Comfort, Stability, Security: The Principles of Effective Repositioning

You’re constantly on the move.

No, we’re not talking about walking, running, taking planes, trains and automobiles to any of our 1001 activities.

We’re talking about your body being constantly on the move, shifting position without you being aware of it while you’re sitting, lying down and even sleeping.

What is your body trying to achieve with all these micro-movements? Three things, from seating and patient repositioning specialist Menno van Etten’s perspective:

1) Comfort

2) Stability

3) Security

If you’ve been sitting in a chair for a while and your lower back is feeling a little uncomfortable, you’ll shift positions ever-so-slightly to relieve some areas of pressure and regain comfort.

If you’re sitting on the edge of a crowded bench at a bus stop and your body senses that if you get nudged any further you might start falling off the bench, you’ll unconsciously readjust your position to regain the most stability possible on the sitting area you have.

That’s what able-bodied people do - automatically.

Non-able-bodied people need others to perform the repositioning for them – consciously and deliberately. The aim, however, is still the same: to provide comfort, stability and security.

Repositioning patients to prevent deformations

Aside from the altruistic desire to prompt the patient to experience as much comfort as possible, making sure the elements of comfort, stability and security are taken care of reduces the risk of future deformations.

If the patient is in a healthy position that meets those three requirements, his body is stable and will remain in the healthy position you placed him in. If he is not stable or secure, however, his body will slowly readjust – seeking the mattress, if he is in a lying position – to try and regain the missing stability or security. Feet will fall to the side, hands will curl, and limb deformations or scoliosis will result.

Any bed-based position should meet the following criteria:

1) Pelvis and hips aligned, with the spine in a straight line between them

2) Hips slightly bent, to reduce tension and discomfort in the lower back

3) Knees slightly abducted and rotated outward

4) Appropriate support (cushions) in all small spaces in between the body and the support surface (not just knees and ankles, but also shoulders, arms and thorax)

An important aspect of maintaining stability and security is choosing the right cushion fill material. Fiber-filled cushions lose their shape under prolonged pressure, changing the original position of the patient to a less stable one. Cushions used for support should be firm (mixtures of firmer pearls and soft foam work well) to maintain the patient’s original position until they are repositioned.

Repositioning patients to prevent pressure injuries

One of the most common mistakes made by well-meaning caregivers, van Etten points out, is positioning patients in the 90 degree side lying position, meaning on his side with his hip and the outside of his thigh directly on the bed. While comfort, stability and security may be achieved, the patient is at considerably higher risk for a pressure injury. Pressure injuries tend to form when there is a high pressure interface between bone and tissues. In the 90 degree position, the patient is right over a bony prominence: the trochanter! Time spent in that position is likely to cause tissue deformation and an eventual pressure injury in the tissue right over the trochanter.

The ideal position for preventing pressure injuries is the 30 degree side tilt position. The patient lying in that position is not directly over any bony prominences, and the position can be very comfortable and stable if the above criteria are followed. The 135 degree side lying position (similar to the 30 degree, but the patient is tilted toward her stomach instead of toward her back) or the prone position can also work, if the patient’s medical condition allows, and if the above criteria are met.

The missioning of repositioning

As caretakers, we have the responsibility of being our patients’ movement managers. With knowledge of the principles and techniques for effectively repositioning patients, we can keep our patients' bodies as healthy, injury- and deformation-free as possible.