Instructional Use Statement
Positioning and Draping
PTA 101 Introduction to Clinical Practice 1
The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.
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The patient's position of comfort is often the position of greatest contracture risk. Attention to correct positioning is relevant to every treatment setting. A contracture is a fixed shortening or tightening of soft tissue resulting in limited motion of the joint. A contraction is a shortening or increase in muscle tension, denoting the normal function of muscle tissue.
Positioning and draping are techniques which maximize patient comfort and dignity, and which minimize injury to tissue. In this lesson, we will define key terms and explore methods for proper positioning and draping. Techniques covered in this lesson will be implemented in laboratory practice, skill checks, and formal testing.
Course level objectives:
Describe theory, therapeutic benefits/outcomes, and application (precautions, contraindications, and procedures) of interventions used to promote healing, functional recovery, and pain management - positioning
Lesson Level Objectives
- Use correct medical terminology to describe a patient position activity during a case simulation activity.
- Define incidence, etiology, and stages of pressure sores.
- Identify basic treatment interventions for prevention and treatment of pressure sores.
- Describe common contractures and primary medical and secondary conditions that may be affected by poor positioning.
- Describe how draping demonstrates respect for the individual in the context of the health care setting
- Describe how positioning and draping influences treatment in various treatment settings (outpatient, inpatient, skilled nursing).
Preparing for Success - Textbook and Lecture as Sources
This video provides some suggestions for how to organize your study so that you can be efficient with your time, and through a systematic approach, learn course objectives at the level you need to succeed in lecture and lab. Note - some of the objectives have been updated since the video, but the strategies for success are still the same.
- When joints and soft tissues are held in one position for an extended period of time, a joint or muscle contracture can develop. Loss of motion leads to loss of function. Tight, stiff joints and muscles become painful to move.
- Sleep and rest times are disturbed by pain due to malpositioning. Rehabilitation is impacted by poor sleep and transition to sleep is challenged by poor positioning in bed.
- Circulation, lymphatics, nerves, and skin maintain are at risk for long-term injury with prolonged compression. Pain, swelling, pressure sores, numbness and tingling, and weakness can all result if your patient is positioned improperly
- Positioning provides proprioceptive input (joint position) to the nervous system. With proper positioning, patients can begin to reintegrate information from their eyes and bodies to improve function and progress through rehabilitation
- Pressure sores place patients at significant risk for infection. Recovery can take many months and require frequent (and costly) treatments with nursing and wound specialists. Pressure sores can lead to amputation.
- Patients with impaired sensation and impaired language function may not be able to feel pain from ischemic compression from soft tissues. Frequent skin check and position changes can prevent tissue injury. If a reddened area does not return to normal after an hour of pressure relief, close monitoring of this area is indicated.
- Comfortable positioning during mat exercises, modality application, and manual techniques is essential for a patient-centered approach to treatment. Therapists must actively seek feedback from patients and show a willingness to adapt an exercise or other treatment modalities based on the positioning needs of the patient. Pillows, towel rolls, bolsters, and wedges are some examples of devices in the rehab department which allow both comfort and access during treatment. This leads us to draping.
- Draping lets your patient know you are concerned for their privacy and modesty. It sends a message that you are working clinically when providing hands-on care.
- Draping prevents inadvertent soiling during bedside activities. This is particularly true for draping in the pelvic/genital area when performing lower extremity ROM in the in-patient and skilled nursing facility settings.
- Creases in pillows, sheets and bed coverings can result in increase shearing and pressure forces to the skin. By taking time to effectively drape during positioning, you are preventing pressure sores
- Draping includes pulling the hospital or other privacy curtain when a body part/segment is exposed. Knocking or asking for permission to enter before accessing a patient space is an essential component of effective draping.
