Body mechanics is the term used to describe the efficient, coordinated, and safe use of the body to move

objects and carry out the activities of daily living. Until recently, it was thought that using good body mechanics reduced energy requirements, fatigue and risk of injury for both nurses and clients, especially during lifting, transferring, and repositioning. Even with careful attentions to body mechanics, nursing is ranked as the 6th most at risk occupation for back injuries. In fact, results from several studies indicate that 52% of nurses complain of chronic back pain; 12% leave the profession because of back pain; 20% transfer to a different work setting due to back pain; 12% consider leaving the profession; 38% suffer work related back pain severe enough to require leave of absence; and 25% reported changing jobs due to neck, shoulder, and back problems. When a person moves, the center of gravity shift continuously in the direction of the moving parts. Balance depends on the interrelationship of the center of gravity, the line of gravity, and the base of support. The closer the line of gravity is to the center of the base of support, the greater the person s stability. Conversely, the closer the line of gravity is to the edge of the base of support, the more precarious the balance. If the line of gravity falls outside the base of support, the person falls. The broader the base of support and the lower the center of gravity, the greater the stability and balance. Body balance, therefore can be greatly enhanced by (a) widening the base of support and (b) lowering the center of gravity, bringing it closer to the base of support. The base of support is easily widened by spreading the feet farther apart. The center of gravity is readily lowered by flexing the hips and knees until a squatting position is achieved. The importance of these alterations cannot be overemphasized for nurses. Two movements to avoid because of their potential for causing back injury are twisting (rotation) of the thoracolumbar spine and acute flexion of the back with hips and knees straight (stooping). Undesirable twisting of the back can be prevented by squarely facing the direction of movement, whether pushing, pulling, or sliding, and moving the object directly toward or away from one s center of gravity. LIFTING y y y It is important to remember that nurses should not lift more than 51 pounds without assistance from proper equipment/ or other persons. Types of assistive equipment include partial standing lifts, permanently mounted ceiling lifts, and horizontal air transfer mattresses (E-Z lift, E-Z lift assist, and Slip Patient mover are examples of such devices). It is always wise to use proper body mechanics, even though they do not guarantee freedom from injury. When a person lifts or carries an object, for example, a suit case, the weight of the object becomes part of the person s body weight. This weight affects the location of the person s center of gravity, which is displaced in the direction of the added weight. To counteract this potential imbalance, body parts (e.g., ram and trunk) move in a direction away from the weight. In this way, the center of gravity is maintained over the base of support. By holding the lifted object as close as possible to the body s center of gravity, the lifter avoids undue displacement of the center of gravity and achieves greater stability. People can lift more weight when they use a lever than when they do not. In the body, the bones of the skeleton can act as levers, a joint is a fulcrum (fixed point about which a lever moves), and the muscles exert the force. Use of the arms as levers is often applied in clinical practice when the nurse needs to raise a client s head off the bed, for example, or give back care to a client in traction. Because lifting involves movement against gravity, the nurse must use the major muscle groups of the thighs, knees, upper and lower arms, abdomen and pelvis to prevent back strain. The nurse can increase overall muscle

strength by synchronized use of as many muscle groups as possible during an activity. For instance, when the arms and legs helps prevent back strain. Another technique based on the principle of leverage can be used when lifting objects from the floor to waist level. In this technique, the back and knees are flexed until the load is at thigh level, at which point the knees remain flexed to provide thrust as the back begins to straighten. This technique provides for balance, leverage, and synchronized use of muscles, which help avoid back pain and injury. When one lifts an object to knee level, the shoulder and arm muscles pull, the abdominal and lumbar muscles contract for leverage and pull, and the thigh and leg muscles exert the upward thrust to bring the object off the floor. When one lifts an object from midthigh to waist level, essentially the leg and thigh muscle groups provide force, but the back and lumbar muscles remain contracted. In all positions, it is important to maintain a distance of at least 30 cm (12 inches) between the feet and to keep the load close to the body, especially when it is at knee level. Before attempting the lift, the nurse must ensure that there are no hazards on the floor, that there is a clear path for moving the object, and that the nurse s base of support is secure.

Lifting heavy objects from the floor to the waist level: a. Stand close to the load and flex the back and the knees, lowering the body to grasp the load. b. Begin lifting the back flexed, and gradually straighten the knees so that the leg muscles bear most of the burden. c. To hold or walk with object, maintain a less flexed but not a completely straight position. PULLING AND PUSHING y When pulling or pushing an object, a person maintains balance with least effort when the base of support is enlarged in the direction in which the movement is to be produced or opposed. For example, when pushing an object, a person can enlarge the base of support by moving the front forward. When pulling an object, a person can enlarge the base of support (a) moving the rear leg back if the person is facing the object (b) moving the front foot forward if the person is facing awa from the object. It is easier and safer o pull an object toward one s own center of gravity than to push it away, because a person exert more control of the object s movement when pulling it.

PIVOTING y Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. To pivot, place one foot ahead of the other, raise the heels very slightly, and put the body weight on the balls of the feet. When the weight is off the heels, the frictional surface is decreased and the knees are not twisted when turning. Keeping the body aligned, turn (pivot) about 90 degrees in the desired direction. The foot that was forward will now be behind.

