Overview
Mobility and positioning is one of the most critical skill areas on the CNA exam, covering safe movement of patients to prevent injury to both the patient and the caregiver. This guide addresses proper body mechanics, therapeutic positioning, transfer techniques, range of motion exercises, and pressure injury prevention. Mastery of these concepts protects patients from skin breakdown, contractures, and falls while keeping CNAs safe from back injuries.
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Body Mechanics
Summary
Proper body mechanics are the foundation of safe patient care. The CNA's goal is to use the body's strongest muscle groups efficiently while protecting the spine from injury during all lifting, moving, and repositioning tasks.
Key Concepts
• Wide Base of Support: Feet shoulder-width apart creates stability before any lift or move
• Power Source: Always lift with the legs (thighs and buttocks), never the back
• Work Close to the Body: Keep the patient or object near your center of gravity to reduce mechanical strain
• No Twisting: Spinal rotation under load dramatically increases injury risk
• Pivot Steps: When changing direction, move feet in small steps, turning the whole body as one unit
• Bed Height: Raise the bed to waist level before any repositioning task to eliminate stooping
Key Terms
• Base of Support — The area beneath a person defined by the points of contact with the ground; wider = more stable
• Center of Gravity — The point around which body weight is balanced; keeping loads close to this point reduces strain
• Pivot Step — A foot-movement technique used to change direction without twisting the spine
• Ergonomics — The science of designing tasks and techniques to reduce physical strain on workers
Watch Out For
> ⚠️ Common Exam Pitfall: The exam may ask what to do FIRST before moving a patient. The answer is almost always raise the bed to working height — not lock wheels or call for help (though those matter too). Order of steps is frequently tested.
> ⚠️ Confusing "lift with your legs" with squatting awkwardly — the knees should bend with the back kept straight, not hunched forward.
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Patient Positioning
Summary
Therapeutic positioning maintains patient comfort, prevents complications such as pressure injuries and contractures, supports breathing, and facilitates clinical procedures. Each position has specific indications and requires proper support with pillows and padding.
Positions at a Glance
| Position | Description | Primary Use |
|---|---|---|
| Supine | Flat on back | General rest; requires sacral skin vigilance |
| Fowler's | HOB 45–60° | Breathing, feeding, oral care |
| Semi-Fowler's | HOB 30–45° | Mild respiratory support, comfort |
| Prone | Face down on abdomen | Pressure relief (when tolerated) |
| Lateral (Side-lying) | On side | Pressure redistribution, comfort |
| Sims' | Semi-prone, left side, upper knee flexed | Enemas, rectal exams |
Key Concepts
• Fowler's Position: Head of bed (HOB) at 45–60 degrees promotes lung expansion and reduces aspiration risk during meals and oral care
• Semi-Fowler's: HOB at 30–45 degrees — a gentler version used for comfort and mild respiratory support
• Supine Position: Highest risk for sacral and heel pressure injuries; requires trochanter rolls to prevent hip external rotation
• Prone Position: Contraindicated in respiratory distress, spinal injuries, and recent abdominal surgery
• Lateral Position: A pillow between knees and ankles is mandatory to prevent bony prominence pressure injuries
• Sims' Position: Left lateral with upper knee drawn forward — gravity assists enema solution flow into the sigmoid colon
• Repositioning Frequency: Every 2 hours minimum for all bedridden patients
• Contracture Management: Support contracted limbs with padding; never force movement beyond the patient's existing range
Key Terms
• Fowler's Position — Semi-sitting position with HOB at 45–60 degrees
• Supine Position — Lying flat on the back (dorsal recumbent)
• Prone Position — Lying face-down on the abdomen
• Sims' Position — Semi-prone left lateral position with upper knee flexed
• Lateral Position — Side-lying position requiring padding between bony prominences
• Trochanter Roll — A rolled towel or pad placed beside the hip to prevent external rotation
• Contracture — Permanent shortening of a muscle or joint due to prolonged immobility
• Bony Prominence — Areas where bone is close to the skin surface and pressure injury risk is highest
Watch Out For
> ⚠️ Angle confusion is a classic trap: Know the difference — Fowler's = 45–60°, Semi-Fowler's = 30–45°. Exams may present these angles out of order.
> ⚠️ The 2-hour repositioning rule applies specifically to bedridden patients. Don't confuse this with wheelchair repositioning, which may be needed more frequently (every 1 hour).
> ⚠️ In the lateral position, the pillow goes between the knees AND ankles — both areas must be protected.
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Transfer & Ambulation Techniques
Summary
Transfers and ambulation are high-risk activities requiring preparation, communication, and correct technique. The CNA must assess the patient, use appropriate equipment, and follow a systematic approach to prevent falls and injuries.
