Positioning and pressure-relieving techniques

Effective pressure-relieving techniques and positioning of patients is crucial to prevent the development of pressure ulcers and in the management of patients who already have acquired a pressure ulcer or pressure damage.

Repositioning of the patient involves either the patient changing their own position to aid pressure relief, or a healthcare professional or carer, assisting the patient to reposition to help relieve pressure from pressure points. This can be a simple movement in bed if the patient is able to do so or it can involve the use of specific equipment, such as slide sheets, to help healthcare professionals to safely reposition the patient.

Repositioning is necessary to reduce or relieve pressure on risk areas, maintain muscle mass and tissue integrity, and maintain good blood supply to the areas that are at risk from pressure (National Institute for Health and Care Excellence (NICE), 2014a). Various studies have examined the effectiveness

Patients may be at increased risk of pressure injury if they undergo long surgical procedures and also have risk factors which may include weight, age and frailty (Burlingame, 2017). Local policies and assessment tools should be used to assess patients at risk of pressure damage for example, the Waterlow score for risk assessment (Nayar et al, 2021). A moving and handling risk assessment should also be carried out on all patients to determine if interventions are required and at what level. Risk assessment should be an ongoing process which is regularly reviewed, documented and care plan updated.

Various types of equipment can be used in positioning patients to prevent pressure damage or manage the patient who already has sustained some pressure area damage. This can include the following items:

• pillows
• towels
• slide sheet or hoist depending on the local policy – these items need to be checked to ensure they are safe to use and should be inspected before use
• footstool if the patient is sat in a chair
• pressure cushion if patient is in a chair or a wheelchair to relieve pressure
• low-tech, low-pressure surfaces, e.g. foam mattress, mattress overlay; and high-tech support surfaces, e.g. alternative pressure mattresses or overlays (NICE 2014b)

Pressure-relieving assessments are required and all clinical staff need to be aware of the risk factors for developing pressure areas or ulcers. Healthcare professionals need to ensure that skin is checked as direct pressure to the skin or friction caused by movement can lead to pressure area damage (Dougherty and Lister, 2015).

Positioning of the patient will depend on a variety of factors including the clinical condition, medical history and the location of the patient i.e. bed, operation theatre, chair, wheelchair. Special attention should be given to surgical patients who are anaesthetised or sedated, as the patient cannot reposition themselves, and healthcare professionals need to ensure that correct positioning minimises the risk of injury to the patient (Spruce and Wicklin, 2014). Regular position changes are recommended and NICE (2015) identified that repositioning is recommended at least every 6 hours for adult patients and 4 hours for adult patients at high

The risks and complications associated with pressure-relieving procedures and repositioning of patients should be considered. Complications can arise from improper positioning; these can include musculoskeletal pain for the patient, potential joint dislocation, injury to the skin and underlying tissues and compromise to the patient’s physiological wellbeing including respiratory compromise. There is also potential risk for the healthcare professional, which can include back injury if they do not follow guidelines, do not assess the patient correctly, and do not apply evidence-based procedures and safe equipment use during patient repositioning.

All healthcare professionals should be provided with training and education on reducing pressure areas. This should include being able to identify those at risk, identify pressure damage, management of pressure damage and being aware of referrals to other team members.

Health care professionals should be able to carry out a risk assessment and skin assessment. They should also be able to use repositioning and appropriate equipment using safe techniques (NICE, 2014b).

Clinical areas as well as community settings should receive regular updates, so staff are able to provide the best possible care for their patients.

References

Burlingame BL. Guideline implementation: positioning the patient. AORN J. 2017;106(3):227-237. https://doi.org/10.1016/j.aorn.2017.07.010

Dougherty L and Lister S. The Royal Marsden Manual of Clinical Nursing Procedures. (9th edn) UK: Wiley Blackwell; 2015.

Nayar SK, Li D, Ijaiya B, Lloyd D, Bharathan R. Waterlow score for risk assessment in surgical patients: a systematic review. Ann R Coll Surg Engl. 2021;103(5):312-317. https://doi.org/10.1308/rcsann.2020.7136

NHS. Pressure ulcer core curriculum. 2018. London https://www.england.nhs.uk/wp-content/uploads/2021/09/Pressure-ulcer-core-curriculum.pdf (accessed 10 November 2022)

National Institute for Health and Care Excellence. Pressure Ulcers. 2015. https://www.nice.org.uk/guidance/qs89/chapter/quality-statement-5-advice-on-repositioning (accessed 10 November 2022)

National Institute for Health and Care Excellence. The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. London: National Institute for Health and Care Excellence (NICE); 2014a.

National Institute for Health and Care Excellence. Pressure Ulcers: prevention and management. 2014b. https://www.nice.org.uk/guidance/cg179/chapter/1-Recommendations#prevention-adults (accessed 10 November 2022)

Nursing and Midwifery Council. Standards of proficiency for registered nurses. 2018. https://www.nmc.org.uk/globalassets/sitedocuments/standards-of-proficiency/nurses/future-nurse-proficiencies.pdf (accessed 25 November 2022)

Spruce