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Clinical Nursing Skills

9.4 Positioning in Bed

Clinical Nursing Skills9.4 Positioning in Bed

Learning Objectives

By the end of this section, you will be able to:

  • Describe how improper positions can lead to musculoskeletal complications
  • Recognize different devices used for joint support, pressure relief, or proper alignment
  • Demonstrate common positions for patients who are immobile

Similar to safe patient transfers and ambulation, the position of patients in bed is also important in maintaining healthy body systems and preventing complications from musculoskeletal injuries and skin breakdown. This section will review patient positioning to prevent complications from immobility, as well as common devices used to aid in patient positioning and body alignment.

Positioning to Prevent Musculoskeletal Complications

An patient who is immobile in bed for long periods of time is at risk for musculoskeletal complications due to reductions in muscle mass and bone mineral density, improper body alignment, and impairment of other body systems. Prolonged time in bed has shown to increase recovery time for patients and impact long-term outcomes. Proper positioning can aid in preventing some of these complications, such as external rotation of the hip and foot drop.

Positioning to Prevent External Rotation of the Hip

Special instructions may be given to patients after surgery to assist in recovery and prevent pain and injury. Patients have just had hip surgery should prevent their legs from abduction (rotating out and away from the body), causing external rotation of the hip, to promote proper alignment and healing. The patient’s provider and physical therapist will make recommendations for the length of time for recovery and restrictions. Typical positioning restrictions include avoiding active extension at the hip and external rotation. In bed, patients should avoid sleeping on the affected side and should have an abductor pillow between their legs, which keeps the hips in a neutral position to avoid external rotation away from the body, and adduction (movement close to the midline of the body). While seated, patients should not bend over (Figure 9.22) or raise their feet to prevent hip hyperflexion and external rotation.

A diagram shows correct and incorrect ways to sit when recovering from an injury.
Figure 9.22 Excessive hip flexion and external rotation can hinder progress with injury recovery. When sitting in chairs, patients should avoid bending over or overflexing the hip by sitting at a 90-degree angle. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Positioning to Prevent Foot Drop

When lying supine in bed, feet naturally fall into plantar flexion because of gravity. If this position is maintained for long periods of time, damage to the muscles in the foot can cause foot drop syndrome. A condition called foot drop syndrome is the inability to raise the front part of the foot due to weakness and paralysis of the dorsiflexors that allow the foot to lift and maintain itself in a perpendicular position; foot drop syndrome makes walking difficult (Figure 9.23). Foot drop syndrome can affect one or both feet, and can be temporary or permanent. Patients are at a high risk for foot drop syndrome if they are on bedrest for extended periods of time, or have compressive nerve disorders, traumatic injuries, or neurologic disorders. To prevent foot drop syndrome, orthotics designed to keep the foot at a 90-degree angle should be worn while in bed.

A diagram shows dorsiflexion and plantar flexion of a foot.
Figure 9.23 Normal range of motion allows for dorsiflexion and plantar flexion. Foot drop can be caused by nerve damage resulting in the inability of the foot to dorsiflex. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

One of the most common orthotics used for foot drop is a podus boot. The brace covers the ankle and foot to support the muscles, immobilizes joints, and corrects positioning.

Positioning to Prevent Skin Integrity Complications

Immobility can lead to skin breakdown and the development of pressure injuries. A pressure injury is defined as any localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to a medical device (The Joint Commission, 2022). Common areas where pressure injuries develop include the coccyx, heels, ears, and other bony prominences (Figure 9.24). Within a few hours, they can start developing in patients who are bedbound, so it is important to minimize pressure, friction, and shear. The nares of the nose is another location. Oxygen tubing can cause pressure injuries here if a patient is immobile and unable to move the tubing.

The repositioning step, which is a change in position of the patient, either passive or assisted, reduces or relieves pressure in areas prone to injury during long periods of pressure. Repositioning can be done with the use of equipment, pillows, wedges, or other assistive aides to relieve pressure.

A diagram shows reclined, sitting, and laying positions which cause pressure injuries.
Figure 9.24 Pressure injuries commonly occur on bony prominences. As the position of the patient changes, so do the areas that are at risk. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Interventions to prevent pressure injury include identifying patients who are at risk for injury as soon as possible. This can be done using a validated assessment tool, such as the Braden Scale, at the beginning of each shift and as the patient’s condition changes. Interventions include repositioning at least every two hours, alternating between the sides and back, and using cushions to help alleviate pressure. Ensure that any medical devices, such as IV or catheter tubing, are not under the patient or pressing into the skin. It is also important to complete a skin assessment with every position change.

The heels can be vulnerable to skin breakdown with constant pressure from the bed. Using pillows to float the heels or using splint devices is an option to reduce pressure. One example is a heel protector, which is designed to adapt to the patient’s foot with adjustable Velcro straps. The material inside the boot-like device is soft and evenly distributes weight to alleviate pressure.

