Positioning critically ill patients in hospital

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learning zone CONTINUING PROFESSIONAL DEVELOPMENT Page 56 Positioning critically ill patients in hospital

Page 66 Critical care multiple choice questionnaire

Page 67 Read Jacqueline Armstrong’s practice profile on hand hygiene

Page 68 Guidelines on how to write a practice profile

Positioning critically ill patients in hospital NS298 Griffiths H, Gallimore D (2005) Positioning critically ill patients in hospital. Nursing Standard. 19, 42, 56-64. Date of acceptance: January 26 2005.

Summary

Introduction

Although moving and handling is an important aspect of nurse training, the emphasis is often more on the health and safety of the nurse than on the importance of the correct therapeutic positioning of patients. This article outlines optimum patient positioning in different critical care settings and for different medical conditions.

Moving and handling is regarded as an important component of nurse education and has been included in the nursing curriculum for more than ten years. The need for training in manual handling has been due, in part, to European regulations regarding health and safety of manual handling of loads (Kneafsey et al 2003). This is in contrast to the need to know therapeutic positioning and reduction of clinical risk in the nursing curriculum. The indicative content and timing of manual handling training for nursing students in higher education is based on preparing students for particular placements in practice, such as critical care areas. It is uncertain, however, whether the importance of correct therapeutic positioning of patients is covered in the preregistration nursing curriculum. This should perhaps be an integral component of the underpinning knowledge of moving and handling training and education for nursing students.

Authors Howard Griffiths is clinical practice tutor, David Gallimore is nurse tutor, School of Health Science, University of Wales, Swansea. Email: [email protected]

Keywords Critical care; Patients: positioning; Student nurses These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

Aim and intended learning outcomes This article aims to review the literature on positioning critically ill patients in a variety of different settings for nurses. After reading this article, you should be able to: Identify clinical risks to the patient when positioned in a variety of critical care settings. Identify how body positioning may influence clinical outcome for these patients. Integrate variations in patient positioning into your own clinical practice. Understand the use of patient positioning in a variety of critical conditions. Review the available evidence for positioning patients in a critical care setting.

Accident and emergency departments One of the main areas of concern for nursing students in accident and emergency (A&E ) departments is the moving and positioning of patients after trauma. Patients will frequently arrive by ambulance on specialist stretchers and moving equipment. These are designed to restrict the movement of patients and so limit further injury during transportation to hospital. The most frequently used items of equipment are spinal boards and cervical collars, both are designed to prevent injury to the spinal column. In A&E the spinal board should be removed as soon as possible once the patient is laterally transferred from the ambulance trolley onto an

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A&E or resuscitation trolley (Vickery 2001, Brohi 2002). The early removal of spinal boards and cervical collars is advocated by spinal units (Sexton 1999, Queen Elizabeth National Spinal Injuries Unit 2000, Hauswald and Braude 2002), provided that set protocols are followed by staff. Complications associated with prolonged use of the spinal board include pressure ulcer development, inadequacies of spinal immobilisation and support, pain and discomfort, respiratory compromise and quality of radiological imaging (Vickery 2001).

Time out 1 Consult with an A&E practitioner with regard to the main difference between undertaking the spinal log roll technique and placing a patient in the recovery position. List three important factors to consider when undertaking the spinal log roll technique to minimise the risk of damage to the patient’s spinal cord. (Answers on page 64) The log roll is the standard manoeuvre to allow examination of the back and transfer on and off spinal boards. A minimum of four people are required: one to hold the head and co-ordinate the roll, and three to roll the chest, pelvis and limbs. The number and degree of rolls should be kept to an absolute minimum. Patients who are agitated or restless because of shock, hypoxia, head injury or intoxication may be impossible to immobilise adequately. Forced restraints or manual fixation of the head may risk further injury to the spine. It may be necessary to remove immobilisation devices to allow the patient to move unhindered (Brohi 2002). Bleeding from fractured bones and damage to surrounding tissue may lead to hypovolaemic or neurological shock. It is good practice to monitor the colour, movement and sensation of the patient’s limbs. Numbness or paralysis distal to the injury site will indicate pressure on the nerves. Any vascular impairment or improper application of a splint will warrant its removal (Beare and Myers 1998). The clinical risks to the patient from poor positioning and manual handling in the A&E setting are many and varied according to the injury and diagnosis. These may range from joint dislocation, displacement of fractures, peripheral nerve damage, to exacerbation of intracranial pressure or spinal cord damage. Some of the above can in turn induce haemodynamic instability, for example, spinal cord damage may bring on spinal shock in the patient (Beare and Myers 1998). Rising intracranial pressure will lead to a loss of consciousness, with subsequent risk of the patient’s airway becoming blocked by the tongue. Nurses working in A&E need to be

aware of these issues when moving and handling the patient to avoid causing harm to the patient.

