Articles Clinical Blog Downloads

Pressure ulcer prevention in the prone position

COVID-19, the virus which has rapidly spread all over the world and has become a great challenge for healthcare workers, causes pulmonary edema, multi-organ failure, and acute respiratory distress syndrome (ARDS). 

Many reports from acute areas treating severe cases of COVID-19, highlight the need to nurse patients in the prone position to assist breathing either with and without a ventilator.

The prone position is defined as lying in a horizontal position with the front of the body facing downward, and is distinguished from pronation (i.e. rotation of the forearm such that the palm of the hand is facing downward).

Just like when you are in the supine position, opposite of Prone, where you lay horizontally on your back, pressure ulcers can occur if prolonged pressure is applied to the same spot without repositioning. They commonly appear over bony prominences but can be caused by general pressure being applied to the skin e.g from medical devices, which effect the top layer of the skin and underlying tissue.

Where do pressure ulcers occur in the prone position:

Below are the pressure care guidelines for an adult critical care patient with acute respiratory distress (adrs) and/or ventilator:

  • Ensure optimal positioning of pillows tailored to the patient’s body shape.
  • Pressure areas should be meticulously checked.
  • No direct pressure on the eyes.
  • Ears not bent over. 
  • ETT not pressed against the corner of the mouth / lips. 
  • Nasogastric tube not pressed against nostril.
  • Penis hanging between the legs with the catheter secured.
  • Lines / tubing not pressed against the skin.
  • When alternating arm position in swimming arm position, assess integrity of skin of arm/head/face.
  • Involve enough trained staff to avoid friction-shear when repositioning.
  • Assess all pressure points:
    Prior to proning (anterior surfaces). Prior to returning to supine position (posterior surfaces).
    When alternating arm position in swimming arm position, assess integrity of skin of arm/head/face.
    Document all skin assessments and preventative measures. 

Useful resources on the prone position and preventing pressure ulcers during covid-19:

NPIAP Tips for Prone Positioning

Guidance For: Prone Positioning in Adult Critical Care

COVID and Pressure Care updates


Positioning the patient may require the assistance of several healthcare workers to avoid problems such as dislodgement of medical devices  especially if the patient has mobility limitations. Always follow medical guidance, institutional policies, manufacturer recommendations and principles of sound clinical judgment in addressing the needs of individual patients.