We report the case of a 52-year-old patient of Palestinian origin, professional cook, right-handed, admitted to the Rehabilitation Unit from ICU after undergoing surgery, with right internal carotid hemicutaneous haematoma for evacuation.
The length of stay is prolonged for months due to several complications (paralytic ileus, renal disorders, respiratory infection, etc.), being even more important the application of these measures for prolonged bedding.
Personal history: no known drug allergies.
Diabetes mellitus type II for 26 years in treatment with oral antidiabetics.
Hypercholesterolaemia, hypercholesterolaemia.
Important toy.
Do not drink alcohol.
Establishment
• A score of 7 is obtained on the grading scale, which translates into very high (maximum) risk of suffering from PU.
• Presents an overall muscle balance of 5/5 according to the Kendall scale (8) in the right hemibody and 0/5 overall in the left hemibody (strength deficit in this hemisphere without objectifying contraction).
• Joint balance is in the right hemisphere, while there is joint limitation to the last degrees of wrist extension, last degrees of flexion and extension of the right hand and small dorsal metaflection, as well as the dorsal metaphalangeal rotation.
The left hemibody is edematous.
This edema, together with the maintained positions, can further limit the joint range.
Acquired ethically in the treatment of the case, obtaining informed consent from the patient's family to perform the photographs and publish them.
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Observation-development of the care plan
To achieve the objectives, different positions in which the bedridden patient usually occurs were taken into account: supine position, lateral decubitus on one side and lateral decubitus on the opposite side.
In these different positions, severity acts differently, taking into account the specific points most vulnerable in each of them.
Each of these positions is detailed below, as well as the different clinical corrections suggested, using materials of easy location (sands, towels, etc.) so that they can be affordable in the field
Postural hygiene of the patient in supine position
It is important to consider a number of key points in relation to postural hygiene that took place in this case.
Cranial analysis caudally.
Head
It is observed that many of these patients keep their head turned to the healthy side due to imbalance of the neck muscles.
In this case, the patient tends to keep his head to the right, being corrected more e.g. neutrally towards the side and maintaining correction by means of a right wedge-shaped roller.
This would favor the re-education of balance on the muscles of the neck, avoiding PU in the ear.
If there was a risk of PU in the occipital region by maintaining this posture, the head could be turned to the left to counteract the tendency shown by the patient and avoid support on the occipital region.
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Male
The position of the limbs at the distal level (hand and foot) is usually excessively corrected when the limb is really misaligned proximally, the most distal part shows all compensation of the limb.
The shoulder is the most mobile joint and to allow this is also the most inconvenient, so much of its stability depends on the reinforcement performed by the muscles.
In the case of this patient, the left shoulder presents marked muscle weakness, so there is a very high risk of suffering a subceiver of the shoulder due to the maintenance of forced positions in an anatomical position that was ligament.
In addition, the sensory-conceptive deficit that presents makes them not aware of these extreme positions at first, and thus cannot modify them or ask for help to do so.
Therefore, it is essential to monitor this position, as well as a correct action not to execute abrupt or hidden movements that lead the articulation to an extreme position.
When the patient is in the supine position, the weight of the patient is displaced to the left, which can cause an increase in pressure at this level that can force the joint, so it should avoid this incorrect positioning.
(9) In this sense, we propose to place a pillow under the plejiccal scapulae, which corrects its position and allows the arm to be extended in a correct and elevated position, i.e. with the back
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A roller under the hand would carry the wrist to extension, keeping it in a more functional poition and avoiding the tension of the circulatory system at this level, thus reducing the risk of hand inflammation.
An antiedema position of the entire upper limb that would favor the return circulation could also be adopted.
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There is a tendency of the shoulder to rotate internally, so it is important to alternate this position with the placement of the shoulder in external rotation.
It is recommended that the arm is placed in external rotation, with 30° position and forearm-hand extension (10).
In this case, wrist and fingers should not be forced because extension of the deformity would increase at this level, but we would rather expect it to be surrendered.
No balls or similar objects should be attached to tightly close the hand, as it will favor "garding hand" by spastic flexion of the fingers (11).
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Chain
Regarding the position of the hip, it would be necessary to correct the tendency to external rotation that favors prolonged supine position.
A roller made with a sheet or towel pointing to the left thigh in its external part with the hip corrected in neutral rotation could be used; this would not be useful to place this thigh laterally.
In turn, the pelvis has to be corrected so that it is not tilted to the left, preventing prolonged support on the left trochanter and avoiding PU at this level.
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Another option would be to position the hip and knee in flexion, with support of the foot, with the help of a double pillow that would rest on the side rail of the bed to avoid falling down the gravity of the external rotation.
A pillow under the foot would facilitate the dorsal flexion of the foot and would give him such important sensations of load for the subsequent march.
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Rodilla
A widespread practice for the prevention of PU in the heel is placing a pillow under the pamphlet.
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It is true that in this way the heel would be free of support, but as seen in the image, an elevation at this level would cause progressively that the knee would be left without overcoming a hyperexic lesion and obviously associated to a knee.
Therefore, it is important to place the pillow or rod in a middle position between the ankle and knee, so that the heel is not supported, but the knee slightly rests in a semi-flexed position.
To avoid knee flexion, this position can be alternated with total support of the lower limb by placing protectors on the heels, as it is convenient not to prolong the positions maintained.
Foot
As observed in the magnet, the foot tends to fall in favor of gravity adopting the posture called equine foot.
In order to avoid this maintained position and until it reaches the posterior aspect of the twin muscles, it would be convenient to place a semi-rigid mechanism (high density gums), as a simpler pillow would favor a rigid appearance.
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Postural hygiene of the patient in lateral decubitus
Contrary to what one might think, the lateral decubitus position is very beneficial for the patient, as long as the patients remain placed in an anatomical position without leading them to extreme degrees of body and distributing the weight.
It is important to perform a complete lateral decubitus position, not only a lateral semi-decubitus that leaves the patient in an intermediate position between lateral decubitus and supine decubitus.
The latter is very common in the hospital environment when postural changes are made, and would be practical to change the patient's support zones on the bed, but it would be important to take the patient to broad joint positions that would otherwise be difficult to maintain.
Having regard to the type of decubitus we use, we can obtain different benefits, so we briefly describe both.
Lateral over the right side (healthy side)
As for the left upper limb (affected), a pillow is placed under it to prevent the arm from falling into a bad position, as if the patient could reach the extreme position on the right upper limb, although we could move it.
The left lower limb is placed in flexion of the hip and knee on a pillow, while the right lower limb is kept in extension of the hip, as this would be a difficult position to keep the patient wheeled bed sitting in other positions (12).
A pillow may be placed on your back to help you keep your lateral decubitus position, to prevent the severity from moving little by little to the supine position (if the patient is conscious and can be cooperative holding up a brief job).
It is important to place a pillow under the head, as the patient would tend to lean too far to the right, and if we do not put severity on it, this trend would potentiate.
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Lateral over the left side (affect)
The position would be similar to the previous one, but on the contrary, taking into account certain aspects.
the left arm should be extended; in this case there should be no
