Pressure Relief, Positioning, Bed Mobility

Appropriate Positioning

• promotes muscle tone control

• provision of appropriate sensory info

• prevents ROM loss, preservation of joint stability

• increased spatial awareness

• assistance with safer eating

• prevents aspiration, contracture, pressure areas, shoulder pain, extremity swelling, reduced QoL, death

• promotes comfort and increased position tolerance

Basic Positioning

Pressure Ulcers

aka pressure injury, pressure sore, decubitus ulcer, bedsore, skin breakdown

• can be life threatening

• can be prevented

• high risk areas: bony prominences at sacrum, ischium, trochanters, elbows, and heels, iliac crest scapula, knees, toes, occiput, rib cage

Mucosal membrane pressure ulcer

found on the mucosal membrane, typically caused by a device at injury location

• can’t be staged due to the anatomy of mucous membrane

  • can be caused by supplemental oxygen, CPAP, nasal prongs, endotracheal tube

Incontinence/Moisture lesion

caused by moisture not pressure/shear force

• skin is damp and not necessarily located on bony prominences

• often misclassified as pressure ulcures

  • there can be a combo of pressure and moisture damage

Flow chart for managing pressure ulcers

OT role in pressure ulcers

• be aware of signs of developing problems

• regular pressure relief and skin inspections

• routine turning and repositioning

• keep skin clean and dry

• maintain adequate nutrition/hydration

• wear properly fitting clothing and shoes

• specialized bedding and wheelchair cushions

• proper transfer techniques

• protect bony prominences

SSKIN

• surfaces

• skin inspection

• keep moving

• increased moisture

• nutrition

  • greatly assist in prevention

pressure mapping

measurement and visual reporting of pressure between two contacting surfaces

supine positioning

• single pillow placed under head

• pillow placed under affected shoulder and arm

  • slight shoulder flexion, abduction, neutral rotation

• high tone- place pillows or blanket rolls to assist in positioning the arm away rom the body

• LEs neutral- extension, slight hip ER, slight hib abd

• use towel rolls to prop heel to reduce heel pressure

• use pillows to elevate LE with edema

supine positioning: head and bed elevated

• head of bed elevated >30 d increases pressure at sacrum

• everything else the same as fully supine

Turning clock schedule: pressure prevention

team effort across nursing and therapy to prevent pressure injury

• signs can be posted in all rooms

• when returning a patient to bed, check the time an position based upon the schedule

Respiratory Considerations

greater efficacy occurs with respiratory treatments when patients are positioned >30 d due to respiratory mechanics

• sitting and standing lead to highest lung volumes where lung and chest wall elastic recoil are greatest

• positioning impacts pulmonary function tests

  • testing SCI patients in supine can provide important info

Tube Feed Considerations

when patients are receiving tube feedings, every effort needs to be made to minimize aspiration

• elevate the head of bed to 30-45 d at all times, unless contraindicated

• bolus feedings- have patient sit if possible and for 1 hour after the feeding; if they can’t sit, have HOB elevated at least 45 d

• there is no benefit from stopping feedings during short periods of HOB lowering, such as during linen changes

• if prolonged procedure will require HOB lowering, the gastric feedings should be stopped during the procedure; feeding should be promptly returned and patient return to HOB elevated position

  • generally small bowel feedings don’t need to be stopped

Foley Care Considerations

preventing catheter-associated UTIs requires team approach

• ensuring continuous downward drainage

• paying attention to foley placement during transfers

• placing below bladder level at all times

Fixed vs Flexed Posture Wheelchair

fixed posture (accommodate)- skeleton does not move out of that posture; equipment must provide optimal support and pressure redistribution; prevent further progression

flexed posture (correct)- skeleton still moves; equipment should correct abnormal posture; prevent fixed posture, achieve most neutral posture that can be maintained over time with support

Sitting-Poor Positioning

Sitting Positioning- Pelvic Tilt

Pelvic Obliquity Sitting Posture

Pelvic Rotation Sitting Posture

Windswept Posture Sitting Posture

Ortho Positioning

know all precautions before moving

• monitor leg rest and footplate positioning, wheelchair height, cushion height for hip precaution compliancy

• ensure cushions precent rotation that may impact spinal precautions

SCI Positioning

cushions filled with air can offer reduced support for individuals with limited trunk control

• be aware of how the patient is sitting or lying and for how long

• impaired sensated reduces skin breakdown awareness

• monitor foot plate placement, avoid foot dragging or obstacle collisions

  • 7-33% of injuries in PW are cause by catching a LE on a doorframe

  • have a pad on the head rest to protect suboccipital region

  • on or above occipital area causes neck strain

  • on the cervical spine results in poor posterior support and head extension

Stroke Positioning

protect the affected limb, don’t allow UE to dangle

• less common to sit in wheelchair or lay supine for long periods

• recommended: sitting in an armchair, side lying on unaffected side, then side lying on affected side

Amputee Positioning

avoid positions that induce risk for hip and knee contractures

• below knee: support residual limb and maintain knee extension when seated, use an amputee board at wheelchair level, use a second chair of same height when seated in regular chair

• do not allow the residual limb to ever dangle

Brain Injury Positioning

extensor tone is common with individuals post TBI; increases risk for sliding forward out of w/c

• tilt-in-space w/c help