SAFETY, COMFORT, HYGIENE

Characteristics of Safety
Pervasiveness safety is integrated or permeates throughout mans life and affects everything he does Perception perception of safety and danger can influence the integration of safety into his activities of daily living. Management knowledge or awareness of safety issues can allow a person to take measures to prevent dangers.

Causes of Altered Safety

Hazards poorly lighted stairways, slippery floors, cluttered areas, unstable ladder, medications and substances left within reach of children, careless smoking, lack of supervision of children at play, defective equipment, procedural errors Invasive trauma overloading of electrical outlets, faulty and defective appliances and equipment, radiation Disease microorganisms, impaired immune system Pollution air, water, land, noise pollution, toxic substances Disregard for safety not wearing protective gear and accessories

Manifestations of Safety Alterations

Falls result in pain, permanent disability, and even death Fires caused by careless smoking practices, faulty electrical equipment among others Burns due to scalds, fires, playing with matches or candles, among others Poisoning ingestion, inhalation or absorption of potentially hazardous substances Suffocation due to drowning smothering, strangling, airway obstruction or from entrapment in a confined space Motor-vehicular accidents because of hazardous driving practices

Manifestations of Safety Alterations

Electrical shock occurs when an electrical current travels to the ground through the body instead of through the electrical wiring; it can also occur from static electricity that builds up on the surface of the body Radiation injuries excessive exposure to radiation Infection - especially among persons who have highrisk health behaviors, debilitated patients, immunecompromised and Immuno-suppressed patients, and those with chronic illnesses, among others Stress-related illnesses may include peptic ulcer disease, anxiety, depression, and psoriasis, among others, often due to fear of the environment which is unfamiliar to them

Nursing Assessment
Intrinsic Factors Biochemical Regulatory functioning sensory, integrative and effector dysfunction, tissue hypoxia Malnutrition Immune-autoimmune conditions Abnormal blood profile leukocytosis, leucopenia, altered clotting factors, thrombocytopenia, sickle cell, thalassemia, hypohemoglobinemia Physical broken skin, altered mobility Developmental age physiologic, psychosocial Psychologic affective, orientation

Nursing Assessment
Extrinsic Factors Biologic immunization status, herd immunity, microorganisms Chemical pollutants, poisons, drugs, pharmaceutical agents, alcohol, caffeine, nicotine, preservatives, cosmetics, dyes Nutrients vitamins, food types Physical design, structure and arrangement of the community, buildings, and/or equipment Mode of transport or transportation Person or provider nosocomial agents, staffing patterns, cognitive, affective, psychomotor factors

Nursing Interventions for Safety

Orient client to the unit including immediate environment, use of call light system, bed controls (if any), location of supplies in bedside stand, location of bathroom, operation of lights, schedule of unit and activities, among others. Ensure the clients room is free from clutter and obstacles especially between the bed and the bathroom. Ensure bedrails and night lights are in proper working order. Instruct client as to activity limitations Assist client with ambulation and ADLs, as needed

Nursing Interventions for Safety

Review client on the hospitals fire safety precautions Limited smoking facilities Location of fire extinguishers and fire alarms including emergency numbers, evacuation equipment and exits Use of non-flammable materials Evacuation routes Institute electrical safety precautions Keep hands dry when manipulating machinery and equipment Immediately mop up spilled fluid Ensure all electrical plugs are grounded (3 pins) Report any electrical equipment damage

Nursing Interventions for Safety

Institute radiation safety precautions Minimize exposure to radiation source Maximize distance from the source Use appropriate shielding Institute effective infection control Perform handwashing before and after every procedure and patient contact Perform disinfection, sterilization, isolation precautions and immunizations according to hospital guidelines Teach about timely vaccination among at-risk individuals Teach about safe sex especially among adolescents

Nursing Interventions to Prevent Falls

Keep the clients room free from clutter, well-lit during transfers and ambulation, and the side rails firmly anchored. Ensure that all surfaces are flat, even, and non-skid Ensure that the brakes of wheelchairs, beds and commode chairs are working properly Ensure that wheelchairs, beds and commode chairs do not have sharp edges and have a comfortable support surface Teach clients with orthostatic hypotension to change position slowly Use restraints only when necessary and as provided for in the hospital protocol

