Chapter 15: Positioning and Activity

positioning:

________supine

________prone

________turn side to side

________abduct ________________

________elevate extremities _____________________

________hEAD OF BED elevated

________neck hyperextended

________no pillows behind head with ear or anterior

             neck burns

activity:

________bedrest

________OUT OF BED in chair ___________

________walking _________________________

________OUT OF BED ad lib

________ace wraps for lower extremity burns

I.          POSITIONING

A.   Positioning is necessary for successful burn rehabilitation. It minimizes formation of edema, prevents tissue destruction, and maintains soft tissues in a lengthened state to facilitate recovery.    There is a popular adage, “the position of comfort (the fetal position) is the position of contracture.”  Indeed, patients should be positioned in a direction that opposes comfort, as these positions often favor contractures, especially around joints and flexor surfaces.  Table 1 lists correct positions for burn patients.

Table 1

1.          Edema develops within 8 to 12 hours after the burn injury and peaks at 36 hours.  A fixed deformity results if edema is not reduced in the first 2 days, with increased calcification and bone density also possible.[ii]^,[iii]

2.          Extremities should be elevated above the level of the heart using pillows, blankets, and towels.  The elevation should be maintained while the patient is lying, sitting, or ambulating.  Lower extremities should be elevated when the patient is sitting.

B.          Supine

Most patients will be placed in the supine position in bed initially. 

C.          Prone

Patients who do not have endotracheal tubes or central lines may be placed prone to avoid pressure to posterior areas if necessary and there is a significant burn wound unresponsive to a therapeutic bed.

D.          Turn side to side

Patients with burns to the sacrum or buttocks should be turned from side to side to prevent the development of sacral pressure sores and to minimize discomfort from pressure on burns to these areas. 

E.          Adduct

Patients with axillary burns will tend to posture their shoulders in adduction and internal rotation.  The shoulder should, therefore, be abducted and externally rotated.  Foam wedges, splints and/or pillows can be used to achieve this goal. 

F.           Elevate extremities

                        Any burn to an extremity should be elevated as discussed above.

G.          Head of bed elevated

Patients with burns to the face and neck should have the head of bed elevated to at least 30 degrees to facilitate drainage of edema. 

H.          Neck hyperextended

Anterior or circumferential burns of the neck predispose patients to neck flexion contractures.  To minimize this the neck should be placed in as much hyperextension as tolerated. This can be accomplished using a foam cervical collar, avoiding use of pillows and by placing a roll under the neck. 

I.       No pillows behind head with ear or anterior neck burns

Pillows are also avoided with burns to the head that include the ears to prevent the development of chondritis.  Instead, a foam or gel-filled donut is useful. 

II. Activity

A.    Bedrest

Patients with major burns or burns to the lower extremities should be maintained initially on bedrest with elevation of the affected extremity to decrease edema.

B.            Out of bed in chair

Patients may be up to a chair as long as the affected areas can be elevated in proper position while the patient is sitting.  Patients who are able to sit in a chair should do so at least twice daily. 

C.          Walking

Any patient who is able to walk should do so at least twice daily, with the exception of burns to the lower extremities.

D.          Out of bed ad lib

Patients with small burns who are able to maneuver themselves in an out of bed without difficulty may leave the bed and ambulate as desired. 

E.          Ace wraps for lower extremity burns

Because of the propensity for lower extremity burns to develop edema, the placement of ace wraps along with elevation can aid in reducing pooling of fluid in the legs and feet.