Specialty Mattress

To prevent skin breakdown and muscle wasting in patients who are immobile, specialty mattresses can be used for patient comfort. A specialty mattress is a mattress designed to relieve pressure over bony prominences and prevent injury. Alternating pressure mattresses are designed to reduce friction and shearing and relieve and distribute pressure. Weight is either distributed over a large contact area or mechanically distributed in active therapy. Some common materials, which are low-tech and do not provide adjustable pressure, include air, foam, or gel. Hi-tech mattresses are pressure-adjustable and can be inflated or deflated.

A gel overlay mattress is made with a combination of foam and gel, and conform to the patient’s body and retain less body heat. A foam mattress is made of crosscut foam, which allows parts of the mattress to shift along with the patient’s body. A constant low-level pressure is placed on the body until repositioning occurs. A low air loss mattress delivers active therapy by pushing air through tiny holes on the surface of the mattress to keep the skin dry, wick moisture, and accommodate pressure points. It is attached to an air pump or compressor that maintains inflation. An alternating pressure mattress is powered with air and can be programmed to inflate and deflate certain sections in a programmable cycle. These mattresses are commonly used when a pressure injury is present.

Devices Used for Joint Support or Proper Alignment

Proper alignment is defined as joints, tendons, ligaments, and muscles in line with the pull of gravity. This should be true with lying, sitting, or standing and should not cause excessive stain. Along with the assisted devices that were mentioned in the mobility section, wedge pillows, towels, washcloths, and pillows can also aid in alignment. The body should be aligned so that the spine is straight, head is neutral, and extremities are in functional positions.

Wedge Pillows

A wedge pillow is a large triangular pillows made of foam that elevate different parts of the body (Figure 9.25). Wedges can be used to elevate limbs at an angle, relieve pressure off certain points, or keep the torso supported. Most commonly in the hospital setting, wedge pillows are used behind the patient’s back to maintain a side-lying position.

A photograph shows a wedge pillow.
Figure 9.25 A wedge pillow can be used in a variety of ways to position patients. (credit: "Best Wedge Pillow for Back Pain" by Carlton Martinez/Flickr, CC BY 2.0)

Towels and Washcloths

Towels and washcloths are easily accessible in most facilities and are easy to use when positioning patients. They serve as adaptable aids in repositioning patients by providing targeted support and alignment. Rolled towels can be strategically placed under specific body parts to alleviate pressure points, support limbs and joints, and maintain proper spinal alignment. For example, a nurse may place a rolled washcloth under the palm of a patient’s contracted hand to wick moisture and maintain a more neutral position of the fingers.

Pillows

Pillows can also aid in elevating extremities and providing support. For patients in a side-lying position, placing a pillow between the knees can prevent pressure injury. Pillows can also be used by the patient to splint the abdomen when doing cough/deep-breathing exercises. Additionally, specialized pressure-relief pillows can help distribute weight evenly, mitigating the risk of pressure ulcers in patients who are bedridden. With their soft and pliable nature, pillows offer not only physical support but also psychological comfort, creating a conducive environment for rest and recovery.

Splints

A splint is a firm support that can be made of metal, plastic, or plaster. They are often used to immobilize or provide extra support to an extremity to promote healing. Splints maintain the extremity in a neutral position to prevent or treat shortening of the muscles and connective tissue.

Common Positions for Immobile Patients

Generally, patients who are immobile and bedbound require repositioning at least every two hours. This reduces the risk of pressure injury, helps blood circulation, and allows frequent skin assessments. Often, diagrams are placed to help nurses and ancillary staff determine the time patients need to turn (Figure 9.26).

A clock diagram shows times of day to turn immobile patients and what position they should be in.
Figure 9.26 A diagram can serve as a reminder to assist nurses and ancillary staff in maintaining a two-hour turn schedule. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Pillows, wedges, sheets, and towels can help align patients in a comfortable position. Common positions include supine, Fowler’s, orthopneic (tripod), prone (stomach), lateral (side-lying), and Sim’s (semiprone) (Table 9.6).

Position Description Illustration
Supine Patient lies flat on the back with a pillow for head support.
A diagram shows the supine position.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Fowler’s Patient lies supine but with the head of the bed raised.
A diagram shows the Fowlers position.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Orthopneic (tripod) Patient is in a sitting position, leaning on an overbed table.
A diagram shows the tripod position.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Prone Patient lies on the abdomen.
A diagram shows the prone position.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Lateral (side-lying) Patient lies on the side with the top leg flexed for support.
A diagram shows the lateral position.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Sim’s (semiprone) Patient lies in a position between prone and lateral positions.
A diagram shows the semiprone position.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Table 9.6 Common Patient Positions
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