How to position a patient with bedsores to prevent further injury

According to Johns Hopkins Medicine, pressure injuries (bedsores) can develop in as little as several hours without movement. Learning how to position a patient with bedsores is the single most important intervention for relieving pressure on vulnerable areas, preventing further tissue damage, and aiding the healing process. Regular and proper repositioning is essential for anyone confined to a bed or wheelchair for extended periods.

Quick Summary

This guide provides detailed instructions on how to reposition a bedridden or chair-bound patient to prevent and manage pressure ulcers. It outlines key positioning techniques, including the recommended 30-degree side-lying position and heel elevation. The article also discusses crucial support surfaces and equipment, outlines an optimal turning schedule, and highlights the importance of proper skin care during repositioning to ensure patient safety and healing.

Key Points

• Change positions frequently: Reposition bedridden patients at least every 2 hours and wheelchair users every 15-30 minutes to relieve pressure.

• Use the 30-degree side-lying position: This technique, known as the 'Rule of 30,' uses pillows or wedges to relieve pressure from the tailbone and hips.

• Offload heels completely: When a patient is on their back, place a pillow under the calves to keep the heels elevated off the bed surface.

• Use specialized support surfaces: Invest in pressure-relieving mattresses (like alternating air or gel) and cushions for wheelchairs to redistribute body weight.

• Lift, don't drag: Use a lift sheet during repositioning to prevent friction and shear damage to fragile skin.

• Inspect skin daily: Use repositioning time to check for early signs of pressure ulcers, such as redness or warmth over bony areas.

• Maintain skin hygiene: Keep skin clean and dry, especially in areas affected by moisture, and use barrier creams if needed.

Bedsores, also known as pressure ulcers, form when constant pressure on a specific area of the body cuts off blood flow to the skin and underlying tissue. If left untreated, this can lead to tissue death and serious, painful wounds. For caregivers, mastering patient positioning is a critical skill for both prevention and treatment. The primary goal is to redistribute pressure evenly and never allow any single bony prominence to bear weight for too long. This requires a systematic and informed approach.

The Bedridden Patient: Key Positioning Techniques

For someone who spends the majority of their time in bed, a structured repositioning plan is vital. The standard guideline is to change a patient's position at least every two hours. However, this frequency may need to be increased for higher-risk individuals.

30-Degree Side-Lying Position (The “Rule of 30”)

This position is widely recommended as it takes pressure off the most vulnerable areas, like the tailbone (sacrum) and hips.

• How to do it: Begin with the patient lying on their back. Gently roll them onto their side, positioning them at a 30-degree angle from the flat mattress.
• Use pillows or wedges: Place pillows or foam wedges behind the patient's back to maintain the angle. An additional pillow between the knees and ankles prevents bony areas from rubbing together.
• Ensure hip offloading: Make sure the patient is not lying directly on their hip bone (trochanter). The pillows should be placed to distribute weight evenly, not concentrating it on a single point.

Back-Lying Position (Supine)

Lying on the back can still cause pressure on the sacrum and heels, so it must be done correctly and alternated frequently.

• Elevate heels: Place a pillow or special foam wedge under the lower legs, from mid-calf to ankle, to lift the heels completely off the mattress. This is crucial, as heels are a common site for pressure ulcers. Never use a doughnut-shaped cushion, as this can increase pressure on the surrounding tissue.
• Limit head-of-bed elevation: Keep the head of the bed elevated at no more than 30 degrees, unless medically necessary. A higher angle can cause the patient to slide down, creating damaging friction and shear force on the sacrum.

Other Techniques

• Prone position: For specific cases, a doctor might recommend the prone (face-down) position. This completely removes pressure from the back, sacrum, and buttocks. This requires pillows under the abdomen, chest, and shins for support.

Seating and Wheelchair Positioning

Individuals in wheelchairs require even more frequent repositioning, ideally every 15 minutes, or at least every hour if they cannot shift their weight independently.

Techniques for Chair-Bound Patients

• Pressure-redistribution cushions: Use a specialized cushion made of foam, gel, or air to help distribute weight away from the tailbone and buttocks. Ensure the cushion fits properly and is used correctly.
• Regular weight shifts: Teach and remind the patient to perform weight shifts every 15 minutes. This can involve leaning to the side or forward to relieve pressure on the sit bones.
• Correct posture: An ideal seated position is upright, with hips and knees at a 90-degree angle and feet fully supported. This helps distribute pressure effectively.
• Use of tilt and recline features: For wheelchairs with tilt-and-recline functionality, a tilt of 25 degrees or more can significantly reduce pressure on the sitting area.

Comparison of Repositioning Needs and Equipment

Feature	Bedridden Patient	Wheelchair-Bound Patient
Repositioning Frequency	Every 2 hours (more for high risk)	Every 15-30 minutes for independent shifts; every hour for assisted shifts
Key Pressure Areas	Tailbone (sacrum), hips (trochanters), heels, elbows, shoulders, back of head	Tailbone (sacrum), buttocks (ischial tuberosities)
Essential Equipment	Pressure-relieving mattress (alternating air, foam, or gel), foam wedges, pillows	Specialized pressure-redistribution seat cushion, tilt/recline wheelchair features
Recommended Positions	30-degree side-lying, supine with heel elevation, prone (if appropriate)	Upright with supported posture, regular weight shifts

Essential Equipment and Best Practices

Using the right equipment is critical for effective positioning.

Support Surfaces

• Alternating Pressure Mattresses: These mattresses use a system of air cells that inflate and deflate alternately, constantly changing pressure points to promote circulation.
• Foam or Gel Overlays: Placed on top of a standard mattress, these can provide an extra layer of pressure redistribution.
• Wedges and Pillows: Use a variety of pillows and specialized foam wedges to maintain positions and offload specific areas. Never use doughnut-shaped cushions.

Best Practices for Repositioning

• Lift, don't drag: Always use a lift sheet or trapeze bar to lift and move the patient, never dragging them. Dragging can cause dangerous friction and shear damage to the skin.
• Skin inspection: Repositioning is the ideal time to perform a thorough skin inspection. Check for redness, discoloration, warmth, or swelling, especially over bony areas. Early detection is key.
• Moisture control: Keep the skin clean and dry, especially in areas prone to moisture from incontinence or perspiration. Use moisture-wicking products or barrier creams as needed.

Conclusion

Effective positioning is the cornerstone of preventing and managing bedsores. For bedridden patients, the 30-degree side-lying position and heel elevation are essential techniques, combined with a turning schedule of at least every two hours. For wheelchair users, frequent weight shifts and pressure-redistribution cushions are necessary. Consistent skin checks, proper hygiene, and the use of appropriate support surfaces are all vital components of a comprehensive care plan. By implementing these strategies, caregivers can significantly reduce the risk of pressure ulcers, promote healing, and improve the patient's overall comfort and well-being. For a more detailed guide on wound care, consult resources from a reputable organization like the National Pressure Ulcer Advisory Panel (NPIAP).

Frequently Asked Questions

How often should I reposition a bedridden patient with bedsores?

A bedridden patient with bedsores should be repositioned at least every two hours to relieve pressure on bony areas. For patients at higher risk, such as those with existing sores, more frequent turns may be necessary, possibly every hour.

What is the 'Rule of 30' for patient positioning?

The 'Rule of 30' is a positioning technique where the head of the bed is elevated no more than 30 degrees, and the patient is placed in a 30-degree, laterally inclined position. This helps relieve direct pressure from the sacrum and hips.

Should I use doughnut-shaped cushions for bedsores?

No, you should never use doughnut-shaped cushions. These devices concentrate pressure on the tissue around the hole, reducing blood flow and causing swelling, which can increase the risk of a pressure ulcer.

How should I position a patient's legs to prevent bedsores on the heels?

To prevent bedsores on the heels, place a pillow or foam wedge under the patient's calves, from mid-calf to the ankle, to elevate the heels completely off the bed surface.

What is the correct way to move a patient to avoid friction on the skin?

To prevent damaging friction and shear force, use a lift sheet to move the patient, rather than dragging or pulling them. Encourage the patient to assist if they are able.

What specialized mattresses are available for preventing bedsores?

Specialty mattresses such as alternating pressure mattresses, which use air cells to constantly change pressure points, or foam and gel mattresses that redistribute weight, are effective for preventing and managing bedsores.

How do I care for a wheelchair-bound patient to prevent bedsores?

For wheelchair users, ensure they use a specialized pressure-redistribution cushion and shift their weight every 15 to 30 minutes. If they can't shift independently, a caregiver should assist them every hour.