Time out 2 List five possible risks that patients may be exposed to when on the operating table. (Answers on page 64)

Operating theatres In the pre-anaesthetic phase most patients will be induced for general anaesthetic in the supine position on a theatre trolley. If the patient is having a spinal anaesthetic, then he or she may adopt a crouch lateral position so that the anaesthetist can access the spaces between the lumbar vertebrae L2 and S1 to inject the anaesthetic drug (Fairchild 1996). A variety of body positions are used for different types of surgery. Nerve damage and pressure necrosis commonly result from poor positioning; the incidence is increased by hypotension and hypothermia (Barker 2002). Ideally, the surgical position of the patient should allow optimal exposure and access to the operative site without compromising organ function or patient safety. The anaesthetist will also require access for inducing the patient with anaesthetic agents and for administration of intravenous (IV) fluids and drugs. All surgical positions are potentially harmful because of their effect on respiration, circulation, peripheral nerves and skin. A variety of attachments are available for the operating table to facilitate surgical positioning and to minimise the risks of harm to the patient, for example, upper limb arm supports and head support attachments. The peripheral nerves and blood vessels are at risk of damage through mechanical injury when the patient is on the operating table (Coppieters et al 2002). Permanent injury may result after only a few minutes of pressure on a nerve or blood vessel. Superficial nerves such as the ulnar and brachial nerves in the upper limbs are at greatest risk. Theatre staff use soft pads to support upper and lower limbs, to minimise the risk of compression on the peripheral nerves during surgery (Fairchild 1996, Barner et al 2003). The patient is also at risk of pressure damage when lying on the operating table and the recovery theatre trolley. Pressure damage occurs through a variety of extrinsic factors, such as direct pressure acting on a point in the tissue, through shearing of tissue by movement of the body on a hard surface and through mechanical friction of the skin on a hard supporting surface. Blood flow may be compromised by a reduction in capillary pressure when under anaesthesia. Pressure points on the heels, sacrum, scapula and back of the head have support surfaces thoroughly padded to reduce the

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learning zone moving and handling amount of pressure acting on a given point of body tissue (Fairchild 1996, Beare and Myers 1998). The respiratory effect of positioning the patient on the operating table could involve shifting visceral pressure, which may restrict movement of the patient’s diaphragm or chest wall on the operating table, thereby reducing effectiveness of respiratory ventilation (Beare and Myers 1998). Any mechanical interference with respiration or position changes may alter the ventilation and circulatory perfusion of the lungs by circulating blood being affected and the movement of secretions in the lower airway (Fairchild 1996, Beare and Myers 1998). General anaesthesia and local anaesthesia reduce central nervous control over the blood vessels, with loss of vasoconstrictive tone. In addition, the diminished muscle tone through inactivity of the patient on the operating table reduces the action of the muscles and contributes to pooling of the blood (Beare and Myers 1998). Lower limb compartment syndrome has been reported to occur after colorectal, urological and gynaecological procedures during which the patient’s lower limbs are elevated for prolonged periods of time (Horgan et al 1999, Meyer et al 2002) and in the hemilithotomy position in a leg holder on a fracture table. During the recovery phase, the patient may be put into a variety of positions on the theatre trolley or bed. The primary goal is to secure the safety of the patient’s airway. This may necessitate the patient being put into the lateral recovery position. The patient may be supine if blood pressure is low or put in a semi-recumbent/semi-Fowler position if the patient is conscious but breathless. The clinical risks to the patient from poor moving and handling include pressure damage, peripheral nerve and blood vessel damage, compartment syndrome and joint dislocation (Barker 2002). Nursing students need to be aware of these issues when moving and handling patients in this setting.

Time out 3 James is a 77-year-old widower who has had an emergency admission to a district general hospital, having sustained an intracapsular fracture of his right hip. Refer to a standardised anatomy and physiology textbook and examine the anatomical structures of the hip region. List four anatomical structures that may be damaged if James’s fracture was displaced by incorrect positioning or handling by nursing staff. (Answers on page 64)

Time out 4 Consult with senior staff in the intensive care unit in your district general hospital and find out their opinion on the indications and contraindications for patients with the following conditions: Acute respiratory distress syndrome Head injury Chest infection Observe the manual handling techniques and aids used by staff to assist with different manoeuvres. Reflect on the areas where practice could be improved.

