerebral angiography
After: Extremity in which
contrast was injected is kept
straight for 6 to 8 hours. Flat,
if femoral artery was used.
Apply firm pressure on site for
15 minutes after the procedure.
Condition
Position
Rationale & Additional Info
Pre-op: surgical table will be
moved to various positions
during test.
Myelogram (air contrast)
Post-op: HOB is lower than
To disperse dye.
trunk.
Myelogram (oil-based
dye)
Pre-op: surgical table will be
moved to various positions
during test.
Post-op: Flat on bed for 6 to
To disperse dye.To prevent
CSF leakage.
8 hours
Myelogram (water-based
dye)
Pre-op: surgical table will be
moved to various positions
during test.
Post-op: HOB elevated for 8
To prevent dye from irritating
the meninges.
hours.
Liver biopsy
During: Supine with RIGHT
side of upper abdomen
exposed; RIGHT arm raised
and extended behind and
and overhead and shoulder.
After: RIGHT side-lying with
To expose the area.
To apply pressure and
minimize bleeding.
pillow under puncture site.
Lung biopsy
Renal biopsy
Flat supine with arms raised
above head and hands
health together; head and
arms on pillow.
PRONE with pillow under the
abdomen and shoulders.
To expose and provide easy
access to the area.
To expose the area.
Don’t sleep on affected side;
encourage exercise by
squeezing a rubber ball.
Arteriovenous fistula
Post-op: Elevate extremity
Don’t use AV arm for BP
reading and venipuncture.
Peritoneal Dialysis
When outflow is
Turning facilitates drainage;
Condition
Position
inadequate: turn patient from
side to side.
Rationale & Additional Info
check for kinks in the tubing.
Possible to have abdominal
cramps and blood-tinged
outflow if catheter was placed
in the last 1-2 weeks.
Cloudy outflow is never
normal.
Meniere’s Disease
Autografting
Internal radiation, during
treatment
Change position slowly;
bedrest during acute phase
Immobilize site for 3 to 7
days.
Provide protection when
ambulating
To promote healing and
maximal adhesion.
To prevent dislodgement of the
implant device.
Strict bedrest while implant is
in place
Provide own urinal or bedpan
Heart failure with
pulmonary edema
Sitting up, with legs dangling
Myocardial infarction
Semi-Fowler’s
Pericarditis
High-Fowlers, upright leaning
forward.
Depending on desired
outcome.
to patient.
To decrease venous return and
reduce congestion; promotes
ventilation and relieves
dyspnea.
To help lessen chest pain and
promote respiration.
To help lessen pain.
Slight elevation of legs but
not above the heart or slightly
Peripheral artery disease
dependent.
To slow or increase arterial
return
Dangle legs on side of the
bed.
Shock
Flat on bed.
To improve or increase
circulation.
Condition
Position
Rationale & Additional Info
Trendelenburg is no longer a
recommended position.
Sickle Cell Anemia
HOB elevated 30 degrees,
avoid knee gatch and putting
strain on painful joints
Varicose veins, leg
ulcers, and venous
insufficiency
Elevate extremities above
heart level.
To promote maximum lung
expansion and assist in
breathing.
To prevent pooling of blood in
the legs and facilitate venous
return; avoid prolonged
standing.
Bed rest with affected limb
elevated.
After 24 hours after heparin
Deep vein thrombosis
therapy, patient can
To promote circulation.
ambulate if pain level
permits.
Tracheoesophageal
fistula (TEF)
Ventriculoperitoneal
shunt (for Hydrocephalus
treatment)
HOB elevated 30-45
degrees.
After shunt placement: Place
on non-operative side in flat
position.
To prevent reflux.
HOB raised 15-30 degrees if
ICP is increased.
Avoid rapid fluid drainage.
Do not hold infant with head
elevated.
HyphemaBlood in
anterior chamber of eye
Abdominal aneurysm
Dehiscence
Dumping Syndrome,
HOB elevated 30-45
degrees, with night shield.
Post-op: HOB no more than
45 degrees
Place in low-Fowler’s position
then raise knees or instruct
knees and support them with
a pillow.
Take meals in reclining
To allow the hyphema to settle
out inferiorly and avoid
obstruction of vision and to
facilitate resolution
To avoid flexion of the graft.
