Comprehensive Review of Positioning in Long - Term - Care

Postioning - Challenging Task Goal : Prevent contractures Maintain skin integrity Improve postural alignment As we all know, appropriate positioning of the resident in the bed, wheelchair or a gerichair is always a very challenging task. As a facility team, nursing and OT work together on a positioning program to prevent contractures, to maintain skin integrity and to improve postural alignment. Let’s see the purpose of positioning and role of OT in the positioning program.

Breathing and body alignment Swallowing Postioning - Purpose Decubitus ulcers Contracture and edema Breathing and body alignment Swallowing Appropriate positioning mainly helps in uniform distribution of pressure on weight- bearing areas. Hence in turn, prevents development of pressure ulcers. In case of existing decubitus ulcer, appropriate positioning becomes all the more essential. The pressure on the broken down area should be strictly avoided and at the same time an alternative way of positioning the resident must be sought. In case of a non-ambulatory resident, appropriate positioning is very important to prevent development of contractures. Similarly, hand edema displays immediate need of positioning of the arm to reduce the edema. Appropriate positioning also promotes good breathing and easier swallowing.

Non-responsive or bed ridden Specific medical diagnosis Conditions Non-responsive or bed ridden Specific medical diagnosis Reduced activity In a SNF, general population is that of elderly residents. As the age advances, general mobility decreases. This, in turn, reduces the use of joints and decreases the possible ROM at any joint. This becomes a favorable condition for gradual development of contracture and leads to hindering of any daily activity. There are some very specific medical conditions that may warrant our attention as a facility team to provide appropriate positioning. One of these could be a stoke, leading to decreased use of one side of the body or imbalance of the muscles, leading to postural asymmetry. This may lead to resident leaning on one side causing back pain and difficulty in performing daily tasks. Pain caused by arthritis leads to a natural tendency of protecting the joint and hence decrease the ROM of that joint. This may lead to development of a contracture. Immobilization following any fracture leads to decreased use of that extremity and decreased function. In such situations, appropriate positioning of the extremity is strongly recommended that maintains a good alignment at the joints during the period of immobilization.

Scale of Functional Status Direction of Progress Independent Need for positioning Total Assistance As we see here, as the level of independence in ADLs increases, the positioning need usually decreases. This happens as the resident’s mobility increases, resident is able to reposition himself independently. Hence in turn, does not need assistance for positioning to distribute the pressure on weight bearing areas. When deficits in mobility are noted, resident needs more and more assistance for appropriate positioning. Let’s see how OT helps nursing with the positioning program.

New admission Referral Care-plan Screening OT Evaluation OT Tx plan Appropriate positioning Assessing device Bed WC gerichair Let’s go through the whole process from Screening to discharge. When a new resident is admitted to the facility, OT does the screening. By screening, OT decides if resident would benefit from OT treatment or not. If conclusion of screening is ‘Yes’, then 'Evaluation' is completed. During evaluation, positioning need is assessed. Resident may display need of appropriate positioning while being in bed, sitting in the wheelchair or in the gerichair. Accordingly, a treatment plan is established. OT treatment goals may be geared towards improving the postural alignment by strengthening the musculature and providing any positioning devices if indicated. OT also aims at improving the functional mobility of the resident, thus decreasing the need of positioning devices. If any positioning devices are used, then they are always monitored by OT to check resident’s tolerance to the positioning device. Once the goal of appropriate positioning is met, discharge planning is initiated.  

Referral to D/C (continued) Caregiver’s education Screening D/C planning D/C Followup by Nursing Change in status Referral The discharge planning involves caregivers’ education regarding the positioning follow-up and a functional maintenance plan is established regarding the positioning schedule. After resident is discharged from skilled OT, the follow-up is done by the caregivers. If any change in status of the resident is noted then the resident is referred back to OT for screening. This same process is performed for care plan referrals.

Commonly Used Positioning Devices Bed: Body positioner Abductor wedge WC: Cusions, Lap buddy, Lap tray, Lateral stabilizer Gerichair: Lap-tray The positioning devices used vary from person to person depending upon the need of positioning. Here are some commonly used positioning devices in the SNF. In bed, a body-positioner is used to maintain the side-lying position for a certain time period. As per the patient’s tolerance, the position is changed from one side to the other and that position is maintained with the help of body-positioner. An abductor wedge,is usually used after the total hip replacement to prevent any post-op complications. Various types of cushions are used while maintaining an upright position. A lap-buddy can be given to prevent forward leaning. The lap-tray can be attached either to a wheelchair or a gerichair. Lateral stabilizer is used to prevent leaning on the either side.

Positioning Guidelines Increase comfort Secured and safe to use Long term use Whenever caregivers monitor any type of positioning, specific guidelines must be followed. A positioning device must be comfortable to the resident and safe to use. It should be appropriate for the long-term use and should be secured in certain position. A specific positioning schedule must be always followed by the caregivers.

Identify positioning needs Mark ‘check list’ Notify OT/Rehab Steps to Follow Identify positioning needs Mark ‘check list’ Notify OT/Rehab Follow-up by OT Steps to be followed are – Step1. Notice any specific positioning needs. Step2. Put a check mark on the ‘check list- positioning’. Step3. Give this list to OT and OT may evaluate the resident. While planning a discharge OT establishes a functional maintenance plan. Caregiver’s education is also completed. Step4. Positioning follow-up is done by restorative nursing as per the functional maintenance plan.

Purpose of appropriate positioning Positioning Guidelines Summary Purpose of appropriate positioning Positioning Guidelines Positioning devices Mark ‘check list’ Today, we have discussed the purpose of appropriate positioning and positioning guidelines that need to be followed. We have also reviewed commonly used positioning devices in the SNF and their use. It is very important for nursing to identify the positioning needs of the residents and to refer them to the therapy department. This enables the therapist to establish a resident-specific positioning program. Finally, restorative nursing can follow up the established Functional Maintenance Plan to monitor appropriate positioning of the resident.