Intensive care unit A multidisciplinary approach is required to plan the positioning of patients in intensive care units (ICUs). This should be evidence based, regularly assessed and reviewed as the patient’s condition changes. It is frequently nurse-led. Patients admitted to an ICU will have multiple system failure and are frequently immobile for long periods of time. During periods of prolonged immobility, patients are at risk of developing decubitus ulcers caused by ischaemia of skin and subcutaneous tissues. This risk is increased in critically ill patients because of poor peripheral circulation, reduced blood oxygenation, sedation during ventilation, excessive moisture to the skin through sweat and poor nutritional status (Beare and Myers 1998). The usual recommendation to prevent this problem is to change the patient’s position every two hours. In intensive care, special equipment can be used to help the prevention of pressure ulcers. This includes special mattresses that can be used on standard beds and specialised beds. When specialised equipment is not being used, regular assessments of pressure ulcer risk are crucial. If this is found to be high, the patient’s position should be changed every two hours (Clark 1998). Krishnagopalan et al (2002) researched this aspect of patient positioning and found it was not being achieved in practice. Their observational study in ICUs in the United States showed that only 3 per cent of patients had their position changed every two hours, and 28 per cent remained in the same position for more than eight hours. A similar study has not been performed in the UK but there are similarities between the two countries, including staffing levels and patient dependency, which may suggest similar research findings. Nurses working in critical care areas should assess the frequency of changing the patient’s position. If this is not being achieved at an appropriate frequency, alternative strategies should be implemented to reduce the risk of


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pressure ulcer formation. These could include the use of specialised mattresses or beds, which are designed to change patient position either at regular intervals or constantly. Prone position Most frequently, patients in ICU are nursed in the supine position, but considerable research has been conducted into prone positioning. This position was first suggested in the early 1970s (Bryan 1974) but is still controversial and is not used frequently. It can be difficult to co-ordinate the movement of an unconscious patient from the supine to prone position, and injuries to nursing staff have been reported when undertaking this manoeuvre. Guidance in undertaking the procedure can be found in the literature (Rowe 2004) and nursing preparation is shown in Box 1. Prone positioning has been found to be beneficial in the ventilated patient by reducing ventilator-acquired pneumonia (Brazzi et al 1999), optimising patient oxygenation (Fridrich et al 1996) and optimising effectiveness of physiotherapy techniques (Chatte et al 1997) as a form of postural drainage. The purpose of postural drainage is to loosen airway secretions, using gravity to drain and remove excess secretions and decrease accumulation of secretions in unconscious or weakened patients (Smith-Temple and Johnson 1998). The appropriateness of this therapy should be assessed carefully before moving the patient (Box 2) since there are a number of contraindications that may make this procedure unsuitable for the patient. If oxygenation improves during the pronation period, the patient can be nursed in this position for up to 20 hours a day (Fridrich et al 1996) and the frequency of turning will ultimately depend on the patient’s response. If a patient is returned to the supine position too early, oxygenation may return to pre-pronation levels (Harcombe 2004). Recently, the main focus of research has examined the use of the prone position as an adjunct in the treatment of acute respiratory distress syndrome (ARDS) (Ball 1999, Curley 1999). There is no recognised treatment for this condition, which has a mortality rate of between 32 and 45 per cent (Udobi et al 2003). In patients with ARDS changes in the lungs reduce the ability to absorb oxygen into the body. One of the main changes is the excessive secretion of fluid into the alveoli. When this occurs, the alveoli are no longer able to absorb oxygen and become damaged. The main physiological benefit for the patient in the prone position appears to be a movement of fluid from the back to the front of the lungs. This allows more oxygen to enter the alveoli and thus be absorbed into the blood. Despite the numerous studies demonstrating significant improvement in oxygenation, prone positioning is still underused (Webster 1997,