To decrease tension on the
abdomen.
To delay gastric emptying time.
Condition
prevention of
Position
position, lie down for 20-30
minutes after.
Rationale & Additional Info
Restrict fluids during meals,
low carb, low fiber diet in small
frequent meals.
Evisceration
Place in low-Fowler’s
position.
Instruct not to cough; place on
NPO; keep intestines moist
and covered with sterile saline
until patient can be wheeled to
OR.
Reverse Trendelenburg,
slanted bed with head higher.
Gastroesophageal reflux
disease (GERD)
Pediatric: prone with HOB
Hiatal hernia
Upright position after meals.
Pyloric stenosis
RIGHT side-lying position
after meals.
Extremity burns
Elevate extremity.
Facial burns or trauma
Head elevated
Initially place in sitting
position or high Fowler’s
position with legs dangling.
HOB elevated 30-45
degrees; bed rest
Autonomic dysreflexia
Cerebral aneurysm
elevated.
To promote gastric emptying
and reduce reflux.
To prevent gastric content
reflux.
To facilitate entry of stomach
contents into the intestines.
To reduce dependent edema
and pressure.
To reduce edema
To reduce blood pressures
below dangerous levels and
provide partial symptom relief.
To prevent pressure on
aneurysm site
To promote venous return and
maintain blood flow to the
head.
To reduce ICP and encourage
blood drainage.Avoid hip and
neck flexion which inhibits
drainage.
To promote venous drainage.
Heat stroke
Supine, flat with legs
elevated.
Hemorrhagic stroke
HOB elevated 30 degrees.
Elevate HOB 30-45 degrees,
maintain head midline and in
neutral position.
Avoid flexion of the neck, head
Increased intracranial
pressure (ICP)
HOB flat in midline, neutral
To facilitate venous drainage
Ischemic stroke
rotation, hip flexion, coughing,
sneezing and bending forward.
Condition
Position
position.
Rationale & Additional Info
and encourage arterial blood
flow.
Avoid hip and neck flexion
which inhibits drainage
Seizure
Spinal cord injury
Side-lying or recovery
position.
Immobilize on spinal
backboard, head in neutral
position and immobilized with
a firm, padded cervical collar.
Must be log rolled without
To drain secretions and
prevent aspiration.
To prevent any movement and
further injury.
allowing any twisting or
bending movements
Head injury
Buck’s Traction
Casted arm
Delayed prosthesis fitting
Hip fracture
Elevate HOB 30 degrees,
head should be kept in
neutral position.
Elevate FOB for countertraction; use trapeze for
moving; place pillow beneath
lower legs.
Elevate at or above level of
heart
Elevate foot of bed to elevate
residual limb.
Affected extremity needs to
be abducted.
To decrease intracranial
pressure (ICP).Keep head from
flexing or rotating.
Avoid frequent suctioning.
Ask patient to dorsiflex foot of
the affected leg to assess
function of peroneal nerve,
weakness may indicate
pressure on the nerve.
To minimize swelling
To hasten venous return and
prevent edema.
Use splints, wedge pillow, or
pillows between legs.
Avoid stooping, flexion position
during sex, and overexertion
during walking or exercise.
Hip replacement
On unaffected
side: maintain abduction
when in supine position with
pillow between legs.
Avoid extreme internal or
external rotation.
Condition
Position
Rationale & Additional Info
HOB raised to 30-45
degrees.
Immediate prosthesis
fitting
Elevate residual limb for 24
hours.
Osteomyelitis
Support affected extremity
with pillows or splints
Total hip replacement
Help to sitting position; place
chair at 90 degrees angle to
bed; stand on affected side;
pivot patient to unaffected
side.
To prevent dizziness and
orthostatic hypotension.
Acute Respiratory
Distress Syndrome
(ARDS)
High Fowler’s
To promote oxygenation via
maximum chest expansion.
Turn to LEFT side or place in
Trendelenburg.
Patient should be immediately
repositioned with the right
atrium above the gas entry site
so that trapped air will not
move into the pulmonary
circulation.
Air embolism from
dislodged central venous
line
Rigid cast acts to control
swelling.
To maintain proper body
alignment; avoid strenuous
exercises.
