Prevention of Pressure Ulcers through Repositioning

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Table of Contents








Eligibility criteria 7

Types of studies 7

Types of participants 8

Types of interventions 9

Types of outcome measures 9

Primary Outcomes 10

Secondary Outcomes 10


Methods of the Review (data collection process): 10

Assessment of methodological quality 11

Data extraction 11

Repositioning 11

Pressure Ulcers Status 12

Data synthesis 12


Description of the selected studies 13

Methodological quality 13

Results of individual studies 13

Tuning and repositioning 13

Effective Positions for Repositioning 14

Effective Together 15


Limitations 15

Conclusions 16

Implications for practice 16

Implications for research 16



A systematic review on the effectiveness of turning and repositioningin the prevention of pressure ulcers in the geriatric population.


This study will investigate the relationship between turning andrepositioning and the prevention and management of pressure ulcersamongst geriatric population.


Pressure ulcers are caused by unrelieved pressure and friction ofskin to bony prominences and it may occur in any healthcare setting. Despite preventive measures being done, its occurrence is stillwidely observed and is most commonly associated with elderly patientsand in patients in intensive care. Different modalities are currentlyemployed with the primary goal of preventing pressure ulcers, and oneof this interventions is regular turning and repositioning. There isan abundance of literature on pressure ulcer interventions, howeverthere is insufficient studies done to determine the effectivity ofturning and repositioning regularly and its role in the prevention ofthe development of pressure ulcers. This systemic review would liketo evaluate the effectiveness of turning and repositioning indecreasing the incidence of pressure ulcers in geriatric population.(Reddy, 2010)


  1. What is the most effective repositioning position for preventing pressure ulcer?

  2. What is the most effective repositioning schedule for preventing pressure ulcers?

  3. What is the utmost effective positions that promotes the prevention of pressure ulcers in adults within any healthcare facility?


The primary intent of this systematic review is to evaluate theeffectiveness of regular turning and repositioning in preventing thedevelopment of pressure ulcers. Therefore this research will assessthe various preventive interventions through the use of repositioningto decrease incidence or severity of pressure ulcers. Additionallythis research will review the evidence and previous researches on therisk-assessment scales for identifying prevalence rates of pressureulcers amongst the geriatric population.

The objectives of this review are categories into three majorsub-units. This research therefore aims to

  1. To assess the impacts of repositioning on the prevention of pressure ulcers in adults of sixty five years and above

  2. To establish the most operative repositioning schedules that would be efficient for the prevention of pressure ulcers.

  3. To ascertain the utmost effective positions that promotes the prevention of pressure ulcers in adults within any healthcare facility.


Pressure ulcers are pressuresores, decubitus ulcers and bed sores that are caused by pressure,rubbing or friction that occurs at the weight-bearing bony points ofthe body. These joints can include the hips, elbow, and heels amongstother regions. Characteristic of&nbsppressureulcer&nbspislocalised injury to the skin or original flesh (Rich et al.,2011). The injury&nbspoccurmostly over bonyprominence that upshots from pressure or shearing, or a combinationof both. The elderly have been faced bythe common problem of Pressure Ulcers which is a complication that iscaused by the immobility amongst these group of the population. Thosewho suffer from the condition of pressure ulcers are likely toexperience pain that is associated with general suffering (Kleckner&amp Sparks, 2007). Patients of pressureulcers also spend a lot of financial expenses in treating andmanaging the condition. Pressure ulcers has hence remained a majorproblem that most of the elderly have been faced within over thepast.

Research has continued to grow regarding thedifferent mechanisms that can be used for the management andelimination of pressure ulcers yet no solid or promising results havebeen found. The above follows the fact that pressure ulcers hasalways been in existence since long ago. Medicare reduced thereimbursements given to hospitals for treatment pressure ulcers(Junkin, 2011). The above was based onthe discovery that pressure ulcers is an easily preventablecondition. The Medicare assumed that pressure ulcers cannot developon patients that receive proper and monitored care from practitionerswith healthcare facilities. However, despite the wide range ofrecommendations provided on the management of pressure ulcers, theeffectiveness of these recommendations has not yet been wellestablished in relation to the prevention of pressure ulcers (Deflooret al., 2013).