Gosheron et al 1998). A recent study found that although there was an increase in oxygen levels when patients were placed in the prone position, this did not result in a reduction in mortality rates (Gattinoni et al 2001). Contraindications to prone positioning are outlined in Box 2. There are also a number of complications associated with placing the patient in the prone position. These include: accidental displacement of the endotracheal tube, venous and arterial catheters and feeding tubes during the turn to the prone position; the development of facial oedema and difficulty performing eye and oral toilet, and tracheal suction; pressure on the frontal areas of the body and joint stiffness and overextension of the limbs (Rowe 2004). As an alternative to the prone position, the use of side lying is recommended for improving oxygenation in patients with ARDS and unilateral lung involvement (Zach et al 1974). The affected lung should be superior. However, side lying is associated with certain haemodynamic risks such as increased cardiac work in patients placed on their left side and decreased preload when patients lie on their right side, especially in patients with moderate right ventricular function (Wong 1999). Despite the problems and contraindications associated with the prone position, Rowe (2004) believes that the BOX 1 Nursing management of patients in the prone position Close the patient’s eyes to avoid direct ocular pressure. Tape the eyes shut or lubricate the patient’s eyes to prevent corneal drying and abrasions Assess neurological status of the patient; sedation may need to be increased during the actual turn Plan and assess adequate pain management before pronating, as many patients have surgical incisions Ensure an unrestricted abdomen allowing the passive movement of the diaphragm and the downward displacement of the abdominal contents Pre-oxygenate the patient before turning and also note the position of the endotracheal tube, which should be tied securely Closed circuit suction should be used on patients with acute respiratory distress syndrome, as they are dependent on high levels of positive end-expiratory pressure Note the trends and changes in the patient’s airway pressures or tidal volumes, depending on the ventilator mode, to monitor progress In the event of a cardiac arrest, the patient should be returned to the supine position immediately (Harcombe 2004)

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learning zone moving and handling increase in oxygen levels is of great benefit to patients. She developed guidelines for using this therapy on ventilated patients in an intensive care setting (Rowe 2004). Backrest elevation If a decision has been made to nurse the patient in the supine position, the nurse should consider whether the patient should be nursed flat or whether the backrest should be raised and if so to what angle should the patient be elevated. BOX 2 Contraindications to the prone position in critical care Acute haemodynamic instability (Vollman 1997) Recent cardiac arrest, cardiac surgery or sternotomy (Chatte et al 1997, Ball 1999) Pain or agitation (Mims 1989) Formation of a tracheostomy within 24 hours (Ball 1999) Bronchopleural fistula (Pappert et al 1994) Recent abdominal surgery, grossly distended abdomen, ischaemic bowel or abdominal stoma (Pappert et al 1994, Stocker et al 1997, Ball 1999) Unstable spinal fractures or evidence of osteoporosis Acute head injury, raised intracranial pressure, frequent seizures (Fridrich et al 1996, Blanch et al 1997, Vollman 1997, Gosheron et al 1998) Raised intraocular pressure/recent ophthalmic surgery (Ball 1999) Multiple trauma, acute pelvic fracture, external pelvic fixation, rib or sternal fractures, and traction (Ryan and Pelosi 1996, Chatte et al 1997, Ball 1999) Pregnancy (second or third trimester) Acute asthma, chronic obstructive pulmonary disease or pulmonary abscess (Blanch et al 1997, Chatte et al 1997, Ball 1999) Acute haemoptysis or acute alveolar haemorrhage (Jolliet et al 1998) Chest wall abnormalities/kyphoscoliosis or advanced arthritis (Blanch et al 1997, Ball 1999) Extensive inguinal or abdominal soft tissue injury (Stocker et al 1997, Jolliet et al 1998) Facial trauma or following oral maxillary facial injury (Fridrich et al 1996, Blanch et al 1997) Extreme obesity Unstable blood pressure Cardiac arrhythmias Worsening dyspnoea and hypoxia

The best backrest angle for respiration in patients has been found to be 45˚, with the patient’s legs lowered – known as the reverse Trendelenburg position (Burns et al 1994). This degree of elevation of the backrest has been shown to reduce the incidence of pneumonia in ventilated patients (Drakulovic et al 1999). It is thought that bacteria from the gut are transmitted into the lungs of ventilated patients, which results in chest infection (Drakulovic et al 1999). By elevating the backrest on the bed, gravity reduces the number of bacteria entering the lungs and thus decreases the risk of aspiration. This is an important factor in patients who are being fed via nasogastric tubes, but is equally important in all ventilated patients. This has resulted in a number of authors advocating the elevation of backrests in ventilated patients to 45˚ (Grap et al 2003, Helman et al 2003, Vollman 2004). There are, however, a number of complications associated with elevating the backrest, especially in critically ill patients. Raising the head of the bed is known to affect haemodynamic stability – as the angle of the backrest is increased cardiac return is reduced. This can cause a significant fall in cardiac output and thus blood pressure (Giuliano et al 2003). However, this has not been found to occur in patients whose primary reason for admission to intensive care units is not cardiac (Giuliano et al 2003). Grap et al (2003) found that nurses do not always assess patients to find out whether elevating the head of the bed will cause changes in haemodynamic stability, and keep patients lying flat for reasons other than to maintain blood pressure. It was also found that intubated patients had lower backrest elevation than those who were not ventilated. Other elements of a patient’s condition such as nasogastric feeding did not influence nurses’ decisions on backrest elevation. It was frequently found that the elevation of the backrest was decided on factors such as the convenience of nursing procedures and the comfort of the patient. The use of backrest elevation over 30˚ was minimal and the mean elevation was only 19˚. The authors of this study suggest the introduction of guidelines to ensure that recommendations are met (Grap et al 2003). Similar reasons for not elevating the back of the bed were also suggested by Helman et al (2003). Their study introduced specific medical orders for the angle of backrest elevation and found that the number of patients with backrests elevated to 45˚ increased from 3 per cent to 29 per cent two months after starting the study. A further complication of elevating the backrest is the increased risk of shearing forces in the development of pressure ulcers, but again there is no evidence that nurses assess this risk in patients before deciding on the elevation of the backrest (Vollman 2004). When deciding the


