Positioning a Bedridden Parent: Turns, Pillows and Comfort

Principles of good positioning

• Change position regularly. A schedule set by a nurse or doctor is better than guessing. Many plans use changes about every two hours in bed, though some people need more frequent changes and some surfaces allow longer. See preventing bedsores at home.
• Keep the body aligned. Head, neck, spine and hips should be in a natural line, without twisting.
• Support, do not squeeze. Pillows fill gaps and hold a position; they should not press hard on a bony point.
• Avoid dragging. Lift or use a slide sheet. Dragging causes friction and shear.
• Keep skin clean and dry, and check it at each change; see bed linen and fabrics for sensitive older skin.
• Respect pain and comfort. If a position hurts, stop and try another way.
• Protect joints, particularly shoulders, hips, knees and ankles, to avoid contractures (permanent stiffening).
• Use the right equipment, such as a pressure-relieving mattress; see air mattresses for pressure sores.
• Involve the person. Explain what you are doing and ask what feels best.

Basic positions

Lying on the back (supine). The simplest, but it places weight on the tailbone, heels, shoulder blades and the back of the head. Use for short periods and alternate with side positions.

• Place a small pillow under the head and neck, so the chin is level, not pushed on the chest.
• Place a pillow under the calves so the heels float free.
• A small pillow or roll under the knees can ease strain, but only a slight bend, since a pillow under the knees for long periods may lead to stiffness or reduce circulation.
• Support the arms on pillows beside the body, with elbows slightly bent.
• Keep feet at a right angle with the legs, using a foot support or a rolled pillow, if the doctor or therapist advises, to prevent foot drop.

Lying on the side at a 30-degree tilt. This is the preferred side position to relieve pressure from the tailbone and the hip bone.

• Roll the person onto their side, then place a wedge or firm pillow behind the back so the body leans about 30 degrees from flat, not a full 90 degrees.
• Place a pillow between the knees and ankles, so the bones do not rub, and the upper leg is supported level with the hip.
• Place a pillow under the head and neck to keep them aligned.
• Support the upper arm on a pillow in front of the body, and place the lower arm forward, not trapped under the body.
• Place a pillow under the lower leg or a gap so the heels are free.
• A full 90-degree side lying position puts weight on the hip bone and shoulder, which is high pressure; avoid it for long.

Semi-seated or head-raised. Sitting up in bed helps with eating, breathing and reflux, but increases pressure on the tailbone and shear. See backrests for sitting up in bed. When using it:

• Raise the knees slightly before raising the head, to stop sliding.
• Keep the head of the bed at the lowest comfortable angle, unless raised for meals, breathing or other reasons.
• Support heels.
• Return to a lower position when the need is over.

Lying on the front (prone). Rarely done at home and only on medical advice, as it can cause breathing and swallowing problems.

A turning rhythm

A simple pattern for a person who cannot move, if advised: back, right side, back, left side, with the changes at the times set by the nurse. For example:

• 8:00 am back with head raised for breakfast, then lower;
• 10:00 right side (30-degree tilt);
• 12:00 back or semi-seated for lunch, then lower;
• 2:00 pm left side;
• 4:00 back;
• 6:00 right side or seated for dinner;
• 8:00 pm left side;
• through the night as the care plan says.

Keep a chart. Use alarms. Share duties among family members. At night, a plan that includes a pressure-relieving mattress may allow longer gaps, but check with the nurse. See night-time caregiving routines.

Pillow and wedge placement: practical guide

• Head: a medium-firm pillow that fills the space between the head and the mattress so the neck is neutral. Too thick pushes the chin down; too thin lets the head fall back. See neck pillow guide.
• Behind the back: a wedge or rolled firm pillow for side-lying. See wedge pillow guide.
• Between the knees: a soft pillow so the knees do not touch.
• Under the calves, to lift heels off the mattress. See leg elevation pillow guide.
• Under the arms: to support the shoulders and prevent them dropping.
• Foot support: a pillow or foot board to keep the ankles at a right angle. Do not wedge feet tightly.
• Hands: a soft roll or washcloth in the palm, if the fingers curl, to keep them from digging in; ask a therapist.

Avoid using too many pillows, which raise pressure, create heat and make cleaning hard. Do not use ring cushions or donuts; see ring cushion guide. Keep pillows clean and covered, with a spare set to rotate; see pillow hygiene and allergies.

Protect the vulnerable spots

The most common bedsore sites are the tailbone (sacrum), hips, heels, ankles, elbows, shoulder blades and the back of the head. Check these at each change.

• Heels: float them. This is one of the most effective measures, because the heel has little padding.
• Tailbone: avoid long periods at a steep head-up angle; relieve pressure by turning.
• Hips: use the 30-degree tilt, not a full side-lying.
• Shoulders and elbows: support arms on pillows, avoid dragging.
• Ears and back of the head: change the position of the head, and use soft pillow covers. Oxygen tubing or glasses straps can mark ears.
• Under tubes and devices: check where catheters, oxygen tubing, splints or braces touch the skin.

Moving and turning safely

1. Prepare. Explain to the person, lower the bed head, put the bed at carer's waist height, and apply brakes. Clear the area. 2. Use a slide sheet or draw sheet under the person, if possible. Two people can lift the sheet to move the person up or sideways without dragging. See turning a bedridden patient. 3. Bend the person's knees and cross the far arm over the chest. 4. Roll them toward you with one hand on the shoulder and the other on the hip, or use the sheet to roll. 5. Position pillows and check alignment. 6. Smooth the sheets, straightening wrinkles. 7. Check the skin on the area that was under pressure. 8. Record the time and position.

Protect your own back by keeping your feet apart, knees bent, back straight, and the person close. If the person is heavy or tense, ask for help. See how to lift and transfer safely.

Comfort beyond position

• Pain. Ask about pain, and watch for grimacing or restlessness. Tell the doctor; see chronic pain in older adults. Do not give extra medicines without advice.
• Temperature. Keep the person warm enough, but not hot; see keeping a bedridden parent cool in Indian summers.
• Skin care. Gentle washing, moisturiser, and barrier cream where advised; see barrier cream and skin care.
• Range of motion. Gentle movement of arms and legs, as taught by a physiotherapist, prevents stiffness. Do not force joints.
• Chest care. Positioning on the side and head-up helps clear secretions; ask a physiotherapist for breathing exercises; see respiratory physiotherapy for elderly lung health.
• Company and stimulation. Position so that the person can see the window, family and the door.
• Dignity. Cover, keep doors closed, and speak respectfully; see dignity in intimate care.

When to ask a professional

A physiotherapist or nurse can show your family how to position, turn and move safely and set a schedule, and can teach range-of-motion exercises. An occupational therapist can advise on equipment such as wedges, splints and slide sheets. Contact a doctor or nurse the same day for skin that stays red, a blister, a break in the skin, swelling in one leg, new pain, stiffness or a limb that looks twisted, difficulty breathing or any new change. Seek urgent help for sudden breathlessness, chest pain or unresponsiveness.