Nursing Interventions to Prevent Falls

Teach parents about preventing falls in infants Not to leave an infant unattended in a bath, bed, or table where the infant may roll or fall off Keep the crib side rails up Use guard rails or gates at the top and bottom of the stairs when the infant begins to crawl Supervise the infant in a walker, swing, jumper or high chair

Nursing Interventions to Prevent Falls

Teach the elderly client Remove throw rugs and clutter from stairways and walkways Make sure that the stairways are adequately lighted and in good condition Install handrails wherever needed Do not use unstable ladders and stepstools Do not attempt to do anything beyond reach or physical ability

Nursing Interventions for Child Safety

Cover unused electrical outlets with plastic safety plugs Secure window screens within reach of the toddler on a chair Cover controls of appliances with tamper-proof locks or covers Keep hot water temperature at no more than 115oF Place non-skid mats in showers and tubs Fence yard for outdoor play within safe perimeters Use only age-appropriate toys Do not use pillows and restrictive blankets on infants and toddlers Do not prop feeding bottles during feeding

Nursing Interventions for Child Safety

Keep the following out of reach of children, Electrical cords and handles of pots and appliances Matches and cigarette lighters Plastic bags Medications, household cleansers, other chemicals and potentially-toxic substances Pails or basins of water Do not hang pacifiers around babys neck Take extra caution in using harness restraints on infants and toddlers Teach children to wear protective gear in activities such as riding a bicycle.

Nursing Interventions to Prevent Burn Injuries

Test bath water temperature first before bathing client, especially someone who has sensory impairment Check heating pads, heat lamps, and other electrical equipment for proper functioning Assist clients in handling hot drinks when required Do not allow clients to smoke in bed Teach parents to turn hot pot handles away from the front of the stove top where children can reach Teach parents not to leave children unsupervised in the kitchen near burning places, barbecue grills, or near containers of flammable materials like gasoline or kerosene Teach parents to use sunscreen on their children when playing outdoors

Sleep and Rest

Sleep a naturally occurring altered state of consciousness that is characterized by decreased awareness and responsiveness to stimuli Rest a state of consciousness where awareness of the environment is maintained but motor or cognitive responses are decreased.

Characteristics of Sleep
Awareness of need to sleep/rest Restoration and protection facilitate physical restoration through anabolic processes Psychological function Sorting and discarding of neurophysiologic data (short-term memory) Character reinforcement and adaptation for mental and emotional stability REM is required for reprocessing of knowledge and memories Circadian rhythm 24-hour biologic rhythms; sleep-wake cycle

Causes of Sleep/Rest Alterations

Distractions noise, light, temperature, environment, caregiving, disruptions in relationships, work shifts Illness loss of stage 3 sleep, pain, etc Drugs sedatives, alcohol, caffeine, nicotine Mood states anxiety, depression

Manifestations of Sleep/Rest Alterations

Sleep deprivation Insomnia Narcolepsy excessive daytime sleeping Sleep apnea Nocturnal myoclonus - repetitive dorsiflexion of the foot and the flexion of the knee during sleep once every 15-20 seconds Altered sleep-wake patterns jet lag syndrome, delayed sleep phase syndrome Parasomnias somnambulism, enuresis, sleeptalking, night terrors, nightmares

Nursing Assessment
Subjective Data Verbalization of difficulty falling asleep, of awakening earlier or later than desired, of interrupted sleep, and of not feeling well-rested Objective Data Changes in behavior and performance increased irritability, restlessness, disorientation, lethargy, listlessness Physical signs mild fleeting nystagmus, slight hand tremor, ptosis or eyelids, expressionless face, dark circles under eyes, frequent yawning, changes in posture Thick speech with mispronunciation and incorrect word usage

Nursing Interventions
Provide Modification of Clients Environment Reserve sleeping room for sleep and encourage children to play in other areas Provide client with opportunities to get out of his room during the day, if feasible Remove items associated with work, conflict, pain or sleeplessness

Nursing Interventions
Provide for Intimacy and Security Assist client in making social contacts Provide backrub before sleep Allow and encourage family members to sit on clients bedside and bring with them their favorite items for enhancing security (blankets, stuffed toys) Reassure client of frequent checks and prompt response to call bell by the nurse Allow for prayer, Scripture-reading and/or meditation

Nursing Interventions
Allow for Sleep Rituals Assist with settling in Assist with washing of hands and face Provide gentle massage Plump pillows and provide extra blanket if needed Help clients focus on small goals accomplished during the day