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elevation of the ventilated patient’s backrest, the nurse should perform a comprehensive assessment of the patient and make a decision based on the best available evidence.

Specific medical conditions The final consideration when planning the position of patients is the patient’s medical condition. The more common conditions and the recommended positions are discussed. Positioning in burns units Therapeutic positioning is designed to reduce oedema by elevating the extremities and to preserve function by proper body alignment and the use of anticontracture positions. Positioning will vary to some extent according to the locality of the burn. The main objectives of splinting are to prevent contractures and deformity occurring in the burnt patient. Maintenance of range of movement is achieved through surgical release and grafting procedures. Splinting is used to correct hypertrophic scarring when surgery is contraindicated, and when the patient is unable to maintain proper position voluntarily (Leveridge 1991). The patient may need to be turned two to three hourly to prevent respiratory congestion and circulatory stasis (Watson and Royle 1992). If the back is burnt or the involvement is circumferential, care is facilitated if the patient is nursed on an air-fluidised support system (Clinitron bed), a Stryker bed or Cicloelectric bed to reduce friction on the patient’s tissue during moving and handling. Because of oedema, burned extremities are elevated on pillows or another form of support during the initial phase. Frequent attention is paid to body alignment, flexion contractures, outward rotation of thighs and footdrop prevention. Burned parts which involve joints are moved through their range of motion as soon as possible. Early skin grafting permits the patient to be mobile earlier and prevents contractures (Fowler 1994). Orthopaedic and trauma units Patients in this setting will be nursed in a variety of positions according to the nature of the trauma. For example, most patients who have an unstable spinal fracture will be positioned in the supine position on bed rest. Those patients who have sustained lower limb fractures will be nursed in a semi-recumbent or semi-Fowler position before and after surgical intervention. Those patients with upper limb fractures will be positioned in a high Fowler or sitting up position, depending on the patient’s haemodynamic stability. Trauma patients may have the following potential complications because of their injury: joint stiffness, pressure damage on tissue and nerves, and compartmental syndrome, in

addition to risk of further complications, such as gas gangrene, osteomyelitis, fat emboli and tetanus. The routine use of traction (either skin or skeletal) does not appear to have any benefit and is not recommended before surgery for a hip fracture (Scottish Intercollegiate Guidelines Network (SIGN) 2002).

BOX 3 Nursing management of patients with rising intracranial pressure Secure the airway, ensure suctioning equipment is in working order. Nasopharyngeal and oropharyngeal suctioning is contraindicated in patients with basal fractures or leakage of cerebrospinal fluid through the nose Perform neurological assessment and vital signs Monitor fluids and electrolytes, and cardiac rhythms for any dysrhythmias Promote venous return from the cranial vault by elevating the head of the bed by 15-30º Avoid neck flexion, extensions and rotation when turning the patient Log roll the patient Teach the conscious patient to maintain a neutral position Avoid activities that would increase intracranial pressure (ICP) Avoid lifting Avoid patient straining to evacuate bowel or void urine Administer appropriate prescribed medication to reduce transient coughing (providing gag reflex is intact) and laxatives for constipation Avoid noxious stimuli such as pain, loud noises or plugged urinary catheters that raise ICP Avoid isometric exercises Reduce fear and anxiety through open communication, information giving and orientating the patient to the setting Support patient in supine position with arms off his or her chest Minimise or prevent seizures through prescribed medication Artificial ventilation, especially with positive end-expiratory pressure, increases intrathoracic pressure and should, therefore, be carefully adjusted to optimise ventilation while minimising complications of rising ICP Minimise brain hypoxia and hypercapnia by maintaining a patent airway, administering oxygen and improving ventilation Reduce manual hyperinflation and limit routine endotracheal suctioning to prevent an accumulative rise in ICP (Chudley 1994, Simmons 1997, Beare and Myers 1998, Palmer 2000, Woodrow 2000, Cree 2003, Price et al 2003)

