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How Correct Positioning Can Prevent Pressure Injuries

Positioning patients properly may aid in preventing pressure injuries. This author provides a practical guide to correct positioning and specialized positioning for those with special conditions, as well as a look at an innovative positioning product.

As a physical therapist for over 30 years, I continue to see the same difficulties that I have seen since I first became interested and involved in wound care. Preventative and positioning efforts to reduce problematic pressures are at times not being addressed, leading to either nosocomial pressure injuries or slow non-healing wounds.
Lower extremity contractures make pressure-relieving positioning in both bed and wheelchair challenging due to higher peak pressures in those areas that remain in contact with the support surface.

Despite advances in support surfaces, education, topical treatments, and other interventions, the incidence of pressure injuries remains high. In the United States pressure injury care and treatment cost approximately $27 million yearly.1

A multidisciplinary approach to wound care and prevention is essential to address this problem. A patient who is assessed to be at high risk should be given similar attention as a patient with an existing pressure injury.2   

Current risk assessment scales need to be further developed and utilized to improve prevention efforts. In an abstract in Ostomy Wound Management, there was a discussion that suggests that the Braden risk assessment scale had decreased predictive validity for pressure injury risk assessment in postoperative patients.3

Positioning efforts need to be implemented based on risk and along with other indicated interventions. In some cases, the intervention is education to patients and their families and in other cases, intervention consists of straightforward positioning efforts, especially in those individuals who are unable to follow directions.

A Guide To Effective Positioning

For patients who are at risk and unable to reposition themselves, a minimum of 4 pillows is needed. When a facility’s wound care team or practitioner does an assessment or wound rounds, it would be wise to assess how many pillows are in the room. When in the quarter-turn side lying position, a patient requires a pillow under the head, one pillow behind the back to maintain the quarter-turn position, one pillow between the knees, and sometimes a pillow under the bottom leg to offload the lateral ankle. In addition, in some cases a pillow to support the individual’s top arm and shoulder is also indicated for comfort and upper extremity support. For the supine position, one pillow is needed for the head and one for pillow bridging.   

Individuals with hip and knee flexion contractures or excessive extensor tone require specialized positioning. Patients with hip and knee flexion contractures typically have difficulty staying on their backs and gravitate to full side lying positions. Full side-lying increases the risk of pressure injury at the trochanter, fibular head, lateral malleoli, lateral heel or foot. In addition to the contractures and increased risk due to positioning issues, these patients commonly have decreased oral nutritional intake and an inability to self-position. Therefore, specialized positioning efforts to prevent full side lying benefit with the quarter-turn from a supine position to reduce direct pressures at the trochanter.

Individuals with extensor tone can be positioned in the quarter-turn from supine with reduced hip and knee flexion if possible and if tolerated. A pillow under the head and bottom knee, a pillow behind the back, and a pillow between the knees with the top leg more forward will assist in maintaining the quarter-turn position.

When in a supine position, patients with foot drop or increase in ankle plantarflexion tone could benefit from a pillow or blanket to assist in providing a static stretch to the heel cord. The addition of a pillow or blanket at the bottom of the bed can help prevent excessive ankle plantarflexion and reduce the risk of pressure injury under the heel. This positioning can reduce that pressure and should be used in conjunction with pillow bridging.

Which Positioning Tools Are Effective?

Helpful items such as a Z-Flo® positioner (Mölnlycke) can be used with high risk populations to improve positioning, comfort and compliance. The Z-Flo positioner is a specialty gel-filled pillow that can assist in positioning a patient in a quarter-turn position when a conventional pillow is not able to maintain the proper position. It can be used behind the back and can be used between the thighs to promote hip abduction. In addition, it can be utilized under the head in high risk cases to reduce occiput and ear pressures.

A good quality plush heel protector is beneficial when protecting the feet and heels of at-risk individuals. Lower extremity contractures require larger size, quality pillow-type heel protectors to protect the whole foot. Positioning strategies used to heal a pressure injury should be the same strategies used to prevent a pressure injury. If an ulceration unfortunately develops on a foot within a quilted heel protector, a heel protector upgrade is indicated.

Lower extremity contracture management can benefit from the use of bracing. Bracing will help to prevent worsening contractures due to abnormal tone commonly seen in individuals with dementia, multiple sclerosis and stroke.  

In addition to bed positioning, patients who have contractures have challenges with wheelchair positioning. The topic of wheelchair positioning is a good topic for a future day.

In Summary

Patients with contractures are challenging to position in bed and specialized positioning strategies with multiple pillows and other devices may be beneficial to prevent high peak pressures and maximize patient comfort.

Diane Holland, PT, has over 30 years of experience as a physical therapist.


Diane Holland, PT

1. Morse S. Pressure ulcers cost the health system $26.8 billion a year. Healthcare Finance News. . Published Oct. 10, 2019.
2. Gottrup F, Holstein P, Jorgensen B, et al. A new concept of a multidisciplinary wound healing center and a national expert function of wound healing. Arch Surg. 2001; 136(7):765–72.
3. He W, Liu P, Chen HL. The Braden Scale cannot be used alone for assessing pressure ulcer risk in surgical patients: a meta-analysis. Ostomy Wound Manage. 2012; 58(2):34,40. 

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