art&sciencetissue viability
nursing standard: clinical · research · education
Susan Hawkins MPH,
BSc(Hons), MCSP, is Senior
Physiotherapist in Acute
Rehabilitation; Katharine Stone
Grad Dip Phys, MCSP, is Senior
Physiotherapist in Neurology;
Lisa Plummer Grad Dip Phys,
MCSP, is Senior Physiotherapist
in Respiratory Care.
key words
■ Nursing care
■ Mobility
■ Pressure sores
These key words are based on
the subject headings from the
British Nursing Index.
This article has been subject
to double-blind review.
An holistic approach to
turning patients
Hawkins S, Stone K, Plummer L (1999) An holistic approach to turning patients. Nursing Standard. 14, 3, 52-56.
Date of acceptance: September 10 1999.
Turning patients who are immobile is usually undertaken expressly to prevent pressure
sores. Here the authors highlight some of the other factors that need to be taken into
account when nursing dependent and/or immobile patients.
T
he process of pressure relief in a healthy
individual can be considered a continuous
dynamic activity, with a recognised chain of
events. Pressure leads to tissue ischaemia which
in turn leads to pain, as a consequence of which
the individual moves to relieve the pressure,
blood supply is restored and the ischaemic pain
disappears (Collins 1998). On average, a healthy
individual will alter his or her posture during
sleep every 11.6 minutes (Keane 1978). For
dependent patients, this process of moving to
relieve pressure is not possible; they are reliant
on health professionals to perform this move-
ment for them.
Traditionally this has been achieved with the
two-hourly turn, but increasingly the use of
devices such as alternating pressure air
mattresses (APAMs) are fulfilling this movement
requirement.
The importance of turning
Many papers stress how important it is to turn
patients regularly for their pressure area care
(Alexander et al 1992, Clarke 1997). Most
healthcare professionals understand the benefits
of two-hourly turns and could describe the
physiological causes of pressure sores (Box 1). A
paper by Helme (1994) shows that although
staff had a high knowledge of turning protocols,
they did not turn their patients as regularly as
‘prescribed’.
The main reasons cited for not turning patients
regularly include lack of time, lack of staff (Bliss
1990, Helme 1994, James and Fong 1996) and
may include lack of access to, or knowledge
about, handling equipment. As Dealey (1994)
points out: ‘Given the demands on their time,
nurses are increasingly relying on pressure-
relieving equipment instead of two-hourly
turning to prevent pressure sores.’
Pressure sores develop as a result of two
processes; occlusion of blood vessels by external
pressure, and endothelial damage of arterioles
and micro-circulation by application of friction
and shearing forces (Collins 1998, McLeod 1997).
Traditionally, the relief of pressure and promotion
of circulation has been achieved by regular two-
hourly turning of patients (Maklebust and
Sieggreen 1991). Now that we have a range of
pressure-relieving mattresses, this dependence on
turning for pressure area care has decreased.
Some claim that APAMs take away the need to
turn patients altogether (Collins 1998, Huntleigh
Healthcare AIM 1995).
Other reasons for turning
Is pressure area care the only reason patients
should be turned? Several months ago a physio-
therapist came into the staff room complaining
about the nursing care received by a patient on
an acute ward. The patient had suffered a
cerebrovascular event (CVE) and had developed
what the physiotherapist considered to be a
preventable chest infection.
She discovered that the patient had been left
lying supine for 24 hours a day since she had
been admitted three days previously. When the
physiotherapist enquired about the reasons for
this, she was told: ‘The patient did not need
Box 1. Physiological causes of
pressure sores
INTRINSIC FACTORS EXTRINSIC FACTORS
■ Malnutrition ■ Medication
■ Neurological deficit ■ Moisture
■ Reduced mobility/activity ■ Pressure
■ Increased age ■ Shear
■ Incontinence ■ Friction
■ Dehydration
■ Mental status
■ Skin condition
■ Sepsis
■ Medication
october 6/vol14/no3/1999 nursing standard 51
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nursing standard: clinical · research · education
turning because she was on an airflow mattress’.
For 72 hours this very ill, dependent patient had
been moved for personal care and bedding
changes only. She had been assessed using the
Waterlow scale (1985) and had been deemed at
high risk of developing pressure sores because of
her level of dependence and fluctuating con-
sciousness. Thereafter she was nursed on an
alternating pressure air mattress (APAM), and
subsequently had rarely been moved.