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learning zone moving and handling Specific fracture sites on the patient’s body require specific nursing and handling care. There is little evidence to guide practice with moving and handling of the patient with a fractured hip. Where arthroplasty or hemi-arthroplasty of the hip has taken place, proper body positioning (avoiding adduction of the lower limbs or excessive flexion of the knee) is a key factor in preventing hip dislocation of the prosthesis (Collins 1999, Peak and Hozack 2004). Most older patients who have sustained a fractured intracapsular joint will receive surgical fixation of the fracture in the form of a joint prosthesis. Spinal cord-injured patients The mechanisms for spinal cord injuries are thought to include hyperflexion or hyperextension of the head, forceful flexion, rotation or axial loading of the head by a compressive force (LeMone and Burke 1996). Patients who have sustained cervical injuries are kept in a neutral position on bed rest in a supine position. Those with fractures above C4 will require ventilation (Woodrow 2000). Paralysis of the intercostal muscles and abdominal muscles predisposes the patient to ineffective coughing and retention of secretions. The nurse should avoid flexing the patient’s head, neck or torso to avoid potential further

damage to the spinal cord. Conservative treatment may involve placing the patient on a special Stryker bed with cervical traction. This will allow the patient to be rotated from the supine to the prone position by wedging the patient between a dorsal and ventral support frame. Stable fractures further down the spine may necessitate bed rest in the supine position until healing of the fracture has occurred. Head-injured patients The aim for the nurse in positioning a patient following a head injury is to reduce intracranial pressure (ICP) and maintain it within set parameters for as long as possible (Box 3). The head-injured patient should be positioned with his or her head elevated (Hughes 2002) in a reverse Trendelenburg position. Some studies suggest a head-up tilt of 30˚ to allow for cerebral drainage (Feldman et al 1992). Some advocate higher positions as the best position without adversely affecting the patient’s blood pressure (Chudley 1994, Simmons 1997). Neck rotation and head flexion increase ICP because drainage of fluid from the brain is impeded. For every 10˚ head elevation, the ICP is thought to drop by 1mmHg (Wong 2000) but cerebral perfusion pressure, which is the mean blood pressure minus the ICP, is believed to reduce, thus compromising blood flow to the brain (Price et al 2003). Changes in ICP during passive limb exercises seem to be small (Wong 2000). Complications of

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Care. 8, 6, 397-405. Dowswell G (2000) Adjusting stroke patients’ poor position: an observational study. Journal of Advanced Nursing. 32, 2, 286-293. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M (1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 354, 9193, 1851-1858. Fairchild SS (1996) Perioperative Nursing: Principles and Practice. Second edition. Lippincott, Philadelphia PA.

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head injuries include hypoxia, hypotension, raised ICP and cerebral vasospasm (Jastremski 1998) or secondary brain damage as a result of the initial injury (Price et al 2003). A sustained increase in ICP can lead to significant tissue ischaemia and damage to the neural tissue. Cerebral oedema is a frequent cause of sustained increase in ICP. There may be other causes, such as head trauma, tumours, abscesses, stroke, inflammation and haemorrhaging. Stroke patients During the acute phase of stroke, complete bed rest in a quiet environment is advocated to prevent abrupt fluctuations in blood pressure, which can lead to aneurysmal bleeding (Rees et al 2002). The benefits of head elevation remain controversial. Some physicians and surgeons advocate strict, flat bed rest with one pillow, but there is no evidence that this reduces re-bleeding. Moreover, this regimen may increase stress and sensory deprivation in patients (Rees et al 2002). The goal of therapy in acute stroke units is to maintain and restore cerebral perfusion to preserve viable tissue. This may be achieved by maintaining stable blood pressure and hydrating body tissues via administration of IV fluids. It is important to maintain the patient’s joint mobility and functioning while simultaneously avoiding hip and neck flexion, which may increase ICP. Nursing staff should avoid isometric limb exercises with stroke patients, which could

Fridrich P, Krafft P, Hochleuthner H, Mauritz W (1996) The effects of long-term prone positioning in patients with trauma-induced adult respiratory distress syndrome. Anaesthesia and Analgesia. 83, 6, 1206-1211. Gattinoni L, Togoni G, Pesenti A et al (2001) Effect of prone positioning on the survival of patients with acute respiratory failure. New England Journal of Medicine. 345, 8, 568-573. Gibbon B (2002) Rehabilitation following stroke. Nursing Standard. 16, 29, 47-52.