Key Concepts
Bed-to-Wheelchair Transfer:
• Wheelchair positioned at 45-degree angle to the bed on the patient's stronger side
• Always lock both wheelchair brakes and remove or swing away footrests before the patient stands
• Assist the patient to a dangling position (sitting on the edge of the bed) before standing
Gait Belt (Transfer Belt):
• Fastened securely around the patient's waist over clothing
• CNA grips the belt with an underhand grasp at the back or side
• CNA walks slightly behind and to the side of the patient
• Provides a secure, safe grip without grabbing clothing or limbs
Mechanical (Hoyer) Lift:
• Minimum of two staff members required
• Patient is properly positioned in the sling before lifting
• Used for patients who cannot bear weight
Responding to a Fall:
• Lower the patient to the floor gently using your own bent knees, guiding them down along your leg
• Never attempt to stop a fall by pulling upright — this injures both patient and CNA
• Stay with the patient, call for help, and complete an incident report
Key Terms
• Gait Belt / Transfer Belt — A safety device worn around the patient's waist to assist the CNA in guiding movement
• Mechanical Lift (Hoyer Lift) — A device using a sling and hydraulic mechanism to transfer non-weight-bearing patients
• Dangling — Sitting on the edge of the bed with legs hanging down; allows the patient to adjust to an upright position before standing
• Pivot Transfer — A transfer technique in which the patient pivots on their stronger leg from one surface to another
• Footrests — Wheelchair components that must be moved out of the way before transfers to prevent tripping
Watch Out For
> ⚠️ Order matters on the exam: For wheelchair transfers, the correct sequence is: (1) lock brakes, (2) remove footrests, (3) assist to dangle, (4) apply gait belt, (5) transfer. Skipping steps = wrong answer.
> ⚠️ The wheelchair goes on the stronger side — not the weaker side. The patient pivots toward their strength.
> ⚠️ If a patient starts to fall, do not try to hold them up — controlled descent to the floor is always the correct answer.
> ⚠️ The gait belt should be snug but not tight enough to restrict breathing — you should be able to slip two fingers underneath.
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Range of Motion (ROM)
Summary
Range of motion exercises maintain joint flexibility, prevent contractures, and promote circulation in patients with limited mobility. The CNA must understand the difference between exercise types and perform them safely and within the nurse's care plan.
Key Concepts
• AROM (Active ROM): Patient moves their own joints using their own muscle strength
• PROM (Passive ROM): CNA moves the patient's joints — no effort from the patient; used when the patient cannot move independently
• AAROM (Active-Assisted ROM): Patient assists as much as possible while the CNA provides support
• Support Above and Below: Always support the limb above and below the joint being exercised
• Stop at Pain: If the patient reports pain, stop immediately, do not push further, and report to the nurse
• Work Distally to Proximally (or follow the care plan) and exercise each joint systematically
Joint Movement Vocabulary
| Term | Definition | Example |
|---|---|---|
| Flexion | Bending a joint, decreasing angle | Bending the elbow |
| Extension | Straightening a joint, increasing angle | Straightening the knee |
| Abduction | Moving limb away from the body's midline | Raising arm out to the side |
| Adduction | Moving limb toward the body's midline | Bringing arm back to side |
| Rotation | Turning a joint around its axis | Turning the head side to side |
| Pronation | Rotating forearm so palm faces down | Turning palm downward |
| Supination | Rotating forearm so palm faces up | Turning palm upward |
| Dorsiflexion | Pulling foot upward toward the shin | Pulling toes toward the knee |
| Plantar Flexion | Pointing foot downward | Pointing toes away |
Key Terms
• Active ROM (AROM) — Exercise performed independently by the patient
• Passive ROM (PROM) — Exercise performed entirely by the CNA on the patient's behalf
• Contracture — A permanent shortening of muscle/joint from lack of movement; ROM exercises prevent this
• Abduction — Moving a limb away from the body's midline
• Adduction — Moving a limb toward the body's midline
Watch Out For
> ⚠️ Abduction vs. Adduction: Use this memory trick — ABduction = Away from the body. ADduction = ADD back to the body.
> ⚠️ ROM is performed to the point of slight resistance, never past the point of pain. The exam will test whether you know to stop.
> ⚠️ PROM does NOT strengthen muscles — it only maintains flexibility. Don't confuse ROM with strengthening exercises.
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Pressure Injury Prevention
Summary
Pressure injuries (formerly called pressure ulcers or bedsores) are preventable wounds caused by sustained pressure, friction, shear, and moisture over bony prominences. CNAs play a central role in preventing these injuries through repositioning, skin assessment, and proper technique.
