Bed Positioning for

Optimum Patient Safety

and Comfort
Carolinas Rehabilitation
There are six basic goals of proper positioning of
the patient while in bed; the first being comfort. The five
others are discussed and described in this module.
This self-directed learning module contains information
you are expected to know on positioning the rehab
patient in response to the manifestations of his or her
condition or injury to protect our patients, our guests
and you.

Target Audience: RN, LPN, PT, PTA, OT, COTA, SLP,

TR
Recommended: Ancillary care givers

Contents
Instructions........................................................ 2
Learning Objectives .......................................... 2
Module Content................................................. 3
Job Aid .............................................................. 10
Posttest ............................................................. 11-12

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INSTRUCTIONS
The material in this module is an introduction to important general information. After
completing this module, contact your supervisor to obtain additional information
specific to your department.

Read this module.

If you have any questions about the material, ask your supervisor.

Complete the online post test for this module

The Job Aid on page 10 may be customized to fit your department and then
used as a quick reference guide.

Completion of this module will be recorded under My Learning in

PeopleLink.

Learning Objectives
When you finish this module, you will be able to:

List six goals of positioning

List areas that are most susceptible to pressure sores and identify ways
to prevent pressure sores
Identify techniques to protect the hemiplegic shoulder
Identify special positioning needs of clients with dysphagia
State techniques used to aid in pain control for clients with tetra paresis.
State special positioning needs of clients who are in a coma,
unresponsive or vegetative state

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I. Diagnoses requiring skilled positioning
A) CVA with Hemiplegia
Hemiplegia is the paralysis of one side of the body caused by a vascular
injury or accident in the hemisphere of the brain on the opposite side of the body.
The impairment of motor function can include low tone or flaccidity (lacking normal
muscle firmness), movement patterns influenced by increased tone (increased
muscle firmness or resistance to movement), poor balance, and poor joint alignment.
There can also be a loss of proprioception, the ability to perceive joint position in
space. Loss of sensation may be complete or partial. The client can even have a
total loss of recognition of the affected side, also known as left neglect.
Clients with hemiplegia are at risk for additional injuries. The hemiplegic
shoulder is especially vulnerable to injury because there is little supporting strength
from the surrounding muscles and bony structures. Skin injuries and pressure ulcers
are both high risks due to immobility, decreased sensation and fragile skin. Risk for
edema and deep vein thrombosis is increased due to poor circulation caused by the
clients immobility. Muscle and tissue contractures (shortening) are a danger from
both increased tone as well as immobility. After a stroke, many patients also have
dysphagia (swallowing difficulty) which may require special positioning.

B) Brain Injury
Clients can have brain injuries from multiple causes that include external
trauma to the head, trauma to the arteries supplying blood to the brain, drug
overdose, tumors, and brain anoxia. Brain injuries can cause a wide variety of
physical deficits that include hemiparesis as described above, monoplegia, and
abnormal reflexes. There can also be cognitive changes that can include posttraumatic amnesia (PTA), agitation and confusion. Patients that have brain injuries
can have varying states of arousal that include coma, vegetative state, general
unresponsiveness, and reduced or hyper alertness. Additional medical problems
may include aphasia, dysphagia, epilepsy and changes in autonomic function.
Because of the wide range of needs of the client with a brain injury, it is
important to identify the special needs of each individual. Knowledge based
creativity may be required by the care taker as all possible needs can not be
foreseen by this module. The client who is in PTA may be dependent to recall and
follow medically necessary precautions. A restless client may require frequent
repositioning. Some of these possible situations will be covered below under IV
Positioning Techniques: C) Special Positioning Needs.

