8.2 Positioning and Range of Motion

The Repositioning Schedule

Any resident who cannot turn or move independently must be repositioned at least every 2 hours — around the clock, day and night. Constant pressure squeezes blood out of the tissue over bony prominences (tailbone, hips, heels, elbows, shoulder blades, back of the head); within hours the skin breaks down into a pressure injury (also called a pressure ulcer or bedsore). Repositioning is a scheduled, documented task — the nursing assistant (NA) follows the care plan's turning schedule and records each position change. Repositioning also prevents pneumonia (secretions pool in dependent lung areas) and keeps joints mobile.

The Common Positions

The Montana exam expects you to know the named positions and, for Fowler's, the angle of the head of the bed:

For the lateral position, the skills-test task "Position resident on side in bed" requires correct support: 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. Support devices maintain alignment:

• 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 — keep fingers gently curled to prevent hand contractures.
• Footboards or high-top sneakers — keep feet at a right angle to prevent footdrop.
• Bed cradle — keeps top linens off the feet and legs.

Pressure-Injury Prevention Through Positioning

Positioning is the frontline defense against pressure injuries. Beyond the two-hour rule: keep heels floated off the mattress with a pillow under the calves; avoid leaving a resident sitting up at 90 degrees for long periods (pressure concentrates on the tailbone and the body slides down, causing shearing — skin pulled one way while bone moves the other); keep skin clean and dry; and check the skin at every position change. Report any reddened area that does not blanch (turn white when pressed and return to pink) — that is a Stage 1 pressure injury and an urgent report.

Range-of-Motion Exercises

Range of motion (ROM) exercises move each joint through its normal arc of movement to preserve flexibility, circulation, and muscle tone. There are three types:

• Active ROM: the resident moves the joint independently — encourage it for every resident who can participate.
• Passive ROM (PROM): the NA moves the joint for a resident who cannot. This is the version on the Montana skills-test task list.
• Active-assistive ROM: the resident moves the joint with help from the NA for the part they cannot complete.

Rules for Safe Range of Motion

• Support the joint — cradle the limb above and below the joint being moved (for the elbow, support the wrist and the upper arm).
• Move slowly and smoothly — never jerky or forced.
• Move only to the point of resistance or pain — never past it. Pain is the stop signal; forcing a joint causes injury.
• Repeat each movement the number of times the care plan specifies (commonly 3-5 times per joint). On Montana's scored ROM task, each named movement of the shoulder, elbow, wrist, hip, knee, and ankle is performed at least three times.
• Follow the care plan for which joints to exercise; a typical sequence works from the neck and shoulders down to the ankles and toes.
• Encourage the resident to do as much as they can — participation builds strength and independence.

Know the basic movement terms: flexion (bending), extension (straightening), abduction (moving away from the body's midline), adduction (moving toward the midline), and rotation (turning the joint).

Contracture Prevention

A contracture is a permanent shortening and stiffening of a muscle, tendon, or joint caused by immobility. Once fixed, a contracture is painful, often irreversible, and destroys function — a contracted hand cannot be cleaned and its skin breaks down in the palm. Contractures can begin forming within days of immobility. Prevention is the combined effect of everything in this section: regular repositioning, correct alignment with support devices (especially footboards against footdrop and hand rolls for the fingers), and daily range-of-motion exercises. Report resistance, stiffness, or a joint that no longer straightens fully — early contractures respond far better than established ones.