All clinical staff should be aware of the risk factors for developing pressure damage. These include:

Direct pressure and friction during movement of patients are two of the most common causes of injury to the skin that can lead to pressure damage. Also consider shearing forces, which may occur when patients are at risk of sliding down in the bed or chair. Consider using a validated scale to support clinical judgement. Any patient with pressure damage or a pressure ulcer or who is thought to be at risk should be positioned with the use of pressure‐relieving equipment such as a specialist mattress and cushion. Additional use of pillows and/or towels may be required depending on individual assessment.

Using a tool such as the ASSKING bundle can manage and prevent pressure damage. ASSKING is a five‐step approach to preventing and treating pressure ulcers (NHS Improvement [85]):

See Chapter c18: Wound management for further information.

Consider the location of wounds and injuries when selecting a comfortable position. Ideally positions should avoid pressure on or stretching of any wounds, and consideration should be given to the timing of dressing changes, which ideally should be done prior to positioning to avoid disturbing the patient twice. Specific surgical needs may also be apparent that will require a patient to remain in certain positions, posing further complications to the moving and positioning of the patient.

Take extra care in positioning patients with decreased sensation as numbness and paraesthesia (abnormal skin sensation) may result in skin damage as the patient is unaware of pressure or chafing. These patients may not be aware of the need to adjust their position or alert nursing staff to discomfort so it is very important to reposition them frequently and check their skin regularly for areas of redness or breakdown.

Where possible, swollen limbs should not be left dependent but be supported on pillows or a footstool, as elevation will help to maximize venous return and minimize further swelling. Oedema may result in pain, fragile skin or loss of joint movement.

It is important to ensure the patient has optimal pain relief before they move. Pain is often a barrier to early mobilization in intensive care settings and after surgery (Dubb et al. [34], Jønsson et al. [54]). It is important to allow adequate time for any pain medication to take effect.

The patient's ability to maintain the position should be considered. Additional support may be required in the form of pillows or towels to maintain the desired posture.

Changes in the soft tissue and joint range benefit from being identified early as some will respond to physiotherapy. Soft tissue changes and contractures can occur through disuse although the pathology is poorly understood (Wong et al. [134]). As a result, restrictions in joint range may mean that positions need to be modified or are inappropriate altogether.

If there is the potential for any joint or soft tissue restriction then it is necessary to liaise with the physiotherapist or occupational therapist regarding any specific exercises or positions necessary for the patient to avoid developing contractures, as this may affect position choice or involve incorporating appropriate splinting to maintain muscle length.

Patients with unstable fractures or suspected fractures should not be moved and the area should be well supported. A change of position could result in pain, fracture displacement and associated complications. Patients with osteoporosis or metastatic bone disease with unexplained bony pain should be treated as having a suspected fracture until this is ruled out.

Osteoporosis refers to a reduction in the quantity and quality of bone due to loss of both bone mineral and protein content. Risk factors for osteoporosis increase with age and include being female, Caucasian or postmenopausal; having a low body mass index (BMI), a positive family history of osteoporosis or a sedentary lifestyle; and having Coeliac or Crohn's disease (NHS [81]).

Muscle tone can be defined as the degree of resistance to a passive movement. The degree of resistance is determined to be less than normal (hypotonic), normal or more than normal (hypertonic). The last of these three may be referred to as spasticity (Latish and Zatsiorsky [60]).

Tone can be altered by positioning with either positive or negative consequences. Further information on moving and handling patients either with neurological impairment or who are unconscious is outlined later in this chapter.

It is important to establish spinal stability before positioning or moving a patient. Failure to do so could lead to further complications such as paralysis. The specifics of moving and positioning a patient with spinal cord compression are discussed later in this chapter.

Care should be taken to avoid pulling on or causing an occlusion if the patient has a catheter, intravenous infusion, venous access device or drain. Pulling on devices may cause pain and/or injury. Prior to any moving or positioning procedure, it is important to ensure that any electrical pumps have been disconnected and sets are untangled and flowing freely. Once the moving or positioning procedure has been completed, a check must be made to ensure all devices are reconnected.

Patients who are medically unstable may become increasingly so during movement. Orthostatic tolerance (postural hypotension) deteriorates rapidly with immobility. Bedrest lessens carotid–cardiac baroreceptor reflex responsiveness, contributing to postural hypotension and tachycardia and, as a result, a reduction in stroke volume and cardiac output (Vollman [128]); therefore, patients who are acutely unwell should be monitored carefully during and after any change of position or when mobilizing. Post‐operative patients may have a drop in blood pressure when sat up in the early post‐operative period. It is advisable to sit a post‐operative patient on the edge of the bed for a few minutes before transferring them into a chair to ensure blood pressure is maintained in a seated posture and the patient is not at risk of fainting.

Fatigue can be a distressing symptom, so advice and help should be given to the patient about how to pace their everyday activities. Therefore, prioritizing activities may help to avoid engaging in tasks that are unnecessary or of little value (de Raaf et al. [26]). Graded exercise programmes can be beneficial in managing fatigue (White et al. [131]).

It is important to explain to the patient the reasons for moving and positioning, and to do so in a manner appropriate to their level of understanding. Step‐by‐step explanations and clear instructions should be given to enable them to participate in the movement. It is known that impaired cognition (the mental process involved in gaining knowledge and comprehension) and depression are intrinsic risk factors for falls in older people (NICE [86]).

Shutting the door and/or the curtains prior to moving the patient will help to maintain privacy and dignity, and will ensure that the environment is as private as possible (CSP [24]). It may be appropriate to ask visitors to wait outside. The process of uncovering the patient may make them feel vulnerable and/or distressed, so keep them covered as much as is practically possible during the procedure. Catheter bags and drains should be hung as discreetly as possible under the patient's bed or chair.

Before changing a patient's position, it is important to fully inform them of the planned change in position so they are able to consent and to participate with the manoeuvre and reduce the need for assistance. Explaining the potential complications associated with immobility may also help to motivate the patient.

There may be instructions or indications regarding moving and positioning the patient in their health records. If there is uncertainty, advice should be sought from the medical team or physiotherapists involved in the patient's care. It is also important to consider the result of the manual handling risk assessment and recommendations from the physiotherapy staff for any special precautions that need to be taken into account prior to moving and positioning.