This incident sparked debate among the physio-
therapy staff from all specialties about the partic-
ular problems that they had encountered while
treating patients who were nursed on APAMs.
The various problems that were highlighted pro-
voked us to take the issue further. A meeting was
convened between nursing, therapy and tissue
viability staff in the hospital, which led to stimu-
lating, constructive, but ultimately non evidence-
based discussion.
This article aims to open out and continue this
discussion, and perhaps stimulate research into
reasons for turning patients, other than solely
for pressure area care. In the example described
above, the nursing staff had anticipated one of
the problems associated with a high level of
dependency, pressure area care, but had not
taken into account other possible complications.
Alternating pressure air mattresses
APAMs work by temporarily removing compres-
sive forces on the skin to restore perfusion. They
reduce localised distortion of capillary beds by
sequentially deflating cells. They may also aid
metabolite clearance by stimulating a myogenic
response that causes dilation of the microvascular
and lymphatic systems (McLeod 1997).
Evidence exists describing the effectiveness of
these mattresses for both the prevention and
treatment of pressure sores (Devine 1995, Exton-
Smith et al 1982) and although there is little
evidence assessing their cost effectiveness, they
are now regularly used in the management of
patients at risk of developing pressure sores
(University of York and University of Leeds 1995).
The literature
Little evidence or information could be found in
the literature specifically discussing the other
advantages of turning patients. Papers that
described the importance of turning for pressure
area management did not describe other physio-
logical or psychological benefits. Lack of informa-
tion in the literature about these other effects
may in part be to blame for the lack of knowledge
among staff of the value of turning patients. This
might mean that patients are not receiving the
best standards of care that should be offered to
them. Outlined below are some reasons to turn
different case-mix groups, but many of the
themes are common to all.
52 nursing standard october 6/vol14/no3/1999
Neurological factors
Disease or damage to the central or peripheral
nervous system can lead to temporary or even
permanent physical, cognitive and psychological
problems. If the person is unable to move, he or
she is deprived of the physical benefits of move-
ment including:
■ Sensory-motor appreciation.
■ Posture and balance control.
■ Maintenance of joint and soft tissue range of
movement (thus preventing contractures).
■ Maximisation of functional independence.
■ Minimisation of tonal changes, such as spasticity.
From a psychological perspective, dependency
can lead to behavioural problems such as with-
drawal, and there is a need for regular contact
and interaction to provide opportunities for ori-
entation, socialisation, and communication (Table
1). In the unconscious patient, regular contact
and stimulation is recommended to increase the
patient’s awareness of self and the environment.
All healthcare professionals handling a dependent
patient should, of course, explain their actions to
them, so that an appropriate response can be
stimulated.
Effective postural management in the acute
stage of any disease that challenges motor or pos-
tural ability, can enhance and reinforce recovery of
function in those with the potential for this (Pope
1996). From an holistic perspective, the patient
will benefit from regular turning and careful posi-
tioning. This will not only prevent secondary com-
plications developing, but will also promote
recovery (Edwards 1996).
Importance of positioning
Several papers caution against turning a patient
to 90º because of the increased interface pressure
that this puts onto the bony prominence of the
greater trochanter (Colin et al 1996, Holmes
1997, Wind et al 1997). For many neurological
patients, particularly those who have had a CVE,
this is an important position for the control of
muscle tone. If patients are well positioned, it
allows them to feel support with their non-affected
side and gives them visual cues from seeing them-
selves on a bed. It also gives them access to visual
information about their upper limbs, as well as
the ability to interact with visitors and to see what
is happening on the ward around them.
If patients are positioned safely and comfortably,
they should be able to move with minimal effort.
This will limit the stress of movement that can
contribute to the development of spasticity. The
person in Figure 1 has been positioned in ‘for-
ward lean side-lying’ which involves turning a
patient to just forward of 90º. It requires careful
attention to positioning, including weight for-
ward off the greater trochanters and good sup-
portive surfaces (for example pillows supporting
anterior and posterior trunk, legs, and arms, as
well as the head) to increase surface area in
art&sciencetissue viability
nursing standard: clinical · research · education
REFERENCES
Alexander C et al (1992) Creating the
optimal environment for pressure
area care. British Journal of Nursing.
1, 15, 751-757.
Bliss M (1990) Geriatric medicine. In
Bader DL (Ed) Pressure Sores: Clinical
Practice and Scientific Approach.
Basingstoke, Macmillan Press.
Clarke G (1997) The problem of
pressure sores and how to treat
them. British Journal of Therapy and
Rehabilitation. 4, 11, 589-595.