High Fowler’s
Tripod position: sitting
Asthma
position while leaning forward
To promote oxygenation via
maximum chest expansion.
with hands on knees.
Chronic Obstructive
Pulmonary
Disease (COPD)
High Fowler’s
Orthopneic position
To promote maximum lung
expansion and assist in
breathing.
High Fowler’s
Emphysema
Orthopneic position
Pleural Effusion
High Fowler’s
High Fowler’s
Pneumonia
Lay on affected side
To promote maximum lung
expansion
To provide maximal
To maximize breathing
mechanisms.
To splint and reduce pain.
Condition
Position
Lay with affected lung up
Pneumothorax
Pulmonary edema
Pulmonary embolism
High Fowler’s
High Fowler’s, legs
dependent position
High Fowler’s
Turn patient to LEFT side
and lower HOB
Flail chest
High Fowler’s
Rib fracture
High Fowler’s
Contraction stress
test (CST)
Placed in semi-Fowler’s or
side-lying position
Cord prolapse
Shrimp or fetal position;
modified Sims’ or
Trendelenburg.
Late decelerations
(placental insufficiency)
Placenta previa
Turn mother to her LEFT
side.
Turn mother to her LEFT
side.
Sitting position.
Variable decelerations
(cord compression)
Place mother in
Trendelenburg position.
Spina Bifida
Prone (on abdomen).
Position on back or in infant
seat.
Cleft lip (congenital)
Hold in upright position while
Fetal distress
feeding.
Prolapsed umbilical cord
During labor: Knee-chest
Rationale & Additional Info
To reduce congestion.
To promote maximum lung
expansion and assist in
breathing.
To decrease edema and
congestion
To promote maximum lung
expansion and assist in
breathing.
To provide maximal comfort
and maximize breathing
mechanisms.
To promote maximum lung
expansion and assist in
breathing.
Monitor for posttest labor onset.
To prevent pressure on the
cord. If cord prolapses, cover
with sterile saline gauze to
prevent drying.
To reduce compression of the
vena cava and aorta.
To allow more blood flow to
the placenta.
To minimize bleeding.
To remove pressure off the
presenting part of the cord and
prevent gravity from pulling the
fetus out of the body.
To prevent sac rupture.
To prevent trauma to suture
line.
Relieves pressure or gravity
Condition
Position
position or Trendelenburg.
Rationale & Additional Info
from pulling the cord.
Hand in vagina to hold
presenting part of fetus off
cord.
Cardiac catheterization
(post)
Continuous Bladder
Irrigation (CBI)
Ear drops
Ear irrigation
HOB elevated no more than
30 degrees or flat as
prescribed.May turn to either
side
Tape catheter to thigh; no
other positioning restrictions
Position affected ear
uppermost then lie on
unaffected ear for absorption.
During procedure: Tilt head
towards affected ear.
After procedure: Lie on
affected side for drainage.
Eye drops
Lumbar puncture
Tilt head back and look up,
pull lid down.
During: Shrimp or fetal
position (side-lying with back
bowed, knees drawn up to
abdomen, neck flexed to rest
chin on chest).
After: Flat on bed for 4-12
hours.
Nasogastric
tube insertion
High Fowler’s with head tilted
forward
Nasogastric tube
irrigation and tube
feedings
HOB elevated 30 to 45
degrees; keep elevated for 1
hour after an intermittent
feeding.
With decreased
Affected extremity should be
kept straight.
Prevents the catheter from
being dislodged.
Pull outer ear upward and back
for adults; upward and down
for children.
Better visualization and
drainage of the medium to the
ear canal via gravity.
Drop to center of the lower
conjunctival sac; blink between
drops; press inner canthus
near nose bridge for 1-2 min to
prevent systemic absorption.
To maximize spine flexion.
To prevent spinal headache
and CSF leakage.
Closes the trachea and opens
the esophagus;
prevents aspiration.
To
prevent aspiration.Promotes
emptying of the stomach and
prevents aspiration.
Condition
Position
LOC: RIGHT side-lying with
Rationale & Additional Info
To prevent aspiration.
HOB elevated.
With
tracheostomy: Maintain in
semi-Fowler’s position
Paracentesis
During: Semi-Fowler’s in bed
or sitting upright on side of
bed with chair; support the
feet.