Nursing Interventions
Assist clients in assessing the individual sleep pattern needs and to anticipate developmental changes Provide adequate rest Administer sedative hypnotics as ordered Identify factors that affect quality of sleep Reduce factors affecting safety by having call light near at hand, bed in the lowest position and using a nightlight

Nursing Interventions
Teach client about Getting up at the same time each day and avoiding sleeping in on days off Eating sensibly and regularly Avoiding alcohol and caffeine which disturb sleep because of longer effects Exercising daily but not too late in the day Setting the mind at rest before going to bed using relaxing music, books or a companion Enjoying the kind of sleep he gets

Comfort and Pain Relief

Pain has been roughly described by McCaffrey (1968) as whatever the experiencing persons says it is, existing whenever he says it does. It is a very individualized experience and one of the most complex human experiences, often involving the interaction of physiologic, psychological, social, cultural, and spiritual factors. Pain is one of the primary reasons why clients seek healthcare.

Characteristics of Pain
Location localized, diffuse, proximal, distal, medial, lateral, etc Intensity mild, moderate, severe, intermittent, spasmodic, constant Quality boring, burning, cramping, crushing, dull, excruciating. Hammering, intermittent, stabbing, lancinating, penetrating, piercing, pounding, radiating, sharp, shooting, spasms, tearing, throbbing, tingling Onset acute, chronic, intractable Associated characteristics

Factors affecting Pain

Pain threshold Pain tolerance Fear Fatigue Lack of knowledge Cultural values and beliefs

Causes of Pain/Discomfort
Biologic disease, microorganisms, cell injury; tissue damage due to alterations in essential cellular life processes Chemical substances released by disease processes and cytotoxic agents Physical trauma, extremes in temperature, electrical burns, radiation injuries Psychological emotional factors that bring distress to the person; anxiety in acute pain and depression in chronic pain

Manifestations of Pain
Physiologic Low to moderate pain pallor, increased BP, dilated pupils, increased skeletal muscle tone, tachypnea, tachycardia, increased perspiration, decreased urine output, decreased GI peristalsis, increased mental activity and BMR Severe pain pallor, decreased BP, pupil constriction, decreased muscle tone, bradycardia, increased GI peristalsis Behavioral Verbalization of pain, crying, moaning Rubbing of painful parts, frowning, grimacing, fatigue Increased muscle tension

Nursing Assessment
Subjective Data report or verbalization of pain Objective Data Guarding, protective behavior Self-focusing Narrowed focus altered time perception, withdrawal from social contacts, impaired thought processes Distraction behavior moaning, crying, pacing, restlessness, seeking out other people and/ or other diversional activities Facial mask of pain lack-luster eyes, beaten look, fixed or scattered movement, grimacing Autonomic responses

Nursing Interventions
Promote Comfort and Prevent Pain Encourage the appropriate use of body position and body mechanics during work and recreation Assist in identifying factor that can bring about or make the pain worse Provide comfort measures for a bed-ridden client Eliminate wrinkles in bed sheets Avoid constrictive clothing Change position at least every 2 hours Provide backrub while listening attentively and continuing the ongoing pain assessment Provide meticulous skin hygiene to prevent pain due to pressure, excoriation and/or irritation

Nursing Interventions
Promote Comfort and Prevent Pain Give anticipatory guidance on the amount of pain that the client can expect from a particular procedure or activity Splinting the surgical incision with pillows to decrease muscle tension at the surgical site Positioning techniques as moving side to side, transferring to one side of the bed and to the chair, and proper posture in walking Premedication with narcotics before activities; teach client to request for pain medication when the pain begins in order for the medication to be more effective in preventing the aggravation of pain

Nursing Interventions
Manage the Acute Pain Experience of the Client Listen actively to the clients description of the pain experience Formulate a plan of care managing pain together with the client Teach client on how to minimize pain by splinting the painful area with a pillow before activities such as moving or coughing Encourage client to use non-invasive, non-pharmacologic management of pain Administer pain medications as ordered, give adequate medication to relieve pain, use medication when pain begins to maximize its efficacy, and monitor the effectiveness of the medication Promote periods of uninterrupted rest after pain relief measures