As explained above, pressure ulcers is majorlycaused by immobility amongst patients. Therefore, increased mobilityis a strategy that is essential for the prevention of pressure ulcersamongst elderly patients (Cooper, 2013).Repositioning is an essential aspect that can be used for theprevention and the treatment of pressure ulcers. Additionally,repositioning has been recommended by various medical institutions tobe an effective preventative measure for the condition (Gillespieet al., 2014). Due to thepromising possibility of the prevention of pressure ulcers, thisstudy systematically reviews the evidence on the use ofrepositioning techniques as a preventive interventions to reduceincidence or severity of pressure ulcers (Krapfl &amp Gray, 2008).

RESEARCHMETHODSEligibility criteria

Eligibility criteria used in this study will consider all trialsand studies using random distribution of individual adult patients inhospital or long-term care within two or more substituteinterventions for pressure ulcers prevention. This study willfurthermore include cluster-randomized trials, irrespective of thecluster group. Studies that involved cross-over trials andquasi-randomized studies will be considered ineligible.

Types of studies

The essential review of health economic evidence will comprisecomparative economic evaluations that will be full and partial andconducted within the framework of eligible RCTs. Moreover, theresearchers used will as well include RCTs reporting more incompleteinformation (Craig, 2009). This review will consider studies that areonly health economics and are conducted alongside efficacy studiesincluded in the efficiency constituent of this review.

The step of study used in thisresearch will be systematic review study. The systematic review willhence focus on a clinical topic on the different methods for reducingpressure ulcers amongst the elderly. The research will answer aspecific question through paying in-depth attention on the use offrequent repositioning of clients and patients within healthcarefacilities. An all-encompassing literature search will be conductedto identify studies with sound methodology that can hence providesolid results for this research. The studies will afterwards bereviewed and assessed for quality. The results retrieved form theanalysis of the literatures will afterwards be summarized accordingto the programmed criteria of the review question.

Types of participants

The criteria that will be used for considering types of people thatwill be included in this systematic review study will besatisfactorily broad and will incorporate all the possible diversityin the topic of the study. Any adult admitted to any healthcare orlong-term care setting, will be eligible (Layder &amp Ayello, 2013).The broad population and setting of interest will be of significancein providing the specific definition of the type of participantsexpected within the study. The important characteristic that willdescribe the participants that will be analysed form the previousresearch will be presence of cases of pressure ulcers and the attemptto prevent and manage the situation through the use of frequentrepositioning (AHRQ, 2013). The participants will be of sixty fiveyears and above without consideration of any other demographicfactors of the participants.

The settings that will be required for the research will be withinhospitals, healthcare facilities, and nursing homes, aged homes, outpatients and any other medical facility or institution that theelderly exists in. the parties that will be making diagnosis with thestudies being reviewed will involve the nurses, medical clinicians,care givers and any other medical practitioner that will be dealingwith the elderly and the prevention and management of pressureulcers. The review will only concentrate on researches that involvethe elderly. Therefore, patients suffering from pressure ulcers andare below the age of sixty five years will not be included in thereview. Studies that only involve a precise subgroup of theparticipants being handled will be included to the detailed subsetfor the study.

Types of interventions

This research anticipates that this research will likely makecomparisons on the repositioning regimens with other varied standardpractices for the prevention of pressure ulcers or even withsubstitute repositioning schedules (Craig, 2009). Therefore, thisresearch is likely to include studies that evaluating the followingcomparisons.

  1. Assessment of comparisons between the frequencies of repositioning.

  2. Assessment of comparisons between diverse positions for repositioning.

  3. Assessment of comparisons of the repositioning regimen with standard practice.

Types of outcome measures

Reliability and validity are essential characteristics that arerequired form outcome measure of any research. Outcomes ofinterventions are significant for physicians, patients, researchcompanies, payers and regulators. Therefore, outcome measures will beclinically essential and meaningful for gauging the advancementtowards the management and prevention of pressure ulcers (Krapfl &ampGray, 2008). Outcome measures therefore involve primary and secondaryoutcome measures.