Post: Assist into any
comfortable position
Postural Drainage
Trendelenburg
Rectal enema
administration
Left side-lying (Sims’
position) with right knee
flexed.
Rectal enemas and
irrigation
Left side-lying, Sims’ position
Sengstaken-Blakemore
and Minnesota tubes
HOB elevated
Empty the bladder before
procedure; report elevated
temperature; assess for
hypovolemia.
Lung area needing drainage
should be in uppermost
position
Allows gravity to work into the
direction of the colon by
placing the descending colon
at its lowest point.
To allow fluid to flow in the
natural direction of the colon.
To enhance lung expansion
and reduce portal blood flow,
permitting esophagogastric
balloon tamponade.
Before: (1) Sitting on edge of
bed while leaning on bedside
table with feet supported by
stool; or lying in bed on
unaffected side with head
elevated 45 degrees.
Thoracentesis
(2) Lying in bed on
unaffected side with HOB
elevated to Fowler’s.
After: Assist patient into any
comfortable position
Prevent fluid leakage into the
thoracic cavity.
Condition
Position
Rationale & Additional Info
preferred.
Total Parenteral Nutrition
(TPN)
Vascular extremity graft
During
insertion: Trendelenburg.
Bed rest for 24 hours, keep
extremity straight and avoid
knee or hip flexion
Perineal procedures
Lithotomy
Appendectomy
Post-op: Fowler’s position
To prevent air embolism.
For maximal adhesion.
For better visualization of the
area.
To relieve abdominal pain and
ease breathing.
Sleep on unaffected side with
a night shield for 1 to 4
weeks.
Cataract surgery
Semi-Fowler’s or Fowler’s on
To prevent edema.
back or on non-operative
side.
HOB elevated 30-45% with
head in a midline, neutral
position.
Craniotomy
Never put client on operative
To facilitate venous drainage.
side, especially if bone was
removed.
Hemorrhoidectomy
Hypophysectomy
Surgical removal of the
pituitary gland.
Infratentorial surgery
Incision at back of head,
above nape of neck
Kidney transplant
Laminectomy
During: Prone Jackknife
position.
Provides better visualization of
the area.
HOB elevated.
To prevent increase in ICP.
Flat and lateral on either
side; avoid neck flexing.
To facilitate drainage.
Post-op: Semi-Fowler’s, turn
from back to non-operative
side
Back is kept straight.Patient
is logrolled if turned.
Sit straight in straight-backed
To promote gas exchange
Condition
Position
Rationale & Additional Info
chair when out of bed or
when ambulating.
Laryngectomy
HOB elevated 30-45 degrees
Mastectomy
Semi-Fowler’s with arm on
affected side elevated.
Myringotomy
Post-op: semi-Fowler’s
position.
Post-op: Position on side of
affected ear .
Bed rest with minimal activity
and repositioning.
Retinal detachment
Area of detachment should
Mitral valve replacement
be in the dependent position.
Supratentorial surgery
Incision front of head
below hairline
Thyroidectomy
Tonsillectomy
HOB elevated 30-45
degrees; maintain
head/neckline in midline
neutral position; avoid
extreme hip and neck flexion.
Post-op: High Fowler’s or
semi-Fowler’s.
Amputation: above the
Turn only on back and on
unaffected side.
To assist in breathing.
To allow drainage of secretions
Helps detached retina fall into
place.
To facilitate drainage.
To reduce swelling and edema
in the neck area.
Avoid extension and
To decrease tension on the
movement by using
suture line and support the
sandbags or pillows.
head and neck.
Post-op: prone or side-lying
Side lying with head tucked
and legs pulled up or;
Bone
marrow aspiration/biopsy
To maintain airway and
decrease edema.
To allow lymph drainage.
To facilitate drainage and
relieve pressure on the neck.
To expose the area.
Apply pressure to the area
Prone with arms folded under
after the procedure to stop
chin.
the bleeding.
Elevate for first 24 hours
To prevent edema.
Condition
knee
Position
using pillow.Position prone
twice daily.
Rationale & Additional Info
To provide for hip extension
and stretching of flexor
muscles; prevent contractures,
abduction
Amputation: below the
knee
Foot of bed elevated for first
24 hours.
Position prone daily.
To prevent edema.
To provide for hip extension.