PREVENTING BACK INJURY y Many factors increase the potential for lower back injuries. A major contributor is habitually poor standing and sitting posture, which produces lordosis. Overweight individuals who carry their extra weight over their abdomen, pregnant women, and women who consistently wear high heeled shoes are at risk because of the exaggerated lumbar curvature these situations produce. Sedentary persons are at risk because of weak back and abdominal muscles.

POSITIONING CLIENTS

When positioning clients in bed, the nurse can do a number of things to ensure proper alignment and promote client comfort and safety: y Make sure the mattress is firm and level yet has enough give to fill in and support natural body curves. A sagging mattress that is too soft, or an underfilled waterbed used over a prolonged period can contribute to the development of hip flexion contractures and low back strain and pain. Bed boards made of plywood and placed beneath a sagging mattress are increasingly recommended for clients who have back problems or are prone to them. Some bed boards are hinged across the middle so that they will bend as the head of the bed is raised. It is particularly important in the home setting to inspect the mattress for support. Ensure that the bed is clean and dry. Wrinkled or damp sheets increase the risk of pressure ulcer formation. Make sure extremities can move freely whenever possible. For example, the top bed clothes need to be loose enough for clients to move their feet. Place support devices in specified areas according to the client s position. Use only those support devices needed to maintain alignment and to prevent stress on the client s muscles and joints. If the person is capable of movement, too many devices limit mobility and increase the potential for muscle weakness and atrophy. Avoid placing one body part, particularly one with bony prominences, directly on top of another part. Excessive pressure can damage veins and predispose client to thrombus formation. Pressure against the popliteal space may damage nerves and blood vessels in this area. Pillows can provide needed cushioning. Plan a systematic 24 hour schedule for positioning changes.

a. FOWLER S POSITION or a semi sitting position, is a bed position in which the head and trunk are raised 45 to 90 degrees. y in low fowler s or semi fowler s position, the head and trunk are 15 to 45 degrees; in high fowler s position, the head and trunk are raised 90 degrees. y Fowler s position is the position of choice for people who have difficulty breathing and for some people with heart problems. When the client is in this position, gravity pulls the diaphragm downward, allowing greater chest expansion and lung ventilation. y A common error nurses make when aligning clients in Fowler s position is placing an overly large pillow or more than one pillow behind the client s head. This promotes the development of neck flexion contractures. If a client desires several head pillows, the nurse should encourage the client to rest without a pillow for several hours each day to extend the neck fully and counteract the effects of poor neck alignment. b. ORTHOPNEIC POSITION y The client sits either in bed or on the side of the bed with an overbed table across the lap. This position facilitates respiration by allowing maximum chest expansion. It is particularly helpful to clients who have problems exhaling , because they can press the lower part of the chest against the edge of the overbed table. c. DORSAL RECUMBENT POSITION y (BACK LYING) the client s head and shoulders are slightly elevated on a small pillow. In some agencies, the terms dorsal recumbent and supine are used interchangeably; strictly speaking, however in supine or dorsal recumbent position the head and shoulders are not elevated. In both positions, the clients forearms may be elevated on pillows or placed at the client s side. Supports are similar in both positions,

except for the head pillow. The dorsal recumbent position is used to provide comfort and to facilitate healing following certain surgeries or anesthetics (e.g. spinal). d. PRONE POSITION y The client lies on the abdomen with the head turned to one side. The hips are not flexed. Both children and adults often sleep in this position, sometimes with one or both arms flexed over their heads. It is the only bed position that allows full extension of hip and knee joints. When used periodically, the prone position helps prevent flexion contractures of the hips and knees, thereby counteracting a problem caused by all other bed positions. The prone position also promotes drainage from the mouth and is especially useful for unconscious clients or those clients recovering from surgery of the mouth or throat. y The prone position poses some distinct disadvantages. The pull of gravity on the trunk produces a marked lordosis in most people, and the neck is rotated laterally to a significant degree. For this reason, the prone position may not be recommended for people with problems of the cervical or lumbar spine. This position also causes plantar flexion. Some clients with cardiac or respiratory problems find the prone position confining and suffocating because chest expansion is inhibited during respirations. The prone position should be used only when the client s back is correctly aligned, only for short periods, and only for people with no evidence of spinal abnormalities. e. LATERAL POSITION y (sidelying)the person lies on one side of the body. 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. For this reason, the lateral position is good for resting and sleeping clients. The lateral position helps to relieve pressure on the sacrum and heels in people who sit for much of the day or who are confined to bed and rest in Fowler s or dorsal recumbent positions much of the time. In the lateral position, most of the body s weight is borne by the lateral aspect of the lower scapula, the lateral aspect of the ilium, and the greater trochanter of the femur. People who have sensory or motor deficits on one side of the body usually find that lying on the uninvolved side is more comfortable. f. SIM S POSITION y (Semi prone position) the client assumes a posture halfway between the lateral and the 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 accurately flexed at both the hip and the knee than is the lower one. y Sim s position 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. Many people, especially pregnant women, find Sim s position comfortable for sleeping. People with sensory or motor deficits on one side of the body usually find that lying on the uninvolved side is more comfortable.