Proper positioning for the prevention of pressure injuries

Elders who are confined to bed or wheelchair may develop complications due to decreased mobility of the limbs; for example, chest infection, pressure injuries (or decubitus ulcer) and muscle contracture. All these complications are related to improper positioning. Caregivers can improve their nursing skills and assist elders in changing their positions regularly to minimise their risk of developing these complications.

I. Pressure injuries:

Pressure injury is defined as localised damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. Pressure injuries usually occur over a bony prominence but may also related to a medical device or other object. When localised parts of the body are under continuous pressure, blood supply to that area is hindered and a pressure injury develop as a consequence.

  • High risk patients:

    Chronically ill and bedridden
    Urinary or faecal incontinent
    Overweight or underweight
  • Common sites:
Prone position Lying position
An elderly man in prone position, red arrows pointing to the common sites of pressure injuries: head, elbow, chin, chest, reproductive organ, knee and toes An elderly man in lying position, red arrows pointing to the common sites of pressure injuries: head, shoulder, elbow, buttock, heel and toes
   
Lateral position Sitting position
An elderly man in lateral position, red arrows pointing to the common sites of pressure injuries: ear, shoulder, elbow (outer side), hip, knee (inner side), knee (outer side), ankle and heel An elderly man in sitting position, red arrows pointing to the common sites of pressure injuries: head, shoulder, sacrum, buttock and heel
  • Prevention of pressure injuries:

Reduce localised pressure

  • Adopt proper positioning to minimise pressure over bony prominences.
  • Change positions frequently and turn every 2 hours.
  • Avoid friction between the body and the bed during lifting and transfer of the elderly.
  • Choose the suitable type of chair and teach a chair-bound elder, if possible, to change posture every 30 min with the help of their upper limbs.
  • Consult health professionals regarding use of pressure-relieving devices, e.g.
Heel protector Wedge pillow Air mattress
Heel protector Wedge pillow Air mattress

Other measures

  • Keep clothing and bed linen clean and dry.
  • Avoid placing heavy objects (e.g. hot-water bottle and beddings) over the body.
  • Wound dressings or bandages should not be too tight.
  • Carers should keep their nails short and avoid wearing jewellery that may cause injury to the elder's skin.

Personal hygiene

  • Keep skin clean and dry; change napkins frequently to decrease risk of skin infection in elders who suffer from incontinence.
  • Pay attention to the skin condition and check for signs of pressure injuries, seek medical advice when necessary.

Balanced diet

  • Maintain a nutritious and high protein diet e.g. meat, eggs, milk and beans to keep skin healthy.

II. Muscle contracture

Muscle contracture is the result of prolonged immobility and improper positioning leading to joint stiffness and decreased range of movement (especially in patients with Stroke, Parkinson’s disease or those who are bedridden).

Prevention of muscle contracture
Adopt proper positioning and change positions every two hours

Lying
 An elderly man in lying position, affected side is supported with pillow, elbow and fingers are straight with palm facing upwards; a pillow is placed under the knee of the affected side, keep knee slightly bent.
  • Support the affected side with pillows, elbow and fingers should be straight with palm facing upwards;
  • Place a pillow under the knee of the affected side, keep knee slightly bent.
   
Prone position
 An elderly man in prone position with his head turned to one side to allow normal breathing; both arms placed by each side of the head; the shoulders, chest and ankles are supported with thin pillows in relaxed position.
  • Turn the head to one side to allow normal breathing;
  • Place both arms by each side of the head;
  • Support the shoulders, chest and ankles with thin pillows in relaxed position.
   
Lateral position
 An elderly man in prone position with his head turned to one side to allow normal breathing; both arms placed by each side of the head; the shoulders, chest and ankles are supported with thin pillows in relaxed position.
  • Use a pillow to keep the knees from direct contact with each other in order to prevent deformity;
  • Use a pillow to support the affected side with elbow straight and knee slightly bent.
   
Sitting
 An elderly man in sitting position, sit straight with the back well supported; the upper limbs are supported with a pillow or table, the feet placed on the floor with the knee flexed at 90 degree (right angle).
  • Sit straight with the back well supported;
  • Support the upper limbs with a pillow or table, place the feet on the floor or foot rest with the knee flexed at 90 degree (right angle).
  • Exercise

    Caregivers should encourage and assist elders in performing regular active or passive stretching exercise in order to maintain good circulation, joint flexibility, and prevent muscle contracture.

  • Others
    • Use firm pillow with a suitable thickness of approximately 5 cm to 10 cm.
    • Use firm mattress to provide adequate support.
    • Choose wheelchair with back and neck rests.
    • Choice of chair:
    • the width of seat = width of pelvis + 5cm;
    • the height of seat = 39cm to 50cm;
    • the depth of seat = the length of client’s thigh – 5cm;
    • the seat should be firm and well supported.
A suitable chair: the seat should be firm and well supported An elderly woman sitting on a chair, the suitable width of seat is width of pelvis + 5cm
A suitable chair
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