LessonsBasic Care and Comfort

Positioning, mobility and skin

Choose a position for a given client's risk, prevent pressure injury and contracture, and teach a client to use a cane, crutches or a walker.

Position for the risk, not for comfort

  • Unconscious with no gag reflex: side-lying, so secretions leave the mouth rather than enter the airway.
  • Receiving a tube feeding: head of the bed at 30 to 45 degrees, during and for a while after.
  • After a lumbar puncture: flat.
  • Increased intracranial pressure: head of the bed up about 30 degrees, head midline, no hip flexion.
  • After a total hip replacement: abduction maintained, no flexion past 90 degrees, no crossing the legs.
  • Air embolism suspected: left side, head down.
  • Autonomic dysreflexia: sit the client UP, then find the trigger.
Autonomic dysreflexia is the one that inverts the usual instinct. The pressure is dangerously high, so sitting the client up lowers it — and the trigger is most often a blocked catheter or a full bowel.

Pressure injury and contracture

Prevention is repositioning on a schedule, skin kept clean and dry, adequate protein and calories, and pressure-redistributing surfaces. Reddened areas are not massaged: the damage is already under the skin and shear makes it worse.

Doughnut cushions are not used — they concentrate pressure in a ring and reduce flow to the middle. Sitting at a steep angle for hours drags the skin over the sacrum.

Contractures form faster than most people expect. A stump resting on a pillow after a below-knee amputation, or a client left semi-recumbent for days, can lose the range needed for a prosthesis or for standing within a week. Passive range of motion and time spent lying flat or prone are the prevention.

Assistive devices

  • Cane: held on the STRONG side, advanced with the weak leg.
  • Crutches upstairs: the good leg goes up first. Downstairs: the crutches and the bad leg go down first. "Up with the good, down with the bad."
  • Crutch height: weight taken on the hands, never in the axillae — pressure there damages the nerve.
  • Walker: all four points down before stepping into it, and the client stands up by pushing off the chair arms rather than by pulling on the walker.

Worth remembering

  • Autonomic dysreflexia: sit the client UP, then find the trigger — usually the catheter or the bowel.
  • Never massage a reddened bony prominence, and never use a doughnut cushion.
  • A cane goes on the strong side and moves with the weak leg.
  • Up with the good leg, down with the bad — and never bear weight in the axillae.
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