Recumbency – everything you need to know

What is recumbency?

Recumbency is the act of lying down, an individual who is unable to stand up from a lying or reclining
position.

Nursing a recumbent patient can be challenging and very time consuming. In some severe cases,
they require a 1:1 nursing approach. Patients can have a varying degree of recumbency from arthritis
to comatose. Although the foundations of nursing a patient who is recumbent can be similar, each
case should be assessed and altered accordingly to the patient’s degree of recumbency.

Decubitus ulcers (pressure/bed sores)
Decubitus ulcers are easier to prevent than to treat, therefore vigilant assessment frequently should
be carried out to prevent these from forming. Patients should have a thick, padded, dry and clean
bed at all times. The heavier the patient, the thicker the bed should be. It is important to use bedding
that can be easily washed, with a layer to help draw the liquid away from the patient, such as a Vet
Bed. Pressure sores are common on elbows, shoulders, hips, hocks, toes, sternum, and patellae. They
can also be found around the neck and face or on any bony area. Treatment includes: turning the
patient every 2 – 4 hours (It is important not to turn the patient from one lateral recumbency to the
other as this can cause lung collapse on both sides), ensure to note which side the patient has
moved to, to avoid long periods of time on one side, ensuring bedding is clean, dry and well padded,
treating previous ulcers and inspecting the skin frequently. They can range in severity from a sore
patch of hairless skin to an open wound with bone exposed. Therefore, we should be scoring ulcers
from 1 – 4. Wound management of decubital ulcers are difficult to treat due to the patient’s
neurological state of being recumbent. It is recommended that we do not massage the skin near or
on the ulcer. This can cause more damage or injury to the affected area. Doughnut shaped cushions
are not recommended for pressure sores as they reduce blood flow to the area and cause a lot of
tension on the skin. A pillow or a foam wedge can be placed in between limbs to provide a
comfortable surface and to stop friction.

Grade 1. Dark reddened area that does not blanch on pressure. Epidermis and upper dermis may
slough. (Can be treated by wound cleaning and removal of sloughing tissue, this wound can heal by
second intention).

Grade 2. Full-thickness skin loss down to the subcutaneous tissue. (These can be surgically or
medically debrided using wet to dry, this will clean the wound of any necrotic tissue. Once
granulation tissue has formed, it can be closed by secondary closure).

Grade 3. Ulcer extends through the subcutaneous tissue down to the deeper fascia. Wound edges
may be undermined. Necrotic tissue is debrided and treated as an open wound. Penrose drains can
be placed, and surgical closure can be carried out when granulation tissue has formed.

Grade 4. Ulcer extends through the deep fascia down to the bone. Osteomyelitis or septic arthritis
may be present. (Ulcers, infected tissue, and any infected bone is removed. Sinus tracts and pockets
are excised, opened, and debrided. Once this has been completed, drains may be used, wet to dry
dressings and surgical closure).

Defecating and Urinating
Every time the bedding is soiled, it needs to be changed immediately. Therefore, checks need to be made frequently to ensure the patient isn’t left for a long period of time unnoticed. When the patient does soil themselves, they need bathing with mild and gentle shampoo. Once the patient is clean, they need thoroughly drying. The grade and frequency of faeces should be recorded at every occurrence.

Urination comes with more complications and risks. If the patient cannot urinate consciously, they
will have to get manually expressed to prevent infection, pain, bladder damage and bladder rupture.
Manual expression can cause several problems such as pain, patient compliance, and reluctance to
be expressed as tense. Drugs such as diazepam may be used to relax the muscles to aid expression.
Manual expression should be carried out 4 – 6 hours and left no longer than 8 – 12 hours. If manual
expression isn’t a viable option, a foley urinary catheter can be placed. However, this can cause
infection if not placed in a sterile manor or can be a great source of infection if the urinary catheter
and collection bag does not get cleaned. Collection bags should be emptied every 4 hours, and the
patient’s ml/kg/hr should be calculated, as well as the patient’s fluid requirements to overall gather
an ins and outs result. A rigid urinary catheter can be placed every 8 hours if a foley isn’t a possibility,
however this cause trauma to the urinary tract, pain, stress, and infection. This option is only
possible in male patients.

Eating and drinking
Ensuring the patient is drinking enough can be a challenge, especially if their mentation is affected. If
they are not receiving their daily fluid requirement through drinking, they will have to be placed on
IVFT (under veterinary guidance). This can be monitored through the patient’s urine output, and
their hydration assessment.