Closs SJ et al (1993) Pain in elderly
orthopaedic patients. Journal of
Clinical Nursing. 2, 41-45.
Colin D et al (1996) Comparison of 90º
and 30º laterally inclined positions in
the prevention of pressure ulcers
using transcutaneous oxygen and
carbon dioxide pressures. Advances
in Wound Care. 9, 3, 35-38.
Collins F (1998) Seated Patients: Clinical
Perspectives. Chertsey, Hayden
Advertising.
Davies P (1994) Starting Again. London,
Springer Verlag.
Dealey C (1994) A prevention and
management aid: evaluation of the
Nimbus II mattress. Professional
Nurse. 9, 12, 798-804.
Dean E, Ross J (1992) Oxygen transport:
the basis for contemporary cardiopul-
monary physical therapy and its
optimization with body positioning
and mobilization. Physical Therapy
Practice. 1, 4, 34-44.
Devine B (1995) Alternating pressure air
mattresses in the management of
established pressure sores. Journal of
Tissue Viability. 5, 3, 94-98.
Edwards S (1998) Physiotherapy
Management of Established
Spasticity, Spasticity Rehabilitation. G
Sheean, Churchill Communications
Europe.
54 nursing standard october 6/vol14/no3/1999
Table 1. Reasons to turn neurological patients
PROBLEM REASONS TO TURN
Sensory disturbance Promotes sensory awareness/appreciation including body image and
perception (Grieve1993, Langdon 1996, Siev and Freistat 1986)
Altered muscle tone Minimises spasticity by frequent change of posture and support
(Davies 1994, Edwards 1998)
Risk of aspiration Promotes safer swallowing with specific positioning (Ray 1985)
Minimises respiratory complications (Hough 1984)
Movement disturbance Promotes effective movement with concurrent responses throughout
the body and stimulates appropriate balance responses and function
(Edwards 1996)
Pressure care is maintained (Alexander et al 1992, Holmes 1997, The
Stroke Association 1996)
Functional posturing of the limbs promotes recovery and maintenance
of joint and muscle length (Edwards 1998, Pope 1996)
Bladder and bowel Essential for incontinent patients to prevent moisture
dysfunction accumulation which is a major contribution to the development of
pressure sores (Clarke 1997, Grundy and Swain 1996)
Perceptual problems Stimulates orientation to the environment and body image awareness
through the senses (Grieve 1993, Langdon 1996, Siev and Freistat
1986)
Behaviour and cognitive Stimulates socialisation, memory, and appropriate behavioural
problems responses (Grieve 1993, Langdon 1996, Siev and Freistat 1986)
Stimulates language and communication skills through learned
behavioural responses (Grieve 1993, Langdon 1996, Siev and Freistat
1986)
contact, thereby decreasing the interface pres-
sure on the greater trochanter. This allows for the
three main elements of positioning: safety, com-
fort and movement facilitation.
Respiratory factors
As well as for the management of patients with
neurological conditions, a regular change of posi-
tion is essential for patients at risk of developing
pulmonary complications, or those already suffer-
ing from chest complaints.
Regular turning enhances the reduction of the
incidence of pulmonary infection and the devel-
opment of sepsis (Gentilello et al 1988). The
movement from the supine position to side-lying
has numerous physiological advantages. Body
position changes enhance oxygen transport due
to the effect of gravity on the distribution of ven- Fig. 1. Pillow-supported forward lean lying
tilation and perfusion throughout the lungs
(Dean and Ross 1992). This alteration in the (Dean and Ross 1992).
areas of dependent lung tissue has preventative Sepsis decreases the body’s ability to withstand
and treatment advantages that help ensure that pressure insults by increasing metabolic demand.
problematic lung areas do not develop. Altering It increases systemic oxygen requirements, making
chest position is thought to redistribute and the skin more susceptible to pressure by affecting
mobilise mucus and interstitial fluid from depen- oxygen supply to the skin (Colin et al 1996). A
dent lung areas, which helps to prevent the chest infection is a major cause of sepsis, so turning
development of atelectasis within these areas to prevent a pressure sore could also prevent a

chest infection, which could also prevent a
pressure sore.
Pape et al (1998) studied patients at risk of
developing adult respiratory distress syndrome
(ARDS) following traumatic injury. Those patients
receiving early positional changes on a regular
basis showed a reduced incidence in the develop-
ment of ARDS, improved systemic oxygenation
and overall improved survival.
