Therapeutic Positioning in Bed and Chair

A person who cannot move themselves depends on you for every change of position. A good position relieves pressure, helps them breathe and keeps joints from stiffening. A careless one can cause a pressure injury within hours, or can injure a weak shoulder or a new hip. Most people can recite "turn every 2 hours." The harder part is knowing what position to use, how to build it so that it really takes pressure off, and when a person's condition changes the rule. Follow the care plan, because the right position depends on the person's condition. The nurse or therapist sets the plan. You carry it out, watch the skin and report what you see.

What You Will Be Able to Do

• Name the main positions, and say when each one is used.
• Build a 30-degree side-lying position that keeps weight off the bones.
• Plan a turning schedule around meals and care.
• Raise and lower a person with less shear.
• Seat a person well in a chair.
• Adjust for stroke, hip surgery, breathing problems and feeding tubes.

The Main Positions

Use the prone position (lying on the stomach) and any head-down position only when there is an order.

Every position has a cost. Raising the head of the bed helps breathing and eating, but it adds pressure and shear at the tailbone. Lying flat takes away that shear but can make breathing and swallowing harder. This is why the care plan matters so much.

Why 30 Degrees

Guidelines from the National Pressure Injury Advisory Panel favor a 30-degree side tilt over lying fully on the side. A full 90-degree side position puts weight directly on the hip bone. At a 30-degree tilt, weight rests on the softer part of the buttock, and the tailbone stays off the bed too.

Building the Position

1. Explain what you are doing, and raise the bed to a working height. Lower the head of the bed as far as the person can tolerate.
2. Use a slide sheet or draw sheet, with a second person, to move the person toward one side of the bed. Do not drag them.
3. Roll them onto their side as a unit, and place a wedge or pillows along the back, from shoulder to hip.
4. Let them lean back onto the support until they are tilted about 30 degrees, not fully on the side.
5. Check the tailbone. Slide a flat hand under it. If the bone is pressing into the bed, adjust.
6. Place a pillow between the knees and ankles so that bone is not resting on bone.
7. Ease the bottom shoulder forward by sliding your hand under the shoulder blade, so that the person is not lying on the point of it. Do not pull on the arm.
8. Float the heels, with a pillow under the calves, so that the heels touch nothing.
9. Check for wrinkles, tubes and call light. Lower the bed.

The back of the head, ears and tops of the feet can also be pressure points. Move oxygen tubing behind the ears if it is pressing, and tell the nurse if the skin is sore.

Planning a Turning Schedule

Many care plans say to turn a person at least every 2 hours. Current guidelines say the schedule should fit the person, their skin, their surface and their condition, so some people need more frequent turns. Follow the care plan, and report it if the skin is red when you turn them.

Worked example. Mr. Ames cannot move himself. The plan says to turn him at least every 2 hours in bed, and he gets up to a chair for lunch. A 24-hour plan could look like this:

The time in the chair counts. When the chair time ends, do not put him back on the same side he was on before. Keep track on a turn clock or a chart. Look at the skin at each turn, because that is your best chance to catch a problem.

If someone is sleeping, turn them anyway, as the plan says. Some plans allow small shifts at night, but that decision belongs to the nurse.

If a person refuses to turn, explain why it matters and try again soon. Tell the nurse. Do not simply skip it without telling anyone.

Keeping Shear Down

Shear happens when skin stays in place while the body slides. It stretches the blood vessels in deep tissue, and it can do a lot of damage with no sign at first.

• Head of the bed. Keep it at 30 degrees or lower unless the care plan needs more, as for meals or breathing.
• Knees first. If the plan allows it, raise the foot of the bed a little before you raise the head, so that the person does not slide down. Keep it to about 20 degrees, and no more than 30.
• Move, do not drag. Use a lift sheet, slide sheet or a lift. Two people are safer.
• Keep linens smooth and dry. Friction and moisture add to the damage.

A person who keeps sliding down is telling you something. The head of the bed may be too high, or the position may be wrong. Tell the nurse if it keeps happening.

Seated Positioning

Sitting puts a lot of weight on a small area, and people often slide without noticing.

1. Sit them with their hips all the way to the back of the chair.
2. Their feet should be flat on the floor or on footrests. Dangling feet pull the body forward.
3. Check that the thighs are supported and that the hips and knees are at about right angles.
4. Keep the head and trunk in the middle, using supports the therapist has set up.
5. Put the ordered cushion in the right way up. Never use a donut cushion.
6. Help them change position at least every hour. Remind anyone who can shift their own weight to do it more often.