Describe normal movement and abnormal movement conditions, such as restricted movement or contracture, is based in a uniform use of anatomical position, planes, and axes of motion. As mentioned in our discussion of body mechanics, there are three anatomical reference planes: sagittal, frontal, and transverse (horizontal). There are three reference axes in each plane that are used to describe motion: frontal, sagittal, and vertical:
- Flexion / extension: Movement occuring in a sagittal plane across a horizontal axis
- Abduction / adduction: Movement occuring in a frontal plane across a sagittal axis
- Rotation (medial/lateral or external/internal): Movement occuring in a transverse (horizontal) plane across a vertical axis.
As you review the images and descriptions of the common contractures below, note the contracture is named based on the direction of the motion restriction.
ankle plantar flexion
prevented or minimized with braces, splint, weight bearing (e.g., standing) and habit modification (footwear)
hip and knee flexion
generally initiated with prolonged positioning with pillows under knees
if patients are using a gatched bed (mattress bows at pelvis with HOB and feet elevated), risk for hip flexion contracture increases
certain neurological conditions will cause the hip and knee to pull into flexion when at rest
Hip external rotation
External rotation is the "open" position of the hip joint. When there is significant extremity weakness, external rotation tendencies are often difficult to avoid
Patients are at risk cervical flexion contractures when positioned with too many pillows or with HOB > 30 degrees for extended periods. Some patients with swallowing restrictions or dysfunction, cardiac condition, lung condition can not safely lie flat. These patients have higher cervical flexion contracture risk
increased spasticity of muscles from neurological disease or injury or general disuse
generally accompanies finger and thumb flexion contractures
The Life of a Pressure Sore
Pressure sores are noted and documented based on STAGES of tissue responses to pressure and shearing.
The two hour guideline for checking in with patients/residents and assisting with a change in position for pressure sore prevention is based on the amount of time it takes tissue to progress from Stage 1 to Stage 2 pressure sore.
Non-blanching Hyperemia (redness that does not turn white when you push on it)
within 30 min
skin redness; patients with dark skin may have discoloration instead of redness
1 hour after removal of
Ischemia (decreased oxygen delivered)
skin blanching (whiteness)
36+ hours and after removal of pressure
Necrosis (tissue death)
skin blueness, hard lump
Within 2 weeks of necrosis
ulceration, infection, bony prominences involved
months; frequently requires surgical repair or amputation. May be fatal
Role of the PTA in Pressure Sore Treatment
A physical therapist evaluates and checks the skin conditions as part of routine care for clients under their care. PTs/PTAs check the epidermis, the dermis or the underlying area of tissue damage. This may include the muscles, tendons or bones. Wound care and dressing changes are within the scope of practice for PTA, however, treatment is complex. A PTA involved in direct wound care is likely to have significant clinical experience and additional continuing education in wound care
Wounds will not completely heal unless the underlying cause of the pressure sore is addressed. Reduction of pressure and prevention of future breakdowns are a PT/PTAs top priority. A procedure to assess the amount of weight bearing across the pelvis is called pressure mapping. Pressure mapping may be recommended to assess specific pressure loads when a patient is sitting in a wheelchair so an optimal wheelchair cushion and seat back can be identified. A wheelchair seating vendor, occupational therapist (OT), nursing and physician are often part of the health care team providing assessment and treatment for pressure sores.
The table below summarizes some basic positioning procedures for clinical treatment and interventions. These procedure are for comfort. A risk of prolonged positioning in a preferred position (e.g., geriatric patient who likes to sit up in her wheelchair to watch an NFL game and post-game highlights) is at risk for progressive loss of joint and soft tissue motion. As you read your text and review the procedures, consider which structures are at risk for contracture with each position. (Hint: See Box 5-2 in your text).