The proportion of new pressure ulcers of any grade, stage or categoryusing previously defined criteria (Agency for Healthcare Research andQuality 2013 Institute of Healthcare Improvement 2015Velentgas,&nbspDreyer &amp&nbspWu, 2010) or neverthelessdemarcated by the trial authors, anywhere on the body followingrecruitment into the study.


Health-related quality of life (HRQoL) assessedthe impact of disease and treatment on the lives of patients andclients. The HRQoL outcomes assessed the feedback that clients ormedical practitioners in charge of the patients gave regarding theadvancements, management and prevention of pressure ulcers (Granger&amp Kishner, 2010). For this randomisedstudy, HRQoL is an effective outcome measurement technique. HRQLrepresentee the patient`s overall perception of the outcome ofpreventative measure for the illness (Mallah, Nassar &ampBadr, 2012).

SEARCH STRATEGY AND INFORMATION SOURCESMethods of the Review (data collection process):

&nbsp CochraneWounds Group, MEDLINE, EMBASE wereused for the research to identify relevant randomized controlledtrials (RCTs). The controls trial will be through the use of frequentmovement to prevent and manage pressure ulcers on elderly patients.UMI Proquest Digital Dissertations, ISI Web of Science, and CambridgeScientific Abstracts will additionally be searched. All the searcheswill use the terms&nbsppressureulcer,&nbsppressuresore,elderlybedsores,&nbspbedsore,prevention,&nbspprophylactic,&nbspreduction,&nbsprandomized,and&nbspclinicaltrials.Bibliographies ofidentified articles will be further reviewed to ensure that theextracted information are authentic and will provide elaboratereports and feedback on the research.

Assessment of methodological quality

This research ensured that the studies used in this research were themost effective for this study by assessing studies using the ad hocdata extraction form. This form was developed by taking intoconsideration reports that have already been published on the qualityassessment of trials included in systematic reviews. For each andevery systematic review this study looked for general information onthe articles and the studies on the topic of study. Evaluation onwhat the others said was afterwards made. The review was therefore ofthe best quality for this research.

Data extraction

The research had three review authors who independently assessed andevaluated all titles and abstracts of studies retrieved fromsearching. All hypothetically relevant trials will have their fullreports retrieved for further assessment of eligibility based on theinclusion criteria. Differences of judgement will be determined byconsensus or referral to a fourth review author. The research willrecord reason for exclusion of any research. Additionally, thisresearch will not blind study authorship.


Repositioning and turning is anaspect that proved to provide mixed results from the retrieved data.The data extraction discovered that there is no strong optimumrepositioning or turning frequency in bed. The retrieved data hadevidence that suggested for the avoidance the 90°&nbsplateralposition due to the high pressures and hence risk of pressure ulcers(Peterson &amp Graveinstein, 2013 Collins, Kleckner &ampSparks, 2015 Cooper, 2013 Rich et al., 2011 Gillespieet al., 2014). Theevidence from the extracted data does not have specific andconclusive guidelines that they support on repositioning. However,30° inclined lateral position has been suggested and the postefficient degree of positioning and repositioning patients to preventpressure ulcers.

PressureUlcers Status

With the proper inclined positioning and positioning frequency of thepatients, the data extracted was able to indicate that the mostpatients are likely not to contract pressure ulcers (Mallah, Nassar &ampBadr, 2015 Layder &amp Ayello, 2013 Kleckner &amp Sparks, 2007Defloor, 2013). However, pressure ulcers is still contractible if therepositioning frequency is not as per the recommendable frequency. With the right intervention, the presence and stages of pressureulcers was determined at each study visit through the necessaryexaminations of wounds on the skin within the whole-body.

