Many of the people in your care will have difficulty changing positions, moving from one place to another, or both. Immobility puts a person at risk for many serious complications. In addition, remaining in one position for too long is very uncomfortable. As a caregiver, you will help to prevent complications of immobility and promote comfort by assisting those in your care to reposition themselves and to transfer (that is, move from one place to another).
Pressure ulcers are one of the most serious complications of immobility. A pressure ulcer is a sore that develops when part of a person’s body presses against a hard surface (such as a mattress or the seat of a chair) for a long period of time. Pressure ulcers usually develop over bony prominences (parts of the body where there is only a thin layer of fat and muscle between the skin and the bone or cartilage underneath). Examples of these areas include the back of the head, shoulder blades, elbows, hips, coccyx (tailbone), knees, ankles and heels.
When a person stays in one position too long, the weight of his body squeezes the tissue between the bone and the surface he is resting on, which slows down blood flow to the area. Because the tissue is not getting enough oxygen and nutrients, it starts to die. This loss of healthy, intact skin, called skin breakdown, can lead to a pressure ulcer.
Friction and shearing injuries can also lead to skin breakdown, putting a person at risk for developing a pressure ulcer. Friction occurs when two surfaces rub against each other. Friction injuries can occur when the skin rubs against another surface, such as the bed linens, or when skin rubs against skin (for example, under folds of skin in very overweight people, under the breasts, or where the buttocks meet the thighs). Medical devices, such as catheter tubing or a nasal cannula (the device used to deliver oxygen through the nose), can also cause friction injuries when they rub against the skin. Shearing occurs when a surface moves one way against another surface that offers resistance, causing a dragging effect. Shearing injuries can occur when a person is pulled across the bed instead of lifted. Because the bed offers resistance, the person’s body does not move easily across the sheets, and the top layer of skin is pulled in a direction opposite the underlying layers, leading to injury.
Pressure ulcers develop in stages and can be very difficult to treat, especially in the later stages. Pressure ulcers are extremely painful for the person, and they can lead to the person’s death. For these reasons, every effort must be made to prevent a pressure ulcer from forming in the first place.
In addition to immobility, many of the people in your care will have other risk factors for developing pressure ulcers. As a caregiver, you will play a very important role in helping to keep the person’s skin healthy and prevent pressure ulcers. Closely observing the person’s skin for signs of excessive pressure and skin breakdown while you are providing care and reporting your observations to the office can help prevent a pressure ulcer in the early stages from getting worse. You also help to prevent pressure ulcers by regularly helping the people in your care to reposition themselves, if they cannot do this independently.
ASSISTING WITH POSITIONING
Many of the people in your care will need your help to change positions and maintain good body alignment. Maintaining good body alignment can help to reduce strain on your joints and muscles and prevent you from injuring yourself on the job. Good body alignment is important for those in your care, too. It is essential for comfort, and it helps to prevent complications such as contractures and pressure ulcers.
Helping people to reposition themselves and ensuring good body alignment are major responsibilities of the caregiver. Some people will only need to be encouraged to change their position, and checked to make sure they are in good body alignment. Other people, such as those who are confused, weak, frail, in pain, paralyzed or unconscious, will need more help from you. To check the alignment of a person who is lying in bed, imagine a line starting at the person’s nose, continuing through the person’s belly button, and ending between the person’s feet. The line should be straight.
When a person is sitting in a chair, his back and buttocks should rest against the back of the chair. His feet should rest flat on the floor (or the footrests of a wheelchair), and his knees should be level with his hips. Many people will have a tendency to lean to the side or slump when they are in bed or sitting in a chair. To help the person maintain good body alignment, you may need to support parts of the body with rolled towels or pillows. Special positioning aids, such as foam wedges, may also be ordered for the person to help keep the body in proper alignment.
In the health care setting, several basic positions are used. A person may be positioned a certain way during a procedure, or to make an activity, such as eating, easier and safer. People who are unable to change positions easily on their own will have an individualized schedule for repositioning. This schedule will be part of the person’s care plan. The schedule uses a sequence of positions to ensure that no single area is under pressure for too long. This is essential for reducing the person’s risk for developing pressure ulcers. Basic positions that are commonly used in the health care setting are described in the sections that follow.
In the supine position, the bed is flat. The person is on her back, with her head supported by a pillow. A small pillow or rolled towel is used to support the small of the back. The person’s arms are extended at her sides, with her palms down. If the person’s arms are paralyzed or weak, they should be supported with small pillows.
The person’s thighs extend in a straight line from her hips. If the person’s feet tend to roll outward, rolled towels or pillows can be placed against the outer thighs to keep the legs in alignment. A foot board may be used to prevent foot drop and keep the toes pointing upward. To keep pressure off the heels, a small pad may be placed under the person’s calves and ankles.
In Fowler’s position, the person is in the supine position, but the head of the bed is raised 45 degrees so that the person is sitting up in bed. There are two variations of Fowler’s position: low Fowler’s position (also called semi-Fowler’s position), where the head of the bed is raised only 30 degrees, and high Fowler’s position, where the head of the bed is raised 90 degrees.