Nursing Interventions
Manage the Chronic Pain Experience of the Client Acknowledge clients pain experience Encourage client to maintain a list of factors relating to pain including activities that precipitate pain, the length and duration of the pain, and the therapies used to relieve pain Teach client on non-pharmacologic, non-invasive pain management techniques Promote a schedule of rest and activity during the day to minimize pain Refer client to appropriate community resources and social support services for evaluation

Nursing Interventions
Administer Pain Medications as Ordered Determine if and when analgesics are given because they are usually ordered prn Select appropriate analgesic when more than one is prescribed, taking into consideration the drugs potency and rate of absorption Evaluate the effectiveness of analgesic after administration via sound pain assessment skills Observe for analgesic side effects through close observation of client Report promptly and accurately to physician when a change in medication is needed

Nursing Interventions
Administer Pain Medications as Ordered Give aspirin and corticosteroids on a full stomach to minimize gastric irritation Do not give aspirin together with oral anticoagulants, methotrexate, probenecid, sulfinipyrazone Use acetaminophen with caution in clients with liver disease Inform physician of a client taking corticosteroids for reduction of inflammation if excessive weight gain, edema, hypertension, bone pain, sore throat, fever, cold, infection, mood changes, or visual disturbances develop

Nursing Interventions
Administer Pain Medications as Ordered Be ready with a narcotic antagonist (naloxone, levallorphan) to counteract respiratory depression in clients receiving narcotic analgesics Teach client on the use of patient-controlled analgesia (PCA)

Non-Invasive, Non-Pharmacologic Pain Management

Distraction - useful in brief periods of sharp, intense pain such as during wound dressing changes, wound debridement, or biopsy. Cutaneous stimulation includes massage, heat and cold applications, contralateral stimulaton, acupuncture, and transcutaneous electrical nerve stimulation for acute and chronic pain. Massage - rubbing the painful area in order to relax muscles and reduce tension; not be used over broken skin, mucous membranes, or rashes. Heat increases inflammation, blood flow, edema and bleeding at site; for joint and muscle pain Cold opposite heat effects; useful in chronic migraine headache and back pain

Non-Invasive, Non-Pharmacologic Pain Management

Contralateral stimulation area opposite the painful one is stimulated with heat or cold applications or massage (example: R hand painful, stimulate L hand); useful for muscle cramps, spasms, itching. Acupuncture insertion of stainless steel needles near nerves in a painful area or at certain body points (dermatomes) Acupressure like acupuncture but instead of needles inserted, the acupuncture points are pressed and massaged Transcutaneous electrical nerve stimulation as an adjunct in the overall pain management.

Non-Invasive, Non-Pharmacologic Pain Management

Relaxation requires a combination of quiet environment, comfortable position, passive attitude, and a focus of concentration Meditation focusing on a single thought or sound. Yoga combination meditation and stretching exercises Progressive relaxation discriminate between tension and relaxation of specific muscles from head to toe Autogenics passive progressive relaxation, repetition of certain phrases silently to induce relaxation without discriminating between tension and relaxation

Non-Invasive, Non-Pharmacologic Pain Management

Guided imagery focusing on a pleasant, relaxed mental image to decrease pain intensity. Hypnosis heightens susceptibility to suggestion and alters the state of consciousness; blocks pain awareness through suggestions or substitution of pain with another feeling Biofeedback learning voluntary control of autonomic functions

Self-Care and Hygiene

Bathing and hygiene keeps skin intact and healthy by removing excess oil, perspiration, and bacteria Hair care removes dirt and oil from hair and scalp Feet and nail care requires comfortable and properly-fitting footwear Care of the eyes, ears, and nose special care for clients with glasses, contact lenses, prostheses Oral care prevent deterioration of the gums as well as tooth loss

Self-Care and Hygiene

Feeding allows independence in making food choices and being able to feed oneself Desire to make food choices and eat Energy and muscular coordination to move food from plate to the mouth Ability to chew and swallow Toileting feeling the urge to void and moving to the toilet or bedpan, independently or with assistance; rearranging clothing, voiding, and effectively cleaning areas of excretion Dressing and grooming ability to get clothes from closet, put them on, manage the fasteners, and put on socks and shoes