The Four Contributing Factors
| Factor | Definition | Prevention |
|---|---|---|
| Pressure | Sustained weight compressing tissue against a surface | Reposition every 2 hours |
| Friction | Rubbing of skin against surfaces during movement | Use lift sheets; avoid dragging |
| Shear | Skin layers moving in opposite directions (e.g., sliding down in bed) | Raise knees of bed when HOB elevated; use proper lifting |
| Moisture | Prolonged exposure to urine, stool, sweat | Prompt incontinence care; keep skin clean and dry |
High-Risk Bony Prominences by Position
Supine:
• Sacrum / Coccyx (highest risk)
• Heels
• Elbows
• Back of head (Occiput)
Lateral (Side-lying):
• Lateral malleolus (ankle bone)
• Knees
• Greater trochanter (hip)
• Ear
• Shoulder
Prone:
• Toes
• Knees
• Genitalia / Breasts
• Forehead / Chin
Fowler's / Seated:
• Sacrum / Coccyx
• Ischial tuberosities (sit bones)
• Heels (on footrests)
Key Concepts
• Shear Force: Skin sticks to the sheet while deeper tissues move — stretches and tears blood vessels beneath the skin. This is distinct from friction, which is surface rubbing.
• Reposition every 2 hours for bedridden patients; document and report any skin changes immediately
• Use pillows between bony prominences in side-lying position
• Trochanter rolls prevent hip external rotation and reduce sacral pressure in supine patients
• Never massage reddened areas — this can cause further tissue damage
• Immediately report any non-blanchable redness (Stage 1 pressure injury) to the nurse
Pressure Injury Stages (Know for the Exam)
| Stage | Description |
|---|---|
| Stage 1 | Intact skin with non-blanchable redness |
| Stage 2 | Partial-thickness skin loss; shallow open wound or blister |
| Stage 3 | Full-thickness skin loss; subcutaneous fat visible |
| Stage 4 | Full-thickness tissue loss; bone, tendon, or muscle exposed |
| Unstageable | Wound base covered by slough or eschar |
Key Terms
• Pressure Injury — Localized damage to skin/tissue from prolonged pressure, friction, shear, or moisture
• Bony Prominence — Area where bone is close to skin surface; highest pressure injury risk sites
• Shear — Opposing forces acting on skin layers that tear underlying blood vessels
• Friction — Surface rubbing that abrades and damages the outer skin layer
• Blanching — Skin turns white when pressed; the ability to blanch indicates intact circulation (non-blanchable = Stage 1 injury)
• Trochanter Roll — Rolled towel/pad used to prevent hip external rotation in supine patients
Watch Out For
> ⚠️ Shear vs. Friction is a commonly tested distinction. Friction = surface rubbing. Shear = internal tissue tearing from layers moving in opposite directions (like sliding down in bed).
> ⚠️ Never massage reddened skin over bony prominences — this is an outdated practice that is now known to cause harm.
> ⚠️ Non-blanchable redness = Stage 1 — report immediately. The skin is still intact, but injury has begun.
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Quick Review Checklist
Use this list to confirm you can answer each item before your exam:
Body Mechanics
• [ ] Feet shoulder-width apart for a wide base of support
• [ ] Lift with legs, not back; keep back straight
• [ ] Keep patient/object close to your center of gravity
• [ ] Use pivot steps — never twist the spine under load
• [ ] Raise bed to waist height FIRST before any repositioning task
Patient Positioning
• [ ] Fowler's = 45–60°; Semi-Fowler's = 30–45°
• [ ] Fowler's = breathing, feeding, aspiration prevention
• [ ] Supine = sacral/heel pressure injury risk; use trochanter rolls
• [ ] Lateral = pillow between knees AND ankles
• [ ] Sims' = left lateral, upper knee flexed; used for enemas
• [ ] Prone = contraindicated in respiratory distress, spinal injury, abdominal surgery
• [ ] Reposition bedridden patients every 2 hours
Transfer & Ambulation
• [ ] Wheelchair at 45° to bed on patient's STRONGER side
• [ ] Lock BOTH brakes and remove footrests BEFORE transfer
• [ ] Gait belt = around waist, underhand grip, CNA behind and to the side
• [ ] If patient falls: guide them to the floor — do NOT try to pull them back up
• [ ] Mechanical lift requires minimum TWO staff members
Range of Motion
• [ ] AROM = patient does it; PROM = CNA does it
• [ ] Support the limb above AND below the joint
• [ ] Stop immediately if the patient reports pain; report to nurse
• [ ] Abduction = away from midline; Adduction = toward midline
Pressure Injury Prevention
• [ ] Four factors: Pressure, Friction, Shear, Moisture
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