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C) Spinal Cord Injury
Spinal cord injury (SCI) which commonly leads to paralysis and sensory
deficits, involves damage to the nerves within the bony protection of the spinal
canal. The most common cause of cord injury is trauma, although damage can occur
from various diseases, tumors, vascular injuries or orthopedic degeneration. The
spinal cord does not have to be severed in order for a loss of function to occur. In
fact, in some people with SCI the spinal cord is bruised but intact.
Since the spinal cord coordinates body movement and sensation, an injured
cord loses the ability to send and receive messages from the brain to the bodys
systems that control sensory, motor and autonomic function below the level of injury.
As swelling from the initial injury begins to decrease, some people will show
functional improvements. Many injuries, especially those that are incomplete, will
show progress even up to 18 months after the injury.
Incomplete injuries can fall into several categories.
Anterior Cord Syndrome results from injury to the motor and sensory
pathways in the anterior parts of the spinal cord. Those affected can feel some types
of crude sensation via the intact pathways in the posterior part of the spinal cord but
movement and detailed sensation are lost.
Central Cord Syndrome is caused by injury to the nerve cells and pathways
located in the center of the cervical spinal cord which produces weakness, paralysis
and some sensory deficits in the arms. Strength and sensation in the legs are
affected much less than in the arms.
Brown-Sequard Syndrome results from injury to the right or left half of the
spinal cord. Movement and some types of sensation are lost below the level of injury
on the injured side, but pain and temperature sensation are lost only on the side of
the body opposite the injury.
Besides a loss of sensation or motor function, injury to the spinal cord leads
to other changes, including loss of bowel, bladder and sexual function, low
blood pressure, autonomic dysreflexia (for injuries above T6), deep vein
thrombosis, spasticity and chronic pain. Secondary conditions include
pressure ulcers, respiratory complications, urinary tract infections, pain,
depression and obesity. These secondary conditions are the ones that we can
help prevent by stressing proper positioning, good overall healthcare, diet and
physical activity.

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II. Goals of Positioning
There are six basic goals of proper positioning:
1) The client should be as comfortable as possible.
In efforts to provide the client with excellent care, providing comfort is the first
step. Taking an extra moment to fluff and align a pillow or providing an extra blanket
can significantly impact someones perception of his or her experience at our facility.
2) The client should have access to his environment.
Providing the client with access to his environment will not only improve the
clients level of comfort but also improve their level of safety and independence. Any
needed item that is out of reach can be a source of frustration to a client that is
restricted to their bed. A critical item, such as a phone or urinal, out of reach will
endanger a client by tempting them to perform an unsafe maneuver to retrieve the
item, which may result in a fall.
3) Maintain and promote normal joint range of motion.
Proper bed positioning will encourage normal joint range and help to prevent
contractures. If increased tone is present, it may cause joints to flex (bend). If
allowed to remain in a flexed position for extended periods of time, there will be
shortening of the muscles which will lead to a loss of motion or tissue contracture.
Positioning the client so that the joints with high tone are extended and the
associated muscle groups are lengthened will assist in inhibition of high tone and the
prevention of loss of motion.
4) Promote healthy and intact skin.
Establishing a proper positioning and turning schedule is essential in the
prevention of pressure sores. Decubitus ulcers, or bed sores, are caused by
prolonged exposure to pressure against the skin. Bony areas of the body that are
especially susceptible to pressure sores include the sacrum, heels, malleoli and the
trochanters.
5) Help to control edema.
Positioning can be an effective tool in combating or preventing edema in the
extremities. Edema is an abnormal build up of excess tissue fluid that can limit range
of motion and decrease skin integrity. Because water flows downhill, the at risk of
swelling or swollen extremity should be positioned above the heart. This allows
gravity to have an effect on the excess fluids and return the fluids to the clients trunk
and therefore aid in the prevention or reduction of edema.

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6) Medically necessary precautions for respiration and swallowing should be
followed.
Clients may have medical restrictions that require the head of their bed
to be elevated at all times. This may be to aid in respiration for clients with
COPD or Respiratory difficulties. It can also be required to aid in the swallowing
of secretions for clients with dysphagia or swallowing difficulties. Some clients may
only need the head of the bed elevated at specific times, such as after meals for
clients with GERD / acid reflux, dysphagia or congestive heart failure.

III.

Theory

Neuromuscular Developmental Treatment (NDT) is a theory formulated

in movement science that explains normal movement and effective
interventions. Based on the principles of NDT, and working with the hemiplegic
client, positioning him or her on the affected side is the most effective position to aid
in the clients recovery. NDT states that weight-bearing encourages normal muscle
tone for the client with hemiplegia. Weight-bearing also increases sensory input,
providing the client with an environment that will facilitate improved proprioception
and awareness of that body part. This principle can be utilized with bed positioning
by positioning the client on his hemiplegic side as tolerated.
Spasticity and high tone can cause a client to repeatedly move himself into
abnormal positions, leading to shortening of muscles, pain and more spasticity. NDT
states that increased tone and spasticity can be inhibited by lengthening the
side or extremity with increased tone. This is why symmetry is emphasized
throughout the following positioning techniques to prevent the client from
continuously positioning himself in a manner influenced by abnormal tone.

IV.

Positioning Techniques

Always ensure that the sheets and pads are free of wrinkles to avoid
discomfort and additional pressure on the skin. Bulky linens and heavy cloth bed
pads are contributors to skin breakdown and should be avoided. Tools such as the
Sally Roller and Sally Tube should be utilized whenever possible to reposition and
to transfer the patient. They will also prevent shearing of skin during positioning.

