Positioning aids for pressure ulcer prophylaxis

With micro positioning, the aim is to minimise pressure, whereas with macro positioning, the aim is to completely relieve pressure on individual areas of the body. If, for example, you make a small movement while sitting and distribute the weight on your buttocks slightly differently, but both halves of your buttocks are still on the seat, then you have, so to speak, made a micro-positioning. In macro positioning, you would lift one half of your buttocks completely off the chair - so the weight would be completely on the other half of your buttocks.
For patients, professional caregivers can perform either micro or macro positioning on the critical parts of the body. If you are a layperson, you should never attempt macro positioning yourself. There are a variety of positioning techniques that professional nurses learn in training. Therefore, before you try to position a loved one differently, it is essential that you receive detailed instruction from a professional.

First of all, you need to know which body regions are at risk in your particular case. Basically, the back of the head, shoulder blades, earlobes (when lying on the side for a long time), coccyx (buttocks) and heels are considered critical body parts. This is because these bear more weight due to the underlying bones when sitting or lying down. If you do not shift the weight from these parts of your body to other parts at least every three hours, the tissue is in danger of dying. Therefore, these areas need to be relieved. The following professional aids are available for this purpose:

• Positioning roll
• Support cushion
• Cube cushion
• Gel pads/gel cushions
• Soft support mattresses
• Alternating pressure mattresses
• Heel protectors

A positioning roll is used if you have to stay in bed for a long time and cannot turn yourself over. They are also important because prolonged bed rest can lead to pressure ulcers, pneumonia, thrombosis and stiff joints. Positioning rolls look something like breastfeeding pillows and can be used in many ways. It is important that you familiarise yourself with the different positioning techniques or, ideally, leave the positioning to the professional staff of the nursing service. This is because improper positioning can even lead to further damage under certain circumstances. The positioning techniques are described in detail below.

You may think that any soft pillow should be suitable for relief. Unfortunately, this is not true. The relief of certain parts of the body depends on various factors. The size of the pillow is just as important as the right filling and the distribution of this filling in the pillow. If, for example, you want to use a support pillow to relieve the coccyx in a wheelchair, it should ideally have a recess for this critical part of the body. Only then is this area really relieved and the area around the coccyx is softly padded.

The filling of a good support pillow should adapt to the shape of the body. A pillow filled with down, for example, does not do this. It is also important that the body region lying on the pillow is well air-conditioned. For this reason, grooves are incorporated into support pillows designed for the back or lower legs of wheelchair users, for example. These ensure air exchange, so that there is less moisture due to sweating. The following therefore applies in principle: A support cushion should be breathable!
A positioning wedge is also called a "wedge pillow" and is used for 30° positioning in bed. You should never use such a wedge for an immobile person as a seat cushion, because it is very firm and not intended for this purpose. The positioning wedge is pushed under the mattress for lying patients so that the body weight is distributed differently.

A side support pillow is good for several parts of the body because of its shape, which is similar to a triangle. For example, it can be ideally placed under the knee bend. In addition, nursing staff like to use such pillows to relieve the chest, sternum and shoulders during the 30/135° positioning. Also popular for lateral positioning are so-called half-moon pillows. Actually, the name "C pillow" would be more appropriate, because basically the pillow looks more like the letter C or a boomerang than a real half-moon. It is suitable for both sitting and lying down and supports the upper part of the body laterally - so it is easy on the back and shoulders.

A ring cushion is not optimal for pressure sore prevention. Although it leaves out the coccyx region and thus relieves this region for the person sitting on it, the remaining body weight is distributed over the ring-shaped surface instead. This region is therefore subjected to a disproportionately higher load, which in turn can lead to problems. Such seat rings are therefore more suitable for patients who are still able to change their posture independently after a certain period of time - for example, in the case of haemorrhoids or after operations in the buttocks or genital area.

Air cell pillows are similar to cube pillows. They are divided into small air chambers and thus allow the air to circulate. They are light and therefore easy to transport. The disadvantage of such air cell pillows is that they can feel unstable to the user. In addition, it can be more difficult for the user to move from the wheelchair to the bed or to another chair because the air cell cushion gives way accordingly and may slip. Apart from that, an air cell cushion can also have too little air if, for example, a small hole allows the air to escape. It is also important to always put in exactly as much or as little air as is individually necessary. This is also related to body weight. Anyone who uses such an air cell pillow should therefore be well advised and trained by an expert on how to use it.

There are also so-called "active" air cushions. These dynamic seat cushions are divided into chambers and are battery-operated. They inflate or deflate themselves at different points every ten minutes or so. So as a user you don't have to do anything yourself. It's all automatic. It's very convenient because the pressure is regularly redistributed. However, these pillows are quite expensive. You should also bear in mind that not everyone is comfortable with this automatic redistribution of pressure. If the seat surface changes without warning, this can cause insecurity or even upset your sense of balance. If you use such a dynamic seat cushion, you should be prepared for something to move on the cushion from time to time - even without external intervention.