Data synthesis

Varied randomized control trialsand researches on preventative measure against pressure ulcers willbe selected. This will ensure that as much varied and in-depthinformation is gained form the sources that shall have been selected.The interventions that will be assessed in these studies will begrouped into three categories (AHRQ, 2013).The groupings will be of those addressing impairments due to mobilityand immobility, impairments due to poor nutrition and the impairmentsdue to poor skin health. The methodological quality for the RCT andthe preventive intervention on the ways of minimizing and preventingpressure ulcers will be of different variables and hence largelysuboptimal. Operative approaches that will address impaired mobilitywill involve the introduction and the utilization of supportsurfaces, mattress overlays on operating tables, and specialized foamand specialized sheepskin overlays (Reddy,Gill &amp Rochon, 2006).Additional approaches that will evaluated that will be addressingmobility will involve the assistance form nurses and medicalpractitioners on clients to ensure and promote frequent physicalmobility and repositioning. While repositioning is a mainstay in mostpressure ulcer prevention protocols, there is insufficient evidenceto recommend specific turning regimens for patients with impairedmobility (Junkin, 2011).Effects of dietary supplements on the prevention of pressure ulcerswill also be analyzed on patients that will be having nutritionalimpairments. The benefit of moisturizers will also be analyzed inrelation to repositioning for patients that have impaired skinhealth.

REVIEWRESULTSDescription of the selected studies

Studies authored by Gilliepie et al. (2012, 2013, 2014), Groah(2015), Krapfl and Gray (2008), Peterson and Graveinstein (2013) andReddy, Gill andRochon, (2006), has used the systematic review of data withinhis research. Through this sources, the research discovered that thecurrent evidence in the research claims that proper support surfacesis required for recommended repositioning of patients in order tominimize the chances of contraction of pressure ulcers. Experimentalresearches such as Kallamn (2015), Layder and Ayello (2013) and Richet al., (2011) amongst other experimental researches used in thestudy also were able to extract data that linked repositioning tospecific positioning techniques in order to prevent occurrences ofpressure ulcers amongst patients.


The methodologies used in the data sources of this research indicatesubstantial quality for this research. Most of the data sources inthis research are either systematic reviews or experimentalresearches. Most of the data sources used have independent andcontrol variables and as a result have been able to provide authenticfindings for the research topic. Authors within this research eitherused risk assessment tools, trained personnel and analysis of thereviews form the past. Therefore, most of the interventions used forthe articles were effective for finding the most effective methods ofprevention of pressure ulcers.

Results of individual studiesTuning and repositioning

The initial findings in this review specified that there wasnegligible statistically noteworthy evidence that proved that turningand repositioning amongst pressure ulcers’ patient as frequent aswithin every two to four hours is operative in the prevention ofpressure ulcers. The article by Gillespie et al. (2014) specifiedthat increasing the frequency of turning and repositioning within theduration of two to four hours was not substantial in the reduction ofpressure ulcers. Hitherto another article initiated that there was noimportant difference in the turning and repositioning intervals inthe decrease of pressure ulcers (Groah et al., 2015). Rich et al.,(2011) on the other hand discovered that frequent repositioning andturning with two and four hour interval could not decrease the rateof pressure ulcers amongst the elderly patients. Conversely, frequentrepositioning and turning is still needed amongst patients thatsuffer from pressure ulcers or patients that are susceptible topressure ulcers (Collins, Kleckner &amp Sparks, 2015). Therefore,the question on how frequent repositioning and turning amongstpressure ulcer patients is a preventative measure still remainsunanswered. The finding solely calls into question how effective T&ampRis at preventing PUs. Supplementary studies are still required in thefield in order to determine the best repositioning schedule that canbe effective for repositioning. In spite of the fact thatrepositioning may be imperative for prevention of pressure ulcers inthe higher risk patient population, further research to prove thisfact is still required

