How often should I turn patients to prevent pressure ulcers?

Approximately 2.5 million patients develop pressure injuries each year in the U.S. acute care facilities, highlighting the critical need for effective prevention. Knowing how often should I turn patients to prevent pressure ulcers? is a cornerstone of this preventative care.

Quick Summary

The standard is to reposition bed-bound patients every two hours and chair-bound individuals every hour, though modern guidelines emphasize individualized schedules based on a patient's specific risk factors, mobility, and tissue tolerance.

Key Points

• Individualized Schedules: A one-size-fits-all approach is outdated; the best practice is an individualized repositioning schedule based on the patient's specific needs, risk, and health status.

• Standard Baseline: For bed-bound patients, the general standard is to reposition at least every two hours, while seated patients should be shifted every hour.

• Daily Skin Checks: Always perform a thorough skin assessment during each repositioning to identify early signs of breakdown, such as redness or discoloration.

• Safe Techniques: Employ techniques like the 'Rule of 30' and remember to lift, not drag, patients to minimize friction and shear, which can cause skin damage.

• Manage Environmental Factors: Use appropriate pressure-relieving support surfaces (mattresses and cushions), and manage skin moisture to maintain skin integrity.

• Higher Risk, More Frequent Turning: Patients with pre-existing pressure injuries, poor circulation, or high Braden Scale scores may need more frequent repositioning than the standard baseline.

The Foundation: Understanding Pressure Ulcers

Pressure ulcers, also known as bedsores or pressure injuries, are localized skin and tissue injuries that occur when unrelieved pressure squeezes tiny blood vessels, cutting off circulation and oxygen. These sores most commonly form over bony areas like the heels, tailbone (sacrum), hips, and ankles. With elderly and immobile patients, vigilance is key, as skin can begin to break down in a matter of hours. Regular repositioning is the primary method for relieving this pressure, ensuring adequate blood flow to all parts of the body.

The Standard 'Every Two Hours' Guideline

The long-standing guideline for preventing pressure ulcers in bedridden patients is to reposition them every two hours. This standard, which has been in place since the time of Florence Nightingale, is an essential starting point for basic patient care. While effective for many, it has become recognized that this blanket approach does not account for the wide variety of patient needs and risk factors. Some patients may be at a higher risk and require more frequent turning, while others might tolerate longer periods between changes, especially if they are on a high-quality, pressure-redistributing mattress.

Individualizing the Repositioning Schedule

Modern clinical practice guidelines recommend creating an individualized turning schedule tailored to the patient's unique needs. This person-centered approach provides more effective and humane care by balancing prevention with a patient's comfort and sleep. Factors that influence the frequency of repositioning include:

• Braden Scale Score: This is a standardized tool used by healthcare professionals to assess a patient's risk for developing a pressure ulcer based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A low score indicates a higher risk, suggesting more frequent repositioning is necessary.
• Tissue Tolerance: Some patients have more fragile skin or underlying health conditions (like diabetes) that impact blood flow, making them more susceptible to damage. A daily skin inspection is vital for monitoring tolerance.
• Mobility Level: A patient's ability to self-reposition, even slightly, can reduce the need for caregiver intervention. For those completely immobile, repositioning is more critical.
• General Medical Condition: Conditions like heart failure, kidney disease, and neurological disorders can affect circulation and risk. A worsening condition may require increased repositioning frequency.
• Support Surfaces: The type of mattress or cushion used (e.g., alternating pressure, viscoelastic foam) can help redistribute pressure, potentially extending the safe interval between turns.

Safe Repositioning Techniques: The 'Rule of 30'

Proper technique is just as important as frequency to avoid friction and shear, which are major contributors to skin damage. For bed-bound individuals, a widely used method is the 'Rule of 30', which involves positioning the body at a 30-degree lateral incline.

1. Preparation: Explain the process to the patient. Stand on the side of the bed the patient will be turning towards and lower the bed rail. Make sure the patient is not at risk of rolling out.
2. Positioning the Patient: Ask the patient to look in the direction of the turn. Place the arm farthest from you across their chest and the nearer arm extended out. Cross the patient's upper ankle over the lower ankle.
3. Turning: Gently pull the patient's shoulder and hip towards you, shifting your weight to perform the turn, rather than straining your back.
4. Proper Placement: Ensure the patient is in the correct 30-degree inclined position. Use pillows or foam wedges to support the back, hips, and between the legs and ankles. This prevents bony prominences from resting on each other and ensures weight is distributed evenly.

