Positioning and Body Alignment Policy 

Standard: 
Each resident who is partially or totally dependent is positioned in good body alignment at all times to ensure comfort, prevent pressure ulcers, and maintain overall well-being. 

Purpose: 

• To change the resident’s position using good body mechanics. 

• To relieve pressure and prevent skin breakdown. 

• To relieve pain. 

• To promote proper body alignment. 

General Guidelines: 

• Explain the procedure to the resident and provide privacy. 

• Maintain standard precautions and safety measures (number of individuals needed to assist resident to change position). 

• Report any concerns regarding skin, pain, or changes in the resident’s condition to the nurse. 

Procedures: 

I. Beginning Procedures: 

• Be aware of any limitations a resident may have in positioning. 

• Have proper equipment to relieve pressure and maintain body alignment at bedside. 

• Identify the resident. 

• Explain the procedure to the resident. If possible, enlist the assistance of the resident. Provide privacy. 

• Wash hands before and after the procedure. 

• Use gloves when contact with body fluids and/or secretions are expected, or if on designated isolation. 

• Position the resident to maintain comfort and reduce pressure. 

• Follow procedures for specific positions as listed below. 

II. Specific Positions: 

A. Dorsal or Supine Position (On Back): 

• Head is in line with the spine. 

• Trunk is positioned to minimize hip flexion. 

• Arms are flexed at the elbow with hands resting against the lateral abdomen or across the chest. 

• Place a pillow under the head of the resident with the edge at the tip of the shoulders. 

• Legs are extended with a small, firm support under the popliteal area. 

• Heels are elevated as indicated with an appropriate device. 

• Toes are pointing up. 

• Use a trochanter roll by rolling a towel or bath blanket and positioning it at the outer aspect of each hip to prevent external rotation of the legs. 

• Position a pillow or padded footboard at the lower end of the mattress to prevent foot-drop. A bed cradle can be used to prevent additional pressure from bedding. 

• Elbow protectors may be used to reduce friction and subsequent skin breakdown over bony prominences. 

B. Side-Lying or Lateral Position: 

• Head is in line with the spine. 

• Body is in alignment and is not twisted. 

• The uppermost hip joint is slightly forward and supported by a pillow in a position of slight abduction. 

• A pillow supports the arm, which is flexed at both the elbow and shoulder joints. 

C. Prone Position (On Abdomen): 

• Turn the resident’s head to one side. Do not use a pillow. The head is in alignment with the rest of the body. 

• Arms are abducted and externally rotated at the shoulder. 

• Place a small, flat support/pillow under the abdomen/pelvis of the resident to reduce strain on the back. 

• Flex one arm and position it above the head. The other arm rests with the palm up at the side of the resident. 

• Position the feet of the resident so the toes fall between the mattress and frame of the bed. If this is not possible, fold a towel and place it under the ankles of the resident so pressure is reduced on the toes. 

D. Fowler’s Position: 

• Raise the back of the bed to a semi-sitting position, no more than 45 degrees and not less than 30 degrees. 

• Prevent the resident from sliding to the foot of the bed by raising the knees slightly using the frame of the bed or a pillow. 

• Support shoulders and arms with extra pillows to serve as armrests and promote good body alignment. 

E. Dorsal Recumbent/Lithotomy Position (Used for Vaginal and Rectal Examinations/Treatment): 

• Place the resident in a horizontal recumbent position. 

• Remove the pillow. 

• Assist the resident to flex the knees and place feet and knees slightly apart with feet flat on the bed. 

• Drape a bath blanket/sheet as a diamond over the resident; one corner over the resident’s chest, sides wrapped around each leg and foot and tuck in; the other corner over the pubic area. 

• Fold back the center corner over the abdomen to expose the genital area when the doctor is ready to examine. To help the resident relax, have the resident spread legs and knees. 

F. Sims Position (Used for Rectal Examinations/Treatment): 

• Place the resident on their left side with a pillow under their head; assist as necessary. 

• Place the resident’s left arm behind their body; the right arm may be placed comfortably for the resident. 

• Flex the right knee against the abdomen and flex the left knee slightly. 

• Expose the anal area by folding back a small portion of the sheet. 

G. Knee-Chest (Genito-Pectoral) Position (Used for Rectal Examination/Treatment): 

• Assist the resident to their knees with the chest resting on the bed; bear weight on the chest and knees; a small pillow may be placed under the chest for support. 

• Have the resident rest their elbows on the bed or put their arms above their head. 

• Have the resident turn their head to one side to ease breathing. 

• Position the thighs straight up and down and the lower portion of the legs flat on the bed. Positioning is important for support; hips should be directly above the knees. Do not leave the resident alone during treatment. 

• Assist the resident to their former position after the treatment is completed. 

H. Standing Position: 

• Ensure the resident is properly dressed and wearing appropriate footwear. 

• Ensure the gait belt is in place. 

• Assist the resident to a standing position. 

I. Trendelenburg Position (Used for Shock): 

• Place the resident in a dorsal recumbent position with the head of the bed lower than the resident’s feet. 

J. Positioning in Chair/Wheelchair: 

• Place the buttocks as far back in the chair/wheelchair as possible. 

• Center the head and shoulders over the hips. 

• Position hips, knees, and feet as close to a 90-90-90 position as possible. 

• Support feet by placing them on footrests if in a chair and feet do not touch the ground, or on footplates or adaptive cushions. 

K. Recliner: 

• Place the buttocks as far back in the chair as possible. 

• Center the head and shoulders against the backrest of the chair, maintaining alignment with the hips. 

• Extend the legs and feet in a straight line. Support them on the leg rest of the chair. 

• Smooth out wrinkles from pads or clothing under the resident. 

• Place adaptive equipment or cushions as per the resident’s care plan. 

• Reposition the resident at least every two hours or more frequently as indicated. 

• Raise the back of the chair as far as possible if the resident is to eat in this position. 

L. Moving the Resident by Using a Lift Sheet: 

• Explain to the resident what you are going to do. 

• Remove the pillow from under the resident’s head. 

• Stabilize the bed by locking the wheels. 

• Raise the bed to a comfortable working height, if possible. 

• With a staff member on each side, roll the lift sheet as close as possible to the resident’s body. Repeat on the opposite side so that the lift sheet is under the resident (under the hips to shoulders). 

• Stand straight with feet about 12 inches apart. Your body should be turned slightly toward the head of the bed, with your feet pointed in the direction of the move (toward the head of the bed). If moving side to side, your toes should be pointed toward the side of the bed. 

• Grasp the rolled sheet with your hands at the resident’s shoulder and at the hips. 

• As you count “one, two, three,” keep your back straight and knees bent, and slide the resident toward the head of the bed (or toward the side of the bed) as you shift your weight from one foot to the other. 

• Position the resident in the desired position. Replace the head pillow. 

• Lower the bed to the appropriate “low” position. 

M. Log Rolling: 

• Follow steps as identified above, EXCEPT when turning the resident, roll the resident onto one side like a log, turning the body as a whole unit without bending the joints. Turn gently. You may need one person to support the leg during the turn. 

• If the resident is left positioned on the side, use pillows against the resident’s back to keep the body in proper alignment. 

References: 

• Centers for Medicare & Medicaid Services (CMS), Requirements of Participation for Long-Term Care Facilities. 

• State Operations Manual (SOM), CMS.