The use of prone ventilation, where the patient
is nursed face down, is a well known treatment in
the management of ARDS. It has been shown to
improve worsening hypoxia resulting from alveoli
filled with watery exudate and increasingly non-
compliant lungs. The alteration of body position
allows the affected lung tissue to aerate because
gravitational forces are altered. This has been
demonstrated with CT scans before and after the
initiation of prone ventilation (Gattinoni et al
1991). These findings reinforce the need for regular
turning of dependent patients at risk of developing
pulmonary complications.
The cardiovascular system is also influenced by
the effects of regular turning. Positioning serves
as a treatment adjunct if mobilisation is not pos-
sible. Changing body position has a greater effect
on the cardiovascular activity than maintaining a
static position (Dean and Ross 1992). This exercises
the cardiovascular system to benefit the patient at
a later stage in recovery.
Musculoskeletal factors
Orthopaedic patients, particularly those who go
on to have an operation, are at high risk of devel-
oping pressure sores. Versluysen (1986) found
that 66 out of 100 patients developed pressure
damage following fractured femur. Particular
problems exist for those on traction or for whom
turning jeopardises their operation site.
These patients are at risk of developing compli-
cations such as:
■ Osteoporosis.
■ Homeostasis and dependent oedema – which
can lead to swollen limbs or deep vein throm-
boses.
■ Deep vein thrombosis – which can lead to
embolic CVEs or pulmonary embolism, with
associated risk of death.
Other problems can include contractures and pos-
tural impairment, such as shortened Achilles ten-
dons or joint fixed flexion deformities, which can
lead to diminished proprioception and altered
balance mechanisms (Nichols 1981).
Discussion will be required with the orthopaedic
surgeons, but any permitted position change will
help diminish these risk factors. The Guide to
Handling of Patients; Introducing a Safer
Handling Policy (Holmes 1997) gives recommen-
dations on how these patients can be safely
moved.
Pain is an important factor contributing to
immobility in the post-operative period for
patients allowed to mobilise. For these, effective
art&sciencetissue viability
nursing standard: clinical · research · education
analgesic management will enable early mobili-
sation, decrease risk factors and expedite
discharge (Closs et al 1993, Hunt 1995). Patients
immobilised following burns encounter similar
problems.
Vascular factors
For patients with vascular problems, such as
amputation, graft surgery or those confined to
bed because of the pain of critical limb ischaemia,
position changes are essential. They can prevent
the development of contractures and assist in the
control of oedema.
Oedema management is essential for amputees
and graft surgery patients to prevent wound
breakdown or delayed healing, which can impede
rehabilitation. This may result in muscle
weakness, decreased tolerance of the upright
position, poor balance, delayed use of the
pneumatic post-amputation mobility (PAM) aid
and delayed fitting of the prosthesis. This delay
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Treatment: Neurological
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october 6/vol14/no3/1999 nursing standard 55
art&sciencetissue viability
nursing standard: clinical · research · education

Fig. 2. Spiral of dependence

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■ Musculoskelatal, eg, DVT
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services and Research and Overview tors associated with movement, shearing and regular turning of patients (Dealey 1994). This can
with Recommendations for Future friction to aid in pressure sore prevention. potentially lead to the development of other, non-
Research. London, The Stroke
Association.
Patients should, within their own capacity, be pressure related complications. This article has out-
University of York, NHS Centre for encouraged to assist with position changes. This lined some of these potential complications and
Reviews and Dissemination; reinforces independence and aids in the preven- hopefully stimulated thought about reinstating reg-
University of Leeds, Nuffield Institute tion of secondary complications resulting from ular turning in the management of immobile or
for Health (1995) The prevention and
dependency. dependent patients.
treatment of pressure sores: how
effective are pressure-relieving Some evidence exists, from a variety of speciali-
interventions and risk assessment for ties, to encourage the use of regular changes of
the prevention and treatment of Conclusion position for reasons beyond the prevention of
pressure sores? Effective Health Care. pressure area problems. We possess the ability to
2, 1, 1-16.
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Sufficient resources (including available equip- prevent some of the respiratory, neurological and
patients with femoral fracture develop ment and staff) and ongoing education are vital musculo-skeletal consequences of enforced
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a reasonable approach? Ostomy/ spiral of dependence and putting them onto the
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alternating-pressure replacement
Pressure sores are a serious but largely preventable
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7, 7, 409-412. morbidity and mortality (Clarke 1997). Pressure-

56 nursing standard october 6/vol14/no3/1999