Effective Positions for Repositioning

This systematic review discovered that when repositioning patients,there are specific positions that are used. This review discoveredthat an interchange between spine and lateral positions is oftenused. 90° lateral positions should be avoided as this results inhigh pressure resulting into pressure ulcers amongst the affectedpatients (AHRQ, 2013). In cases where a lateral position is required,the 30 lateral position isdesirable as well as preferable (Kalman, 2015). Laboratory studieshave also indicated that the 30lateral position reduces interface pressure over bony prominences(Peterson &amp Graveinstein, 2013). Thisresearch included three RCTs and one economic study representing atotal of 502 randomized participants from acute and long-term caresettings (Gillespie et al., 2012).Two trials compared the 30º and 90º tilt positions and howeffective the two positioning were when it came to the prevention ofpressure ulcers (Rich et al., 2011 &amp Gillespie et al.,2014). The research discovered thatthe 30º tilt was more effective at reducing the development as wellas the prevention of pressure ulcers.


The concluding discovery was that turning and repositioning whencoupled with the effective position when repositioning is effectivein the prevention of pressure ulcers (Collins, Kleckner &amp Sparks,2015). Rich et al. (2011) states that tilting of the patients atspecific angles when repositioning serves as a reminder for frequentrepositioning and turning of patients.


Notwithstanding the supplementary worth of a systematic reviewapproach, this systematic review research encountered numerousconcrete glitches throughout the process. The searching, screeningand synthesis stages were all faced with varied difficulties.Systematic reviews necessitate entree to a wide range of databasesand peer-reviewed journals. Access of these types of data prove to beproblematic and very expensive for this research (Mallett, 2012, etal.). Access to institutional websites proved to be a challenge yetinformation form these websites was of essence for this particularresearch.

Therefore, based on the experience during these research, it wasdiscovered that there is an intrinsic illogicality between theinformation required to conduct a systematic review and the writingtechnique and formula of peer-reviewed journal articles indevelopment studies (Bartolucci &amp Hillegass, 2010). Subsequent,it was discovered that it might have bene much tougher to assessevidence in development studies. Finally, the systematic reviewsindicated lack of context and process.

Finally, the review was faced by limitation on the basis of the lackof generalization across the patient population. In Rich et al.(2011) the authors stated that the findings of the study werenon-generalizable due to the limited population of the targetaudience


Even though there is no clearfinest positioning or turning regularity in bed for patients withpressure ulcers, the evidence from the above systematic reviewproposes evading the 90°&nbsplateral position due to the highpressures that causes risk for pressure ulcers. With the comparisonof the 30°&nbsplateral position and increased turning andrepositioning frequencies, combination of these two strategies can beessential in the prevention and management of pressure ulcers. Thissystematic review will conclude that pressure ulcers risk is anindividualized risk and hence there should be continued research thatprovide flexible strategies for the prevention of the condition.

Implications for practice

With the findings form this research, the practices within thehealthcare facilities aimed at reducing and preventing pressureulcers should adopt the recommended findings form this research. Therecommendation of the researchers, founded on the evidence collectedthroughout this process states that the standard care for theprevention of pressure ulcers should encompass frequent turning andrepositioning within every two hour with 30°&nbsplateralposition (IHI, 2015).

Implications for research

A gap still exists on this area of research. Therefore, and furtherstudies are needed to address the efficacy of the recommendation andfindings that have been discovered by this systematic review.


Agency for Healthcare Research and Quality (AHRQ). (2013). PressureUlcer Risk Assessment and Prevention: Comparative Effectiveness.Comparative Effectiveness Review, (12)13.

Bartolucci, A. A. &amp Hillegass, W. B. (2010). Overview,Strengths, and Limitations of Systematic Reviews and Meta-Analyses.

Collins, M. R., Kleckner, A. A. &amp Sparks, B. P. (2015). TheUse of Turning and Repositioning Versus Pressure RedistributingSupport Surfaces in the Prevention of Pressure Ulcers. TheResearch and Scholarship Symposium. Retrieved form:

Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers inthe intensive care unit. Skin and Wound Care, (33)6, 57-67.