For seated patients, repositioning is required at least every hour. If the patient can, encourage weight shifts every 15 minutes by doing 'wheelchair push-ups' or leaning side to side.

Comparison of Patient Repositioning Schedules

Condition / Risk Level	Repositioning Schedule Recommendation	Considerations
Standard Bed-Bound Patient	Every 2 hours	Foundational guideline for preventing pressure buildup.
High-Risk Bed-Bound Patient	Every 1-2 hours	Increased vigilance for patients with poor mobility, fragile skin, or compromised circulation.
Standard Seated Patient	Every hour	High pressure on the ischial tuberosities requires more frequent shifting.
Standard Seated Patient (Self-Moving)	Every 15 minutes	Teach the patient to do 'wheelchair push-ups' to shift weight independently.
Patient on Advanced Support Surface	Every 3-4 hours (bed)	High-end mattresses and cushions can extend safe intervals, as validated by clinical studies.
Patient with Existing Ulcer	Dependent on the wound	Repositioning must offload the specific wound area. A more frequent schedule is often necessary.

Essential Caregiver Checklist

In addition to the repositioning schedule, caregivers should follow a comprehensive plan for pressure ulcer prevention:

• Daily Skin Assessment: Check all skin, especially over bony areas, for redness, warmth, or discoloration. Use a mirror for hard-to-see areas.
• Skin Cleanliness and Moisture Management: Keep the skin clean and dry. For incontinence, use barrier creams and moisture-wicking products.
• Proper Nutrition and Hydration: A healthy diet rich in protein, vitamins, and fluids is vital for skin health and healing.
• Use of Pressure-Relieving Equipment: Invest in specialized mattresses, cushions, and heel protectors to help redistribute pressure. Avoid donut-shaped cushions, which can concentrate pressure.
• Avoid Dragging: Always lift and move the patient to minimize friction and shear, which can damage the skin's top layer.
• Encourage Activity: If possible, encourage even minimal movement and light exercise, as this improves circulation and reduces risk.
• Patient and Family Education: Involve patients and their families in the prevention process to increase awareness and compliance.

For additional authoritative resources on managing pressure ulcers, visit the Mayo Clinic's guide to bedsores.

Conclusion

While a 2-hour turning interval for bed-bound patients serves as a baseline, the most effective approach to pressure ulcer prevention is a tailored, individualized plan. This customized strategy, which considers the patient's unique risk factors and health status, coupled with consistent skin checks and proper repositioning techniques, is the gold standard for senior care. By moving beyond a one-size-fits-all mentality, caregivers can significantly reduce the risk of these painful and serious complications, ensuring greater comfort and quality of life for those under their care.

Frequently Asked Questions

What is the standard turning schedule for bed-bound patients?

The widely accepted standard is to turn and reposition bed-bound patients at least every two hours. This practice helps to relieve pressure points and maintain healthy blood flow to the skin and tissues.

How often should a patient in a wheelchair be repositioned?

Patients who spend a significant amount of time in a chair or wheelchair should be repositioned at least every hour. If they are able, they should also be encouraged to perform weight shifts every 15 minutes.

Can I use a pressure-relieving mattress instead of turning a patient?

While pressure-relieving mattresses and cushions are very effective and highly recommended, they do not eliminate the need for regular repositioning. They are a tool to supplement a turning schedule, not replace it.

What should I look for during a skin check?

During a skin check, which should be done at least daily, look for any areas of redness, discoloration, warmth, or tenderness, especially over bony prominences like the tailbone, hips, and heels. Report any concerns to a healthcare provider.

What is the 'Rule of 30' for repositioning?

The 'Rule of 30' is a positioning guideline where the patient's body is placed at a 30-degree laterally inclined position, and the head of the bed is elevated no more than 30 degrees. This helps to offload pressure from the sacrum and hips.

How can I prevent friction and shear while turning a patient?

To prevent friction and shear, always lift the patient's body rather than dragging it. Use sheets or lift assists to help during repositioning. Moving slowly and deliberately also minimizes skin damage.

What kind of nutritional support is important for preventing pressure ulcers?

Adequate nutrition and hydration are critical for maintaining healthy skin and tissue. A diet rich in protein, calories, vitamins, and minerals helps the body repair and maintain healthy skin.