Repositioning in a bed or wheelchair
Frequency
Repositioning should occur every 2 hours. Position should be changed every 1-2 hours to keep the pressure off any one spot.[19] According to recommendations from the Agency for Health Care Policy and Research, patients who are bedridden should be repositioned every 2 hours.[20] Patient should shift his weight in his wheelchair every 15-20 minutes and if with assistance changes in position
is every hour.
Repositioning devices
People with enough upper body strength may be able to reposition themselves with the assistance of a device such as a trapeze bar. Using bed linens to help lift and reposition a person can reduce friction and shearing. In moving the patient, nurses should lift the patient or use a draw sheet (a special sheet used for this purpose) to move him. Sheets and clothing should be dry and smooth, with no wrinkles. If patient is on wheelchair, he should be encouraged to can do wheelchair push-ups.
Pressure-release wheelchairs, which tilt to redistribute pressure, should be provided.
Special mattresses and support surfaces
Special cushions, foam mattress pads, air-filled mattresses and water-filled mattresses can help a person lie in an appropriate position in bed or chair, relieve pressure and protect vulnerable areas from damage. The fitting of patient to wheel chair should be checked once or twice a year. If the patient gains weight, the doctor or physical therapist should review size of wheelchair. Patient must sit on a foam or gel seat cushion that fits his wheelchair. Patient should not sit on donut-shaped
cushions. A physical therapist can advise on the appropriate placement of cushions and their role in
regular repositioning.
Bed elevation
Hospital beds that can be elevated at the head should be raised no more than 30 degrees angle to prevent shearing. Being flatter keeps the body from sliding down. Sliding may harm the skin. To minimize shear, the head of the bed should not be elevated more than 30 degrees and should be maintained at the lowest degree of elevation needed to prevent other medical complications, such as aspiration and worsening congestive heart failure symptoms.[21]
Protecting bony areas
Bony areas can be protected with proper positioning and cushioning. Rather than lying directly on a hip, it’s best to lie at an angle with cushions supporting the back or front. Cushions should also be used to relieve pressure against and between the knees and ankles. Heels can be cushioned or “floated” with cushions below the calves. Patient should never be dragged to change his position or get him in or out of bed. Dragging will cause skin breakdown. The nurse should get help if there is need in moving him on the bed or getting in or out of bed. For patients who are at very high risk: Implement a full range of pressure reduction strategies, in addition to repositioning. The strategies one implements should be based on level of risk and available resources.
The sixth line of action is ensuring that the patient is adequately nourished. Adequate nutrition is a cornerstone, not only for healing ulcers, but for preventing them as well. As part of a programme of pressure ulcer prevention ongoing nutritional assessments need to be done to ensure the patient is receiving enough nutrition in the form of calories, protein, hydration and vitamins and minerals.
If a patient is unable to consume enough nutrients through regular meals and snacks, other methods must be considered, such as supplementation or Enteral support. A nutritional consult is recommended for any patient who has ANY difficulty consuming adequate nutrition. Although poor nutrition is associated with pressure ulcers, a causal relationship has not been established. One large trial has shown that oral nutritional supplementation reduces risk, but several other trials have not.[22]
• Diet: He may need to increase the amount of calories, protein, vitamins and minerals in his diet.
The doctor may also prescribe dietary supplements, such as vitamin C and zinc
• Fluids: Adequate hydration is important for maintaining healthy skin. The care team can advise on how much fluid to drink and signs of poor hydration, such as decreased urine output, darker urine, dry or sticky mouth, thirst, dry skin, or constipation
• Feeding assistance: Some patients with limited mobility or significant weakness may need assistance with eating in order to get adequate nutrition.