Introduction

Pressure injuries are injuries to the skin and deeper tissues that occur due to direct pressure, shear, or friction forces. It is estimated that in the United States, 2.5 million pressure injuries occur yearly in acute care facilities alone.¹ The price of managing a single full-thickness pressure injury is as much as $70,000, and expenditures in the United States for pressure injury treatment have been estimated at $11 billion per year.^2,3

Pressure Injury Development: Risk Factors and Prevention

The exposure of bony prominences to surfaces and the use of pressure-causing medical devices further the risk of injury. Risk factors for pressure injury development include⁵:

• Advanced age
• Severe illness
• Immobilization
• Malnutrition
• Sensory deficit
• Skin fragility
• Incontinence
• Reduced perfusion
• Recent fracture
• Edema
• Diabetes

Prevention can be achieved through risk assessment, clinical consultation, and pain management. In addition, proper prevention should combine individualized patient turning timelines and repositioning techniques with offloading products and pressure-sensing technology. Clinicians should also consider widely accepted pressure injury risk assessment tools, which include the Braden Scale, the Norton Scale, and the Waterlow Scale.

Why Turning and Repositioning is Important

The purpose of routinely turning patients is to relieve pressure and ensure adequate blood perfusion to the skin and soft tissues, especially in at-risk areas, such as at the heels, the sacrum, the hips, elbows, ischia, and the base of the skull. The National Pressure Injury Advisory Panel (NPIAP) had historically recommended turning patients every 2 hours. In 2019, the guidelines were updated to suggest that turning schedules should be based on a patient’s overall medical condition, skin condition, activity level, and ability to reposition themselves. Patients who are critically ill, cognitively or motor impaired, obese, immobilized, or require mechanical ventilation may typically require aid.⁶

Pressure Monitoring Devices

Variability exists in how well patients are turned, and patients and support devices can shift, affecting how desired positions are achieved. For this reason, pressure-monitoring devices have become more popular. Pressure sensors can be positioned over specific at-risk locations on the body or can come in the form of mattress or wheelchair seat covers. Most pressure sensors are designed to monitor pressure and send alerts when repositioning is indicated. Sensors can even help assess and manage healing parameters. These devices are emerging as a critical, cost-effective alternative to previous standards of care.⁷

How to Turn and Reposition the Patient

Safety and ergonomics are paramount in patient turning techniques. To avoid work-related injuries, the clinician should recruit assistance when necessary. While turning the patient, the wound care professional should maintain head, neck, and back alignment, refrain from twisting, and only bend at the knees or waist—never at the back. The clinician should adjust the bed to match the center of gravity and stand as close to the patient as possible before turning to avoid undue strain. Inflatable sheets, patient lifts, and flex tilt chairs can help ease the burden of repositioning.⁴ Preceding turning, clinicians should explain what to expect and why the maneuver is essential. This process may require encouragement. You may want to follow the following steps for this process⁴:

• Caregivers should stand on the side of the bed to which the patient will be turned, lower the bed rail, and ask the patient to look toward them.
• The patient should be moved to the center of the bed to avoid the risk of rolling over the edge.
• The patient’s bottom arm should be stretched toward the direction of the turn, and the top arm should be positioned across the chest. The patient’s ankles should be crossed.
• The caregiver should place one hand on the patient’s shoulder and the other on the patient’s hip.
• The caregiver should shift their weight to their front foot, which should be positioned ahead of their back foot. During this process, before shifting weight to their back foot, the caregiver should pull the patient’s shoulder toward them while gently pulling the patient’s hip forward.
• The process may require repetition until the desired position is achieved.
• The bed should be returned to a comfortable position with the side rails up.⁴

To ensure correct positioning, one should consider the “Rule of 30 Degrees.”⁴ This rule reminds caregivers to elevate the head of the bed no more than 30 degrees and to place the body at a 30-degree, laterally inclined position with hips and shoulders 30 degrees from supine, using pillows or wedges for support as necessary. Caregivers should always lift versus drag patients (to minimize skin shearing), ensure that patients’ ankles, knees, and elbows are not resting on each other, and refrain from positioning patients on bony prominences with existing nonblanchable skin.⁴

Pressure Relieving Tools

Once a patient is successfully turned, products designed to relieve pressure and prevent skin breakdown should be used according to protocol. These products can include the following²:

• Foam mattresses
• Sheepskins
• Continuous low-pressure supports
• Alternating pressure devices
• Advanced static mattresses or mattress overlays
• Dressings with features that can contribute to offloading, such as foam dressings.

To prevent skin breakdown and reduce shearing, daily moisturizers and barrier creams should be used after proper cleansing, especially when incontinence is a factor.

Conclusion

Prevention efforts are essential in reducing the morbidity, mortality, and exorbitant unnecessary costs associated with pressure injuries and require multi-specialty collaboration, individualized care plans, monitoring, adherence to protocols, and re-evaluation as necessary.

References

1. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296:974–84. doi: 10.1001/jama.296.8.974.
2. Gordon MD, Gottschlich MM, Helvig EI, et al. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil. 2004;25:388–410. doi: 10.1097/01.bcr.0000138289.83335.f4
3. Kuhn BA, Coulter SJ. Balancing the pressure ulcer cost and quality equation. Nurs Econ. 1992;10:353–9. Accessed September 22, 2022. https://pubmed.ncbi.nlm.nih.gov/1465158
4. MedlinePlus. Turning patients over in bed. National Library of Medicine (US). Updated October 23, 2021. Accessed September 22, 2022. https://medlineplus.gov/ency/patientinstructions/000426.htm
5. Alderden J, Rondinelli J, Pepper G, et al. Risk factors for pressure injuries among critical care patients: A systematic review. Int J Nurs Stud. 2017;71:97-114. doi: 10.1016/j.ijnurstu.2017.03.012.
6. Haesler E. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance; 2019.
7. Pickham D, Berte N, Pihulic M, et al. Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). Int J Nurs Stud. 2018;80,12-19. doi: 10.1016/j.ijnurstu.2017.12.012.