Gel pads and gel cushions belong to the so-called "soft support systems". The mode of action of these gel pads is based on the assumption that due to a better adaptation of the lying surface to the body, the pressure on critical areas is reduced and distributed more evenly overall. In any case, it is important for you to know that you will still have to reposition yourself regularly in spite of a gel pad in your bed. A gel pad cannot replace repositioning!

There are big differences in the quality of gel pads. Therefore, ask explicitly before purchasing and get precise advice: Where and how often and for how long should the cushion be used? The advantage of gel pillows is that they adapt to the shape of the body and thus increase the surface on which the weight rests. They also have a cooling effect because the body heat is conducted away from the skin. The same applies to gel pillows: balance could be affected. Therefore, try the pillow first. It is also important to smooth out the pillow from time to time - otherwise it will sag.

Alternating pressure mattresses are very practical. Because, like the dynamic air cushion, they change automatically at certain intervals as the air chambers inflate or deflate themselves. These mattresses are a great help for immobile bedridden patients and their caring relatives. There are inexpensive models for a few hundred euros, but they can also cost over 1,000 euros. It all depends on the quality. But remember: a person will lie on this mattress for a long time. Therefore, put comfort in the foreground, because the goal is to let a chronic wound heal or to prevent it. The disadvantage of such alternating pressure mattresses is that the automatically changing pressure conditions can sometimes cause pain. Therefore, always check if everything is OK or if perhaps a leg or an arm should be positioned slightly differently.

Moreover, such mattresses are not suitable for people with disturbed body perception. This is because the permanent movement of the mattress can impair body perception during prolonged use. This means that the perception of the limits of one's own body decreases. The person lying on the mattress can no longer assess where which part of his or her body is currently located in space. This can make communication with the person difficult.

The health insurance fund makes a difference whether a positioning aid or a corresponding mattress is requested for a nursing home resident or a person in home care. Within home care, aids such as bedding rolls are covered by the insurance. However, because bedding aids such as bedding rolls are part of the equipment in nursing homes, they are not paid for for nursing home residents. However: If the doctor issues a prescription for a special positioning aid because it fulfils a specific individual therapeutic purpose, positioning aids for nursing home residents are also covered by the insurance. Soft positioning or alternating pressure mattresses for prevention and generally "aids for the prevention of decubiti" are usually not approved for nursing home residents, because in the nursing home, appropriate positioning should be carried out by the responsible specialist staff.

Only as soon as a pressure ulcer is acute or already being treated does the insurance fund pay for a nursing home resident. The announcement of the GKV-Spitzenverband on this question also states that the insurance company will pay the costs in the case of an imminent pressure ulcer - in practice, an "imminent pressure ulcer" is ultimately an already existing pressure ulcer - because as long as there are still any signs of a pressure ulcer, a corresponding mattress would fall under pure prevention. And this does not imply any obligation to pay benefits on the part of the insurance fund.

In practice, unfortunately, it is often the case in the nursing home as well as in the home environment that it is already too late when a pressure sore is "imminent". By the time an alternating pressure mattress, for example, has been approved by the insurance company, the pressure ulcer has long been there.

Ideally, you can have a medical supply store explain to you individually which prerequisites are necessary for your doctor to prescribe such aids. The experts there know exactly when the health insurance fund will cover which aids and which diagnoses are more likely to cause an application to be rejected.

You can rent alternating pressure mattresses from various providers. Often these mattresses are offered for rent when you order a nursing home bed, for example. You can rent such mattresses by the week, usually there is a flat rate offer for a certain rental period. You can also rent a mattress without a doctor's prescription - but then you have to pay the costs.

Heel pads, heel protectors, heel protectors - all serve the same purpose: to relieve the heel. Heel pads come in different sizes, colours and shapes. The same applies to these anti-decubitus aids: Make sure they are breathable and fit properly according to your weight and size. It is best to go to a medical supply store for advice.

The bottom line is that you are definitely well advised not to experiment with pressure ulcer prevention. Do not try to cushion or support the body with pillows. This can have serious consequences. Not only may your efforts be useless and the pressure ulcer develop anyway, but it may even cause damage to the body elsewhere. If the patient is not positioned correctly, he or she could lie or sit unstably and fall out of the bed or wheelchair. In addition, commercially available pillows are not designed to allow air to circulate and wick moisture away from the body. When it comes to pressure ulcer prevention and treatment, rely only on the advice of professionals and only use your own bedding if you know exactly what to do. Without professional instruction, your efforts will not be successful and may backfire.