Levels of Self-Care
Level 0 client is fully independent in self-care activities (a healthy college student living in a pad by herself) Level 1 the client uses equipment of devices to perform self-care activities independently ( an elderly man with a cane to assist for walking) Level 2 client needs assistance or supervision from another person to complete the self-care activities (client needing help in taking a bath 1 day postoperatively) Level 3 client needs assistance or supervision from another person as well as the use of devices or equipment (client who ambulates using a walker and a physical therapist for supervision) Level 4 client is fully dependent on another person to perform self-care (comatose client)

Index of Independence in ADLs

Bathing Independent client bathes self completely or needs assistance only in bathing a single part of the body (the back or a disabled extremity) Dependent client does not bathe self or needs assistance in getting in or out of tub and in bathing more than one body part Dressing Independent client gets clothes from closets and drawers; puts on clothes, outer garments, braces, manages fasteners Dependent client does not dress self or remains partly undressed

Index of Independence in ADLs

Toileting Independent client gets to, on, and off the toilet; arranges clothes, cleans organs of excretion Dependent client uses bedpan or commode or needs assistance in getting to and using the toilet Transferring Independent - Client independently moves in and out of bed and chair Dependent client needs assistance in moving in and out of bed and/or chair or client does not perform one or more transfers

Index of Independence in ADLs

Continence Independent client has self-control of urination and defecation Dependent client has partial or total incontinence in urination or defecation; partially controlled by catheters, enemas, or the regulated use of urinals and/or bedpans Feeding Independent client gets food from plate and into mouth Dependent client needs assistance in feeding, does not eat at all, or uses parenteral feeding

Causes of Alterations in Self-Care and Hygiene

Decreased energy - response to medication, compromised cardiopulmonary functioning, fluid and electrolyte imbalance, disruption in diet, infection, disturbed GI function Sensorimotor deficits - visual and hearing impairments due to surgery, injury, infection Pain can cause immobility or decreased willingness to move, some analgesics cause lightheadedness or drowsiness

Causes of Alterations in Self-Care and Hygiene

Neuromuscular impairment stroke, spinal cord injury, Parkinsons disease, cerebral palsy, myasthenia gravis, muscular dystrophy, other neurologic problems; muscle weakness and/or atrophy, lack of coordination, spasticity, paralysis, joint contractures; immobility due to casts, splints, pain, weakness Acute illness and surgery confusion and drowsiness from analgesics, fluid and electrolyte imbalance, and hypoxemia; nausea and vomiting; weakness due to anesthesia, hypovolemia, low hematocrit level, atelectasis; casts, IV lines, incisions, splints, urinary catheters, NGT, surgical drains, anxiety

Causes of Alterations in Self-Care and Hygiene

Cognitive dysfunction decreased level of consciousness, confusion Emotional disturbance and depression inattention due to side effects of medications, unfamiliar environment, psychosis, schizophrenia; autism; depression Dysfunctional environment poverty, poor living conditions, limited access to facilities required for self-care; attitude of other people

Alterations in Self-Care and Hygiene

Poor hygiene and grooming Soiled, dry, flaky skin with or without rashes and excoriated areas Oily, unwashed, uncombed, smelly hair, dirty and broken nails, generally offensive body odor, soiled, torn, inappropriate clothing Mouth sores, dental caries, inflamed gums, dental plaque buildup, stained teeth, bad breath or halitosis, soiled pants with urine or feces Inability to demonstrate self-care activities Reporting of reluctance to perform self-care due to depression, cognitive alteration, a dependent personality, fear of pain or anxiety

Nursing Assessment
Subjective Data - verbalization of reluctance to perform self-care Objective Data Inability to wash boy or body part Inability to obtain water Inability to regulate temperature or flow of water Impaired ability to fasten clothing Inability to maintain appearance at a satisfactory level Inability to get to toilet or commode Inability to sit on toilet or commode Inability to manipulate clothing for toileting Inability to carry out proper toilet hygiene Inability to flush toilet or to empty commode Inability to cut food Inability to bring food from receptacle to mouth

Nursing Interventions: Bathing

Plan to render hygiene measures when the client is well-rested Gather supplies as necessary such as basin, water, soap, toilet articles Offer pain medications as prescribed and if necessary before hygiene measures Encourage client to sit by the sink or shower when endurance is limited Check and adjust water temperature to avoid burns Use caution when moving in and out of bathtub or shower by using handrails or other support measures