Take a look at the handout included in the right sidebar on this web page. Here you will find some excellent images and procedures for positioning in bed. We will be practicing these techniques in lab.
head and neck
small pillow/towel at head and neck
positioned at side or supported on pillows; limbs totally supported by bed/mat
small pillow behind knees; "float" ankles to decrease pressure; may use towel rolls on lateral leg for neutral rotation
small pillow/towel roll at forehead
rolled towel under anterior scapula; hands under head or along sides
pillow at anterior lower leg/ankles;
aligned with trunk and pelvis; supported in midline position; may need bolsters or extra pillows to support trunk in midline
upper UE supported on pillows and slightly forward
hip and knee flexion with pillow between knees
support as needed depending on patient function
supported as needed for the intervention; lap tray or use of arm rests on w/c for prolonged sitting
supported with feet on floor/footrests/stool
Considerations for Specific Patient Populations
Trans femoral amputation
A surgical removal of the lower leg above the knee
Prone to prevent hip flexor contractures; limit sitting; limit hip flexion
Trans tibal amputation
A surgical removal of the lower leg below the knee
Prone to prevent hip flexor contractures; limit sitting; limit hip flexion
Condition which may result in significant weakness or spasticity on one side of the body
Avoid surgical slings for upper extremity support; use resting hand splints to prevent contractures; monitor head and neck and assist with positioning in neutral; vary position of hip, knee and ankle joints during the day to prevent contractures due to spasticity or decreased use
An inflammatory disease process which affects joints in the extremities
Avoid prolonged immobilization; encourage gentle ROM with progressive return to active exercise as able when symptoms subside
Burns and Skin Grafts
May include harvested (donor) or regenerating skin
Avoid positions of comfort; soft tissue stress are necessary to prevent skin (and therefore joint) contractures; coordinate with health care team to assure ROM parameters follow physician orders and PT guidelines.
Sample Positioning Devices
Use the linked activities to check your understanding of common bony landmarks which are at risk for pressure injuries
- pressure risk areas when supine. Link
The following videos are included to support instruction in the interactive lecture and your course readings. These are optional, so access these as your time and needs arise .. Approaching the material in different ways and different formats helps with both memory and application of knowledge to the clinical setting. Nonetheless, the videos are strictly supplemental. Disclaimer: there are some graphic images of pressure sores.
Post your questions and comments to classroom forums.
Be sure to check your course calendar for assignments and deadlines
Draping has been a part of the surgical ritual since the 19th century, helping maintain the sterile field in the OR by creating a barrier to protect the patient from his own flora as well as bacteria in the room's air. The Centers for Disease Control and Prevention and the Association of periOperative Registered Nurses recommend draping the patient to prevent surgical site infections.1,2 But how much science is really behind these guidelines? Read on and then take our quiz on drapes, their benefits and drawbacks and the most effective ways to use them.
A barrier against bacteria
"Surgical drapes should establish an aseptic barrier," say the AORN guidelines for maintaining a sterile field. The drapes should also create a barrier against liquid suited to the procedure, based on how much fluid it will generate and its duration.
Studies show that disposable, non-woven drapes are more resistant to bacteria than reusable drapes. In 2000, British researchers at the University of Bristol sandwiched disposable and reusable drapes between a blood agar plate inoculated with bacteria and another that was free of bacteria.3 Ashley Blom, MD, PhD, and colleagues found that Streptococcus viridans and coagulase-negative Staphylococci penetrated reusable fabrics in 30 minutes but did not penetrate the disposable drapes.
But disposable drapes aren't always impermeable to bacteria. In 2007, Dr. Blom and colleagues tested the bacterial resistance of 6 brands of disposable drapes using the same double-plate technique and spores of coagulase-negative Staphylococci. After running the experiment 4 times, they found that each brand let bacteria pass though the barrier after 90 minutes at least once. Four of the 6 brands allowed bacteria to pass in as few as 30 minutes.4
Based on this and other data, the length of the procedure should be considered when draping. "Sterile fields should be prepared as close as possible to the time of use. The potential for contamination increases with time because dust and other particles present in horizontal surfaces over time," according to AORN.2
Patient Draping Quiz
1. The intent of patient draping is to:
2. Where should you report defects and failures of surgical drapes?
3. Disposable drapes create an impermeable barrier that stops migration of Staphylococci bacteria.
4. During a procedure in which oxygen is used, the air under the drapes has a
5. Fire-resistant drapes can ignite when exposed to laser energy.
6. Using disposable drapes can send lint and wood pulp into the air, which can be a vector for bacteria.
7. The proper way to transport drapes is
8. According to the Centers for Disease Control and Prevention, the evidence is clear that using surgical drapes reduces the risk of surgical site infections.
Does draping prevent infections?
Theoretically, covering the patient should reduce the risk of bacteria reaching the surgical site. But the limited peer-reviewed evidence shows mixed results. Even the CDC, which recommends using surgical drapes, admits that there is limited data linking drapes to fewer surgical site infections.1 "The wide variation in the products and study designs make interpretation of the literature difficult," says the CDC in its guidelines.
The move toward using disposable instead of reusable drapes began in the 1980s. But the results remain unclear. In 1987, researchers from Duke University found that using disposable drapes reduced surgical site infections to 2.8%, compared to 6.5% for reusable drapes, in 2,181 general surgical procedures. However, in 1999, surgeons at the Royal Brompton Hospital in London reported no added benefit from disposable drapes in 505 cases.6
Once you open drapes, handle them as little as possible. "Rapid movement of draping materials creates air currents on which dust, lint and other particles can migrate," say AORN guidelines.
In 1999, epidemiologist Charles E. Edmiston, Jr., PhD, CIC, and clinicians at the Froedert Lutheran Hospital in Milwaukee, Wis., sampled the OR air during 38 surgeries to measure the amount of bacteria and see whether the use of disposable drapes and gowns added to the amount of lint in the air, which could act as a vector for bacteria. In the air samples they found wood pulp fibers from disposable drapes and gowns and several pathogens that could cause surgical site infections, including Staphylococcus aureus and Staphylococcus epidermidis.7 These are floating around in the OR every day.
Drapes should be opened and placed by a team member wearing gloves. "During draping, gloved hands should be protected by cuffing the drape material over the gloved hands to reduce the potential for contamination," according to AORN guidelines.2 This helps keep the gloves sterile while transporting the drapes, says Gina Tamberino, RN, BSN, MSN, CNOR, manager of surgical services at St. Joseph Medical Center in Towson, Md. "The concept is that you don't touch anything that is not sterile." Likewise, drapes should be held as compactly as possible and held higher than the OR table. AORN calls for the patient to be draped closest to the surgical site first and then out towards the periphery. Once in place, the drapes should not be moved. "Shifting or moving the sterile drape can compromise the sterility of the field," says AORN.2
AORN recommends the use of fire-resistant drapes in its Recommended Practices for Selection and Use of Surgical Gowns and Drapes.8 Today many drapes are fire-resistant, but that doesn't mean that they can't catch fire.
Lasers can ignite drapes, especially in environments with higher O2 levels than in ambient air. In 1992, the ECRI Institute performed a study on the flammability of drapes when exposed to laser energy. Even at the lowest O2 level (ambient air at 21%) flame-resistant drapes caught fire. "Most lasers can ignite cellulose-based and cotton-based drapes in room air. Polymeric and synthetic drapes will melt away from the laser, and a high-power-density laser beam can penetrate most drapes without igniting them; in these cases, a patient injury or an unseen, smoldering fire could occur," write the ECRI researchers in their guidance report on fire safety: The Patient is on Fire! A Surgical Fires Primer.9
The combination of drapes and O2 supplied to the patient during anesthesia delivery can create a fire hazard if O2 accumulates underneath the drape. In 2000, anesthesia provider Angela Barnes, CRNA, MSN, and Rita Frantz, RN, PhD, FAAN, a professor of nursing at the University of Iowa, used a gas analyzer to record the O2 levels beneath drapes in simulated surgeries with and without supplemental O2. With supplemental O2 they found O2 concentrations as high as 45%, more than twice that of ambient air. Even when an O2 scavenger system was used, the average concentration was 34%, report Ms. Barnes and Ms. Frantz.10
Do adhesive drapes protect better?