increase the intrathoracic pressure by interfering with venous blood flow return from the brain, increasing ICP (Rowe 2004). During the rehabilitation phase, early mobilisation is important, a range of positions should be adopted, each of which has a therapeutic effect in terms of discouraging development of abnormal tone and contractures. The patient’s position should be changed frequently – at least two hourly – to discourage skin breakdown and respiratory problems (Gibbon 2002). When positioning the stroke patient, nurses should avoid inducing trauma to the patient’s shoulder by pulling on the patient’s upper limb – this could lead to subluxation of the patient’s shoulder where the joint has been affected by muscle weakness (Beare and Myers 1998). Patients should be nursed in neutral positions with their limbs kept in symmetry. The head should not be extended or allowed to fall forward, as this could rise to abnormal tone or inhibit walking at a later stage. The arms should be positioned so that the shoulder is not allowed to droop, giving rise to subluxation of the shoulder. The hands should be positioned with the fingers extended to counteract the tendency for the hand to close into the grip position, and the wrist should be held in a neutral position. The legs should be placed straight or bent at 90˚ at the knee and ankle. It is important to prevent the legs crossing, especially when lying on the side of the

Ashtiani B (2003) Predictors of backrest elevation in critical care. Intensive and Critical Care Nursing. 19, 2, 68-74. Harcombe CJ (2004) Nursing patients with ARDS in the prone position. Nursing Standard. 18, 19, 33-39. Hauswald M, Braude D (2002) Spinal immobilization in trauma patients: is it really necessary? Current Opinion in Critical Care. 8, 6, 566-570.

Giuliano KK, Scott SS, Brown V, Olson M (2003) Backrest angle and cardiac output measurement in critically ill patients. Nursing Research. 52, 4, 242-248.

Helman DL, Sherner JH, Fitzpatrick TM, Callender ME, Shorr AF (2003) Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients. Critical Care Medicine. 31, 9, 2285-2290.

Gosheron M, Leaver G, Forester A, Harmsworth A (1998) Prone lying: a nursing perspective. Care of the Critically Ill. 14, 3, 89-92.

Horgan AF, Geddes S, Finlay IG (1999) Lloyd-Davies position with Trendelenburg: a disaster waiting to happen? Diseases of the Colon and Rectum. 42, 7, 916-919.

Grap MJ, Munro CL, Bryant S,

Hughes R (2002) Care of patients

with brain injury in the critical care environment. Professional Nurse. 17, 10, 593-597.

Leveridge A (1991) Therapy for the burn patient. Therapy in Practice 27. Chapman and Hall, London.

Jastremski C (1998) Trauma! Head injuries. RN. 61, 12, 40-44.

Meyer RS, White KK, Smith JM, Groppo ER, Mubarak SJ, Hargens AR (2002) Intramuscular and blood pressures in legs positioned in the hemilithotomy position: clarification of risk factors for well-leg acute compartment syndrome. Journal of Bone and Joint Surgery: American Volume. 84-A, 10, 1829-1835.

Jolliet P, Bulpa P, Chevrolet JC (1998) Effects of the prone position on gas exchange and hemodynamics in severe acute respiratory distress syndrome. Critical Care Medicine. 26, 12, 1977-1985. Kneafsey R, Baker C, Robinson J (2003) Ten years on from the 1992 ‘Manual handling operations regulations’: a perspective from higher education in the UK. Nurses’ Education in Practice. 3, 3, 121-122. Krishnagopalan S, Johnson EW, Low LL, Kaufman LJ (2002) Body positioning of intensive care patients: clinical practice versus standards. Critical Care Medicine. 30, 11, 2588-2592. LeMone P, Burke KM (1996) Medical-surgical Nursing. Critical Thinking in Client Care. Addison-Wesley, Menlo Park CA.

Mims B (1989) Physiologic rationale of SvO2 monitoring. Critical Care Nursing Clinics of North America. 1, 3, 619-628. Palmer J (2000) Management of raised intracranial pressure in children. Intensive and Critical Care Nursing. 16, 5, 319-327. Pappert D, Rossaint R, Slama K, Gruning T, Falke KJ (1994) Influence of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome. Chest. 106, 5, 1511-1516.

vol uses 19 no 42 :: 2005 63 NURSING DownloadedSTANDARD from RCNi.com by ${individualUser.displayName} on Jan 25, 2016. For personal use june only. 29 No ::other without permission. Copyright © 2016 RCNi Ltd. All rights reserved.

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learning zone moving and handling bed, as this can inhibit mobility at a later stage (Gibbon 2002). Stroke patients benefit from good posture yet they can spend a long period in inappropriate positions (Dowswell 2000).