A. Supine
When positioning a client in supine, the head, neck, shoulders, and hips
should be as symmetrical as possible. To support the desired alignment, pillows
may be required to support the head and lower extremities.
Care should be taken when placing a pillow under the clients knees for
comfort. While this is allowable for brief periods, it can lead to shortening of the knee
and hip flexor muscles if used for a prolonged period of time. It can also create
increased pressure on the clients heels.
Extremities with edema should be elevated above the level of the
clients heart with pillows or positioning wedges.

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B. Side lying
When positioning a client in sidelying, pressure on the extremities against
the bed must be minimized while the extremities away from the bed are
supported by pillows. The head and neck should be supported symmetrically by a
pillow. The trunk can be rotated back or forward, supported by a pillow placed
posteriorly or anteriorly to the trunk if needed. To avoid pressure on the
glenohumeral joint on the bodys side against the bed, the shoulder should be
protracted (brought forward). A pillow should also be placed under the entire length
of the clients leg away from the bed to align the leg with the hips and trunk while
reducing pressure between bony areas and the bed.

C. Special Positioning Needs

1. The Hemiplegic Client
When positioning the client with hemiplegia in sidelying on either side,
the hemiplegic shoulder should always be protracted with 90 degrees of
shoulder flexion.
When lying on the hemiplegic side, have the affected forearm flexed and
supinated (palm up) with the elbow flexed. You can place the hand under the pillow
supporting the head and neck to stabilize the hemiplegic arm in this position. The
nonaffected leg can be supported in a flexed position by a pillow. The affected legs
hip should be extended with the knee slightly flexed.
When lying on the nonhemiplegic side, the hemiplegic extremities should be
fully supported by pillows with the leg flexed at the hip and knee.

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In supine, the clients hemiplegic shoulder will require the support of a
pillow or folded towel to maintain symmetry with the opposing shoulder. If
elevated above a symmetrical position, the client will be a greater risk for anterior
luxation (dislocation) of the glenohumeral joint. The rest of the arm will require
support through its entire length by a pillow to provide elevation with the elbow
extended and the forearm supinated. A thin pillow may also be used to keep the hips
symmetrical and reduce a retracted (drawn back) pelvis.

The clients bed should be situated so that the majority of the room is on their
hemiplegic side to improve attention and awareness of that side.

2. The Client in a Coma, Unresponsive or Persistent

Vegetative State
This client will be unable to voice needs or concerns. This makes him
especially vulnerable to pressure sores. A turning schedule is paramount and skin
should be checked daily for redness as a possible warning sign of possible forming
decubitus ulcers.
Because of changes in autonomic function, this client may have excessive
sweating that will require frequent changes of his clothing and bed sheets to prevent
skin breakdown.
If the client has areas of increased tone, follow the above recommendations
(III Theory) for management of tone.

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3. The Restless Client
Frequently repositioning the client in a restless state may be beneficial when
the client has brief periods of relaxation. During the periods of extreme restlessness,
the emphasis should be placed on prevention of injury to the client. Special padding
may be needed for the client to avoid becoming caught between the side rails and
the bed. Additionally, the staff should monitor and make constant checks on this
client for safety. A Net Bed can be used when the client makes attempts at getting
out of bed but is unsafe. This bed allows the client to move freely within the bed
environment without injury to self. A LowBoy bed may also be utilized if the patient is
at risk for falling.

4. Spinal Cord Injury

a) Pressure Relief - People with SCI will need assistance to reposition
themselves every 2 hours to avoid prolonged pressure on insensate bony
prominences. Areas especially prone to pressure ulcers include the sacrum (lower
back), greater trochanters (hip bones), lateral malleoli (ankle bones), calcanei
(heels) and occiput (back of the head). Patients should sleep on both right and left
sides as well as on their back even if they are on a low airloss mattress. In prone,
pillows should be used to elevate heels off of the bed if splints are not used. Towel
rolls placed on the outside of the persons hip will also keep their legs from rolling
outward (a position that will place excessive pressure on their hip bones and outer
ankle bones). In side lying, be sure to place a pillow between the persons legs from
their knees all the way down to their feet. This will alleviate pressure on their inner
knees and inner ankle bones.
b) Spasticity Management Use of resting foot splints is often imperative
for prevention of function limiting heel cord contractures. Many patients may also
have splints to preserve hand and finger positioning. Slow sustained stretching or
movement is the best way to limit a flexion or extension spasm. In side lying, flexing
the top leg while keeping the bottom leg extended may also assist in breaking up
spastic patterns.
c) Pain control Many patients with tetra paresis experience severe
shoulder pain and are unable to tolerate side lying positions. Use of one to two
pillows placed horizontally under their ribcage (see photo) will un-weight the
shoulder joint and greatly improve their comfort. This technique will allow the patient
to be placed more fully on their side therefore eliminating the need for multiple
pillows behind their back. Flexing the top leg and arm forward and resting them on
pillows will also improve comfort, spasticity, edema and pressure relief.