Nursing Interventions: Bathing

Prevent chilling by closing the door to prevent drafts, using warm water, and increasing room temperature if possible Dry exposed parts quickly and cover body parts not being bathed Monitor adults frequently when they are taking a bath If a client cannot tolerate bathing while standing, use a shower chair or help client bathe at bedside Avoid vigorous rubbing of dry skin to prevent skin breakdown; instead pat dry the area Use non-slip surfaces and handrails in bathroom and shower stalls

Nursing Interventions: Bathing

Move slowly when changing body positions to allow circulation changes and avoid falls Use leg exercises to stimulate circulation before rising from a sitting position Do not leave infants or young children unattended in or near the bathtub or shower Teach client about prevention of skin dryness Assist client with perineal care Provide client with a soothing backrub Provide care of the feet and nails Provide hair shampooing Assist male client with shaving, if needed

Nursing Interventions: Bathing

Assist client with toothbrushing and flossing Assist client in the care of dentures Assist client in the care of the eyes, eye glasses, contact lenses Assist client in the care of the ears and hearing aids Work with an occupational therapist to teach re-learning of skills when new cognitive or physical impairments occur Use verbal cuing if necessary Praise client for accomplishments Assist with hygiene measures that the client cannot perform independently

Nursing Interventions: Bathing

Methods of bathing Sitz bath cleanse, soothe and reduce inflammation of the perineum after childbirth, vaginal or rectal surgery, or local irritation of hemorrhoids and fissures; water temperature = 105o-113oF Hot-water bath - relieve muscle spasms and soreness by total body immersion; water temperature = 113o-114.8oF; watch out for vasodilation, orthostatic hypotension, and scadling Warm-water bath - cleanse, promote relaxation, and relieve tension; water temperature = client preference

Nursing Interventions: Bathing

Methods of bathing Cool-water bath relieve muscle tension, decrease body temperature in clients with fever; tepid water = 98.6oF; alcohol can be added to enhance cooling via evaporation; avoid chilling as it may increase body temperature through shivering Soaks soften and loosen secretions during dressing changes, reduce pain and swelling or itching of inflamed or irritated skin; medications or topical agents may be added to hot, warm, or cold water applied to an isolated body part

Nursing Interventions: Feeding

Assist client to sit in chair or in a high Fowlers position in bed Medicate as necessary for pain or nausea before meals Provide opportunity for oral care and make sure dentures are in place Plan rest periods before and after meals Provide an environment free from unpleasant odors or sights that may have a negative impact on feeding Provide assistance with organizing food tray as needed

Nursing Interventions: Feeding

Provide appropriate food as needed Provide utensils that aid feeding Use verbal cuing and positive encouragement Work with speech therapists or occupational therapists to individualize the teaching plan for clients with new physical or cognitive impairments

Nursing Interventions: Dressing and Grooming

Provide rest period before dressing or grooming activities Space different grooming activities throughout the day to avoid fatigue Assemble all necessary clothing or grooming aids Assist client with brushing and combing the hair Ensure that clothing is loose-fitting and easy to fasten Perform activities in a sitting position, if possible Ask client preferences if he is unable to perform activities independently so the client will feel involved Work with occupational therapists to individualize the teaching plan for clients with new physical or cognitive impairments

Nursing Interventions: Toileting

Encourage routine toileting to avoid urgent need to reach toilet facilities Provide with needed toileting supplies Ensure clear and easy access to toilet or bedside commode by removing clutter Encourage clothing that is easy to remove Provide equipment to ensure safety Provide ambulation aids or bedside commode if ambulation is difficult

Nursing Interventions: Toileting

Assist the client in urination Turn on the bathroom tap Have the client visualize his bathroom at home Warm the bedpan Have the client assume a comfortable position Provide analgesia for pain, if needed Pour warm water over perineum

Nursing Interventions: Care of the Patients Room

Ensure all equipment are in good working order and supplies are adequate to meet clients needs Ensure call light is functioning Ensure that the bed is properly made whether it is an occupied bed, unoccupied bed, or a surgical bed Maintain asepsis in bed-making Assemble all required linens before starting to conserve energy

Nursing Interventions: Care of the Patients Room

Change bed positions according to the clients therapeutic needs Flat mattress is completely flat Fowlers upper part of the bed is raised to a semi-sitting position (15o to 45o; low or semiFowlers) or to an almost upright position (90o; high Fowlers) Trendelenburg entire bed is tilted with the head of the bed downward