Managing their calorie intake is more complex. Patients who are recumbent are often not interested
in food, or they do not have the energy to eat. There are certain things that we can put in place to
encourage them, such as hand feeding, potent food, feeding outside of bed, and appetite stimulates
can be used such as mirtazapine. A feeding tube such as oesophageal or nasal can be placed if they
are reluctant to eat. There is a large risk of aspiration in a recumbent patient, therefore they should
be sat up in sternal when feeding, this will also help prevent any vomit or regurgitation. The formula
30 × (BW kg) + 70 = RER per 24 hours can be used for patients weighing more than 2 kg and less than
45 kg. Multiple small meals per day can help encourage the patient to eat instead of 2 or 3 large
ones, as well as using toys such as Kongs, and Licky matts. We do not want to prevent food aversion
in our recumbent patients, so it is important to only feed them a small amount of one type of food.
Before removing it after 20 minutes and trying a different type of food later in the day.

Circulation and respiratory
Recumbent patients are not having a natural range of movement, so they are at risk of oedema and
thrombosis. We need to check blood pressure every 4 -6 hours to monitor the perfusion of all
organs. Oedematous limbs should be massaged using circulating movements and using hand
movements to ‘milk’ the fluid down. Patients should be turned every 2 – 4 hours to help circulation
too.

Passage range of motion should be carried out every 4 – 6 hours to improve circulation and
lymphatic drainage. PROM includes but not limited to: Range of motion, bicycling limbs, enhanced
range of motion, assisted sit to stand, assisted walking, toe tickles and toe turns. The muscles should
be warmed prior to PROM for 10 minutes. Lengthy recumbency, especially on one side can cause
collapsed lung due the pressure of the body on one side. This is another reason why we should be
turning our patients every 2 – 4 hours. Sternal recumbency is preferred due to the increase perfusion
to both lungs.

Body temperature
Recumbent patients will find it difficult to maintain their own body temperature, therefore we need
to ensure that their temperature is checked frequently, and the results are acted upon. Hypothermic
patients would benefit from heat pads, heat discs, Bair Huggers and providing a warmer surrounding
environment. Always ensure they are not left with the heating device for too long as they are risk of
hyperthermia, and the heating equipment is never placed directly on skin as this can cause heat
burns. The patients are unable to move away from the heat source.

If the patients are hyperthermic, a cool matt, cooling pads or active air flow can help to cool them.
Ensure their temperature is checked often to prevent hypothermia.

Pain management with stiff muscles/PROM
Passive range of motion exercises are a vital part of a recumbent patient’s day. If not completed the muscles seize up and become stiff and painful. They can also develop muscle atrophy
which prolongs the recovery time. Using heat therapy for 10 – 15 minutes prior to exercise will help with pain management and help loosen the muscle before we work it. When giving opioids for pain,
we do not cause a sedation effect, as this will make the PROM slower and more difficult to carry out,
which in turn will prolong the recovery period. Pain scores should be carried out every 4 hours to
ensure the patient requires the correct dosage of opioids. Harnesses, slings, carts, and exercise balls
can be used to provide PROM. Getting the patient upright will also help the respiratory, circulatory,
lymphatic, and endocrine system. Assisting a patient to stand will reduce the risk or slow down
muscle atrophy, improve muscle strength, and improve balance. Standing will also remove the
pressure of bony prominences and help heal the decubitus ulcers.

Eye and mouth complications
When a patient is in a certain degree of recumbency, they will need lubricant in their eyes every 2
hours to prevent eyes becoming dry which can cause eye ulcers. They are also at risk of developing a
dry mouth which can cause mouth ulcers. The mouth ulcers can be painful (which might prevent
them from eating, and they are at risk of getting infected. Therefore, wetting of the tongue, wetting
gums and cleaning mouths using swabs is required every 4 hours. Be careful not to make their mouth
too wet due to the risk of aspirating. This task must be performed in sternal recumbency. If the
patient develops too much saliva, we can suction to prevent aspiration.

Mental stimulation
Patients who are recumbent for a long period of time whilst in hospital will become less enthusiastic
about their day, especially as they learn the routine of their day. They will stop eating, stop wanting
to play, and will lose the passion and motivation for activities they used to enjoy. For this reason, it is
vital we provide mental stimulation to our long-term recumbent patients. Moving them into different
rooms, with different people and smells can be one way to encourage them to look around and
watch people. This will also encourage people to interact with the patient. Puzzle games and snuffle
matts can be very useful to help encourage the patient to eat and makes the routine of feeding
something new and exciting every day. Taking the patient outside to carry out PROM, feeding,
grooming, and washing can also be great mental stimulation due to different smells and sights. Being
recumbent is unnatural to our patients and can be very stressful as they do not understand why they
cannot move. So, speaking softly, having relaxing music, or the tv on to mimic a home environment
can benefit them greatly.

Conclusion
Nursing a recumbent patient can be time consuming and requires a full team of dedicated nurses.
However, they can also be rewarding and extremely worthwhile. There are multiple risks to monitor
and assess for which can cause detrimental effects for the patient, so these cases take a multi model
approach of nursing care, involving every aspect of the role. As nurses we are the difference between
the patient having a bad day, and the patient feeling secure, safe, and comfortable. So, it is important
we advocate for them and try to give them the best possible outcome.