Skin considerations in lying

Selecting the right bed and mattress for a person with a spinal cord injury (SCI) can make a significant difference to the risk of acquiring pressure injuries. This section explains how optimal bed and mattress selection and use support skin integrity in people with an SCI.

Mattress selection and monitoring

Pressure-relieving equipment does not eliminate all pressure, or remove the need for regular repositioning and pressure relief. Selecting the most suitable mattress for a person with spinal cord injury (SCI) requires trial and clinical observation. A two-week trial period is recommended to assess its impact on the person’s skin integrity, functional ability and it’s interface with their environment.

• Begin with turning every 2 hours, inspecting the skin at each position change.
• If tolerated, gradually increase time spent in each position.
• If skin concerns arise, reduce the time between turns and continue doing so until a mattress review and change can be completed.
• Ensure the mattress provides adequate pressure redistribution. Assess for areas of high pressure or ‘bottoming out’ by sliding a hand between the person’s bony prominence and the mattress surface.

Positioning in bed

Lying

•  Ideally, keep the head of the bed flat.
• Rotate between different positions that the person can tolerate in bed, such as side-to-side, supine and prone.
• There are added benefits to side-lying, such as a stretched position, to maintain joint range and respiratory function. Side-lying also establishes an alternative lying position, if a skin injury occurs.
• The following are examples of various lying positions in bed, with practical tips for each.

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90-degree hip flexion in supine

This position can provide pressure relief for the ischium, lateral and posterior greater trochanter areas. Always check clearance with any pressure injury after repositioning.

Important tips on this positioning:

• Stack pillows to gain enough height to achieve approximately 90-degree hip flexion.
• Pillows can be placed at the end of the bed to provide support to the pillow ‘stack’.
• Note: this technique doesn’t provide ankle support to prevent foot drop.
• Keep the bed flat to avoid movement of the pillows and pressure to the ischial tuberosities and greater trochanter areas.

Supine positioning

Can provide pressure relief for the lateral greater trochanters. Always check clearance with any pressure injury after repositioning.

Important tips on this positioning:

• Make sure the knees are supported to prevent injury, with a slight knee bend. This can also reduce triggering spasms.
• Elevate the heels off the bed, using pillows, and separate the feet to hip width.
• Use pillows at the end of the bed, to support ankles in a 90-degree position, to prevent foot drop.
• Consider using the knee-bend feature on the bed, when sitting, to prevent sliding down the bed.

Side-lying

Side-lying can provide pressure relief for the ischium, sacrum, coccyx and non-weight-bearing lateral and posterior greater trochanter.

Important tips on this positioning:

• Firmly place two pillows behind the person, to prevent rolling onto their back.
• Separate the medial aspect of the knees with pillows. The top leg can be brought further forward, to prevent rolling back.
• Keep the leg in alignment with the hip.
• For comfort, avoid placing the person directly onto the shoulder tip and provide a ‘cuddle’ pillow in front, if needed.

Side-lying: quarter turn

This lying position can provide pressure relief for the ischium, sacrum, coccyx, lateral and opposite posterior greater trochanters. It works well if the person experiences shoulder pain and cannot tolerate turning onto their shoulder. Always check clearance with any pressure injury after repositioning.

Important tips on this positioning:

This positioning allows the top half to be almost flat. The lower half is rotated to offload the sacral region. To maintain this position, the bed needs to remain flat or with very little head raise.

One pillow is placed behind the person, with a focus on propping the back of the lumbar area/pelvis to prevent rolling into supine.

The leg pillows can be positioned either across, as seen in the side-lying position. Alternatively, two pillows can be placed under the top leg and one under the bottom leg.

Sitting up in bed

• Limit sitting upright in bed to no more than 20 minutes, regardless of mattress quality, due to increased risk of shear and friction.

Use of pillows

• Use pillows to relieve pressure between bony areas (e.g. knees and ankles) in side-lying, and to elevate heels in supine.
• When supine, ensure pillows support the knees to avoid hyperextension

Wedges in Side-Lying

• Consider using positioning wedges to improve comfort and increase tolerance for side-lying

Person’s dimensions

• Height: Bed and mattress lengths can be customised to suit individuals of above-average height.
• Weight: Mattresses have specific minimum and maximum weight limits. Always refer to manufacturer guidelines to ensure suitability and safe pressure redistribution

Bed functions and skin integrity

• Hi-lo function: Facilitates safe transfers by allowing height adjustment for hoisting or seated transfers.
• Knee bend: Helps prevent sliding down the bed.
• Bed accessories: The addition of bed rails and bed ladders can enable a person with an SCI to assist or self-manage repositioning. Overbed rings are not recommended, due to the risk of shoulder injury.
• Size: A wider bed can provide more space, allowing greater flexibility and choice of positions for turning and repositioning. However, other factors will also influence the width of the bed including the person’s bed mobility, access to environmental controls and care support, room circulation space, whether rails need to be within reach, funding and preference for sleeping beside a partner.

Mattress functions

• Comfort: The mattress should optimise personal comfort, addressing temperature regulation, pain management, and motor noise.
• Fowler boost: This feature enhances airflow beneath the seated area when sitting up, helping to prevent ‘bottoming out’. Please note this feature does not eliminate the risk of ‘bottoming out’, always assess this.
• Bed protectors and continence sheets: These can impair the ability of the person to immerse themselves into the mattress, compromising pressure redistribution. Protectors and continence sheets can also increase body temperature and wrinkle under the person, compromising comfort.
• Power supply: Consider power supply options and how this might influence bed and/or mattress selection.

Balancing pressure relief and independence

• The mattress should provide optimal pressure relief while supporting independent bed mobility and transfers. Firmer surfaces may facilitate independence but typically offer less pressure relief.
• Consider whether the person can take their mattress when travelling or if a suitable alternative is available.