Craig, P. (2009). Developing and Evaluating Complex Interventions:New Guidance. Retrieved form:

Defloor, T., Vanderwee, K., Wilborn, D. &amp Dassen, T. (2013).Pressure Ulcer Prevention and Repositioning. Retrieved form:

Gillespie, B. M., Chaboyer, W. P., McInnes, E., Kent, B. &ampWhitty, J. A. (2012). Repositioning for pressure ulcer prevention inadults (Protocol). The Cochrane Collaboration, 7, 1-17.

Gillespie,B. M., Chaboyer, W. P., McInnes, E., Kent, B., Whitty, J. A., &ampThalib, L. (2014). Repositioning to Prevent PressureUlcers. Retrieved form:

Gillespie, B. M., Chaboyer, W. P., McInnes, E., Kent, B., Whitty, J.A. &amp Thalib, L. (2014). Repositioning for pressure ulcerprevention in adults. Cochrane Database System Review, 3(4).

Gillespie, B. M.,&nbspChaboyer, W. P.,McInnes,&nbspE., Kent,&nbspB., Whitty,&nbspJ. A. &ampThalib,L. (2013).Repositioning for Pressure Ulcers Prevention in Adults.

Granger, C. V. &amp Kishner, S. (2010). Quality and OutcomeMeasurement for Rehabilitation Programs. Retrieved form:

Groah, S. L., Schladen, M., Pineda, C. G. &ampHsieh, C. H. (2015). Prevention of pressure ulcers among people withspinal cord injury: a systematic review. MEDLINE, 7(6),613-636.

Institute of Healthcare Improvement (IHI). (2015). Relieve thePressure and Reduce Harm. Retrieved form:

Junkin, J. (2011). Preventing Pressure Ulcers: Turning andPositioning. Retrieved form:

Kallamn, U. (2015). Evaluation of Repositioning in Pressure UlcerPrevention. Division of Nursing Science Department of Medical andHealth Sciences Linköping University, Sweden. Retrieved form:

Kleckner, A. A. &amp Sparks, B. P. (2007). The Use of Turning andRepositioning Versus Pressure Redistributing Support Surfaces in thePrevention of Pressure Ulcers. Cedarville University School ofNursing.

Krapfl, L. A. &amp Gray, M. (2008). DoesRegular Repositioning Prevent Pressure Ulcers? Journalof Wound, Ostomy and Continence Nursing,(35)6, 571-577.

Layder, H. C. &amp Ayello, E. A. (2013). Patient Safetyand Quality: An Evidence-Based Handbook for Nurses. Retrievedfrom:

Mallah, Z., Nassar, N. &amp Badr, L. K. The effective of a pressureulcer intervention program on the prevalence of hospital acquiredpressure ulcers: controlled before and after study. AppliedNursing Research, (28)2, 106-113.

Mallett, R, Hagen-Zanker, J, Slater, R. &amp Duvendack, M. (2012).The benefits and challenges of using systematic reviews ininternational development research, Journal of DevelopmentEffectiveness, (4)3, 445-455.

Peterson, M. J., &amp Graveinstein, N. (2013). Patient repositioningand pressure ulcer risk-monitoring interface pressure of at-riskpatients. Journal of Rehabilitation Research and Development,50(4), 477-488.

Reddy, M. (2010). Clinical Evidence. Pressure Ulcers.

Reddy, M., Gill, S. S. &ampRochon, P. A. (2006). Preventingpressure ulcers: Asystematic review. The Journalof the American Medical Association,(296)8, 974-984.

Rich, E. S., Margolis, D., Shardell, M. &amp Hawkes, W. G. (2011).Frequent manual repositioning and incidence ofpressure ulcers among bedbound elderly hip fracture patients, WoundRepair Regen, (9)11, 10-18.

Rohrig, B., Prel, J., Wachtlin, D. &amp Blettner, M. (2009). Typesof study in medical research. Deutsches Arzteblatt International,(106)15, 262-268.

Velentgas, P.,&nbspDreyer, N. A. &amp&nbspWu, A. W. (2010).Outcome Definition and Measurement. Retrieved form: