Repositioning and Pressure Injury Prevention: The Devil is in the Detail

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By Margaret Heale, RN, MSc, CWOCN

In our point, click, fill-in-the -blanks world of ever increasing wound care algorithms and MOs, I have an ax to grind (straight into my so-called smart phone if I had the courage).

Where is the detail? Pronouncing sweeping statements such as 'Q 2 hourly turns' is easy. Ensuring a person is repositioned at a time that is prescheduled, that fits in with meal times, a self-catheterization schedule, OT, PT, and doctors' visits while taking into account that the patient would like to feel in control and watch the baseball game is, no doubt, less straightforward. That is only the beginning of the necessary detail we avoid by documenting simply 'Q2 hour turn' for our wound patients. Please bear with me while I go into the microscopic level of the sweeping statement for a spinal injury patient because actually doing is much less straightforward when implementing a pressure injury prevention plan.

Assessment on Admission: The Start of Consistent Pressure Injury Prevention

Admission to one unit from another is a key time to ensure a baseline skin assessment is done. Promoting four eyes to check the skin is a fine start, but there is so much more to the initial skin assessment. Doing a skin assessment on admission needs to happen as the patient is transferred from the gurney to the bed. It is a unique opportunity to do much more than look at the skin. The nurse can see how well the patient moves, whether he or she is clean and dry, in pain, and if the bed and mattress will be suitable. If not, there needs to be a system in place to get the correct equipment with minimal delay. Weight on admission remains a difficult task, though I am not sure why. The patient needs to be positioned appropriately and told the approximate time when the task will be performed again. The importance of a repositioning schedule needs to be impressed upon patients from the moment they arrive, so leaving them tangled in sheets with humps and bumps of excess linens underneath them is not an option.

Scheduling Repositioning: Consistency is the Key to Patient Compliance

The two-hour gap between each "turn" came from the spinal injury unit at Stoke Mandeville hospital in the United Kingdom, although others might take claim for it, I suppose. My father was in the unit for over a year in 1956, and the ward orderlies would start at one end of the Nightingale ward, and by the time they got to the last patient, two hours had elapsed, and they would start again. Quite different from the spinal injury units of today.

There is no doubt in my mind at all: The most important thing about repositioning schedules is that the manager of the floor insists on a consistent approach and follows up with checks to ensure whatever system is chosen is actually carried out. It is just too important to assume the nursing assistants and other staff will actually stick to the policy without oversight. Total patient involvement happens only if there is total staff involvement. If there is a posted schedule and patients don't see anyone refer to it, they know it is not important. For them, this translates to all pressure injury prevention strategies, not just a posted schedule that no one has updated because everyone ignores it. This is why oversight from management and senior staff is important.

There are a myriad of ways to schedule repositioning, and with spinal injury patients the best way has to be with their commitment. If no commitment is evident from staff, they will not develop commitment. Involving the patient and being collaborative about pressure injury prevention means being motivational about all aspects of prevention.

An Example Position for Pressure Injury Prevention Repositioning

Side lying is for short periods only, but it is a great position if a patient has been sitting for too long, after transport for an appointment, or when a patient with ischial ulcers has sat up in a chair for a meal. A side tilt of 30 degrees is most popular but is often done so the patient is almost side lying with wedges stuffed into the back and a plastic-covered pillow between the legs. The quantum tilt is an excellent position for prevention and when patients are being transported by ambulance. It is not a well-known method of repositioning and requires some staff training.

Quantum Tilt

quatum_tilt_1.jpg
  • Ensure patient is clean and dry having dabbed off excess barrier cream.
  • Straighten sheet, no crumbs/creases.
  • Place pillow to support upper back, above buttocks.
  • Place two pillows for under top leg.
  • Relax patient onto pillows.
  • Abduct lower leg (encourage legs away from each other)
  • Place top leg onto pillows.
  • Gently 'scoop thru' buttock if necessary (do not tug sheet)

quatum_tilt_2.jpg
  • On down side, release shoulder by 'scooping' sheet and garment straight.
  • Place soft boot on lower foot.
  • Raise the HOB to the lowest possible position letting the knee gatch.
  • Reposition top leg.
  • Place third pillow if needed.
  • Ensure the heel is offloaded.
  • A pillow or elbow protector may be needed for the arm on the downside.

quatum_tilt_3.jpg

Note this position is used because:
  • It offloads coccyx with half the sacrum.
  • Less pain and discomfort for patients with stroke/paraplegia.
  • Patient can see door, window and TV.
  • The top heel is offloaded so only one soft boot is needed.

However

  • A splint for foot drop may be needed.
  • A bed cradle for offloading linen weight might be necessary.
  • The sacrum may not be fully offloaded so if there is a sacral pressure ulcer use a more side lying position.

30 Degree Tilt

30-degree_tilit_1.jpg

The pillow behind the back needs to be above the buttocks and sacrum. This position offloads the sacrum well. It is always best to have the head of the bed as low as possible.

30-degree_tilit_2.jpg

Repositioning is not all about "the bed." It is about the sheets under the patient, or the wheelchair cushion, the catheter tube, with foot splinting of any contractures the patient may have. Tilt in space chairs, pushups, forward leans, and side leans all have a place. Some work done on pushups showed that in order to be effective a "pushup" needs to last for over three minutes.1 Almost impossible, doing a series of three is often a way forward people think worthwhile.

So now take a breath and see some detail. Not merely a 'turn,' but an opportunity for care in the most important sense, as reflected by a well written plan of care (point, point, click, click, click). The detail is paramount, and taking pride in a job well done is rewarding.

Reference
1. Lavrencic L. A review of the literature to determine the recommended nursing interventions aimed at decreasing the risk of pressure ulcer development in patients with spinal cord injury. Wound Practice and Research.2011;19(1):6–13.

About the Author
Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

Margaret: THANKS for this blog, your usual mix of practicality, humor, and wisdom. The Q2 deal is so difficult to perform for all of the practical reasons you give. The pictures are very helpful - I've never heard of the quantum tilt. I would advocate for the use of foam wedge rather than a pillow for under the back. I find wedges stay in place, pillows slide and compress and soon you're right back on your back through no fault of your own. And then those nurses come in and fuss at you. :) I have a SCI and am a PT, so have been on both sides of that repositioning discussion. Thanks again, Margaret. I was glad to see you are still sharing your wisdom.

Hi Laurie, thank you for your comments. I have to admit to not being a fan of wedges but agree they can work better than pillows especially when pillows are wedged into place, hardly the comfort I would be looking for. I discovered the quantum tilt when reading the paper on the 30 degree tilt by Shae ({Shea, 1975 Clinical Orthopaedics 112, 89-100}. There is a picture much more like the quantum tilt than what we do as a 30 degree tilt. I was a clinical teacher and covered orthopaedics. We had problems getting the total hip replacement patients re-positioned safely after surgery the surgeon agreed to using this position after I badgered them. When at Spaulding Rehab Boston we had problems with the SCI patients refusing turns and introducing this really made a difference to them. I started a research project and managed to do a quick pilot before I left but sadly patients were not well versed enough to differentiate between the 2 positions. We have met at conference long time ago, you nearly ran me over. Glad you like the blogs, Take Care
Margaret

Great article Margaret. Repositioning is a challenging aspect of caring for patients with grievous injuries. Many of them also develop bed sores in the long run, which add on to the woes of the patient and caregivers.

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