8.2 Positioning and Range of Motion

The Repositioning Schedule

A resident who cannot reposition independently needs assistance on an individualized repositioning plan, during the day and overnight as assigned. The nurse’s assessment considers activity, mobility, skin and tissue tolerance, clinical condition, comfort, sleep, goals and the support surface. A two-hour interval may be prescribed for a particular resident; it is not a universal rule that overrides the plan. A pressure-redistributing mattress does not eliminate the need for repositioning.

Sustained pressure and shear can damage tissue over bony prominences such as the sacrum, hips, heels, elbows, shoulder blades and back of the head. The nursing assistant follows the assigned technique and schedule, uses the required equipment and assistance, documents care and tolerance, and promptly reports inability to complete the plan, new pain or skin changes. Do not wait for the next scheduled turn when a problem arises. Position changes also support comfort, breathing and mobility; they do not guarantee that every pressure injury, pneumonia or contracture will be prevented.

The Common Positions

Learn these common teaching names and ranges. The resident’s actual head-of-bed angle, supports and duration follow the care plan and clinical needs, including breathing, feeding and aspiration precautions; a position name is not permission to choose one angle for everyone:

For the lateral position, use the current skills-task instructions when testing and the individualized care plan in practice. Common support placements include: a pillow under the head, one supporting the upper arm, one behind the back to hold the position, and a pillow between the knees so the upper leg does not pull the spine out of line.

Alignment and Support Devices

Body alignment means the spine is straight and each joint rests in a natural, functional position — no twisted neck, no dropped wrist, no foot plantar-flexed against the mattress. Use the support devices assigned in the care plan; check fit, skin contact and comfort rather than applying one arrangement to every resident:

• Pillows — the everyday tool: behind the back, under arms, between knees, under calves to float heels off the bed.
• Trochanter rolls — rolled towels or blankets tucked alongside the hip to prevent the leg from rotating outward.
• Hand rolls or splints — support the prescribed hand position when assigned; check fit and skin. They do not guarantee prevention of contracture.
• Footboards or prescribed footwear/supports — help maintain the assigned foot position when appropriate; do not force a fixed ankle to a right angle or create pressure on the feet.
• Bed cradle — keeps top linens off the feet and legs.

Pressure-Injury Prevention Through Positioning

Positioning is one part of pressure-injury prevention. Alongside the individualized schedule: offload the heels using the prescribed method, such as suitable support under the calves; use the prescribed head-of-bed elevation and assistance to reduce sliding and shear; do not lower an angle needed for breathing or aspiration precautions on your own; keep skin clean and dry; and check the skin at every position change. Promptly report a persistent area that does not blanch, new discoloration, unusual warmth or coolness, pain, firmness, blistering or an open area. Non-blanchable redness of intact skin can be a Stage 1 pressure-injury finding, but color changes may look different in darkly pigmented skin. The nurse assesses and stages the injury; the CNA reports observations and follows the assigned offloading and skin-care measures.

Source boundaries: 42 CFR 483.21 and 483.25(b)–(c) link care to assessment, professional standards and the person-centered plan. The 2026 CMS pressure-injury measure’s clinical recommendation statement reproduces the 2025 guidance for individualized repositioning and early skin reassessment; it is clinical evidence, not a Montana rule fixing one turning interval.

Range-of-Motion Exercises

Range of motion (ROM) describes how far a joint can move. Assigned ROM exercises help maintain available movement and function. Choose the type and joints in the resident's care plan; an injury, surgery, pain or another condition may limit movement:

• Active ROM: the resident moves independently within the permitted range.
• Passive ROM: a trained nursing assistant moves the joint when the resident needs that assistance, following the assigned plan.
• Active-assistive ROM: the resident contributes movement and receives help with the part they cannot complete.

Rules for Safe Range of Motion

• Explain the procedure, protect privacy and follow hand-hygiene and positioning instructions.
• Support the limb and joint as trained; for example, support above and below the elbow rather than pulling on the hand.
• Move slowly and smoothly through the available pain-free range. Stop and report pain, new resistance or distress; never push past free movement or force a stiff joint.
• Follow the care plan's joints, directions, repetitions and restrictions. Do not invent a daily repetition count or exercise an injured joint without instructions.
• Encourage the resident to participate as safely permitted. Preserve comfort, alignment and access to the call light.

For testing, the Headmaster Montana candidate handbook currently linked by the provider, effective February 2025, Version 6, printed page 50, lists the resident ROM task. It specifies each listed shoulder, elbow, wrist, hip, knee and ankle movement at least 3 times, with proper joint support and no discomfort, pain or forcing beyond free movement. Use the current testing instructions at the time of your test; that scoring checklist is not a prescription to perform every listed movement on every clinical resident.

Key movement terms: flexion bends; extension straightens; abduction moves away from the body's midline; adduction moves toward it; rotation turns around an axis. Use only the movements assigned for that joint and resident.

Contractures: Recognition and Care

A contracture restricts movement when tissues around a joint shorten or lose normal elasticity. Reduced mobility is one cause; neurological disease, nerve injury, severe injury and scarring can also contribute. Pain is common but not inevitable. Contractures may make movement, positioning or hygiene difficult; their persistence and possible improvement depend on the cause, severity and treatment.

Follow prescribed positioning, gentle ROM and any ordered support or therapy plan. These measures may maintain function or reduce risk; they do not guarantee prevention or reversal. Do not force a hand open, straighten a fixed joint or apply a splint independently. Report new stiffness, decreasing movement, pain, skin problems or difficulty providing hygiene so the nurse and therapy team can assess and adjust care. The MedlinePlus contracture overview describes multiple causes and treatments; diagnosis and treatment decisions belong to the clinical team.