If the person is in an adjustable bed, the bed may be raised under the person’s knees to prevent him from sliding down in the bed. Alternatively, a small pillow or folded blanket can be placed under the person’s knees. As in the supine position, positioning aids should be used as necessary to support the arms, legs and feet.
Fowler’s position should only be used for short periods of time (for example, when the person is eating in bed). Leaving a person in Fowler’s position for too long puts the person at risk for shearing injuries, because the person will tend to slide down in the bed.
Fowler’s position also places a great deal of pressure on the person’s tailbone, which can lead to pressure ulcer formation.
Side-lying (Lateral) Position
In the side-lying (lateral) position, the person is lying on her side, with her head supported by a pillow. The lower arm is positioned so that the person is not lying on it, and the top arm is supported on a pillow. A rolled blanket or towel is placed along the back to keep the person in the proper position. The bottom leg is straight, and the top knee is bent. A pillow is placed lengthwise between the lower legs to support the knee and ankle and prevent the legs from resting on each other.
The modified side-lying position is a variation of the side-lying position. In the modified side-lying position, a pillow is placed along the person’s back, and the person is tilted slightly backward to lean onto the pillow. This helps to relieve pressure on the hip. The modified side-lying position is frequently part of the sequence of positions used in a repositioning schedule. For example, the person may move from the left modified side-lying position (left side down) to the supine or low Fowler’s position, and then to the right modified side-lying position (right side down).
In the prone position, the person lies on his stomach, with his head turned toward the side. The head is supported with a small pillow. The arm the person is facing is bent at a 90-degree angle, with the hand placed palm-down near the person’s head. The other arm is extended straight along his side.
A folded blanket or small pillow is tucked underneath the person’s lower abdomen or pelvis to give the person’s chest room to expand when the person breathes. A pillow is placed under the person’s shins to raise the person’s toes off the bed. The prone position is not used often because many people find it uncomfortable. If the prone position has been ordered for a person (or the person prefers the prone position), ask someone to help you assist the person into the prone position.
Sims’ position is an exaggerated side-lying position that is used for procedures such as taking a rectal temperature or giving an enema. In Sims’ position, the person is almost lying on his stomach. His head is turned to the side. The top leg is bent at the knee and supported by a pillow, and the top arm is bent at the elbow, with the hand near the face and supported by a pillow. The bottom leg is straight and the bottom arm is positioned so that the hand is near the person’s hips. Make sure the person is not lying on the arm.
Helping a Person to Change Position in a Bed or a Chair
Before repositioning a person in bed, it is important to know the person’s capabilities and plan the move accordingly. Always encourage the person to help you as much as possible with the move. This is important for the person’s self-esteem and sense of independence.
Equipment such as a trapeze that hangs over the bed or a raised side rail that the person can grasp may increase the person’s ability to assist with the move. Also consider whether or not you will need help from someone to move the person safely. Two people can lift or move someone more easily than one person can. Generally, if a person is much heavier or larger than you are, or very ill or injured, it is best to ask for assistance (if available) with repositioning the person. Just remember to return the favor!
Many different skills are used for repositioning a person in bed or a chair:
Lifting a person’s head and shoulders. To adjust a pillow or help a person sit up in bed (for example, to readjust her clothing), you will have to lift the person’s head and shoulders off the bed.
Moving a person up in bed. A person who is sitting up in bed may slide down toward the end of the bed. To ensure good body alignment and to keep the person comfortable, you will need to move the person up in bed.
Moving a person to the side of the bed. The first step of many procedures is to move the person to the side of the bed. For example, if you want to turn a person onto his side in bed, you will need to move him to the side of the bed so that he is in the center of the bed when you are finished repositioning him.
Turning a person onto her side in bed. Logrolling is the method used to turn a person onto her side in bed when her spine must be kept in alignment throughout the move.
Repositioning a person in a chair. A person who is seated in a chair may slide down in the chair over time. You will need to move the person back up in the chair for proper body alignment.
ASSISTING WITH TRANSFERRING
To transfer means to move from one place to another (for example, from the bed to a chair). As when repositioning a person in bed or a chair, you will need to plan the safest way to transfer the person and make arrangements for help or special equipment (such as a mechanical lift or standing-assist device) as needed.
When planning a transfer, knowledge about the person’s mobility and level of independence can help you determine how much the person will be able to help with the transfer. Questions to consider include:
Can the person support all of his weight on one leg or both legs?
Is one side stronger than the other?
Can the person maintain his sense of balance?
Does the person have vision problems?
Is the person able to hear and respond to verbal instructions?
Does the person have pain when he moves?
Is the person afraid of being moved?
Has the person ever suddenly refused to cooperate?
Does the person behave in a predictable way?
When assisting a person who can bear weight, a transfer belt is used unless the person has a medical condition that makes it dangerous to use a transfer belt. During the transfer, you grasp the transfer belt to support the person, rather than the person’s clothing or arms. Remember that the transfer belt is a support device, not a lifting device! A person who cannot bear any weight at all or who is very heavy will need to be transferred using a mechanical lift. There are many different types of mechanical lifts. Although they all work in generally the same way, make sure you have been trained specifically in how to use the lift before actually using it. For many people, being moved in a lift is very frightening, so be sure to reassure the person throughout the procedure.