Conclusion The moving and handling training received by nursing students has traditionally emphasised the health and safety aspect of back care. It is important to incorporate positioning within manual handling training that enables nurses to understand the importance of moving and handling patients into appropriate therapeutic positions, to maximise their physiological functioning and recovery. Nurses require a combination of underpinning back care knowledge, critical care haemodynamics and understanding of the availability of manual handling products to safely position the patient in an acute care setting NS Acknowledgement The authors wish to acknowledge peer support from Simone Bedford, a nurse tutor at School of Health Science, University of Wales, in writing this article

Anwers to Time out activities Time out 1 Head and neck need to be supported in a neutral position. Head, trunk and lower limbs all need to be moved simultaneously to avoid spinal twisting in the casualty’s back. The patient’s knees need to be supported to avoid adducting them across the midline of body and twisting the spine, causing further damage to the spinal cord. Time out 2 Peripheral nerve and blood vessel damage. Pressure tissue necrosis. Reduction in effectiveness of respiratory ventilation. Lower limb compartment syndrome. Deep vein thrombosis. Time out 3 Sciatic nerve. Lateral cutaneous nerve of thigh. Femoral artery. Femoral vein.

Time out 5 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 68.

References (continued) Peak EL, Hozack WJ (2004) Total Hip Replacement Dislocations: What to do? Rothman Institute Orthopaedics. www.rothmaninstitute.com/patiente ducation/joint/hip/thr-dislocation. htm (Last accessed: May 16 2005.) Price AM, Collins TJ, Gallagher A (2003) Nursing care of the acute head injury: a review of the evidence. Nursing in Critical Care. 8, 3, 126-133. Queen Elizabeth National Spinal Injuries Unit (2000) Pre-Hospital Care and Transfer of a Spinal Cord Injury. Second edition. The Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital NHS Trust, Glasgow. Rees G, Shah S, Hanley C, Brunker C (2002) Subarachnoid haemorrhage: a clinical overview. Nursing Standard. 16, 42, 47-54. Rowe C (2004) Development of clinical guidelines for prone positioning in critically ill adults.

Nursing in Critical Care. 9, 2, 50-57. Ryan DW, Pelosi P (1996) The prone position in acute respiratory distress syndrome. British Medical Journal. 312, 7035, 860-861. Scottish Intercollegiate Guidelines Network (2002) Prevention and Management of Hip Fracture in Older People. www.sign.ac.uk/guidelines/ fulltext/56/index.html (Last accessed: May 16 2005.) Sexton J (1999) Can nurses remove spinal boards and cervical collars safely? Emergency Nursing. 6, 9, 8-12. Simmons BJ (1997) Management of intracranial haemodynamics in the adult: a research analysis of head positioning and recommendations for clinical practice and future research. Journal of Neuroscience Nursing. 29, 1, 44-49. Smith-Temple J, Johnson JY (1998) Nurses’ Guide to Clinical

Procedures. Third edition. Lippincott, Philadelphia PA. Stocker R, Neff T, Stein S, Ecknauer E, Trentz O, Russi E (1997) Prone positioning and low-volume pressure-limited ventilation improve survival in patients with severe ARDS. Chest. 111, 4, 1008-1017. Udobi KF, Childs E, Touijer K (2003) Acute respiratory distress syndrome. American Family Physician. 67, 2, 315-322. Vickery D (2001) The use of spinal board after the pre-hospital phase of trauma management. Emergency Medicine Journal. 18, 1, 51-54. Vollman KM (1997) Prone positioning for the ARDS patient. Dimensions of Critical Care Nursing. 16, 4, 184-193. Vollman KM (2004) The right position at the right time: mobility makes a difference. Intensive and Critical Care Nursing. 20, 4, 179-182.

Watson JE, Royle JA (1992) Watson’s Medical-Surgical Nursing and Related Physiology. Third edition. Baillière Tindall, London. Webster N (1997) Ventilation in the prone position. Lancet. 349, 9066, 1638-1639. Wong WP (1999) Use of body positioning in the mechanically ventilated patient with acute respiratory failure: application of Sackett’s rules of evidence. Physiotherapy Theory and Practice. 15, 1, 25-41. Wong FW (2000) Prevention of secondary brain injury. Critical Care Nurse. 20, 5, 18-27. Woodrow P (2000) Intensive Care Nursing: A Framework for Practice. Routledge, London. Zach MB, Pontoppidan H, Kazemi H (1974) The effect of lateral positions on gas exchange in pulmonary disease. A retrospective evaluation. American Review of Respiratory Disease. 110, 1, 49-55.