Plastic adhesive-back drapes are commonly used to create an additional microbial barrier at the site of the incision. The logic behind this practice is to further isolate the site from exposed skin that can become re-colonized as the procedure progresses.11
But how well do these drapes work? Joan Webster, RN, BA, of the Royal Brisbane and Women's Hospital in Australia and Abdullah Alghamdi, MD, MSc, FRCSC, of the University of Toronto, performed a systematic review of 7 studies of adhesive drapes with a total of 4,195 patients. "[We] could find no evidence that adhesive drapes reduce surgical site infection rates and some evidence that they may increase infection rates," write Ms. Webster and Dr. Alghamdi. Patients in the group with adhesive drapes had a 23% greater chance of surgical site infection than those in the group without adhesive drapes. They found no difference in the rates of infection between iodine-impregnated adhesive drapes and plain plastic drapes, according to the review published in the Cochrane Library.
"If adequately disinfected prior to surgery, the patient's skin is unlikely to be a primary cause of SSI; so attempts to isolate the skin from the wound, using an adhesive drape, may be pointless and potentially harmful as excessive moisture under plastic drapes may encourage bacteria residing in hair follicles to migrate to the surface and multiply," write Ms. Webster and Dr. Alghamdi.
Although drapes are a common surgical supply that you order in bulk, it's important to remember that the FDA considers them medical devices. Recurring problems or failures of the drapes to work properly should be reported to the FDA's Medical Device Reporting program.12 AORN recommends reporting any problems with drapes to both the FDA and the manufacturer in order to alert other users that may be using the same drapes. "Any strike-through constitutes a threat of exposure to potentially harmful bloodborne pathogens," say AORN's guidelines for gowns and drapes.8
While the evidence doesn't always coincide with the theory that using drapes for invasive procedures reduces the risk of surgical site infection, drapes are still recommended by AORN and the CDC. Draping the patient does not guarantee protection from a surgical site infection, but in most cases, data suggest that it at least does no harm. Until more evidence comes out, the ritual will go on, so it's important that you know how and why you drape a patient.
1. a; 2. d; 3. b; 4. a; 5. a; 6. a; 7. d; 8. b
Draping the patient
The whole of the shoulder, arm and hand of the side to be arthroscoped is prepared with chlorhexidine in spirit, paying particular attention to the axilla. The preparation must extend to the midline of the chest to back and front, and include the neck (see Figure 4.11). A glove is placed over the hand, after preparation, and the arm is held by the assistant. A stockinette is then rolled down the arm (Figure 4.12).
Figure 4.11 Preparation of the skin must be adequate, extending to the midline and up onto the neck.
Figure 4.12 After the hand has been prepared, a stockinette is rolled down the arm.
Figure 4.13 Drapes are then placed over the patient's body, from the axilla down.
Figures 4.14 and 4.15 A sterile 'U-drape' is placed to prevent irrigation fluid leaking over the patient's hair and face during the procedure.
Figure 4.16 Draping is completed with an arm drape through which the arm is placed.
Figure 4.17 When starting to perform shoulder arthroscopies, it is useful to mark the landmarks of the acromion, the clavicle and the coracoid with a skin marking pen prior to portal placement.
The draping starts with waterproof drapes being placed to cover the patient's body, from the axilla downwards (Figure 4.13). A waterproof 'U-drape' is then placed over the patient's head to prevent irrigation fluid and blood from reaching the unprepared parts of the patient (Figures 4.14 and 4.15). A further drape with a hole in the centre is then placed over the arm (Figure 4.16). The skin markings of the clavicle and acromion are marked with a sterile skin marker, as well as the coracoid process and the posterior portal entry site, one thumb's breadth below and medial to the posterior angle of the acromion, as shown before draping in Figure 4.17.
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A patient draping
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Mashenka, a twenty-year-old blue-eyed brunette with an aspen waist, slender legs, decorated on top with tempting buttocks. That resemble two elastic balls, pinkish papillae on her chest, barely noticeable under the thin, translucent white fabric of her blouse, raised her clearly plucked arched brows in surprise and raised her arched brows from her back to chair, stopped a puzzled look on the concentrated face of a tall, athletic-build guy standing in front of her, in jeans and a red T-shirt.Draping an extremity
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