When someone slides down in a wheelchair, do not pull them up by the arms or lift them under the armpits. Use a lift or the method in the plan. Ask the nurse or therapist to check the seat if this keeps happening, because the chair may not fit.

Adjusting for the Person's Condition

Some conditions change the rules. Check the care plan each time, because orders vary.

Hip replacement. Some surgeons order hip precautions, especially after a surgery done from the back of the hip. These commonly limit bending the hip past 90 degrees, crossing the legs, and turning the leg inward. A pillow between the legs is often used during turns. Practice has been changing, and not every surgeon uses these rules. Follow the plan, and ask the nurse if it is not clear. Do not remove a pillow or wedge unless you know why it is there.

After a stroke. A weak shoulder can be damaged easily, because the muscles that hold the joint may not work. Never pull on that arm. Support it on a pillow in bed and in a chair. Keep the person's things on the side the plan says.

Breathing and shear. Someone with heart failure or lung disease may need the head of the bed well above 30 degrees. In this case breathing comes first, and the plan will tell you what is allowed. Check the tailbone and heels more often. Tell the nurse if the person is sliding down or if the skin is getting red.

Eating. Sit the person fully upright for meals, and keep them upright for at least 30 minutes afterward. Do not lay someone flat right after a meal to do a turn. Plan around it.

Equipment Can Cause Injuries

Pressure injuries can form under anything that presses on the skin. Check the skin under these items at each turn:

• Oxygen tubing and masks, at the ears, nose and cheeks.
• Catheter tubing on the thigh.
• Splints, braces and compression stockings.
• Identification bands.
• Anything left in the bed: a call light, a cap, a phone, a sling clip.

Move what you can move without changing how it works, and tell the nurse about any marks. Do not remove a splint or a brace unless the plan says that you may.

A special mattress does not replace turning. Air mattresses work only when set up correctly, so report one that has gone flat or has an alarm on.

When to Stop and Call the Nurse

Stop the move and call the nurse if the person has:

• New pain during a move, especially in a hip, a leg, a shoulder or the back.
• New shortness of breath, dizziness or chest pain.
• A new red or dark area that does not lighten when you press it. Compare with nearby skin in darker skin tones, and feel for warmth, coolness or firmness.
• A blister or broken skin.
• A leg that looks shorter or turned out after a move.
• A calf that is newly swollen, warm or painful.
• Any tube that has come out or pulled.

Keep the person off a red area until the nurse has looked at it.

Common Mistakes

Check Your Understanding

1. You turn Mrs. Young to her right side, and you can feel the point of her hip pressing into the mattress. What do you change?

Tilt her back onto a wedge or pillows, to about 30 degrees, so that her weight rests on the soft part of the buttock. Check that the tailbone is clear too.

2. A person with heart failure keeps sliding down in bed with the head raised high. The plan says that he needs it high to breathe. What do you do?

Keep the head up as ordered, raise the foot of the bed a little if the plan allows it, and use a lift sheet and a second person to move him up. Check his tailbone and heels more often, and tell the nurse.

3. Mr. Bell had a stroke and his left arm is weak. A coworker reaches for that arm to pull him up in the chair. What do you say?

Stop her. Pulling on a weak arm can injure the shoulder. Use a lift or the method in the plan, and support his arm on a pillow.

4. You arrive to turn a resident who has a tube feeding running. The plan says to keep her head raised. What do you do during care?

Keep the head of the bed up as ordered, and do not lay her flat. If care needs another position, ask the nurse first.

5. During a turn you see a dark area on a resident's heel. It does not change when you press it. What do you do?

Keep all pressure off the heel, and tell the nurse the same day. A dark area can be a deep tissue injury. Record what you saw.

Key Takeaways

• A 30-degree tilt beats lying on the hip, and a hand under the tailbone shows if you got it right.
• Float the heels by placing the pillow under the calves.
• Keep the head of the bed at 30 degrees or lower unless the plan calls for more.
• Turning schedules are set for the person. Every 2 hours is a common starting point, and some people need turns more often.
• Raise the knees first, and lift instead of dragging, to reduce shear.
• Check the plan for stroke, hip surgery, tube feeding and breathing problems.
• Report new pain and skin changes, and keep the person off a red area.