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JOB AID

Ensuring someone is positioned comfortably can significantly impact

their perception of their experience at our facility
Environmental access is important for client independence and safety
Positioning joints with high tone in extension will help to prevent loss of
motion
Bony areas, including the sacrum, heels, malleoli and the trochanters
are especially susceptible to pressure sores
Positioning an extremity above the heart may decrease or prevent
swelling and edema
There may be medical restrictions that require the head of the bed to
be elevated at some or all times
Clients with tetra paresis may have shoulder pain and be unable to
tolerate side lying positions without a pillow supporting their rib cage
Positioning can be an effective tool in management of spasticity
Job aid tools such as the Sally Roller and Sally Tubes help prevent
skin shearing and help make transfers and repositioning easier for the
patient as well as team members.

References
Davis, J.Z. (2001). Neurodevelopment treatment of adult hemiplegia: The
Bobath Approach. In Pedretti, L.W., & Early, M.B. (Eds.). Occupational
therapy practice skills for physical dysfunction (5th ed.). (pp 624-640). St.
Louis, MO: Mosby.
Minor, M.A.D., & Minor, S.D. (1995). Patient care skills (3rd ed.). Norwalk, CT:
Appleton & Lange.
Umphred, D.A. (Ed.). (1995). Neurological rehabilitation (3rd ed.). St. Louis,
MD: Mosby.

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Posttest
Name: _____________________________________________
Date: ______________________________________________

Circle the correct answer.

1. Which of the following is not a goal of proper positioning?
a. The client should have his knees supported by a pillow.
b. The client should have access to his environment.
c. Healthy skin should be promoted.
d. Precautions for swallowing should be followed.
2. A swollen arm should be elevated above the heart because of what law or
principle?
a. Neuromuscular Developmental Treatment or NDT.
b. Gravity.
c. Proprioception.
d. Protection and management of the hemiplegic shoulder.
3. What bony area is not usually at risk for pressure sores?
a. The malleolus.
b. The sacrum.
c. The xiphoid process.
d. The greater trochanter.
4. Dysphagia is a consideration when positioning someone because
a. Prolonged dysphagia can cause pressure sores.
b. It can cause an excessive build up of fluids in the extremities.
c. It may be medically necessary for the head of the bed to be elevated for
safe swallowing.
d. It is critical in the prevention and management of congestive heart failure.
5. When positioning a client in side lying, pressure on the _______ is always a
concern and should always be avoided.
a. Glenohumeral joint
b. Sacrum
c. Extremity with edema
d. Head

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6. When positioning the client in supine, how many pillows should be under the
clients head?
a. One pillow should always be used to ensure proper positioning of the head
and neck.
b. Two pillows are standard for all clients.
c. No pillows should be placed under the head as it encourages excessive
neck flexion and prevents symmetry with the shoulders and hips.
d. One or more pillows may or may not be required to position the clients
head and neck symmetrical with the shoulders and hips.
7. To un-weight the shoulder joint of a client with tetra paresis in side lying, you can
a. Position a pillow under their shoulder.
b. Position a pillow under their rib cage.
c. Add a second pillow under their head.
d. Position a pillow behind their back.
8. The best way to limit a flexion or extension spasm is to
a. position the client in a slow and sustained stretch.
b. elevate the head of the clients bed.
c. elevate the foot of the clients bed.
d. add a second pillow to the area of concern.
9. A client in a coma or unresponsive state is especially vulnerable to
a. the media.
b. shoulder subluxation.
c. low back pain.
d. pressure sores.
10. Special equipment that a restless patient may require.
a. A net bed.
b. A trapeze bar.
c. Heavy blankets.
d. A body pillow.
11. Equipment such as the Sally Roller and Sally Tube are used
a. to prevent skin shearing
b. when transferring or repositioning the patient in bed
c. used only in therapy
d. used only with stroke patients with left hemiplegia
e. both a and b
f. none of the above

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