Correct positioning is important to prevent contractures; measures are used to relieve
pressure, assist in maintaining good body alignment, and prevent compressive
neuropathies, especially of the ulnar and peroneal nerves. Because flexor muscles are
stronger than extensor muscles, a posterior splint applied at night to the affected
extremity may prevent flexion and maintain correct positioning during sleep. (See
Chapter 11 for additional information.)
Preventing Shoulder Adduction
To prevent adduction of the affected shoulder while the patient is in bed, a pillow is
placed in the axilla when there is limited external rotation; this keeps the arm away
from the chest. A pillow is placed under the arm, and the arm is placed in a neutral
(slightly flexed) position, with distal joints positioned higher than the more proximal
joints (ie, the elbow is positioned higher than the shoulder and the wrist higher than the
elbow). This helps to prevent edema and the resultant joint fibrosis that will limit range
of motion if the patient regains control of the arm (Fig. 62-3).
Positioning the Hand and Fingers
The fingers are positioned so that they are barely flexed. The hand is placed in slight
supination (palm faces upward), which is its most functional position. If the upper
extremity is flaccid, a volar resting splint can be used to support the wrist and hand in a
functional position. If the upper extremity is spastic, a hand roll is not used, because it
stimulates the grasp reflex. In this instance a dorsal wrist splint is useful in allowing the
palm to be free of pressure. Every effort is made to prevent hand edema.
Spasticity, particularly in the hand, can be a disabling complication after stroke.
Researchers reported that repeated intramuscular injections of botulinum toxin A into
wrist and finger muscles reduced upper limb spasticity after stroke, resulting in
significant and sustained improvements in muscle tone.
Changing Positions
The patient's position should be changed every 2 hours. To place a patient in a lateral
(side-lying) position, a pillow is placed between the legs before the patient is turned. To
promote venous return and prevent edema, the upper thigh should not be acutely flexed.
The patient may be turned from side to side, but if sensation is impaired, the amount of
time spent on the affected side should be limited.