Pressure ulcers are the result of constant pressure being placed on the tissue. A body in motion via the utilization of repositioning is ultra urgent when it comes to preventing pressure ulcers.
When a person is in good health, unrelieved pressure results in an unconscious or conscious change in position so that the pressure is redistributed over the body or eliminated altogether. This is what is called the pressure-pain stimulus. A patient is at substantial risk for PUs when they cannot feel the stimulus or respond to it in a manner that will adequately relieve the pressure.
Areas of Greatest Pressure in Positions:
- If a patient is lying face down:
- elbows
- rib cage
- thighs
- knees
- toes
- If a patient is lying on his/her back:
- back of head
- shoulders
- elbows
- buttocks
- heels
- If a patient is lying on his/her side:
- ear
- shoulder
- elbow
- hip
- thigh
- legs
- heels
- If a patient is seated upright with legs extended:
- head
- shoulder
- sacrum
- buttocks
- heels
All patients that are at a risk for PUs should be repositioned unless it is contraindicated by a clinician who has indicated an individualized schedule for repositioning. When positioning a patient, it should always be remembered that individual anatomy varies from patient to patient.
What may provide good offloading for one patient may not work well at all for another. No matter what position is used it is of utmost urgency that the patient’s dignity, hygiene, and ability to function is maintained as well as his/her comfort. If you are not sure of your patient’s comfort this will likely be the quickest path to him/her being intolerant of the position in which he/she is placed.
Self-repositioning
If your patient is able to reposition on their own you should definitely be encouraging and motivating for him/her to do this on their own. Pressure can be relieved by doing arm lifts or having your patient lean forward when seated in a wheelchair.
The movement needs to be enough to relieve the pressure and for the relief to last long enough to allow for reperfusion. You can offer your patient simple cues for repositioning such as moving every time a commercial comes on television while watching at home or setting an alarm to remind him/her to change their position whether they are seated or lying down.
The Thirty Degree Tilt
If your patient is confined to the bed, the 30-degree tilt is the best position. If done the right way, it will ensure that your patient isn’t placed on any of the larger bones:
- the sacrococcygeal area (located at the base of the spine near the coccyx)
- both trochanters (located near the hip)
These bones should be palpable and if the legs are supported properly neither the knees nor the ankle bones should be touching. Utilize pillows or wedges to keep the position and be sure that the patient has adequate support. If your patient is large, the tilt may not be enough to lift the areas of the body away from the surface so alternate positioning should be used. This will vary according to the patient’s weight and the frame of their body.
Electric Bed Frame
The usage of electronic bed frames is common in hospitals and skilled nursing facilities. The profile function on the beds can be utilized to maximize your patient’s position by keeping their headrest elevated below thirty degrees and utilizing the knee break to reduce shear from the patient’s position changing if they slide down in the bed. If sitting your patient up by way of the backrest it’s important you use a slide sheet beneath the heels because they will be pushed about 15 cm along the surface of the mattress.
The Prone Position
If your patient can tolerate it, the prone position can be used but only for short periods of time because it exposes new areas of the body to pressure and can increase the risk for medical devices getting trapped. You should check your patient for uneven distribution of pressure and be sure medical devices are in proper placement once your patient is positioned. Areas that require specific attention once the patient is placed include:
- breast region
- knees
- toes
- penis/pelvis
- clavicles
- iliac crest
- symphysis pubis
The use of other redistributing devices such as prophylactic dressing over bony prominences should be considered. The prone position (also known as the “swim” position) is used mostly in the ICU and CCU.
Manual Patient Handling
All staff should use manual-handling aids when they are moving patients. Dragging a patient along a mattress can cause tissue damage (both friction and shear).
Types of manual-handling aids include:
- slide sheets
- glide and lock sheets
- hoist slings
- lateral transfer board
- electric profiling bed
It’s urgent to know when to use the equipment and how to use it properly to minimize the risk for staff and patients alike. Nurses must follow the manufacturers’ instructions and their employer’s protocol when using any equipment. Slide sheets need to be removed when possible and should never be left in position for more than the time it takes to complete the repositioning of the patient.
Regularly check your patient’s skin that is over the bony prominences. Look for areas of skin that are reddened and don’t turn white when finger pressure is applied or there are changes to the skin’s color or texture.
Patients that are Unstable
In certain clinical areas such as ICU and CCU, patients can’t be repositioned fully because of issues such as the instability of the spine. Nurses should perform small but frequent movements to be sure there is enough relief of any pressure. There are programmable devices for repositioning that could possibly be tolerated better by the patient than manual repositioning, but this needs to be a joint decision made by the multidisciplinary team.
The Urgency of Documentation
Repositioning is not just a nursing task Therapists should also be engaged in the schedule for repositioning and all activities that are the promotion of rehabilitation. Every activity should be documented fully to give a complete record of all the position changes.
This includes the patient going to the bathroom, sitting up to eat, being repositioned to change clothes, and any other function that involves movement. The frequent movement will ease the risk for pressure ulcers, but the patient’s condition needs to be taken into account and he/she should not be pushed to the point of fatigue. Keep your patient tailored to only what they can feasibly handle medically, physically, and psychologically.
ABOUT THE AUTHOR: Heidi West is a medical writer for Vohra Wound Physicians, a national wound care physician group. She writes about general health and wound healing topics.
